Fighting for Space

  While ruts have formed along dopamine pathways, causing the brain to prioritize short-term gains, habitual drug use has simultaneously alerted the prefrontal cortex to degrade the strength of inhibition; what makes us think twice about performing an action that’s risky or that we expect to have a negative outcome.

  Lewis describes the bottom line like this: “Drug use is always a choice, to begin with. An addiction is less of a choice.

  “The pure disease-model advocates will say that addicts lose the capacity for choice entirely,” he continues. “I don’t believe that. I think the choice becomes more difficult. The choice becomes greatly modified by habit, by perspective, and by association and needs and by all kinds of other factors. It is anything but free.”

  Lewis struggled with addiction himself, spending years on morphine and then heroin. He remained a functional addict, and his book focuses on people like him: middle-class professionals and university students who struggled with very real addictions but who did not fall all the way into a life on the street. He admits he was shocked by what he saw in the Downtown Eastside.

  He listened to support workers at Portland’s Stanley Hotel relate their tenants’ stories of trauma and the difficulties they face feeding drug addictions on the streets. The Stanley’s tenants are generally a bit younger than those of PHS’s other supportive-housing sites. Many of them struggle with a mental-health condition and are also addicted to crystal methamphetamine, staff explained.

  “A lot of people think of addiction in terms of a spectrum, and there we were looking at the end five percent,” he says. “I often think of addiction as a choice, to some degree. But at that level of addiction, I saw it as a blight.”

  Lewis emphasizes that his writing and the theories of Bruce Alexander and Dr Gabor Maté about addiction do not stand in opposition. They exist beside one another, overlapping and interacting in complex ways. “All three of us are all pretty interested in environmental precursors and experiential precursors, how the personality is shaped and moulded by experiences, and how that personality is then more or less prone to becoming addicted,” Lewis says.

  He acknowledges that his theory—in its simplest form, a focus on the brain’s adaptation to repetition—does not directly take into account factors affecting a person’s predilection to addiction.

  “There are often problems in childhood that lead to depression and anxiety, and those can lead to experimentation, which can lead to this kind of self-medication,” he says. “And that realization that people can make themselves feel better, that can lead to addiction.”

  To continue with Lewis’s analogy that compares the brain to a flat surface of mud, environmental factors and experiences of childhood trauma affect the consistency of that surface, making some more susceptible to the effects of rainwater and more likely than others to develop ruts.

  “Walking around the streets [of the Downtown Eastside] took me further away from the brain and more out into the social surround,” Lewis says. “Unpredictability in childhood or adolescence can lead, through repetition, to a narrowing pathway that has a much more coherent, articulated shape to it, as people move into adulthood.”

  He acknowledges that in response to his theory of addiction, harm-reduction programs might sound illogical or counter-productive. But Lewis says that is not the case. “You’re not doing someone a favour by casting them into street life instead of helping them to feel less tension, less fear, less threatened,” he explains.

  Lewis emphasizes that those sorts of negative emotions—triggered by a confrontational family intervention, for example, or a run-in with a police officer—do not make an addict less likely to seek drugs. On the contrary, he says, an individual experiencing heightened emotional discomfort will feel a stronger craving for the comfort they find in drugs.

  “If people are going to use anyway, they are going to have that reinforcing activity, and it is probably going to be strengthened and amplified by the trials and tribulations people have to go through just to get drugs, to get what they need, and to survive,” he says.

  Lewis describes harm reduction like this: “It gives them time, gives them a chance, and lets them breathe.”

  Chapter 19

  The Vancouver Agreement

  By 2001, activists had the ear of Vancouver’s mayor, Philip Owen. Dean Wilson in particular had managed to make an impression, establishing a friendship. For a while, he’d somehow even convinced city hall security to let him pass for pop-in visits on the mayor. “It got to the point where they actually sent a memo around city hall saying that I was not to be left alone with him,” Wilson says. “Because they knew I’d get his fucking mind going.”

  It wasn’t always that way.

  Owen was a member of the Non-Partisan Association (NPA), a right-of-centre political party with a voter base consisting of Vancouver’s wealthy and established. He was born and raised in Vancouver’s tony Shaughnessy neighbourhood, where the city’s power players have typically lived in big houses with tall hedges around them. For five years in the 1970s, his father, Walter, served as the Lieutenant Governor of BC, the direct representative of the United Kingdom’s Queen Elizabeth II. They were as establishment as one family could get. They were also about law and order. Walter’s father was a police officer and then the warden of BC’s Oakalla Prison (which closed in 1991).

  Today, Owen, eighty-four-years old, recalls his grandfather taking him and his brother on weekend trips to a farm that was connected to the prison and where the inmates worked the land. “My brother and I would run around freely among the prisoners and the cattle and so on,” he recounts. “My grandfather, he never said to us that these were bad or rotten people. He told my brother and I that these prisoners were people who had done something wrong and who had to pay a price and that is why they were in there. That made an impression on me,” he continues. “These were just people who had broken the law and they had to pay a price to society. But they were all decent people.”

