From the outside, no one would have seen the trauma at play in Guy Felicella’s middle-class suburban life.
Behind the closed doors of the family’s home, however, Felicella’s mother hid an alcohol addiction and his father, a compulsive gambler, was verbally abusive.
“Verbal abuse for a young child just literally crippled me,” he said.“It gave me low self-esteem, definitely self-hatred, which led to depression, which led to isolation, which led to self-medicating.”
Felicella began using heroin as a young adult; the drug quickly took over his life. He lived on the streets of Vancouver, B.C.’s Downtown Eastside, going 20 years without a home, a job or familial support.
“I was the guy that was shouting at the sky when you walked by,” Felicella said. “You’d actually probably just cross the street.”
Felicella’s outlook was bleak, but he said that he managed to turn his life around at age 43. He credits a facility in Vancouver called Insite for his recovery, North America’s first supervised consumption site. A supervised consumption site is a facility that provides users of illicit drugs with a safe space and clean materials so that they are not injecting drugs on the street and spreading disease through discarding infected needles.
Felicella found that he was able to confide his struggles in the nurses who worked at the site. He now calls them friends, and recalls how they encouraged him to seek treatment at a neighboring detox facility named Onsite.
“A safe injection site … builds a rapport. You start to get to know your clients and when people feel that, they’re able to start reaching out about their story,” Felicella said.
While Insite is best known for providing users of illicit drugs with sterile supplies to prevent the spread of blood-borne illnesses, that is only a part of its services. The nurses interviewed for this story said that serving as a non-judgmental listening ear and supportive shoulder for people to lean on is just as important as preventing disease and being on hand in case of overdose.
“The opposite of addiction is human connection,” said Insite nurse Tim Gauthier, who has worked at Insite for a decade. “A big part of nursing is getting people to tell their stories.”
Gauthier remembers meeting a woman at a bar after work one evening who noticed his Insite t-shirt. The woman told him that she had once been a heroin addict, but had been able to recover thanks to the compassionate nurses at Insite.
“What stood out to her was that the staff was so nice to her,” he said.
Brandi, who lives in an apartment building near Insite, said that she regularly visits the facility, and has since it opened 15 years ago.
“We’re people too, so we should be treated differently but not too differently … it’s not just staff, they’re friends too,” Brandi said. “I don’t know how they can remember so many people’s names, but they do. And they don’t just remember names, they remember [stuff] about you.”
Seven years post-rehab, Felicella has been able to rebuild his life. He now has a wife and two young children, owns a home and works for Vancouver Coastal Health. As a community liaison worker, Felicella said he is devoted to bringing the resources that saved him to other addicts in need.
“My job and my passion is to break stigma, definitely break stigma, and let the harm reduction services be accepted in not just one community, but all communities, anywhere there’s an opioid or an overdose epidemic,” he said.
That list of communities is set to include Seattle, thanks to a 2016 recommendation by the King County Opiate Task Force. A subgroup of the force, the User Health Services and Overdose Prevention Workgroup, recommended that the county “establish, on a pilot program basis, at least two Community Health Engagement Locations (CHEL sites) where supervised consumption occurs for adults with substance use disorders in the Seattle and King County region.”
While supporters, such as King County Executive Dow Constantine, the King County Board of Health and the King County Sheriff’s Office, celebrated consumption sites as an innovative way to fight heroin fatalities, the first of its kind in the United States, the move also drew plenty of heated criticism.
And last summer and fall, while some King County cities — Sammamish, Bellevue, Renton, Black Diamond, Maple Valley, Auburn, Kent, Burien, SeaTac and Federal Way — began taking firm action to ban such sites within their borders, Issaquah notably took a different approach.
Rather than banning the supervised consumption sites, outright, the Issaquah City Council elected to enact a six-month ban so that the benefits of a possible site could continue to be researched. After hearing testimony from sobbing parents who had lost children to heroin addiction, council members called consumption sites a possible “tool in the toolkit.”
However, a much larger group of people from not only Issaquah but the greater Seattle area came out to a November public hearing in Issaquah to decry the idea of CHELs. Speakers painted a scene in which a hub for drug addicts in downtown Issaquah would attract addicts from around the county like bees to a flowerbed and render Olde Town a dangerous place.
Steve Foot, who has lived in unincorporated King County near Issaquah for 30 years, said at the hearing that he was an expert on the opioid crisis. Foot said that giving addicts a space in which to inject heroin was akin to killing them, declaring, “As a taxpayer I will feel violated very deeply if you use any of my tax money to provide these people with the means of their own death.”
