The historic core of Cobourg, Ont., brims with small-town charm. There are stately buildings, quaint shops and old-fashioned iron lampposts decorated with hanging flower baskets. The local business authority even coined a hashtag, “#8BlocksofAwesome.”

But on Friday nights, just steps off the postcard main street, another side of life comes into view. Volunteers are setting up camp chairs and folding tables in an alleyway and laying out supplies, including alcohol swabs, plastic pipes and naloxone kits to be used in case of overdoses. All for an unsanctioned, pop-up Safe site for local drug users, specifically geared to people who inhale rather than inject.

“It just seemed that there was more and more need, and more and more people dying,” said Ashley Smoke, one of the organizers. “There’s just so many people that are struggling and no one to help.”

Cobourg, home to 20,000 on the shore of Lake Ontario east of Toronto, has had a dozen fatal overdoses over the past 18 months. The nearest official safe consumption site is in Peterborough, almost 60 kilometres away. And like all government-funded harm reduction facilities in Ontario — and most of the rest of the country — it doesn’t permit drug smoking, just injection, oral and nasal use. 

Smoke said the cost of not having supervised spaces for those who inhale drugs can be seen in Canada’s near-record overdose numbers. 

“The consequences have been death. A lot of people have lost their lives. There’s just so much loss and grief,” they said. 

In 2022, more than 7,300 Canadians died of apparent opioid overdoses, with 87 per cent of those deaths occurring in British Columbia, Alberta and Ontario.

Overdose prevention has become a pillar of government efforts to combat the opioid epidemic, with a growing, national network of safe consumption sites approved by the federal government and funded by the provinces and territories. 

Yet even as this system expands, it’s failing to meet the needs of drug users because it largely excludes Inhalation — the most common method of consumption, advocates and experts say.

“What the country is really lacking is the indoor inhalation sites,” said Patrick McDougall, a Vancouver-based harm-reduction specialist who helps community groups across the country set up consumption sites.

“There’s not some safe and secure places for folks to be using right now, unlike what we have with injection.”

In B.C., there have been 3.87 million visits to safe sites since 2017, according to the Ministry of Mental Health and Addictions, with 25,000 overdoses and just one death. That compares to 2,342 fatal overdoses in homes and on the streets in 2022.

Studies suggest that adding inhalation spaces would save additional saves.

Only B.C. and Ontario keep statistics on the mode of consumption associated with drug deaths, but the trend towards smoking is both clear and longstanding.

In British Columbia, inhalation overtook injections back in 2017, causing 56 per cent of drug deaths in 2021. Ontario’s numbers flipped five years ago, with smoking accounting for 68 per cent of fatalities by late 2022.

But there remain only five approved indoor inhalation sites across the country, versus almost 50 focused on injection . 

The reasons why appear to be mostly bureaucratic.

“In my opinion, it’s red tape,” said McDougall. “And I think the consequence is what we’re seeing now: six deaths a day in British Columbia, 20 deaths a day in Canada … several times what you might get from motor vehicle accidents and suicides and other forms of death combined.”

Health Canada will exempt inhalation sites from federal drug laws, demanding the same safeguards as for injection or other uses, a process that usually takes just a few weeks with community support. But things appear to bog down at the provincial level.

$10,000 to build, 18 months to approve

Ontario has one sanctioned smoking site, a small room that exclusively serves clients of Casey House, a specialized HIV hospital in Toronto. It was simple to build, said Joanne Simons, the hospital’s CEO.

“What we needed to install was just a really big fan that could blow the smoke out as quickly as possible,” she said. The construction cost about $10,000 and was covered by hospital donors, as are the room’s ongoing operating costs. 

However, even without taxpayer funds on the line, the approval process took 18 months. 

“The piece that seemed to be the barrier initially was around the Smoke Free Ontario Act because you can’t smoke obviously within a public facility, especially a hospital,” said Simons. “And that took some time to understand from the government’s perspective whether they were going to allow us to have people use illicit drugs in this space.”

