Insite, a safe consumption facility in Vancouver. Image: Hungarian Civil Liberties Union (CC BY-NC-SA 3.0). How should we address the opioid crisis? Perhaps we should ask those with the most experience of it – drug users. Having spoken to hundreds of drug users over the last 12 years as an ethnographic researcher, one thing made clear to me no matter where I go is that the best way to address problematic drug use is not through law and order but through care and community.
Perhaps the best example of a community-orientated approach to drug addiction can be found in Vancouver’s Downtown Eastside neighbourhood, where organisations of active and former drug users and their allies responded to a drug epidemic in the 1990s with a focus on community-building and local revitalisation. When I visited in 2013, I witnessed first-hand how the scheme was transforming the lives of people living there. Small businesses and social enterprises, such as the community bank Pigeon Park Savings, had been created to offer employment and services to active drug users. There was a significant increase in social and affordable housing, several health – including mental health – facilities, and abundant community events open to public – including musical concerts. All of these various projects are supported by mixture of public funding, won by campaigners, and private donations and non-profit grants.
In two years the fatal overdose rate decreased by over a third.
None of this would have been possible without the establishment of Insite, the first legally sanctioned safe consumption facility in North America. These facilities provide a space for people to consume pre-obtained drugs in controlled settings, under the supervision of trained staff, and with access to sterile injecting equipment. When Insite was first established in 2003, the Downtown Eastside had been home to hundreds of overdose deaths over the previous decade. In two years the fatal overdose rate decreased by 35% – then the fentanyl crisis hit. As in cities and small towns across the United States and Canada, many Downtown Eastsiders are now scrambling to respond to this latest drug-war exacerbated crisis. The difference is that because of the twenty-year-long political activism led by active and former drug users, the Downtown Eastside has the broadest and most integrated harm reduction infrastructure in the world from which to respond.
Harm reduction is a public health approach to drug use that begins from the nonjudgmental position that some people use drugs, those people will continue to use drugs until they decide to make a change, and until then certain measures should be taken to reduce the potential harm they cause themselves and others. The most common harm reduction measures are syringe exchange and substitution therapy (e.g. methadone). But perhaps the most effective one is safe consumption facilities like Insite. The facts bear this out: not only did overdose deaths radically decrease in the Downtown Eastside once Insite was opened, but so have they anywhere else in the world such facilities exist.
As one of the early Downtown Eastside activists Dean Wilson put it: ‘addiction is a disease of loneliness’.
What makes the Downtown Eastside different from these other locations – and as a result, a global model for addressing opioid crises – is that harm reduction in the neighbourhood goes way beyond syringe exchange, substitution therapy, safe consumption facilities, and most recently heroin prescription. All of this is a great foundation for addressing opioid crises, but what the drug-using activists and their allies recognised from the very beginning is that it simply is not enough. Most people begin using hardcore drugs like heroin for a reason: sometimes to alleviate physical pain, and commonly to relieve emotional and mental pain. But too often the underlying condition shared by many of these users is a deep sense of isolation and loneliness, which is likely the result of social and economic precarity and anxiety. As one of the early Downtown Eastside activists Dean Wilson put it: “addiction is a disease of loneliness.”
The real success of the Vancouver model is that it addresses this loneliness. This is what Teresa, one of the workers at a Downtown Eastside social enterprise who also happens to use drugs, described to me as giving people opportunities to become connected. When Teresa arrived in the neighbourhood she had been homeless, using drugs, and doing sex work for several years. Despite years of being uncared for, harassed by the police, and essentially left to die, Teresa was welcomed in the Downtown Eastside, where she easily found a safe and well-maintained single-occupancy-room in which to live, a social enterprise job that paid a fair wage and adjusted to the vicissitudes of her schedule, and most importantly she found people who cared about her as a person no matter her drug using habits.
"Stop the war on the poor": graffiti in Vancouver. Abid Virani (CC BY-NC 3.0)What Teresa found in the Downtown Eastside was a community of what I call “attuned care”, and this community was built by organisations of active and former drug users and their allies. Attuned care is a kind of care that doesn’t try to turn someone into something they are not, but rather cares for them as they are. This is another way of articulating the harm reduction motto of “meeting people where they are at”. The magic of attuned care is that it often opens possibilities for the person given care to become someone who is themselves more caring, connected, and responsible to others. For example, though still an active drug user, Teresa now lives in her own apartment in a quiet neighborhood near Vancouver’s Stanley Park, where she is writing a book on her experiences as a homeless person as a guidebook to help currently homeless people get back on their feet. This is just one example of the success of the Vancouver model, where success is marked by connecting drug users with others, with shared projects, and with a future filled with possibilities, rather than simply in terms of the cessation of drug use.
The war on drugs is primarily one characterised by the punishment and marginalisation of drug users.
This model can be contrasted with the American model addressing the current opioid crisis. This model is better known as the war on drugs, or what many drug user activists call the war on people. They call it this because the American model of the war on drugs is primarily one characterised by the punishment and marginalisation of drug users and those associated with them. It has been a significant factor in the rise of mass incarceration in the country, and not unrelatedly, its policies have overwhelmingly impacted African-American and Latino-American communities in a negative manner. The war on drugs has also created a culture in which any person who problematically uses drugs is systematically dehumanised by being labeled an “addict,” who almost by definition is considered to have lost all the capacities of what today’s society considers a human to be, that is, rational and responsible. Because of this drug war “mentality,” as many activists call it, too many drug users are further isolated as family, friends, and too often, medical and social service workers stigmatise and turn their backs on them. As if this were not enough, the war on drugs has absolutely failed to deter drug use, and this failure has cost American taxpayers over $50 billion annually. Not surprisingly, the current response in the United States to the opioid crisis has been a doubling down on the failed policies of this law and order approach.
For well over a generation, however, American drug user activists and their allies have worked hard to implement harm reduction policies despite the oppressive conditions of the war on drugs, and have been inspired by the Vancouver model to go beyond harm reduction’s public health components. It is now time that Americans politicians and the medical establishment join them and begin to take the Vancouver model seriously as well. As a first step, this means the United States needs a robust harm reduction infrastructure – including safe consumption facilities – to address the public health aspects of the opioid crisis.
Ultimately, however, local projects of dynamic community-building are needed so that people can once again become connected with one another, engage in shared projects of purpose with others, find economic stability and security, and, thus, regain a future that matters to them. Only with such practices of attuned care will the United States finally begin to address the precarity, anxiety, and loneliness that truly lies at the heart of the opioid crisis.
Jarrett Zigon is the author of A War on People: Drug User Politics and a New Ethics of Community.