Insite has been a frequent player in both sides of the debate, with consumption site advocates lauding the Vancouver facility as a progressive way to combat the drug crisis and opposers of consumption sites describing Insite as a heroin den that only spreads addiction problems.
Former Bothell City Councilmember Joshua Freed said at the Issaquah hearing that he had visited Insite multiple times and called the neighborhood around the site “apocalyptic.”
At an Issaquah Chamber of Commerce luncheon last month, King County Councilmember Kathy Lambert described her own visit to Insite. She recalled stepping over heroin addicts passed out on the street and a plethora of syringes on the sidewalks.
“That is not what we want in Issaquah,” she stated.
The local efforts to ban CHELs were just one part of the opposition. The citizen group Citizens for a Safe King County even attempted to use the February special election to get rid of them; I-27, an initiative chiefly sponsored by Freed that would have banned consumption sites in the county, was set for the special election ballot until King County Superior Court Judge Veronica Alicea Galvan declared the initiative invalid in October.
“Supervised drug consumption sites are inconsistent with protecting citizens and helping drug addicts,” states I-27’s website.
In her findings, Galvan stated that the “Supreme Court has recognized the broad authority public health authorities have in protecting public health and addressing responses to public health crisis,” and that “I-27 in its entirety extends beyond the scope of the local initiative power.”
Jerry Blackburn, program manager for substance abuse and prevention services at Issaquah Friends of Youth, said that the people behind the “no” campaign stirred up panic in the community without spreading around actual facts. What was spread in public comment at council meetings was “180 degrees different than the concept behind [consumption sites],” he said.
“They’ve done an unbelievably good job in creating a great deal of fear of something that is not going to occur in our community,” he said. “It got politicized.”
Blackburn, who himself is in long-term recovery from substance use disorders, prefers the name CHEL over consumption site because it takes into account the many services that take place at a site besides consumption of drugs, such as providing people with items that will cut down on the spread of HIV/AIDS, and, most importantly he said, providing them with the opportunity to interact with other people.
Felicella said that no consumption site will encourage a non-heroin user to begin using; instead, he said, the sites will combat a problem that is already in existence and help addicts to take steps for getting off the drugs.
“Nobody is sitting in the morning, reading their morning paper and saying, ‘Honey, they just opened a safe consumption site. I think I’m gonna go inject heroin today,’” Felicella said, adding, “When it doesn’t exist, people with drugs are going to continue to use no matter what.”
Gauthier, the Insite nurse, noted that if someone who has just recently started using heroin visits Insite, the staff encourages that person to quit before becoming more deeply addicted.
Supervised injection sites have been used in countries around the world to treat drug users and prevent the spread of disease since 1988. Australia, Germany, Luxembourg, the Netherlands, Norway, Spain and Switzerland all have some form of supervised consumption sites.
While different countries have found varied ways to tackle the opioid crisis, what is universal is the drugs’ presence; they are found across continents in communities rich and poor.
In Washington state, opioids have surpassed automobile accidents and gun violence as the largest accidental cause of death. According to Governor Jay Inslee’s office, 718 Washingtonians died of opioid overdoses in 2015.
Opioids constitute not only heroin, but also prescription painkillers such as oxycodone. The rise in heroin use has been “paralleled by increases in pharmaceutical opioid misuse and opioid use disorder,” according to the King County Opiate Task Force’s Final Report and Recommendations.
According to information provided by Northwest High Intensity Drug Trafficking Area Prevention/Treatment Manager Dr. Steven Freng, oxycodone was prescribed 1,937,349 times in Washington in 2016. Hydrocodone, another opioid, was prescribed 2,371,802 times.
And as the county’s task force noted in its report, 229 of the statewide opioid deaths in 2015 occurred in King County alone. The majority of the overdoses came from heroin. King County’s numbers for 2016 remained similar, with 219 opioid overdose deaths.
“From 2010 to 2014 the number of people who entered the publicly funded treatment system for heroin use disorders annually in King County grew from 1,439 to 2,886,” the task force’s report stated.
Inslee’s 2016 State Opioid Response Plan laid out goals for fighting the opioid epidemic that included more conventional remedies such as improving prescribing practices, expanding access to opioid treatment, expanding the distribution of naloxone in the case of overdoses, and increasing data sources to monitor and evaluate the crisis.
