The sign on the door of the Insite supervised injection site was gone again. Russ wasn’t surprised. He said it happened all the time, so we continued our tour outside. We walked down a couple of blocks inhabited by the most dessicated, fragile, and helpless humans I’d ever seen except maybe in India. They looked like they were hanging on by a thread.
Addicts come to Vancouver from all over Canada. Some from the U.S. as well. Why? Because the weather is more tolerant than anywhere else in the country, and so is the city. Everyone knows they’re here. They live here. They’re left alone by the police and other agents of society. And they have the Portland Hotel Society to look after them.
The PHS runs Insite, but that isn’t their main contribution. Their larger project is to provide decent housing — at least marginally clean and well-run rooming houses — for the 
population of addicts that live here. Russ (Russ Maynard — see last post) ushered me into the lobby of a beautifully refurbished historical building, past the bearded, wizened security guy in the little booth — “Hey Russ, How’s it going?” — into an elevator with walnut walls and gleaming brass metalwork. He beamed as he told me how they’d acquired the building by promising to renovate it at half the cost demanded by standard developers. Yet behind the stately doors, past the supervisor’s station on each floor, lived people who’ve been addicted to heavy drugs for most of their lives. People whose lives depended not only on getting the drugs they needed but on treating current infections, avoiding new infections, escaping the violence that surrounded this place like an encampment of stormtroopers.
Most of the buildings weren’t nearly that nice. They were all converted single-room-occupancy hotels, left to rot when the lumber and mining industries scaled back and their population of seasonal workers slackened as well. But even the most run-down residence had this glow to it. I stood in the supervisor’s station (not sure what else to call it) in a building that looked ready to cave in. The stairs creaked and the walls were riven with cracks. Yet the workers were 
bright, cheery, competent young people bustling about their little office, attending to the petty and portentous problems of straggling residents, one trying to carry his bike upstairs, barely strong enough to carry his own spindly body all that way — “We’ll take care of it for you, Hal” — another who’d lost his keys again, a third whose sores were weeping uncontrollably. “Come into the infirmary, Mary. We’ll fix you up.” I turned away. She was a mess.
They’re not addiction counselors, said Russ. They’re not mental health workers. They’re a different breed. Young, idealistic kids, studded with tattoos and rings, doing this job because they cared. They had big hearts and good brains. They could do it. They wanted to do it.
And they understood what the PHS was about and what this community needed. It’s a civil rights issue, Russ told me. Not an addiction issue. In a nutshell, abstinence doesn’t work for a lot of people. Sure, we encourage people to detox, and we’ve got special residences for that. But we don’t expect them to stay clean. Rather, we’re providing them with a respite, a break from the 
chaos of their lives, constantly needing to score, and sell themselves or do whatever they have to do to get dope. We don’t get mad or kick them out when they go back to it. We need to heal these people, not displace them.
You have to understand where they come from, Russ explained. They grew up in foster homes. They’re cut off from mainstream society. They don’t know how to talk with normal people. They don’t know any normal people. They’re so used to being threatened, shamed, hunted, reviled. But we don’t shame them. Shame is so counter-productive. We’re killing people with shame.
So would you say they fit the “self-medication” model of addiction? I asked him. Sure, you could say that, he replied, not much caring what model I chose. But there’s a connection to be made with mainstream thinking in addiction. Some of these folks are the ones Gabor Mate wrote about in Hungry Ghosts. I now saw how the label fit.
This was the one stop on my book tour that took me completely out of myself, out of my clever arguments, my pride of accomplishment, my illusion that I understood addiction. My head was spinning. I had never seen people living so close to death, kept alive and cared for by such unstinting kindness. I’d never seen an institution with such a human heart.
But the one scene at the core of all this, the experience I’ll never forget, was being inside Insite. It’s the first and most famous supervised injection site in the world. Active for 13 years now, according to Russ. People came in off the street, signed in with their usual nickname or pseudonym, sat in a waiting room if there were no booths available, and were then invited into the injection room. There they gathered supplies at a counter, placing what they needed — sterile solution, a wrapped syringe, alcohol swabs, etc. — in a cardboard container, the way you would at a cut-rate cafeteria. Then one of the workers would place a hand on their shoulder and point them to a booth, a well-lit counter top, about a meter wide, with a single chair pulled up to it. The booths were arranged in a broad semicircle, with at least one staff member keeping an eye on things. Unobtrusively.
