Dan SmallPicture of Dan Small is a medical anthropologist and lecturer at the University of British Columbia.


Since 2018, British Columbia has been pursuing legal action against pharmaceutical companies for their involvement in the opioid crisis. Within the wider context of North America, there have been over 2600 such lawsuits against the pharmaceutical companies including Purdue, Johnston and Johnson, Teva Pharmaceutical and Endo International. The Purdue pharmaceutical company, the maker of OxyContin, has recently filed for bankruptcy in response to the lawsuits. I believe a suitable strategy for examining the wider variables that have contributed to the opioid crisis: a Royal Commission. This is needed in order to widen public scrutiny beyond the role of pharmaceutical companies to include investigation of the overarching causes of Canada’s overdose epidemic.

Much of my work has focused on developing healthcare, housing and support services for hard to reach populations facing multiple health and psychosocial challenges including active intravenous drug addiction, HIV/AIDS, mental illness, conflict with the law, sex trade involvement and adverse life events. I was one of the leads in establishing and managing North America’s first Supervised Injection Facility (Insite). Over the past year, I have been corresponding with the office of the Prime Minister, Health Minister and Governor General of Canada in order to request a Royal Commission

The logic for a Royal Comission goes back to the establishment of Insite. Once opened, Insite went on to be successful in reaching a challenging target population, reducing fatal overdoses and HIV while bringing people with addictions into the doorway of a successful life along with detox and treatment. The independent, scientific, peer-reviewed evaluation resulted in dozens of publications indicating its success. In my capacity as co-director of the community agency that established and co-managed Insite, I wrote to the health authority several times requesting a scale up of supervised injection services to meet the increasing population based need. The request was consistently rejected. Similarly, I wrote to the other jurisdictions including mayors and councils of the cities of Toronto and Victoria, offering assistance in the development of supervised injection services there. Here, too, I was unsuccessful. My request to scale up supervised injection services wasn’t visionary; it was epidemiological common-sense.

After the Supreme Court decision in favour of Insite in 2011, Canada was poised for a drug policy paradigm shift. Despite the decision arguably establishing supervised injection as a part of the standard of care, such services remained isolated to a single program in Vancouver operating for only 18 hours per day well over a decade. Until the advent of temporary pop up services in 2016, Insite remained as the only supervised injection facility open to the general public in Canada. Despite the fact that this life-saving service was legally enshrined in the nation’s highest law, it was only made available for 75% of each calendar day in only one city in the entire country. Its standard operational hours left a 6-hour daily period during which supervised injection was unavailable (Insite was closed for 2190 hours per annum/91 days per year).

The conclusion of the Insite legal case was a symbolic stop in a long cultural journey where the implicit values of harm reduction had the possibility to root and blossom across Canada. However, it took the tragedy of an astonishing overdose epidemic to bring about significant government or institutional action to increase supervised injection services to substantively address the dangers of illicit drug use. The fact that the failure to scale up supervised injection services in Canada could have saved hundreds, if not thousands, of lives across the nation is as subtle as an open grave.  The obstacles that have prevented robust harm reduction services across Canada in advance were not scientific, medical or epidemiological. The barriers were, in my view, implicit and explicit values, the bedrock of our culture and institutions, regarding addiction and drug use. I believe that the opioid epidemic, the crisis of our generation, is due to structural violence in our institutions, largely perpetuated by benign neglect of drug users, exemplified by inaction when action in the form of robust harm reduction services (including supervised injection) would have saved lives. Were this any other group, the failure of societal institutions to address the preventable deaths would be a source of public outcry.

A Commission would allow us to investigate the structural violence at play and allow for a sound accounting of the institutional, societal and cultural variables that led us to fail, so miserably, in our public duty to prevent thousands of deaths due to opioid overdose.  Canada’s opioid epidemic was given a huge, multi-year, run-up which eventually resulted in a tsunami of overdose death across the entire nation. To make matters worse, there was even some legislative violence at work as well. At the federal level in Canada, the Conservative Government sought a legislative strategy to hamper the creation of supervised injection in the form of Bill C-31. It is difficult to imagine the political deployment of such a government strategy in another healthcare realm such as, say, legislation to hinder the development of cancer agencies.

A Royal Commission could take place alongside continued efforts to address the opioid overdose epidemic. In order to understand why medical, scientific and legal findings were not enough to move forward substantively on supervised injection services until the advent of an astronomical overdose epidemic, we need to investigate the underlying the “social machinery of oppression” that has been at play. Beyond seeking the truth and uncovering errors, a Commission has the potential to contribute to positive social change through recommendations, action items and public education. Such processes also serve a restorative function in that commissions and inquiries can make a contribution towards the healing of individuals, families, systems and a society that has lost so many lives to preventable deaths.