Shifting focus…

Exploring and discussing the demographics and causes of addiction in Vancouver’s DTES has shown me how diverse and far reaching this social issue is- not only in Vancouver but in other communities as well. The insight I have gained from research and discussion has been valuable in formulating an informed opinion regarding this contentious issue. It has made me consider addiction in a different way and approach formulating solutions with more infomative input.

I believe substance abuse and drug addiction remains one of the largest social issues facing Vancouver; and as such must be approached with an open mind and a willingness to identify and address its core issues as well as its residual issues- homelessness, poverty, and mental illness. Substance abuse and addiction damages individuals and communities and it requires thoughtful debate on solutions.

In line with the objectives of this blog and goals of SFU Business Social Innovation seminar, I will be shifting my efforts and focus to addressing addiction. Specifically, myself along with my colleagues will be thinking about, discussing, and proposing novel solutions for this prevalent social issue. Our group will be approaching those already at work on dealing with this issue to evaluate what has worked and what has not. We hope to take from this some aspects that will help us achieve our objectives and propose meaningful solutions.

My colleagues and I will be shifting focus to develop novel ideas and I invite you to leave your comments and feedback on our proposals for addiction solutions at our collaborative blog here.

Man’s Best Friend

According to the disease and adaptive models of addiction, substance abuse has been linked to, among others, feelings of hopelessness and isolation. Addicts often continue their use of drugs to avoid such feelings contributing to a lessening of responsibility for their lives and an
increased dependency. It has also been found that addicts are discouraged from beginning or completing treatment due to fears of personal failure.

To focus on this specific issue, a non-profit organization may be introduced which provides individuals undergoing treatment responsibility of regular care for a small animal. Combining treatment programs with a delegation of responsibility, such as caring for a pet, may be a means of inspiring feelings of personal accomplishment and success in making a positive difference. Through guidance these can help build confidence in the participant to then transform this to make positive changes in their own lives. This confidence and accomplishment may be used as a catalyst for succeeding in treatment and overcoming the addiction.

This specific non-profit would benefit from aligning with the BCSPCA or other animal care and shelter groups in the greater Vancouver area to bring in participants on a regular basis. The organization would be quite small and require minimal funding. There would likely be only a few paid employees responsible for the core responsibilities and a volunteer base.

Following the successes and progress of participants in their treatment programs would assess the transformative potential of this venture. This is clearly not a solution for solving addiction on large scale, however, it may be useful in transforming the confidence and personal outlook of a concentrated number of addicts in the DTES. If participants are selected based on the most need for this type of program (such as individuals who have not seen success in treatments prior), then this program may prove to have a substantial impact in their lives regarding their addictions.

This type of non-profit program is fairly limited in its scale for addressing such a large issue, but may have the potential to inspire changes in a small number of participants. Measures would also need to be in place to ensure that this program would not have ultimately negative impacts on the animals that are involved and this would depend on the discretion of the animal group partners.

Center for Addiction and Health Services (CAHS)

The DTES has a high concentration of substance abusers that often are victims of other social circumstances that affect the area. Some of the other social issues in the DTES- homelessness, poverty, and mental illness- play a role in sustaining and aggravating drug addiction. The presence of these other factors likely increase pressure on substance abusers and intensify the difficulty in addiction treatment and overcoming addiction.

A these social issues may be addressed by a multi-purpose facility that tackles a number of these issues at once- providing proper shelter, adequate nutrition and health services, addiction treatment, and mental health counseling.  The overall objective would be to provide a place for substance abusers in the DTES to live for an extended period of time with the necessities they are not obtaining adequately in the DTES. This includes a comprehensive program to provide the necessary means and support for dealing with their addictions. It would be located in an area outside the DTES itself in order to remove participants from the circumstances they are used to and provide them with a refreshing and novel environment to inspire life changes.

The facility would be run by a government agency in order to provide it with the necessary long-term intensive support and funding. This is also a means for ensuring the goals and objectives to make transformative changes in individual lives and the community is maintained, as a social enterprise or for profit business may stray from these.