  Owen was elected mayor of Vancouver in 1993. That year, drug-overdose deaths in the city numbered 201, more than doubling the ninety-one deaths recorded the year before. “I realized that I had to find out what was going on in the Downtown Eastside,” Owen says. So he started going for walks.

  In the late evenings, usually around ten or eleven, Owen changed out of the slacks and shiny shoes that he wore at city hall and put on a pair of blue jeans and running shoes. Then he would make the short drive from his office to the Downtown Eastside and go for walks, striking up conversations with the people he met on East Hastings Street. It was often raining, he remembers, and so he would carry an umbrella. With his casual appearance and the umbrella over his head, nobody recognized him as the mayor.

  “I would just start chatting with people and ask them about who they are and where they were from,” Owen says. “One of the first people I spoke to was a girl who was missing a couple of teeth and had her arm in a sling,” he remembers. “I said to her, ‘Do you have a place to sleep? A place to stay? Do you have contact with your family? Where are you from? How long have you been here? What are you taking?’ And you’d hear these stories …” He trails off.

  Owen invited this group of people to casual meetings he convened in different restaurants along Hastings Street. The group nicknamed them “tea parties.”

  “These women would have a pimp on one side of them and a drug dealer on the other—and they were being killed by those guys,” Owen says. “It became apparent to me that this was painful and as the mayor of the city, I saw that we had to do something about that. It didn’t take me long to come to the conclusion that the dealer was evil, and for them we had the criminal justice system. And that the user was sick, and for them we had the health-care system.”

  Bud Osborn’s old friend, Donald MacPherson, remembers that Owen was still far from a convert to the cause of harm reduction. But he saw addiction as something that was complicated, and he saw drug use as an act that shouldn’t simply be treat
ed as a crime. MacPherson was director of the Carnegie Community Centre during this time, and he recalls that Osborn would drop by his office there and the two of them would brainstorm over how they might get the mayor’s attention.

  “Bud even went to his church,” MacPherson says with a laugh. “Philip went to church every Sunday morning. So Bud went to his church and ended up talking to him one Sunday.”

  Around the same time, MacPherson resigned from his leadership role at Carnegie. After many years working on the corner of Main and Hastings, he felt burned out. The city liked MacPherson and wanted to keep him around, and so it offered him a deal.

  “I said I would work for them again but only on one issue, and that was the drug issue,” MacPherson says. “So my boss [at the city’s social-planning department] said, ‘You take your six months and then come back and we’ll see what we can do.’”

  In 1998, MacPherson had attended the Portland’s harm-reduction conference in Oppenheimer Park. He describes the Out of Harm’s Way conference as a “watershed” experience. Then, in the spring of 1999, the International Harm Reduction Conference was in Geneva, Switzerland, and “I decided I had to go,” he says. “I went there and I had this epiphany.”

  In Europe, MacPherson met with politicians, police departments, and health-care providers. He visited harm-reduction programs including various forms of supervised-injection sites that by 1999 had operated for several years. When he returned to Vancouver, MacPherson was a convert.

  The report that he produced based on that trip recounts how, a decade earlier, Geneva and Frankfurt had struggled with drug problems very similar to the challenges Vancouver was struggling with in the late 1990s. They had responded with police actions that targeted neighbourhoods where open-air drug markets were known to operate, but also with expansions of health-care services that were consciously low-barrier. Both countries reduced prescription requirements for methadone, for example. They also made significant investments in health care, implementing programs that facilitated access to treatment and other social services in areas where drug users were known to congregate.

  Key to both strategies, MacPherson noted, was the establishment of supervised-injection facilities. His report explains how these sites operated, not only as places where addicts could use drugs with clean supplies and under the care of nurses, but also as service hubs that connected people with counsellors, housing, and employment assistance.

  “The Swiss and German approaches to substance misuse are based on a four fold approach which includes: Prevention, Treatment, Harm Reduction and Enforcement,” it reads.

  “In response to increasing health risks of drug use and to public pressure to close down the open drug scene, the Swiss instituted a broad harm reduction approach that resulted in the development of a range of low threshold services or services that were easy for drug users to access. The aim of these services was to bring drug users in contact with the system of care as much as possible and to intervene earlier in their drug use.”42

  Statistics included in the report that were provided by the Frankfurt police department’s drug squad show that between 1991 and 1997, when the city’s harm-reduction program was implemented, auto thefts declined by thirty-six percent, apartment break-ins by thirteen percent, and assaults by nineteen percent. In addition, police recorded a thirty-nine-percent drop in police-registered first-time consumers of hard drugs.

  “There was a significant decrease in the drug activity in the inner city,” the report states. “As the users moved into services, primarily the safe injection rooms, shelters and drop-in centres, police were more easily able to separate the addicted dealers (dealers who sell in order by buy drugs) and the non-addicted dealers.”

  MacPherson was now on a mission. “I was curious and interested before that, but then I became a total crusader,” he says. “So I went to the city with one goal: to find a politician who would move this issue … But I didn’t think it was going to be the mayor.”

  MacPherson recalls the extent to which he was pitching ideas from outside the box of accepted public policy norms of the day. Upon his return from Europe, he sat down with his immediate superior, Vancouver’s general manager of community services. In a small conference room at city hall, he took her through his report, excitedly jotting down bullet points on a whiteboard that was mounted on the wall there.