It wasn’t until the county Opiate Task Force’s report that the phrase “community health engagement locations” officially came on the table.
The 43-member task force — which was made up of a group of community members that included county employees, police officers, attorneys and medical professionals — met regularly between March and September 2016 to analyze the local strategies being used and study alternative methods used by other cities and countries.
The task force members formed three smaller workgroups — the Primary Prevention Workgroup, the Treatment Expansion and Enhancement Workgroup, and the User Health Services and Overdose Prevention Workgroup — each of which presented its official recommendations to be voted on by the 30 voting members of the task force.
The User Health Services and Overdose Prevention Workgroup proposed in its CHEL recommendation that one site should be located within the city of Seattle and the other site elsewhere in the county, “reflecting the geographic distribution of drug use in other King County areas.”
Though this proposal received the most varied votes of all eight recommendations, the recommendation nevertheless passed with 23 “yes” votes, three “no” votes, one abstention and three silent votes.
Despite initially giving a little more time to look at the issue, it looks as though Issaquah will be following the route of the other cities in King County. At a January Issaquah Planning Policy Commission meeting, the commission recommended that CHELs be banned permanently in the city.
The issue was included as part of the council’s consent calendar as an item to be referred to the Feb. 8 Council Land and Shore Committee meeting, and return to the full council on Feb. 20.
In a Dec. 19 letter to the mayor and Issaquah City Council, the Issaquah Human Services Commission — which had initially been directed by the council in September to review the benefits and drawbacks of CHELs — expressed the wish for safe consumption sites to be given a more thorough analysis.
“Issaquah is likely not an appropriate location for a safe injection site,” the letter acknowledged. “Yet, the process could have involved more space for education and discussion broadly. Our community would benefit from learning more about how the opioid crisis is impacting Issaquah and how the community might support appropriate services in the context of a continuum of care.”
It continued, “We hope that options such as CHELs are not summarily dismissed without thorough vetting … the HSC had anticipated the opportunity to give feedback on CHELs and was disappointed that the decision was made to enact a moratorium. The HSC hopes that future debate concerning the CHELs in Issaquah will include a more in-depth and thorough review of literature, available science, and expert testimony.”
Rather than the dirty drug den that Lambert’s account might bring to mind, Insite resembles a doctor’s office more than a shooting gallery. Sterile and orderly, the facility — which is visited by about 800 people per day, 550 of whom use it for drug consumption — is well-regulated.
Upon entry, participants (which is what Insite calls its clientele) register and wait for between five and 20 minutes. If they want to wait a little longer, they have the option to have their drugs tested, which can determine if heroin is laced with fentanyl, an extremely dangerous opioid that is commonly mixed with heroin to lower production costs.
Insite does not provide participants with drugs.
In the actual consumption room, participants have access to sanitary syringes, sterile cotton filters (to prevent particulate from getting trapped in veins, which can be fatal), water (Gauthier said that people on the street will resort to using water from puddles or toilets to mix with heroin) and other non-drug-related supplies that prevent the spread of diseases, such as condoms.
“It’s such a sterile procedure and we guard that process really well,” Gauthier said.
Participants enter separated booths that look akin to voting booths, where they are allowed to consume drugs—by injecting or eating them—while being carefully monitored. Gauthier said that the nurses on duty are “constantly scanning the room … checking for anyone who looks drowsy, tired or is passed out.” This lethargy is the first sign of overdose.
Overdoses typically happen seven to eight times a day, though Gauthier said he once saw 14 in two hours. No one has ever died of an overdose at Insite.
When overdoses do happen, the nurses calmly handle the situation, getting the person to breathe again, since, as Gauthier explained, it’s lack of oxygen that kills people during an overdose. If the overdose is more serious, the person is taken to a hospital. Gauthier said that the staff members never let their attention to one person prevent them from helping everyone in the center.
“Even as you’re putting breath into someone, you’re still scanning the room,” Gauthier said.
“If somebody even starts to go to sleep, they’re always checking on them to make sure they’re still breathing,” Brandi, the Insite participant, said.
Some people come to Insite for services other than drug consumption; the facility includes a clinic where people can get tested for STDs and other illnesses, receive flu shots and have injuries cleaned and treated. Many of the people who use Insite do not have a regular doctor or health insurance. The King County sites would include similar medical services.