The transformative potential will be measured by the impact that is catalyzed by the changes inspired in the lives of participants and more long-term transformations in the community itself. This is obviously a very large and intensive undertaking requiring long term commitments, however, radical transformations may be realized for the community in the future by first addressing the individual needs and separate social issues in the DTES.

As this is a large undertaking limitations to its impact must be considered.  Building and organizing a facility like this is time consuming not to mention the coordination needed among levels of government. This also requires a long term, intensive commitment in support and funding to be successful and catalyze transformations in the community. This will contribute to its initially low impact. It may also be difficult to demonstrate to substance abusers in the DTES the benefits of leaving their community for a facility like this, which may make reaching those of greatest need challenging.

the buddy system

Studies of various treatment programs for drug addicts and substance abusers indicate a high percentage of participants either do not complete the treatment, or worse, will complete the treatment and revert back to substance abuse soon after. This has often been linked to the environment the participants find themselves in during treatment and following its completion. Substance abusers are likely to be surrounded by an environment of other abusers and drugs, which is thought to perpetuate the addiction itself, make it more difficult to be successful in treatment, and can revert the patient back to drug use after successful treatment.

To address this specific issue, a pool of non-addict “buddies” can be utilized to provide a support network for addicts undergoing treatment or who have recently completed treatment. These buddies will be trained volunteers to provide addicts with a relationship structure other than the addictive environment they may be used to or find themselves in during or post treatment. The organization will operate a center in the DTES to provide a location where participants can meet with their specific buddy or meet with other buddies in an open drop in format. The goal is to provide an open, accepting, and supportive environment where patients can find a friendship network that counters their often-addictive environment.

Organized as a non-profit, it will be responsible for recruiting, adequately training, and matching volunteers to perform this role. This organization will be partnered with the bodies in the DTES that provide the various addiction treatment programs and networks, such as Vancouver Coastal Health, in order to properly match patients with buddies. Paid staff at this non-profit will include the management and executive who will be responsible for overall organization, volunteer recruitment, marketing, and sequestering funding.

Assessing the transformative potential will rely on information from the partners administering treatment to indicate the number of patients both maintaining their treatment and remaining drug free after treatment, as well as input from volunteers and participants. The success of this organization will depend upon the active participation of addicts in treatment programs. This non-profit is limited in the fact that we are not proving addiction treatment or an alternative to treatment. This is meant to provide a complement and support to a viable addiction treatment program offered by a qualified body. This limits this organization from providing fundamental change on its own, and increases its dependence on its partners, volunteers, supporters and funders.

The transformative goal is to change the way patients think about their ability to succeed in and after treatment programs, and empower them to change their own lives by providing them with supportive relationships.

NAOMI and Campbell

Vancouver continues to provide an outlet for experimenting with drug treatments and provides an outlet for attempting understand and address the complex issue of addiction. The DTES population has participated in large scale addiction treatment studies, such as the North American Opiate Medication Initiative (NAOMI) supported by the federal and municipal governments, including then Vancouver Mayor Larry Campbell.

NAOMI is a 2005-2008 clinical study that examined whether heroin-assisted therapy benefits people suffering from chronic opiate addictions who have not been successful with other treatments, such as methadone and abstinence programs. It is funded by the Canadian Institutes of Health Research and approved by Health Canada with participants enrolled participants in Vancouver and Montreal as these cities have the highest heroin addicted populations in the country. The treatment in the study involves treating heroin addicts with either heroin in a controlled fashion or methadone treatment followed by a transition phase where the participants are transferred to other treatment programs, including drug free and detox programs.

Results of the treatment program indicate that the heroin therapy “keeps patients in treatment, improves their health and reduces illegal activity” and that the program is particularly effective at attracting and retaining the most difficult-to-reach and the hardest-to-treat individuals that saw no success in existing treatments. It was shown to decrease heroin usage by about 70 percent, involvement in illegal activity fell by almost half, and participants overall medical status increased 27 percent.

