A pillar of the community

The City of Vancouver, Vancouver Coastal Health, and the Vancouver Police Department currently approach drug policy following Vancouver’s Four Pillars Drug Strategy defined as ’a coordinated, comprehensive approach that balances public order and public health in order to create a safer, healthier community’.

This not only includes policy makers and drug enforcement agencies, but the Four Pillars Coalition; a consortium including government, businesses, non-profit organizations, and advocacy groups to engage and collaborate in addressing the drug problem and related crime in this city. No one group is responsible for the strategy’s implementation as it is a cooperative strategy and each partner applies their efforts within their areas of responsibility.

PREVENTION: refers to strategies that aim to prevent the use of all addictive substances, including alcohol and tobacco as well as illegal and prescription drugs. This pillar of the strategy aims to achieve specific goals including reducing harm from substance abuse for all areas of the community, delaying first substance use, reduced rate of new cases and number of current cases of substance dependence, and improved health, safety, and order. To achieve these programs including public education, training and jobs, transition housing, accessible health care, and prevention efforts tailored specifically to Vancouver’s youth. 

TREATMENT: includes interventions and support programs that target individuals with addiction problems to make healthier choices in their lives. The overall goal is to improve health by decreasing preventable deaths, disease, and injuries, and improving social integration. Also focuses on tailored treatment to individual needs as well as treatment targeting specific populations. 

ENFORCEMENT: The VPD plays the greatest role in this particular pillar of the strategy, although, the organization has openly endorsed the Four Pillars Strategy overall. This pillar focuses on the need for peace, order, and safety. The VPD’s drug policy outlines a mission to reduce crime, fear of crime, and street disorder while protecting the vulnerable and preserving and protecting life.

HARM REDUCTION: The overall goal of the Four Pillars Strategy is harm reduction, which centers on the need to minimize harm to those suffering from substance addiction and focuses on the harm caused by problematic substance use, rather than substance use specifically. This is done by setting a strata of achievable goals that when met create incremental gains that lead to a healthier life for users and a healthier community overall. Vancouver’s harm reduction programs include the supervised injection site (SIS), needle exchanges and low-threshold community health services.

With the cooperative implementation of the Four Pillars Drug Strategy and the collaboration of the partners involved, the City of Vancouver, VPD, and Coastal Health all support and encourage a harm reduction model of approaching substance abuse. The strategy itself does include elements not directly associated with harm reduction, such as drug enforcement, which do garner resources. However, the focus is not on this pillar. Resources and focus are placed in the other three pillars as well as an open attitude towards experimental treatment, innovative approaches, and harm reduction initiatives. 

This is evident in the way the strategy engages all areas of the community including substance users and focuses on the harms to the community as a whole. The harm reduction model is visible through programs such as the safe injection site (Insite) openly supported by all involved in this strategy and other community groups, needle exchange programs, and participation in novel approaches to addiction treatment including the North American Opiate Medication Initiative (NAOMI).

Harm Reduction

Harm reduction is a systematic way of approaching and addressing drug abuse and addiction. It focuses on keeping people safe, minimizing death, disease, and other residual affects from this high risk behavior while openly recognizing that such behavior may continue despite the risks.

This view goes beyond the traditional notion of drug enforcement and the abstinence model for dealing with substance abuse. It centers around the concept that risks associated with drug use not only affect the users but all members of the community through residual affects associated with disease, loss of public space, drug related criminal activity, and decreases in real and perceived public safety. 

The International Harm Reduction Association defines harm reduction as:

Policies and programs which attempt primarily to reduce that adverse health, social, and economic consequences of mood altering substances to individual drug users, their families, and communities, without requiring decrease in drug use.

This approach takes on a neutral view towards drug abuse and the drug user emphasizing the harms from the drug rather than on the drug use itself. It neither encourages or opposes abstaining from drug use and recognizing the active role of the user in harm reduction initiatives.

The overall intention of harm reduction is to reduce the more immediate harms associated with drug use through realistic and practical programs, such as needle exchanges, safe injection sites, and educational outreach programs. Harm reduction is a broad response to substance abuse that complements prevention, treatment, and enforcement. All parties must ask two questions; first, what specifically are the harms associated with different psychoactive drugs, and second, what can be done to reduce the risks of those harms occurring?

According to a publication by the Government of British Columbia aimed at establishing this model in communities across BC, there are six principles of harm reduction which must be encompassed: pragmatism, upholding human rights and dignity of users, focus on harms over addiction itself, maximization of intervention options, priority of immediate goals and incremental gains over time, and active involvement of users. 

Leave this to the professionals.

In light of the approaching Olympic games in Vancouver and its increased focus in the global spotlight, a number of local and national new media have been debating the social problems that exist in the DTES. 