  On the whiteboard, MacPherson drew a large pyramid. Copying from a policy document that was shared with him by the Swiss, he described the top of the pyramid as “high threshold services” that only reached fifteen percent of people addicted to drugs—expensive rehab facilities, for example. The middle of the pyramid consisted of “medium threshold services” such as methadone, which reached another fifty percent of users. The bottom of the pyramid is where the bulk of the Swiss government’s harm-reduction programs fit—needle exchange, low-barrier drop-in centres, street outreach, and supervised-injection facilities. They were the services that connected with the remaining forty-five percent of drug users that had previously had little or no interaction with the system.

  “I was explaining the Swiss approach and drew it up on a whiteboard,” MacPherson says. “And when we left the meeting, I said to my boss, ‘You’re going to leave that up there?’ It was like it had to be kept a secret, like we couldn’t even be talking about this stuff. It was really radical.”

  They did leave the pyramid up on the whiteboard. MacPherson’s boss was sold, and agreed that his report should go straight to the mayor. “So then I gave him this report, and he loved it,” MacPherson says. “Now he had an epiphany.”

  The next day, Owen was at a conference attended by mayors from cities across the region. In a room full of BC’s most powerful politicians, he literally went down on his hands and knees, risking the fabric of an expensive suit, took a piece of large flipchart paper, and sketched out the Swiss triangle of addiction services. MacPherson recalls how the mayor’s assistant could barely believe what she saw that day.

  “So we had a plan,” MacPherson says. “It became a tangible, concrete thing that the mayor’s coalition could promote.”

  Philip Owen was coming around to the idea of harm reduction, but he wasn’t convinced overnight. Meanwhile a pair of politicians named Jenny Kwan and Dr Hedy Fry began to cultivate the simpler idea of addiction as a health-care issue.

  The three were an unusual group: at the municipal level, Owen belonged to the conservative Non-Partisan Association; representing the province, Kwan was from the left-leaning NDP and had previously been a city councillor with the even more left Coalition of Progressive Electors, the NPA’s opponent; and from the federal level, there was Fry, whose Liberal Party of Canada is politically centrist but didn’t have a lot in common with either of the other two parties. Three politicians from three different parties representing three levels of government; they called themselves the Vancouver Caucus.

  The Downtown Eastside had gained national and then international attention as a place best known for crime and disease, and that had begun to get to Owen. He brought the Vancouver Caucus together to see what they could do about it.

  Fry remembers that the first task was to just get Owen and Kwan to speak to one another. “There was no love lost there,” she says. “I thought that being a physician was an apt role for me, because I had to be a marriage counsellor and get them to talk to each other.”

  Kwan’s provincial riding included the Downtown Eastside, and she says that Bud Osborn and Liz Evans had convinced her of the merits of harm reduction in the early 1990s, long before most of Vancouver even knew what it was. Back then, Owen was still very skeptical, Kwan says.

  It took more than a year of informal “caucus” meetings at city hall, but the three of them finally put something together. In March 2000, they signed the Vancouver Agreement. “We agreed that you had to have this comprehensive way of looking at addiction,” Fry says. “We agreed that substance misuse was a public health issue and not a criminal issue. But we also
felt, in order to keep law and order in the streets, that we needed to make sure that the police were still involved.” The Vancouver Agreement made addiction a health-care issue for BC and was crucial in laying the groundwork for the city’s next policy move on harm reduction.

  On September 12, 2000, dozens of drug users from the Downtown Eastside forced their way into Vancouver city hall and made a case for health-care services before Mayor Philip Owen (right).

  Photo: Elaine Brière

  While Kwan and Fry were meeting with the mayor, MacPherson had continued to pester him with ideas he’d picked up from Europe. Frankfurt had a drug-policy coordinator, MacPherson told Owen, an office at the municipal level that coordinated all things related to illegal narcotics. He recommended that he occupy the same position with the City of Vancouver. Owen gave it to him.

  Along with his new title, MacPherson was given a task: come up with a drug strategy, an entirely new one unlike anything in North America. It was to be a master plan for how Vancouver should respond to the illicit narcotics trade and drug addiction as a health issue—no longer a problem solely left to police.

  But why reinvent the wheel? “I went away for two minutes and then came back and said, ‘Why don’t we just take the Swiss program?’” The Swiss plan was far more progressive than anything that had been tried in North America and, in MacPherson’s mind, was just about perfect. They called it A Framework for Action: A Four-Pillar Approach to the Drug Problems in Vancouver.

  The police were still going to be very much involved—the “enforcement” pillar in MacPherson’s strategy—but now they would officially be deployed alongside three other approaches to illicit drugs. Going forward, the city would give equal emphasis to prevention, treatment, and harm reduction. MacPherson defined his key pillar like this: “Harm Reduction is a pragmatic approach that focuses on decreasing the negative consequences of drug use for communities and individuals. It recognizes that abstinence-based approaches are limited in dealing with a street-entrenched open drug scene and that the protection of communities and individuals is the primary goal of programs to tackle substance misuse.”