This is another example of experimental addiction treatments that show considerable success and benefits for addicts over traditional enforcement programs. As this was only a small, concentrated study the overall impact and scale was low. However, the study did focus on helping those in greatest need who found no success in other treatments and the findings of the study present some interesting findings that may provide useful in implementing future novel solutions and treatment to addiction.  Sustainability of these types of programs will be greatly increased by combining them with a facilitated access to other health and addiction services to aid in overcoming the addiction.

The findings also present a novel treatment alternative that has transformational ability- altering how addicts behave and live their lives. This is  shown by the results of decreased involvement in illegal activity, decreased expenditure and usage of heroin, and an increase in overall health. Observing the success of experimental treatments such as this in the DTES can only help in building a novel solution to addiction that faces the community.

The pinnacle of experimental addiction research

With the DTES comprising such a large concentration of substance abuse and injection drug users, its no wonder its home to addiction treatment considered novel and experimental. The most well known is Insite- the legal safe injection site operated by Vancouver Coastal Health and openly supported by the City of Vancouver, the Vancouver Police Department, and other community bodies and professionals in the field of addiction.

Insite is a North America’s first legal safe injection site where  people can go to inject their own drugs and connect to addiction, health care and community services. For many injection drug users, Insite is the first step to recovery by reaching out to a hard to reach, marginalized population. It currently operates under a constitutional exception to the Controlled Drug and Substances Act; the BC Supreme Court ruled in May that the federal government does not have the authority to shut down Insite and gave the government until a year to amend the country’s drug laws to allow for medical use of drugs if tied to a health care initiative. The federal government is currently appealing that decision.

Research has shown that Insite is effective in preventing the loss of life from overdoses, decreasing needle sharing and other risky behaviors amongst local intravenous drug users, increasing the access and uptake of addiction treatment and decreasing public injection and injection-related disorder. A May 2008 poll found that of over 200 overdose annually there were no fatalities and that Insite users were twice as likely to engage in addiction and health services than non-Insite users. According to the BC Center for Excellence in HIV/AIDS, the body that conducts independent research on Insite to examine its impact, they found among other things:

• Insite is leading to increased uptake into detoxification programs and addiction treatment. (New England Journal of Medicine)
• Insite has not led to an increase in drug-related crime, rates of arrest for drug trafficking, assaults and robbery were similar after the facility’s opening and rates of vehicle break-ins/theft declined significantly. (Substance Abuse Treatment, Prevention, and Policy)
• Insite has reduced the number of people injecting in public and the amount of injection-related litter in the Downtown Eastside. (Canadian Medical Association Journal)
• Insite is attracting the highest-risk users – those more likely to be vulnerable to HIV infection and overdose, and who were contributing to problems of public drug use and unsafe syringe disposal. (American Journal of Preventive Medicine)

The effectiveness and relevance of Vancouver’s Insite safe injection site is a much debated topic. The evidence presented in favor of the safe injection site is heavily focused on getting addicts and drug related materials off the streets, decreasing overdose deaths and injection associated disease spread, improving users’ overall health, and providing an outlet for the most hard to reach to access help and treatment services- the pinnacle of harm reduction. Although controversial and experimental, Insite is a radical transformational approach to addiction by actively changing the community and the way addicts think about their lives and addictions, and how they live. Insite seeks to transform the lives of a marginalized population in a stepwise manner- first by improving their health conditions then facilitating access to help and treatment followed by integration into the array of programs Vancouver Coastal Health (VCH) operates such as societal reintegration.

The integration of Insite with VCH and its comprehensive services as well as the community support for the safe injection site (Police, City Hall, professionals, etc) contribute to its overall impact and effectiveness at addressing addiction in the DTES. This integration with a host of other addiction services also creates a sustainable solution by providing a long term means of supporting and maintaining the change.  Insite’s success and benefits as an experimental approach to addiction also greatly increase its impact around the world to other areas with addiction. Its scale is effective as Instie’s programs reach those most affected and of the greatest need.