The Globe and Mail brought together a panel of professionals to give their input on innovative solutions to the problems plaguing the DTES. Each an expert in their field, they participated in a panel discussion outlining their respective plans and beliefs about the causes and solutions for this prominent social issue. 

The Democratic Solution 

Jim Green is a former city councillor and co-founder of the Portland Hotel Society, founder of the Downtown Eastside’s controversial safe injection site.

Proposes a ‘women and children solution’ which would provide strength and security to any community. The problem lies in the fact that the community is overwhelmingly single males which makes it difficult to move forward. Green argues that by democratizing the processes in the community and housing mothers and children reintegrating into society is how the DTES is going to move forward. Overall two things need to be done: There needs to be a democratic voice for the people that live here and that voice needs to be a grass-roots voice, and the DTES residents need to be brought out of their continuous state of dependency by offering adequate and effective resources. 

The Architecture Solution

Gregory Henriquez is a Vancouver architect and author of Towards an Ethical Architecture. He designed the Woodward’s building, a mixed-income development in the Downtown Eastside combining residences for wealthy condo dwellers and subsidized social housing units.

Henriquez proposes a solution involving community redevelopment in the area. The first step is to end homelessness and provide all citizens with a safe, affordable home. Following appropriate support structures must be in place to help people who cannot help themselves. The solution involves creating a neighbourhood that combines people of all socio-economic backgrounds in the DTES. However, gentrification must be avoided completely and the most disadvantaged must be taken care of first for it to be meaningful.

The Universal Solution

Aprodicio Laquian is an emeritus professor of human settlement at the University of British Columbia, and author of Beyond Metropolis, a book exploring ways to improve the lives of slum-dwellers in mega-cities such as Mumbai and Manila. He moved to Vancouver from New York in 1991.

Argues that a comprehensive solution is required, drawing on co-ordinated action among residents and supporters of DTES, City of Vancouver, province of B.C. and the federal government. The solution should not only focus on the DTES alone but be integrated with developments in the whole city and the Lower Mainland. An inner-city redevelopment program should be formulated for DTES and include:

(a) A mix of housing that includes high-end condos, medium-priced units and at least 30 per cent of social housing; (b) A heritage conservation program that will renovate and preserve properties that will maintain the cultural features of the community; (c) Employment opportunities in the area focused on the service, entertainment and tourism industries; (d) Upgrading of the physical infrastructure, amenities and urban services in the area; and (e) Repopulating the DTES area with a more balanced mix of residents . . .

The Education Solution

Margo Fryer is the founding director of the UBC Learning Exchange, a storefront education program based in the Downtown Eastside. The exchange sees volunteer UBC students and faculty teach everything from basic computer skills to English-as-a-second language classes.

Fryer takes a more educational approach- using education to reinforce the positive change in the neighborhood. She argues that there not only be focus on individuals and their problems and capacities but also be mindful of the role that relationships in the community play, such as a drug abuser whose friends are all also drug abusers will have a more difficult time overcoming their addiction. There needs to be an active effort to strengthen the ‘social capital’ in the neighbourhood so it is a force for positive change.

Collaborative Ideas

There is no question that addiction in Vancouver’s DTES is a complex and intricate social issue. How to address the problem effectively and properly is an ongoing discussion facing all levels of government, local organizations, and citizens alike. Most people would agree that there is a very complex problem in the DTES involving not only addiction, and more than not would agree that something needs to be done. The consensus on what exactly needs to be done, however, is less clear.

The Globe and Mail recently estimated over $1.4 billion has been spent in the DTES since 2000 based on the cumulative reports from the levels of government and organizations that operate in the area. These funds have been spent on and array of services for its nearly 16,000 residents- $717.5-million spent on health and social services, $348.6-million on housing, $154.5-million on safety and justice, $230-million on economic development and $16.8-million on services that bridged those classifications. However, the publication claims this has overall been spent ineffectively and the DTES is no better off than it was at the outset .

We cannot accurately know what or how the DTES might have been if these funds had not been distributed and spent in the area. The fact that investment of this amount has not ‘fixed’ the problem should only serve as an indication of its complexity, severity, and importance, and not as an encouragement for giving up or abandoning the issue.

With the investments in health and social services, the problem of drug abuse and addiction still  affects nearly 5000 residents of the DTES.  A social issue consuming this much money, affecting this amount of people, and involving an issue that is not only a problem in the DTES but in every community requires attention and thoughtful debate.  Addressing addiction may require brainstorming, thinking in a different way, combining a variety of ideas, and novel solutions. Addiction is important to discuss and concentrate on because it is far reaching, devastating, and often  a perpetuating factor for a host of associated social issues such as homelessness, disease, and mental illness.

treating drugs with drugs.