And then they’d do their thing.
I hadn’t seen anyone shoot up for decades. The sight of it fascinated and disgusted me. The spidery search for veins that still worked, the bruises and scars and sores they worked around, the needle penetrating flesh, the change you could see, feel, almost taste, in body and soul, as the drug took effect. And then they were allowed to just sit there for awhile, draped on their little chair, their eyes droopy or glassy, the tension drained out of their thin frames. They were allowed to indulge in this brief moment of peace or contentment, before it was time to move on, vacate the booth for the next customer. And they were ushered into another room, asked if they needed anything, if they needed any kind of medical care. Then they got a handshake or a pat on the back, and back outside they went, back into the street that was a jungle, an impoverished playground, and, to many, a home.
Informed by unparalleled neuroscientific insight and written with his usual flare, Marc Lewis’s The Biology of Desire effectively refutes the medical view of addiction as a brain disease. A bracing and informative corrective to the muddle that now characterizes public and professional discourse on this topic.” —Gabor Maté, M.D., author of In The Realm of Hungry Ghosts: Close Encounters With Addiction
Hiya Marc
What a beautiful, compassionate post, I could almost feel your experience through your words. You’ve pretty much captured the very real world of addiction which, for the people you describe, is a daily battle between life and death in the eternal search for the brief respite of dignity which that soothing brown liquid provides. Unfortunately not many people understand addiction, they think they can pigeon hole it, control it, wrap it up in a nice little programme which will pump out nice abstinent citizens at the other end. Although there is a certain amount of predictability in addiction much of it involves massive amounts of uncertainty. The addict deals with this uncertainty with the certainty of the the fix but the people who choose to work with them and the system created to support them simply cannot tolerate uncertainty so desperately tries to make it certain by placing it in programmes run by the latest expert who is usually heavily influenced by medical model ideology.
Fortunately there are places like the Portland Hotel and insite. Places where the people working there can tolerate uncertainty and are prepared to meet the addict exactly where he is without wanting or needing to change him. Thank you very much for sharing this it’s given me a real boost.
That’s great, Peter. The experience brought me closer to the world you work in. It’s a whole different scene….and it makes that empty phrase “harm reduction” mean something vivid and compassionate.
Marc, Thanks for this very moving (and beautifully written) blog entry. It gives a very vivid picture of what is happening in Vancouver which to me is more optimistic than anything I’ve read in a long time, particularly how you describe the “young, idealistic kids studded with tattoos and rings, doing this job because they cared,” – finally, I thought, a bit of the spirit of the ’60’s brought into today’s techno world. Perhaps the headline of your article might be this: “…they were allowed to indulge in this brief moment of peace or contentment,…” Because isn’t that in the end what we are all looking for? And isn’t that ultimately what addiction is about? While we’re all on a path seeking peace and contentment, from D. Trump to these frail humans you describe, it’s the details of each path that vary; the essence is the same.
Excellent piece, Marc! So much of the humanity of the addict is overlooked when attempting to cure. And yes, abstinence just doesn’t work for so many and those that fall have added to their heavy load of guilt and shame, the fact that once again they failed. I see this all the time in 12 step recovery, which on some levels, almost creates a different problem…that of “relapse” being equal to failure.
Anyway, thanks for writing.
Jill
There is such love, compassion and understanding in this post, thank you! What the PHS is doing for so many in Vancouver is heroic and deeply caring. Question: is addiction inevitable? Is there a sense of acceptance and resignation implied? Is it true that there will always, under any circumstance and with the best intentions, be people who cannot, simply cannot, function in this world without drugs? Might it not be possible (in a perfect world) to flag potential users at a very early age, recognize and understand their core belief structure and help them to transform this structure starting in pre-school?
Wow! I am so impressed with the folks that work so lovingly with those seeking love and relief. That is such a special kind of talent, gift or genius.
In his recent book , Chasing the Scream Johann Hari nicely describes all this in thoroughly trashing any rationale for the war on drugs .
Would that some one listen
Mark:
There is no question that you are an exceptionally talented person as well as being very humane as well so this is not in question but what is in question is whether you, yourself, have been seeing what we may call the situation of the average drug addict.
There is a tendency to associate addiction with the refined aesthetics of famous artists either from History or current popular culture.