This novel approach to addiction and its residual effects in the DTES appears to be making strides into treatment of drug addiction. These types of experimental treatments for addiction are what is needed over traditional enforcement methods- a view that is increasing in research support.

Socially Inclusive Development

There is no disagreement that Vancouver’s DTES neighborhood is comprised of a high concentration of low-income families and individuals, homeless people, and drug addicts. There is little social diversity in the residents that call the area home and in this fact some envision a solution to addressing the issues plaguing this neighborhood. 

Gregory Henriquez is an well known Vancouver architect known for the design of several community-based mixed-use, institutional and social housing projects in the DTES. He has stated that for architecture to be meaningful it must be a “poetic expression of social justice”. He has also stated that drug addiction is one of the issues at the root of the neighborhood’s problems and that gentrification must be avoided with the communities most disadvantaged being taken care of first. Henriquez is the managing partner of Henriquez Partners Architects and is behind the the socially inclusive Woodward’s Redevelopment- the largest mixed-use project in the history of Vancouver.

In 2003, the City of Vancouver purchased the original Woodward’s site from the province for $5 million, and began a public consultation process to ask the community what they wanted from the redevelopment. What would come of those consultations is what is being developed today- a mixed-income, socially inclusive community development.  The 400 million dollar project, includes 536 market housing units, 125 singles non-market housing units to be operated by Portland Hotel Society Community Services, 75 family non-market housing units to be operated by Affordable Housing Society, and an array of service and stores including a new addition to Simon Fraser University’s Downtown campus. The oldest part of the complex (built 1903–1908) will be restored, and will serve as non-profit office and community space.

While Woodward’s project does little to directly treat drug addiction, I feel it is worth mentioning the idea presented regarding the power an inclusive community may have on a struggling neighborhood. It has been suggested that addiction in the DTES is aggravated by the other social problems in the area- homelessness, social dependency, and poverty. The DTES has been somewhat isolated for some time in terms of a broad socio-economic mix of residents and a development such as Woodwards may help to bring about some needed change to the area. 

By encouraging an inclusive community through projects like this, the potential impact on the community is large. This can bring array of people together and create fundamental change in the way people think, behave, and interact. This type of change not only affect residents of the DTES and the new residents who may come to live in these inclusive communities, but also citizens across Vancouver can alter their negative outlook on the DTES which is so often the norm. In this way, socially inclusive communities have the potential to have very large impact on a very large scale, reaching out to the city as a whole and setting an example for other cities.

Although this solution’s trans-formative potential has yet to be seen, it has the potential to change many people’s ways of thinking and behavior in a fundamental way. The community itself is also designed in a sustainable and long lasting fashion incorporating groups and people from all facets of society; varying socio-economic circumstances, businesses, non-profits, social causes, universities, art, and community space. This type of collaboration and inclusiveness brings together different ways of thinking about social issues in the area, and this is the true novel solution.

Woodwards is an architectural marvel and a community inclusive solution to the problems in the DTES including addiction as well as its aggravating factors of homelessness, social dependency, and poverty. The idea is a novel solution to a long history of problems pursuing social change and innovation by changing the way people perceive the area in terms of its livability, safety, community, and inclusiveness.

A failed approach?

The National Anti-Drug Strategy is the government of Canada’s approach to deliver on decreasing the supply of and demand for illicit drugs, as well as addressing the crime associated with them. The overall goal is to bring about safer, healthier communities through three umbrella categories: prevention, treatment, and enforcement. Vancouver’s DTC was implemented from 2001-2005. 

To deliver on these initiatives, Health Canada in partnership with the Department of Justice, Ministry of Public Safety, and regional health bodies operated Drug Treatment Courts (DTCs). Dubbed by the government as a “problem-solving approach”, these “aim to reduce crime committed as a result of drug dependency through court-monitored treatment and community service support for offenders with drug addictions” as well as to reduce the “burden of substance abuse on the Canadian economy estimated at $9 billion annually for areas including law enforcement, prosecution and incarceration”. 