Now that such questions have been answered, Simons is hopeful that future approvals will be faster.

But other significant bureaucratic hurdles remain, especially for safe sites that receive provincial funding. 

Kerri Kightley is the manager of consumption treatment services for a facility in Peterborough, Ont., a city of 135,000 people that experienced 59 overdose fatalities in 2022 and 38 more over the first six months of this year. Her safe site serves as many as 70 users a day, a number she estimates would at least triple if smoking were permitted.

“There’s been a dramatic shift away from injection use and towards inhalation use and the provincial government just hasn’t caught up to that,” said Kightley.

Under the existing funding agreement with the province, Ontario safe sites must use their government money to support injection, oral and nasal drug use and nothing else. Even using the same supplies, space or staff to facilitate smoking might be a breach.

“The requirements prevent us from using the provincial funds towards anything other than what we’re approved for,” said Kightley. “It’s a bit complicated.”

CBC News made repeated requests for an interview with Sylvia Jones, Ontario’s minister of health, but did not receive a reply from her office or the ministry.

We also asked the Alberta government about its plans for supervised inhalation sites. The province’s only smoking area, part of a facility in Lethbridge, closed in 2020, after a provincial audit found evidence of financial mismanagement.

Dan Williams, Alberta’s minister of mental health and addiction, provided a statement saying his focus is on treatment and holding criminals “accountable.”

“Our vision for Alberta is one where families have an opportunity to live in healthy communities that are free of illicit drug use and trafficking. Our vision is one where those suffering with addiction have immediate access to treatment,” he wrote, pointing to plans for 11 new “recovery communities.”

British Columbia, which began a three-year trial this past winter decriminalizing possession of small amounts of opioids, cocaine and methamphetamine, has also rapidly expanded access to safe smoking, with one indoor facility and 16 indoor-outdoor hybrid sites in tents and other shelters now in operation. 

In April, the inhalation sites recorded more than 35,000 visits, according to the latest update from the Ministry of Mental Health and Addictions. 

But it’s not clear how practical such hybrid sites might prove in parts of the country with harsher winters or whether the political climate is favourable to such innovations, with Conservative Leader Pierre Poilievre and his federal party on the attack over harm reduction strategies like safer drug supplies. 

Users told smoking is safer

All this worries experts like Tara Gomes, a Toronto epidemiologist and principal investigator for the Ontario Drug Policy Research Network.

Gomes and her colleagues have been tracking the switch to inhalation — a trend fuelled by multiple factors: pandemic isolation, the wear and tear on veins from injecting powerful opioids like fentanyl and public health advice that smoking reduces risk from an increasingly toxic supply. 

She draws a contrast between government response to the COVID-19 pandemic and the opioid crisis. 

“An ongoing concern of many of us who work in this space is just the ability to mobilize funds to be able to make changes to legislation if necessary to react to this emergency. We saw how quickly that could happen in the pandemic,” said Gomes.

“And unfortunately because of the stigma that exists around substance use, this doesn’t often have the same level of urgency even though we’re losing thousands of people across our country and thousands of people in Ontario every year from this.” 

Back in Cobourg, reaction to the pop-up inhalation site has been decidedly mixed.

When volunteers set up a tent to provide users with privacy, the town council responded by sending out bylaw officers and threatening fines of up to $50,000 for zoning infractions.

Cobourg police, however, have made it clear that they support sanctioned harm-reduction approaches and will not arrest individuals for simple possession of illicit drugs alone. So far, the table-and-chairs setup has been left alone. 

John, a Friday night smoker whom CBC News is not fully identifying, said he is hopeful that some compromise can be found. 

“The people down here need something. They need somewhere safe to go,” he said. Maybe just a trailer down by the beach, he suggested, a place for users to look out for each other.

“Being out here with kids on the street and the police and everything is just too much,” he said. “These people aren’t safe out here. They don’t have the help that they need.”

Jonathon Gatehouse can be contacted via email at [email protected] or reached via the CBC’s digitally encrypted Securedrop system at https://www.cbc.ca/securedrop/