Are Drugs the Problem?

A lot of the comments I’ve received on my posts about homelessness lately have been about drug use. Some of them have been nasty, blaming people for their own poverty because they use drugs; others have been more generous, simply acknowledging that drugs are part of the problem. So let’s take a closer look: are drugs the problem? Yes and no. Let’s start with no.

Drugs Are Complicated

I grew up in the era of TV public service announcements about drugs. Drugs drugs drugs; which are good? Which are bad? Drugs drugs drugs; ask your mom or ask your dad! This is your brain; this is your brain on drugs. The ads were relentless, and simple. I was convinced that if I did drugs I’d probably die right there on the spot.

Some narratives about homelessness are equally simple: homeless people do drugs; people are homeless because they do drugs; doing drugs makes you homeless; if you choose to do drugs you’ll become homeless; so homelessness is your fault, and if you’d just stop doing drugs you wouldn’t be homeless anymore.

But of course it isn’t that simple. First of all, the vast majority of people who do drugs are not homeless; even the majority of drug overdoses happen in people’s homes. Many of your neighbours do drugs, but because they do them inside you simply don’t know about it. When unhoused residents do drugs, it’s visible for all to see.

But much more importantly, drug use is not the first cause of a person’s problems; it’s a symptom of other problems. For some people, the other problem is an injury that leads to a prescription; a great many addictions start with a doctor’s visit, not with wild parties. For other people, drug use is a way of coping with the difficulties of life. It’s downright cliché for someone who has had a hard day to get home and pour a glass of hard liquor or wine, and some people use alcohol for pain control too. For many of the unhoused people who use drugs, they were homeless first, and drugs were a way of helping them deal with the trauma of homelessness.

A Canadian study in the late 1970’s, called Rat Park, offered rats two water sources: one with pure water, and one sweetened and laced with morphine. They could have as much as they wanted of either. Then they experimented with changing the environment. Rats who were isolated preferred the drugs; rats who were living in the Rat Park colony with other rats, more space, and freedom to do normal rat behaviours preferred the pure water. Even rats who had been forced to drink the drugged water for weeks, and were then introduced to the Rat Park, chose the clean water, even though they showed some signs of withdrawal. The lesson: social isolation and exclusion, as well as other hardships, make people seek drugs. Healthy people don’t seek drugs.

These insights are what have led us to current drug strategies, which treat drug use as a health issue rather than a criminal justice issue. It’s been a long road to get here; it’s only been in the past few decades, long after the Rat Park studies, that laws and enforcement policies have shifted away from punishing people for drug use. Strategies that focus on treatment rather than punishment are much more effective, because punishment only increases the trauma that makes people seek drugs.

But in order for treatment to be effective, it needs to be part of a larger change in the person’s living conditions. Getting off of drugs, without changing your traumatic living conditions, is a recipe for pain, struggle, and even death. Because when someone is using drugs regularly, they build a tolerance; and when they go through withdrawal and stop using drugs for a time, that tolerance decreases. But if they are released from treatment right back into the same intolerable living conditions, they’re likely to seek drugs again; and using the same amount they used to use, but with lower tolerance, leads to overdoses.

This is the weakness–and since it’s well-documented and predictable, the evil–of the “involuntary treatment” or “mandated treatment” model that’s currently being proposed for Northumberland (at a County Council meeting on Wednesday, December 17th, at 9:30am at 555 Courthouse Road, Cobourg). There has been a shift toward this model in several jurisdictions in North America over the past few years, notably BC and Alberta.

California calls it “conservatorship”, as it involves making someone a ward of the state, which is to say, if you don’t choose to stop doing drugs we’re going to arrest you and confine you until you’ve stopped doing drugs. Last month, a story in The Atlantic explored how well it’s working there, and found that while the state has approved conservatorship programs and is urging municipalities to implement them, few have. In those that have, continued under-funding of services has led to situations where people are being detained for their own safety, but there’s inadequate space or supports for them, so they’re no better off but also have fewer rights. What’s the point of forcing people into services if those services lack the capacity to actually help them? And what’s the point of forcing people into sobriety if you’re just going to dump them back onto the street afterward?

That’s why the “housing first” model is so important. When someone comes to Transition House, the first thing staff do is try to find a way to “divert” them to more stable housing; the shelter is supposed to be a place of last resort, and it’s far less stable than most alternate arrangements. If someone can find a relative or friend to stay with, they’re usually much better off there. But when someone who is using the shelter shows that their life is stabilizing and staff determine that they’re ready for something more permanent, they can be recommended for one of the Transitional housing units the county operates. Transitional housing is a lot like a rental apartment, except that it has some extra supports: staff check in from time to time and help the person stick to their plan for a better life, but it’s not the same 24 hour supports needed in the shelter. Eventually, someone in a Transitional unit will be ready to move out to a regular rental apartment or other living arrangement, and we have another success story. But without the housing, there would be no success story.