Insite, North America’s firs legal supervised safe injection site, is the epicenter for experimental addiction treatment in the country. One of its main goals is to asses the impact of supervised injection on the incidence of disease, overdose, and other adverse affects associated with drug use. Insite is currently operated by Vancouver Coastal Health and operates under a constitutional exception to the Controlled Drug and Substances Act.

Evidence and arguments for and against Insite have been presented by residents and professionals alike. Vancouver Coastal Health’s presentation on the role of Insite in the community presents some thought provoking answers and a new alternative to addressing the  issue of addiction.

Is continuing to to allow drug use a form of treatment, or just perpetuating the addiction? Do people who use Insite benefit? Does Insite benefit society? Can Insite itself be considered a social innovation?

the demographics of addiction in the DTES

The Downtown Eastside Demographic Study of Single Room Occupancy (SRO) and Social Housing Tenants, was completed in July 2008 by the City of Vancouver to examine many aspects and demographics of DTES residents. Included in this was the issue of drug use, which provided a look into the reach of drug addiction in the area.

Over half of the respondents, 57 percent said they were drug users including 28 percent who responded they were regular users.

Respondents were asked to identify the type of drugs they use and to estimate the cost of their substance use.  

Of those who responded they were active drug users: 51 percent said they use marijuana, 35 percent said they use crack, 13 percent reported using cocaine, 10 percent reported using heroin, and four percent responded they were crystal methamphetamine users. Some respondents did report that they use more than one drug. 

In terms of the total cost of their habits: the estimated average cost was $30 per day. Eleven percent estimated their drug addiction use to be more than $100 per day. $20 per day was spent by 45 percent of respondents, 34 percent of respondents said they spent $5 to $19 per day on drug use, while 22 percent of respondents spent less than $5 per day.

For respondents who identified as active drug users, over half- 57 percent- said they began their drug use at age 16 or younger and 73 percent reported alcohol abuse beginning at age 16 or younger.

Visions and Models Of Addiction

The causes and roots of addiction are of great interest as addiction affects people from all demographics and areas of life. The reasons and triggers that lead people to resort to substance abuse are diverse, however two main models of addiction have been proposed:

The Disease Model 

Looks at addiction as a set of causal relationships that suggest people follow a logical process whereby they first become susceptible to addiction, addicted, and then self destructive. Their individual susceptibility is attributed to a genetic predisposition and/or psychological damage from childhood. 

When a susceptible individual is then exposed to either drugs or environmental stress, drug addiction or alcoholism is likely to result due to their predisposition. This typically leads to an array of other issues such as self hate, depression, and dependence.

The Adaptive Model

This model also looks at a series of causal relationships for addiction, but beginning with a combination of faulty upbringing, inadequate environmental support, and genetic unfitness such as a disability. These issues, in addition to how the individual understands them, results in failure to achieve some of the basic expectations of society- competence, social integration, acceptance, and self reliance.

The failure to meet integration is a causal problem itself; often resulting in social ostracism, despair, and creation of an urgent need to search out and utilize substitute ways of providing meaning and social support. Various ‘substitute adaptations’ may be considered for this purpose including substance abuse. Drug addictions are ‘adaptive’ because alternatives to it are worse- despair, mental disintegration, and suicide.

A Critical Comparison

• The disease model assumes people who are addicts are sick and that this is causal to their addiction. The adaptive model instead assumes that addicted people are adapting to the situation they have found themselves in given the abilities they possess.
• Drug addiction is seen as causal of an array of associated problems in the disease model, while the adaptive model states that drug addiction is in fact the result of the problems an individual faces.
• The adaptive model takes on a more critical view of the environment the addict may find themselves than the disease model. 
• The disease model hinges on a susceptibility of the addict to becoming a dug abuser based on a predisposition or sickness. Contrastingly, the adaptive model focuses on the idea of ‘search and choice’ where actions are viewed as more deliberate.

Source: Alexander, Bruce K. The Disease and Adaptive Models of Addiction: A Framework Evaluation. 

The consideration of how addiction arises and critical thought of causal factors that these models put forth are essential. The model of addiction that is applied by professional individuals- treatment personnel, law enforcement, and policy makers to name a few- will determine how the problem is addressed, attitudes toward addicts, and the specific design of addiction treatment.

The recognition of addiction models is especially critical to policy makers and treatment personnel. Drug policy and addiction treatment may need to differ considerably depending on whether addicts are viewed as suffering from a disease imparting them a susceptibility for substance abuse, or viewed as failing to properly integrate into society and substituting their need for adaptation with substance abuse.

Empirical evidence does not favor one model over the other. Perhaps this is a reason why there are differing beliefs and attitudes surrounding the causes of addiction, drug policy that emerges, and treatment options that are available for addicts.

Addiction and the DTES : MYTHS

As outlined by Vancouver Costal Health and the Downtown Eastside Demographic Study of Single Room Occupancy (SRO) and Social Housing Tenants .

