On a weekday afternoon, Max — who didn't want his last name used — sat on a plastic chair in a private clinic in downtown Ottawa waiting to get a supply of the drug he uses to get high.
"I used to be a complete mess before I got on this program," he said. "I used to inject a gram of meth every day three times a day."
Max is a fragile-looking man, 26 years old, who has been injecting methamphetamines for more than a decade. He doesn't have a permanent home and still gets high on the streets.
But instead of buying high-risk drugs, often laced with fentanyl and other chemicals by dealers, he injects stable doses of Ritalin prescribed by a doctor and dispensed by a pharmacist.
He receives this controversial form of addiction care, known as "safe supply," every week. The program is funded in large part by government insurance programs and closely monitored by Canadian health officials.
Max says with this kind of medical supervision, his overall drug use has declined sharply: "I've gone dramatically down. I've made big progress since last year."
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This program, operated by a private company called Recovery Care, is part of a growing network of healthcare services across Canada pushing the boundaries of the public health response to an overdose crisis killing record numbers of people.
The goal of this kind of treatment, often described as harm reduction, is to reduce the catastrophic surge of drug deaths — not by ending illicit drug use but by helping people get high more safely.
Max joined the program in Ottawa after an overdose nearly killed him.
"I got on safe supply after I came out of the ICU, and I'm pretty sure it saved my life," he told NPR.
A tsunami of drug deaths prompts a shift in addiction care
For decades, the overwhelming majority of addiction treatment, in the United States and Canada, focused on urging people toward abstinence and long-term recovery.
But research shows tens of millions of people in both countries actively use drugs. At any given time, most of those active users, like Max, aren't ready or able to quit.
Meanwhile, the supply of street drugs has grown far more treacherous.
Most illicit opioids and stimulants are now heavily laced with fentanyl, benzodiazepines and other deadly chemicals.
As a consequence, drug deaths across North America have roughly doubled over the last five years. In the U.S., a record 107,000 people died from overdoses in 2021.
Canada's per capita death rate was lower, but a record 7,560 people suffered fatal overdoses the same year.
Critics say focusing healthcare on those willing or able to stop getting high leaves huge numbers of active drug-users profoundly vulnerable.
"We've seen abstinence being forced on people, and it just doesn't work," said Dr. Charles Breau, a physician who helped pioneer Ottawa's safe supply program.
Breau now writes prescriptions every month for hundreds of patients.
People like Max use his medications, paid for by Canada's public health system, to achieve the euphoric high they crave without purchasing toxic drugs from street dealers.
"It's about survival," Breau said. "I feel like we're helping a lot more people by keeping them alive so we can offer care. This should have happened at the start, when the overdose epidemic started."
The Canadian government has concluded these programs are helping keep people alive.
Pushing the boundaries of "harm reduction"
In the U.S., less ambitious forms of harm reduction are now fairly common.
Needle exchange programs are widespread, helping people avoid diseases such as HIV/AIDS and hepatitis. Many communities have begun dispensing Naloxone, a medication that reverses opioid overdoses.
Acceptance of these programs has been driven in part by the grim scale of the public health crisis.
"We have an American perishing every five minutes around the clock and that is unacceptable," said Dr. Rahul Gupta, head of the Office of National Drug Control Policy in an interview with NPR.
"We know there is so much we need to do, making sure we save lives with harm reduction such as Naloxone," Gupta said.
The Canadian experiment in harm reduction goes much further.
With support and oversight from the Canadian government, most major cities, from Vancouver to Montreal, now offer a safety-net for people actively using high-risk drugs.
That includes ready access to Naloxone. People can also receive prescription drugs to get high. They can also use street drugs in supervised consumption sites.
Outreach programs bring safe "gear" — syringes, smoking pipes and other drug paraphernalia — into the community, so people can use drugs without spreading disease.
While receiving these services, patients are offered other healthcare, along with access to housing and counseling.
Those ready to enter full recovery are guided toward rehabilitation clinics and offered medical treatments that can ease withdrawal.
"We see people in a vulnerable state. We see people who are just raw," said physician assistant Saskia Knol, part of a mobile outreach team that operates an addiction care clinic in a van.
Knol said her goal isn't to get the people she cares for off street drugs in the short term. "That's not going to happen," she said.
But she believes this kind of front-line addiction care is helping; and she rejects criticism that harm reduction might encourage illicit drug use.
"Giving someone a clean needle is not going to kill an active user. In fact, it's going to do the opposite," she said.
"There is no recovery if you're dead"
Anne Marie Hopkins, who runs an addiction program called Ottawa Inner City Health, said the basic philosophy of this harm reduction approach is simple: "There is no recovery if you're dead."