Great talented people may also become drug addicts, deal with it in some manner, and resume life in some well remunerated fashion as you have and no offense is suggested or intended in any way. Many Hollywood people who make millions performing in films like Ironman have used drugs to disability and return to make millions even if apparently using a variety of controlled substances.
But, and this is the point, the average drug addict is not a particularly talented person in terms of modern economic rewards. In the Pacific NW we are replete with ruined artists of all descriptions subsisting on drugs and broken dreams. Their dreams may not have been unreasonable at all at age 18 and admirable as well then and now.
This is one aspect certainly but the majority of talented people simply are never recognized outside of their personal circle and live performing on street corners for tips. The majority of addicts, though, and they are the majority are average or below average people with regard to every metric you could apply to their lives and as a Scientist you certainly are in a position to have discovered this through research.
In Vancouver you had the personal experience of the average drug experience/addiction which often simply continues and completes the destruction of lives and even hardened by experience and education you felt the need to turn away.
From my past experiences on the street I met one real wood carver with established
global potential and one established aboriginal painter who were abusers. One has kind of recovered on a shaky basis and one seems finally ruined.
What one will see statistically is ruined and sometimes skeletal people with open sores and ruined teeth moving from shot to shot in what is a Concentration Camp without the wire where the Gendarmes are following orders to look away and move the action out of sight where possible.
That these *volunteers* are well meaning people I do not question and we always consider the intentions of the actors. They do not have evil minds but they are acting to telescope and extend the suffering of the average addict indefinitely under terrifying holocaust type conditions.
If we have studied the Social History of how average people like these average addicts have lived and suffered during revolutions, famines, and sweeping economic/technical changes we can find as many parallels as we care to.
Many of those you see will be the descendants of those forcibly deported from Scotland after the Highland Clearances or from Ireland after the British conquest where there was scarcely a living creature across vast areas due to human slaughter, famine and Plague. They are the children of those sentenced to long terms of penal servitude at forced labor across the Western Hemisphere including the endless Canadian wilderness when they were the ruined alcoholics occupying the spaces currently occupied by Heroin and Crack addicts. You would have to have seen some of these *logging camps* out in remote areas or, preferably, worked in them yourself to see what we are and where we have come from.
So, having been away from your blog for some time I am calling out to you to really look, see, smell, and understand what is going on in the streets. The odd casualty from the more talented ranks such as yourself is collateral, incidental damage never intended.
See how doors were opened for you by family and professors to permit the escape of one unintended victim not that it was not done wisely for you as it certainly was but such manufactured anomalies should not be considered in the data.
Most will not, cannot, nor will be permitted to escape or rise from their station.
Thanks for your good work but let is not be drawn away by the illusions of well meaning Victorian Era charity.
I read your post twice looking for some takeaway. What is it you think Marc (and the rest of us?) should be doing?
Mike Johnson :
I have read you’re post several times and the line:
“But, and this is the point, the average drug addict is not a particularly talented person in terms of modern economic rewards.”
Reeks of FACISM , the lets put everyone in a *Logging Camp* portion is below , well low as 1 can go .
I am tempted to ask Marc ( you can’t even spell his name ) to have this post removed . Instead , I think it should stand a *Shinning Example* as to what *Human Beings* have to deal with .
Albert Einstein one said :
” Great spirits have always encountered violent opposition from mediocre minds.”
You sir , are neither .
Donnie Mac / 15
Gentlemen, please. There will be no fighting in the war room.
I see that I have upset you which is the problem in posting any observation on this or any other site dealing with difficult subject matter.
My brother spells his name with as K so I acknowledge the error in not using the spelling less commonly used in North America.
Reality is that the average person is not particularly talented whether they are an addict or not and you will realize when you reflect on what the words average and median or mean are supposed to signify.
There is a kind of myth that substance abusers tend to be exceptionally talented people whose great talents have driven them to addiction and if this could be cured in some way that we would immediately have a great increase in supply of extraordinarily talented people were a cure even possible.
I listened to a very talented street musician recently and he is obliged in late middle age to play for tips. Over time you may meet many very talented people who have skills no one in the economy will pay them anything but spare change to employ.
They might be prepared to pay them a wage to drive the bus or perform some other utilitarian function but their Art will have to be for purely personal amusement. Surely you have seen this already if you are not already in this category.