1. Addiction is self inflicted – addiction is an illness, and nobody chooses to have any illness including addiction.
2. People can stop using drugs if they really want to – it is very difficult for injection drug users to stop using without a great deal of assistance as drug use can alter a person’s neural and cognitive ability.
3. The same treatment works for all injection drug users – people have very different addictions, they respond to treatment differently, and think and behave differently. Bottom line: everyone is unique and different. For treatment to be most effective for an individual it must be tailored to them.
4. Once an individual completes treatment they are cured – returning to substance abuse after treatment is common and most people require support throughout their lives.
5. Relapse of an addict means they are a failure – addiction is an illness as stated before, so relapse is possible and common among users after treatment.
6. The majority of residents of the DTES are chronic drug users or addicts – surveys show that a greater percentage of DTES residents are below the poverty line than drug or substance abusers.
7. Injection drug use is a problem of the DTES and not a prevalent issue in Vancouver or BC – While the DTES does contain just over half the injection drug users in the city of Vancouver the other proportion lives throughout the city. It is not an isolated issue; addictiom affects people from all walks of life in all areas of the city and in communities throughout BC and Canada.
8. Insite does not facilitate treatment for addicts, but only provide a free place to use drugs – research has shown that Insite users are twice as likely to engage in addiction treatment than non-Insite users. This is in addition to the research that supports the claim that Insite decreases the transmission of disease caused by needle sharing and contamination and prevents deaths due to overdose.

Addiction and the DTES : FACTS

ADDICTION: as defined by Vancouver Coastal Health, who operates Insite supervised injection site, “addiction is a chronic, relapsing illness. It is defined as a compulsive physiological and psychological need for a habit-forming substance.”

For the purposes of this blog I will be focusing on the substance abuse of the most prevalent drugs in Vancouver’s DTES: injection drugs including heroine, cocaine, and morphine.

Addiction is not an isolated problem. It is not just a social problem in the DTES area.  Addiction affects people of all ages, ethnicity, cultures, income, and education level and in all types of communities. The concentration of substance abuse in Vancouver’s DTES thrusts it into the spotlight as a high use area and tends to result in a significant amount of coverage and profiling of the DTES.

Addicts are often viewed by others as inadequate or dangerous. These people also have been shown to be discriminated against which perpetuates the cycle of addiction by restricting them from employment, health care, housing, and social assistance that they need. This stigma imparted on addicts also has been shown to make them less likely to seek help or discuss their addiction problems, often further deepening them into substance abuse.

Anticipating overflow.

Today’s Globe and Mail ran an article in its British Columbia section outlining the intentions of the Vancouver Olympic Committee (VANOC) to deal with an influx of young people to the games in 2010. Their goals are to provide a reasonable number of temporary ‘hostel’ type accommodation in order to avoid burdening the existing low income housing and shelters in the city. The organizing committee released a call for hostel proposals Friday. An excerpt from the article, VANOC executive describes:

Donna Wilson, VANOC executive vice-president for people and sustainability, said the hostels will exist as an accommodation safety net to ensure that existing low-income housing and shelters for the homeless are not affected by a Games-time influx of visitors without an arranged place to stay.

Ms. Wilson said VANOC wants to avoid what happened in Salt Lake City during the 2002 Olympics when Games planners, unprepared for hundreds of young people who flocked to the city, wound up housing them in an abandoned mattress factory.

VANOC is seeking an operator or group of operators to be responsible for the temporary accommodation. It will be open from November 15 to March 15 and VANOC is hoping it to be run in a not for profit manner- with VANOC tossing in a $250,000 to help with upgrades. The idea is that operators of existing shelters for the homeless will refer those looking for accommodation during the games to one of the temporary Olympic hostels.

I think we can all agree that there will be a large influx of visitors to the city over the games. VANOC has come under criticism by organizations in the DTES for affecting their neighborhood adversely and not living up to commitments made in the 2010 Bid Book. This proposal for temporary hostel units over the games in the hope of not burdening the already stretched shelter situation in the city has not been openly toted as an act of ‘making good’, but it is a step in the right direction.

Interestingly, these units are temporary. After the games end and the visitors leave, these structures will just become another abandoned building somewhere in the city- although likely in the DTES.

For a games that prides itself on being sustainable, this sure does not look as though it will be with absolutely no mention of what will be done with this accommodation following the games. This is the initial stages of planning for this undertaking, so perhaps this issue will emerge later, but the tone of the proposal does not give any indication that the structures are for the long term.

Perhaps if VANOC really wanted to make an impression on the residents of the city, combat criticisms, and be a model games for the world, they could instead build permanent hostel type accommodations that could then be converted after the games to much needed shelter units or social housing.