Ottawa Inner City Health operates a clinic where people come daily to inject street drugs under medical supervision.
On a recent day, a half-dozen people sat in small booths — like the study desks in a library — getting high. A team of nurses and other care workers watched closely for signs of overdose.
"The individual in that booth is under a very mild overdose," Hopkins said, pointing to a woman slumped forward in a chair.
"We're just going to pop her on just a little bit of oxygen, probably a very low level, to make sure she doesn't dip down further."
This kind of addiction care can appear jarring. Hopkins pointed to a booth where a nurse knelt, helping a man find a vein in his arm so he could successfully inject and get high.
"For us that's harm reduction," Hopkins said. "If we don't assist that, what we were seeing over and over again was people injecting in veins that were much more dangerous — like for example the jugular."
This kind of medical care is unavailable for the overwhelming majority of people using drugs in the U.S. and would be illegal in most states.
But in interviews with NPR, people getting high at the Ottawa clinic described the program as a lifeline.
"The staff here are very special people, to come and be here with us and for us," said a middle-aged woman named Shelly, who also asked her last name not be used.
Shelly has battled addiction for decades and now comes to Ottawa's supervised injection site regularly to take opioids. She said getting high on the street has grown far more deadly.
"I see it every day, I see overdoses. Many, many friends have lost their lives," Shelly said.
Addiction experts and policy makers in the US are watching
Preliminary data suggests Canada's harm-reduction programs are working, helping reduce overdose deaths.
Meanwhile, as drugs deaths surge, policy experts in the U.S. are watching the Canadian experiment with a mix of hope and skepticism.
"There is a tremendous number of Americans at risk for an overdose who will not go into treatment, or at least they're not going to go into treatment right now," said Dr. Brian Hurley, an addiction physician with the Los Angeles County Public Health Department.
"If we say, 'Let's wait until they're ready [for abstinence-focused treatment],' they might be dead."
Hurley, who is slated to take over next year as head of the influential American Society of Addiction Medicine, said he's not yet convinced it makes sense to prescribe drugs so people can get high more safely.
But ASAM has endorsed the idea of supervised consumption sites, like the ones in Canada, opening across the U.S.
"I think we should see more communities start and test safe consumption sites, see what works and what doesn't, and make modifications, in order to bring these to scale," Hurley said.
Keith Humphreys, a leading addiction researcher at Stanford University, is more critical of the Canadian approach.
According to Humphreys, opening enough supervised drug-use sites in the U.S. to help large numbers of people would be costly and controversial, diverting funds from other, more well-established forms of treatment.
He also believes safe supply drugs programs are likely to be abused, with prescription medications sold on the black market.
"When you start distributing opioids in the community, [people] will in some cases sell them and initiate new people onto drugs and those people will overdose," Humphreys said.
Despite these concerns, efforts are under way to provide more medical support to people using drugs in the U.S.:
Two supervised injection sites opened last year in New York City, with approval from local officials. State and federal agencies have allowed the clinics to operate, and care providers say they've already helped reverse hundreds of potentially lethal overdoses.
California's legislature approved a pilot program this year that would have opened similar clinics in Los Angeles, San Francisco and other major cities. The plan was vetoed in August by the state's Democratic Gov. Gavin Newsom.
The U.S. Justice Department is negotiating with a group that hopes to open a supervised injection clinic in Philadelphia. If such a program were to win approval from the federal government's top law enforcement agency, it would signal a major policy shift.
"We're chasing a crisis"
Canada's embrace of harm reduction is more ambitious than in the U.S., but the debate over how to help people actively using drugs remains volatile in both countries.
"There's a division and sometimes a really harsh division," said Donna Sarrazin, head of an Ottawa-based program called Recovery Care, which provides a wide variety of medical care to people using street drugs.
In part, this divide reflects a grudging shift in how substance use disorder is viewed. For decades, drug-users in Canada and the U.S. have been criminalized, often sent to prison rather than offered treatment.
While addiction is now widely recognized as a treatable illness, experts say stigma remains, complicating the public health response.
Here in Canada, front-line addiction workers offering services like supervised injection sites and prescription narcotics say they face a backlash from the community and others in healthcare — who sometimes compare them to drug dealers.
In interviews with NPR, those same care providers suggested the rest of the healthcare system will have to join them quickly, offering more medical care to active drug users, if the two countries hope to stem the epidemic of overdose deaths.
"We're chasing a crisis," Sarrazin said. "I don't see an end in sight. No matter how progressive we are or cutting edge or how much we're doing, it doesn't feel like enough."
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