“When you get wounded or sick, you come here … you can get rest here, you can get cleaned up here,” Brandi said.
Gauthier said that in the 1990s, Vancouver was “being compared to Sub-Saharan Africa” in terms of HIV/AIDS. Since then, however, he said that Insite has helped to “put a huge dent in HIV” transmission.
“Everybody who works here feels like they’re doing good … At the end of the day, you know everybody who came here survived,” Gauthier said. “You’re part of this agency, this practice, this way of being with people that is really keeping them alive.”
In Vancouver, supervised consumption sites fall under “harm reduction,” one of four pillars used by the British Columbian government to combat the opioid crisis — other pillars include enforcement, treatment and prevention. The pillars were brought to Canada on a research trip taken by a British Columbian delegation to observe safe injection sites in Europe before Insite was established in 2003.
“Insite is an amazing facility; they’ve saved a lot of lives,” Vancouver Police Department Inspector Bill Spearn said. “The Vancouver Police Department supports anything that saves lives, especially when it saves people suffering addiction.”
Spearn was not always an enthusiast of supervised cosumption sites, however. When the conversation first began in Vancouver back around 2000, Spearn said he was “against harm reduction 100 percent.”
“It has taken me a long time to realize that harm reduction works,” Spearn said. “It saves lives.”
Yet, the death toll from opioids has skyrocketed in Vancouver in recent years. This, said Spearn, is due to a rise in the of the prevalence of fentanyl.
In Spearn’s view, the only way to fight this deadly enemy is to give drug users “clean” drugs at clinics — drugs like hydromorphone that are used in medical settings and are far less dangerous than risking street drugs laced with fentanyl. This way, users can slowly be weaned off of harmful substances and encouraged to enter rehab.
Crosstown Clinic in Vancouver is one example of a clinic that uses this approach. No part of the King County plan as of yet has included the distribution of drugs at the proposed CHELs.
“We believe addiction and safe injection sites are health care issues, not law enforcement issues,” Spearn said. “Anything that can be done to save people with addictions, we support.”
Two-and-a-half hours south of Vancouver, Issaquah Police Commander Paula Schwan said that overdoses are also looked at through a health lens rather than a criminal one; police treat overdoses as a medical call rather than a crime. She explained that while it is illegal to deal or possess drugs, it is not illegal to be caught high.
Though some may believe that Issaquah does not have an opioid problem, Schwan said that the police department routinely works with people addicted to harmful substances.
“We work with it on a regular basis on patrol in Issaquah … We come into contact with people under the influence,” she said.
At Issaquah Friends of Youth, Blackburn works with locals aged 12 to 25 who have, among other issues, an addiction to opioids. Blackburn noted that “the majority of substance abuse really does start in early adolescence.”
According to the county task force’s recommendations, four fatal opioid overdoses occurred at Swedish Hospital in Issaquah between 2013 and 2015.
Those who know former addicts or who themselves are survivors attest to the power of facilities like Insite.
Shelley Bolton runs East Van Roasters, a cafe and chocolate shop around the corner from Insite that provides jobs for women going through or right out of treatment who are looking to rebuild their resumes, earn some money, and find a sense of accomplishment.
“I know a lot of people that, if those places didn’t exist, would probably not be alive today. A lot of the women that have worked here have actually said, ‘If it wasn’t for these places and these programs, I would not be alive,’” Bolton said. “So that’s enough for me right there.”
Felicella said that he owed his life to Insite. Throughout his addiction, he overdosed six times. Luckily for him, each of those overdoses occurred at Insite, and the nurses brought him back to life after he stopped breathing.
“It brought me back to life six times,” Felicella said. “I wouldn’t have two children, Noah and Gia … I wouldn’t have gotten married. I wouldn’t have bought a house. I wouldn’t have a job that I’m very passionate about. And I wouldn’t get the opportunities that I have to inspire people.”
Insite, he said, gives people that life raft to hang onto while they try to turn their lives around.
“It keeps people alive long enough for them to have the ability to one day, possibly, change their life and get the help that they’re searching for,” Felicella said.
For Bolton, it’s a moral decision to do everything possible to save a human life.
“Places like Insite and safe consumption sites, they are those touch points for people who are desperately looking for a connection and … just some type of hope,” Bolton said. “It saves lives, and how can that be something that’s not a positive way forward for people? You have the opportunity for another day, to decide what you’re going to do … When it comes right down to it, what price do you put on human life?”