Right now we don’t have enough housing, period. We don’t have enough shelter beds for everyone who is in need, though we’re making do through diversion efforts and occasional rental of motel rooms. We don’t have enough transitional housing, though the move to 310 Division St resulted in 10 new transitional housing units, which is a massive improvement. We don’t have enough supportive housing, where people who need more intensive supports can live in a semi-congregate home; but a few years ago the county purchased a former B&B in Campbellford and converted it to supportive housing. And we don’t have enough regular housing, and what housing we do have is far too expensive for most people to afford. I would be willing to wager that you, dear reader, couldn’t afford your own home if you had to buy it today. I know that I couldn’t. I couldn’t afford to rent it, either.

So in such conditions, it’s more surprising that there isn’t more drug use, and homelessness. Getting rid of the drugs won’t change the conditions that drive people to do drugs. This problem didn’t start with drugs, and it won’t end by getting rid of drugs.

But Of Course Drugs Are a Problem

All of that said, of course drugs are part of the problem. They make a person feel better in terrible circumstances, but ultimately they make everything worse. The relief that drugs provide fades over time, making people come back for more; and the relief decreases over time as the person builds tolerance, making them need more to get the same relief. And “need” is the right word: addiction can be a physical dependency, and without taking their drug an addicted person will get very sick in a process called “withdrawal”. In that sense, it’s helpful to think of an addicted person’s drug as medicine, because it keeps them from getting sick.

A person who is on drugs can show outward signs of intoxication: aggression, hallucination, spacing out, lack of social inhibitions. These can be disturbing to witness, and that’s a big part of what makes drug use so upsetting to folks in the community. It can feel extremely unsafe around someone in that state. Usually it actually is safe; statistically, unhoused residents have more to fear from the rest of us than we do from them, as violence against unhoused people is surprisingly common and violence by unhoused people is relatively uncommon (they’re more likely than housed folks to do property crimes, like theft, vandalism and breaking and entering, because they’re looking for necessities of life, but they’re rarely violent). Even so, it’s natural to feel upset and afraid when people are visibly intoxicated in public.

That said, not all signs of intoxication are related to drugs. Unhoused people often have pre-existing mental health conditions that have contributed to them using drugs or being unhoused (or both) in the first place. It is very difficult to remember to take medication for schizophrenia, for example, when you live on the street. It’s also very difficult to even hang on to medicine, when you are vulnerable to being robbed and have to carry all of your belongings with you at all times or risk losing them. But even the exhaustion of sleep deprivation can have the same effects as intoxication: as I referenced a few posts ago, after 21 hours of wakefulness the effect is comparable to a .08 blood alcohol level, and people living on the street often get only a few hours of sleep here or there as they’re able. Extended sleep deprivation can cause hallucinations, disassociation, and even death; all of the side effects of drugs, with none of the relief.

Being dependent on drugs makes an unhoused resident’s life extra challenging. With careful support and a safe supply of un-tainted drugs, they can often balance their doses and live a relatively normal life, even maintain a job; but safe consumption sites have been closed across the province, and opposed in places that didn’t have them to begin with, so folks who use drugs are on their own, always at risk of getting a dose wrong or discovering their drugs are laced with fentanyl, with nobody to help them except other drug users. They use together in groups to try to stay safe, because there is no legitimate safe space for them.

Transition House doesn’t allow people to use drugs on site. This is a good thing: some of the people who use the shelter are in recovery, or don’t use drugs at all, and either way do not want to be around people who are doing drugs. People used to be able to put their drugs in an “amnesty locker”, that they could collect when they leave the shelter without having the drugs confiscated. But the new “higher-barrier” rules imposed on the shelter eliminated the amnesty lockers, and require a visual sobriety test in order to enter the shelter (this is problematic because, as I mentioned above, sleeplessness can look an awful lot like intoxication). Cobourg’s Emergency Care Establishment By-Law sets a 500m perimeter around the shelter for security patrols, so if someone secures a room at the shelter for the night but then leaves to take their medicine, they’re followed by security; if they’re spotted doing drugs, they’re ejected from the shelter on a service restriction that might last for days, or even weeks. So if someone who is addicted to drugs wants to keep their place at the shelter, they need to walk at least a 1km round trip and find a place to do drugs in secret to avoid the symptoms of withdrawal, and then try to make it back to the shelter and appear sober enough to be able to get back in and sleep for the night. For some people, this isn’t possible: social workers have told me stories about people with Trench Foot (yes, the World War I malady caused by walking or standing all day with wet socks). So drug addiction, combined with the rules of the shelter and the local by-laws, make the shelter inaccessible to the people who need the most help.