Patients in the DTCs attended both individual and group counseling sessions, received appropriate medical treatment, and were subject to random drug tests. They were requireed to also appear regularly in court, where a judge reviewed their progress. Under the sole discretion of the judge they could then either impose sanctions (anything from verbal reprimands to expulsion from the program) or provide rewards (ranging from verbal commendations to a reduction in court appearances).

When a patient was deemed to have gained enough social stability and demonstrate control over the addiction, criminal charges were either stayed (meaning a judgement is suspended or postponed) or the offender received a non-custodial sentence (meaning restrictions other than jail, including house arrest). If unsuccessful, an offender would be sentenced as part of the regular court process for whatever crime they had committed. Although DTC are no longer operational in Vancouver, examining the program may shed some light on future initiatives in dealing with addiction.

According to assessments done by the bodies running the DTCs:

• Participants failed to show up for over half the group sessions and over one third of the individual sessions.
• Only 14% of participants completed the program; the remainder (65%) withdrew voluntarily, were discharged by the crown and did not continue, or were asked to leave (20%).
• Half (52%) of all DTCV participants had new charges and about 24% had new convictions within 6 months after their participation in the program ended.
• Almost all (88%) participants tested positive for heroin, cocaine or other drugs within 6 months of exiting the program.

This approach to addressing addiction through DTCs appears to combine efforts for both treatment and enforcement. At the outset, the main goals of the DTC program are to reduce crime associated with addiction and drugs and reduce the ‘burden’ on the economy stemming from law enforcement, prosecution, and incarceration. If an addiction treatment program’s main goal is to reduce a financial burden on the economy, its overall impact and effectiveness on actual treatment is likely to suffer. The lack of treatment focus and concentration on enforcement is also visible in the fact that this program is a joint effort between health bodies and the justice and public safety departments. 

DTC programs are only targeting adults charged with offenses motivated by their drug addiction resulting in a highly selective and concentrated program. This contributes to a decreased impact on drug addiction overall and seeks to address the problem of addiction on a small scale. It is unable to reach others who require addiction treatment as well but may not have broken the law specifically. Mandatory regular court appearances where a judicial official decides on an addicts progress in treatment is somewhat contradictory- is a judicial official capable of adequately assessing the progress of an addict through a treatment program or that the patient has ‘demonstrated control over the addiction’ as they put it?

Offering incentives for curbing their addiction and threatening punishment for failing to do so seems to be an ineffective way to address the issue of addiction. Whether they overcome their addiction or not the offender is still in the hands of the justice system, and verbal commendations or verbal reprimands will do little to fundamentally change the way the addicts live their lives. DTCs therefore are lacking in transformational thinking and relying more on traditional enforcement and punishment methods of addressing addiction.

The key findings reinforce the ineffectiveness and poor design of the DTC program. The DTCs treatment for addicts, or lack thereof, is offered in an overwhelmingly forceful way, with poorly set goals and a lack of focus on treating the addiction contributing to its overall ineffectiveness.

Vancouver Coastal Health Comprehensive Approach

Vancouver Coastal Health (VCH) provides a wide array of addiction services in addition to the safe injection site that cumulatively requires over $113.5 million with more than 80 percent going towards the treatment category. The VCH’s addiction services comprise three main categories:

1. Prevention- programs aimed at preventing the initial stages of drug use and delaying or reducing abuse of drugs and alcohol for both youth and adults. These are school based programs for youth and intervention programs targeting at risk members of society. 

2. Harm Reduction- This includes both needle exchange and recovery as well as Insite safe injection facility. Needle exchange and recovery is coordinated with more than 35 groups across the city to as well as outdoor needle disposal boxes and regular needle sweeps in high use neighbourhoods. Insite is the first legalized safe injection site in North America where users can safely inject drugs and connect with health and addiction services. 

3. Treatment- An array of treatment services are offered by VCH which can be easily accessed through a toll free service. Withdrawal Management Services are medically managed detox programs that address sever and harmful withdrawal symptoms providing a safe, supportive environment for overcoming the addiction. There is also a home detox program with daily visits from physicians and 24 hour telephone support. Residential Treatment provides safe and structured living arrangements in substance free environments in a short term setting aimed at facilitating reintegration into the community. Supported Recovery comprises licensed facilities that provide safe, drug free structured living for up to 90 days which promotes lasting changes in behavior and social functioning. Community Based Treatments are health centers that provide counseling, response teams, methadone management and addiction support. 

