VANCOUVER — The smell of rubbing alcohol permeates a tiny room where chronic heroin users inject a pharmaceutical-grade version of the drug three times a day to just feel normal.
Justin Hall, 48, exits the freshly cleaned injection room at the Crosstown Clinic in Vancouver's Downtown Eastside after his second visit of the day. He plans to return in the evening for his third "shift," the same routine he has followed for 2 1/2 years.
"A lot of people just muscle it, they don't bother with the veins," Hall says as the next group of people line up outside the room containing eight orange chairs in front of a counter and a mirrored wall.
Nurses behind a glass wall slide doses of heroin through an opening, dispensing an average of 200 mg of heroin. Patients must inject the opioid and leave the room within seven minutes before it's cleaned for the next group.
"It just levels me out," Hall says five minutes after the shot. "For most addicts the use of getting high is a thing of the past. It's just to keep a person level, just normal."
About 94 participants come into Crosstown two or three times a day, rotating through a schedule starting at 7:30 a.m. and ending at 10:05 p.m. at the only clinic in North America that provides treatment with supervised medicinal heroin, or diacetylmorphine.
"It's clean, it's safe, it's what I need to get through the day," Hall says. "And I'm not being a burden to anybody else. I'm not committing crimes or abusing anybody. I'm not hustling for money."
Hall says he began using marijuana, cocaine and other drugs at age 18 and then became addicted to heroin for 15 years before getting into treatment at Crosstown.
"A lot of people would be dead if it wasn't for this place, that's guaranteed, not just because of the fentanyl," the former construction worker says of the potentially deadly painkiller that's often cut into heroin.
The BC Coroners Office says 914 people died of overdoses in British Columbia in 2016, the highest number of annual fatalities in a Canadian jurisdiction ever attributed to illicit drugs, including fentanyl.
Hall says that besides the pure heroin he receives at Crosstown, support services at the clinic have allowed him to leave a single-room occupancy hotel and move into stable housing so his four daughters can visit him.
"There were quite a few years there when I didn't have much contact with them. They see that my life has stabilized and I'm able to see them when they come for visits."
Most people who chronically use heroin don't take it for the high but to avoid becoming "dope sick" with withdrawal symptoms, such as vomiting, sweating and diarrhea, Hall says.
"I definitely see myself having a job, working somewhere, making money. I may still be going to the program, maybe not going three times a day, maybe twice a day," he says, adding some Crosstown patients go to work between injections.
Dr. Scott MacDonald, lead physician at Crosstown, says the program was modelled after supervised heroin assistance treatment that started in Switzerland in the 1990s.
"They are now closing clinics," he said of the successful outcomes in that country. "They've solved their opioid problem. With adequate treatment they basically have stopped recruiting new people into the program."
He says about 15 patients at Crosstown have transitioned to other less intensive treatments, such as methadone or suboxone, as their lives stabilized.
MacDonald says Crosstown clients tried and failed to quit an average of 11 times with other treatments.
"This is not a lifelong treatment for everyone. Some people need an intensified treatment option. They will get some order into their lives, get healthier, get reconnected with their families, get back to work."
MacDonald, who testified before the U.S. Senate committee on homeland security and government affairs in June as part of its research into Vancouver's experience with addiction treatment, says officials from Seattle have visited Crosstown as has the mayor of Ithaca, N.Y.
He says the clinic's pharmaceutical heroin is brought in from Switzerland but the lack of an import-export agreement involving controlled substances between the two countries means multiple permits are required as part of an onerous process that has the drug arriving via Scotland.
The heroin could be made domestically if a drug company stepped up to produce it and Health Canada provided it with a drug identification number, MacDonald says, adding at least 500 more people in Vancouver alone would be eligible for pure heroin treatment if the Crosstown program were expanded.
He says the need is great across Canada.
"What we need is the provinces stepping up and saying there's a market. It's a safe, effective, cost-saving approach."