In the absence of the shelter or any safe consumption site, people look for warm and secure places to do the drugs they physically need. This leads to situations like the one being reported lately, in which someone trying to access an ATM downtown at night found several people in the bank vestibule, doing drugs. Other times, people find someone with an apartment or house in town that allows people to do drugs there, and even sleep there; those are the “drug dens” that we definitely don’t want to see in our communities, and using them often comes at a high price, particularly for women. All of this is awful.

All of that to say that yes, drugs are part of the problem. They make all of the realities of homelessness significantly worse, even as they make the person experiencing the traumas of homelessness feel better for a time. And yet, our anti-drug policies can often get in the way of people being able to get off drugs, or to limit the damage that drugs can do to them and the community. The thing that people need most in order to do less drugs is the stability that can only come with stable housing, and if sobriety is a requirement to access that housing then someone with a serious addiction is denied that help.

So What Can We Do?

A commenter suggested that we provide more treatment services, and I think that’s a fantastic idea. Drug treatment is provided by Fourcast, which provides direct support to people experiencing addiction as well as training to help prevent and stop an overdose, and advocacy on government policy. Like every other agency and support service, they’re under-resourced: North America has been in a drug-poisoning crisis for the last decade or more, as more and more people are addicted to opioids and more and more drugs come laced with fentanyl to make them more addictive and potent. Getting more resources for services like Fourcast is a good start.

But it seems to me that if we want to avoid the harms of having people do drugs in public, then we would benefit greatly from having a place where people can do drugs in private. This is called a “safe consumption site,” and typically consists of a room to provide privacy, and supervision by someone who can revive the drug user if they overdose. And while we’re at it, let’s let the users of such a space have somewhere to sleep for the night: an additional shelter for drug users whose use is restricted to the safe consumption site would provide the shelter users who want to stay far away from drug use with better safety and stability. And if we want people not to overdose, let’s provide them with drugs we know aren’t poisoned with fentanyl; this is called “safe supply”. This reduces people’s dependency on drug dealers, and makes for less profit for those drug dealers.

Many people oppose safe consumption sites and safe supply on moral grounds; they see them as supporting drug use, rather than supporting people as they work to get off drugs. This is an understandable misunderstanding! But we need to move past it. We cannot moralize our way out of addiction; it’s a long-term process, and we politicians prefer quick-fixes. Rules that demand people not use drugs don’t do anything about drug cravings and withdrawal symptoms; forcing people to go through withdrawal has been flagged as a possible violation of human rights. Even so, we currently force people to choose between withdrawal and access to the safety of the shelter.

The motion Councillor Cleveland is bringing to County Council this week is about changing the model of our Social Services department to emphasize “mandated treatment” (i.e., involuntary treatment), and then to shift funding to services that support that approach. The motion claims that the current model doesn’t work; but as I hope is by now clear, it can’t work if we don’t fund it. The only way that involuntary treatment would yield better results is if a) there were sufficient treatment services available to meet the current need, which there are not; and b) if there was sufficient housing services available for people to move into once they’ve made it through treatment, which there are not. But if we had both of those things, then we wouldn’t need involuntary treatment, because voluntary treatment would be more readily available and effective too.

As I mentioned in my last few posts, the provincial and federal funding provided to end homelessness is a small fraction of what it would take to do the job properly; and yet we pay more than what it would take to end homelessness, by prolonging homelessness and letting the issue get worse by not adequately funding solutions. The province has closed the safe consumption sites that did exist, and then provided an estimated 6% of the funding needed for HART Hubs (their replacement program for the safe consumption sites); we didn’t get one, though we applied for it. And in order to keep taxes low this year, the County opted to cut their 1% housing levy, which will further set back our ability to provide affordable housing to those in need, at a time when the waitlist for affordable housing is as long as 10 years in Cobourg, and about 6 years in Brighton.

Solutions do exist, and we know that housing-first models, safe supply, and safe consumption sites are the most effective way forward. But they aren’t quick fixes. If we want to address this problem, and actually end it, we need the political will to treat addiction as the health crisis it is rather than punishing people for using the drugs they need. We need the will to fund our programs so they can actually be effective, rather than half-assing it and then complaining that it hasn’t worked. We need to support our staff, who are scrambling to do their best against a rising tide of need and without adequate resources, rather than looking to outside consultants to critique our systems and throw our staff under the bus.

We can’t have it both ways. We can’t prevent drug users from accessing services, and then blame them for still being homeless. We can’t under-fund housing and then demonize unhoused residents for doing what it takes to survive on the street. And we need to make it clear that nobody wants homelessness or drug use to continue; we are so divided over the moral outrage of drug use that we’re making things worse for both unhoused and housed residents. The way to get people off the street is to provide them with the safety and stability they need; then they’ll finally be able to choose the clean water. Until then, we can’t expect them to perform the miracle of sober street living.