With over 80 percent of its operating budget invested in treatment options, the focus for VCH is overwhelmingly on those that are already addicted and trying to treat and curb the addiction. This is effective in a region like Vancouver due to its large population of drug users. The wide range of treatment options and programs addresses the evidence that not all addicts respond successfully to the same treatment, which is particularly effective in this case due to the varying stages of addiction and specific needs of addicts. VCH’s treatment options are also effective as they provide substance free environments that acts to combat the trend of relapse associated with treatment patients who find themselves in a drug filled environment.

VCH’s treatment programs and other addiction services are transformational as they aim to change the fundamental behaviors and attitudes of addicts. The comprehensive services aim to address all stages of addiction and specific needs of addicts. Through guided processes and professional help the goal is to alter the way addicts live and behave. The role of individual transformation of the addicts is fundamental to success- through empowering them to make positive choices and change their everyday experiences they can transform their lives. 

VCH’s services have a large impact on those that take part in them as well as the community as a whole. Through transforming addicts lives the community can be changed as well in a systematic way. However, many of the programs offered by VCH require the patient to reach out and seek the help though phone access or otherwise. This may present a scalability issue for such services as addicts may be unlikely to take the first step resulting in such services not reaching those with the greatest need for them.

VCH provides varying levels of services for all stages of addicts- from those at risk of drug use to heavy drug users to individuals who take part in services and undergo supported reintegration. By providing assistance at every step VCH’s approach to addiction in Vancouver is a sustainable solution to addressing a problem that is so prevalent in our community.

This is your government on Drugs

Despite the fact that harm reduction has both shown to address the residual harms associated with addiction and proved its effectiveness in practice, the federal government continues to remain faithful to our criminal justice system and enforcement for dealing with drugs and addiction. Their actions often go beyond just relying on the traditional mode of enforcement- they openly oppose programs and initiatives that may be considered as part of the harm reduction scheme. 

Insite, the first legal supervised safe injection site in North America, operated under a special constitutional exception up until the exception was set to expire in 2008. The federal government took this chance to advocate its negative effects and announce plans to shut it down, despite outcry from professionals and researchers about its beneficial effects for addicts and the community as a whole. Insite only operates today due to a decision of the BC Supreme Court to exempt the facility from ceasing its operation and a mandate to the federal government to revise their approach. 

Taking a more direct approach to changing voters attitudes about harm reduction and Insite, in 2008 the Conservative federal government circulated a publication in every riding across Canada referring to addicts as “junkies” who “don’t belong near children and families” and promising to clean up drug crime. The prime minister’s office openly supported the campaign including its enforcement and anti-harm reduction tone. The PMO’s director of communications at the time offered further support saying, “We think drug dealers should be behind bars and addicts should be in rehab. That’s our approach”

Following the decree of closure for Insite and the distribution of materials to constituents, the government issued a press release and funding announcement including what they call ‘critical treatment initiatives’ under the National Anti-Drug Strategy . Interestingly, the current federal government strategy comprises three main pillars: prevention, treatment, and enforcement. There is no mention of harm-reduction whatsoever despite its growing support among professionals in addiction and medicine and evidence of its success. 

This announcement included a significant investment with, interestingly, a large proportion going to treatment. However, when this is added to the total investment amounts already in place enforcement receives about 70 per cent of the total funding with only 17 per cent going to treatment.

The actions and words of the federal government suggest they are openly against harm-reduction initiatives for dealing with addiction. It would seem that the current government drug strategy is perhaps outdated and in need of refreshening. Drug enforcement is the tradition; it has been the norm in dealing with drugs for a long time. Perhaps the fact that addiction and drugs are still rampant suggests a new outlook and approach is needed from the side of public policy and government.