You appear to have no comprehension of what are the commonplaces of History as to war, massacre, famine, and plague.
Nothing I have posted here is even remotely inconsistent with social reality going back long before the first records. In fact this is the softest sustained period in all of the human experience as to the output of the economy and its redistribution to those unable to be responsible for themselves.
In Vancouver we provide First Aid, free syringes, Heroin on every corner at $5-$10./ injection, prostitution is legal, and most property crime entirely ignored. The System will provide you with unlimited government paid hospital and hospice care.
Try not to focus entirely upon yourself and your complaints as we all have our problems and do take advantage of our entirely free public library system.
Hi Mike and others. It’s hard for me to get into this debate… I’m travelling with family and I get deservedly evil looks from family members when I’m at my computer. For now let me just say that debate is usually healthy and this seems no exception. I look forward to reading your comments more thoroughly soon.
There is no sweeping answer possible as it is my view that we are simply observing a not too particularly intense example of what has happened throughout History and Prehistory for that matter as massacres and similar events are regularly discovered by Historians and Archaeologists.
Even the use of Opium based drugs is recorded many 1000s of years ago when India was known as a source for drugs of stupefaction and you can discover this for yourself if you read what remains of the written record from 2000 and more years ago. In more recent times Britain fought wars to impose the Opium habit on China destroying millions of lives with no compunctions whatsoever simply to balance their trade accounts with China.
The average citizen is not in a position of authority either elected or appointed so there is not a lot Marc (sp.!) who is a Professor and respected author or ourselves can do that is both legal and effective. You could have done nothing when the end of the Middle Ages (Feudalism) in Western Europe resulted in the mass deportation of those considered to be economically redundant or when effective steam power drove millions out of work who once operated handlooms in the cottage industry that prevailed directly before the Steam Era.
On occasion people are directly destroyed in the millions by industrial means such as WW1 while they are permitted to destroy themselves with alcohol and drugs on a steady basis. This was vastly increased by the industrial production of what we now call Gin and machine made cigarettes supported by saturation advertising.
People earn hundreds of billions of dollars annually distributing all these pernicious drugs and this is so attractive that no one is interested in stopping it including governments who through such programs as The War on Drugs have never sought to do anything more than manage the problem.
Out of compassion in what is otherwise a hopeless task one might volunteer to work as a Medic in the trenches of WW1 without any expectation that your activities could possibly shorten that one war by a single day or the one that was to follow it shortly after 1918.
It is not a mistake, an accident, or sourced from some misunderstanding on the part of the authorities whether clerical, monarchical, dictatorial, or elected as they have benignly neglected these situations when they have not actively created them.
But above all and as I was moved to comment by Marc’s post is that to begin to understand we must look directly at the damage and not turn away. Turning away allows us to drive narratives based on hopes, dreams, and political fantasies and we have far too much of that now. In the late 1950s actually minimizing the damage caused by drugs might have been a distant expectation that could have been reached but 60 years later the situation is grotesquely more intense as those familiar with both the streets and the logging camps can easily attest. The largest source of earlier generations of substance abusing derelicts were those seasonally released by the logging and other resource industries who lived in the old Vancouver hotels drinking themselves to Death.
The good Doctor managed to escape as a few always seem to do no matter how tight the captivity but they are a vanishingly small percentage of those who are captured.
As I mentioned above if the addict is also a very talented person who can have a well paying career as professor/author he or she can make a lot of money compared to the median income. Top earning Professors can earn many millions of dollars over their careers. Successful addicts in Hollywood films make millions per picture and if you can attain that exempt social status you can coexist with your dependency tolerably if not entirely comfortably and any relapses can be made to go away administratively if remedial action is undertaken. It was once a commonplace that successful writers were likely to be thoroughly alcoholic but it was their talent and earning ability that allowed their deficiencies to be overlooked.
If Marc had not been an exceptionally talented person to begin with and only been accepted for probationary part time employment as an inner city bus driver or in private security work the outcome could have been considerably different both for himself and his family.
As he pulled on that sweaty uniform for the 100th or 1000th split shift temptation might have been too much and rightfully so in my opinion as I do not excoriate those who collapse into partial or compete drug dependency as it has been for countless millions of people in every geographical place and time.
In my view these are the parameters of our social experience though I agree that we do not have the life long longitudinal studies with full data capture including genetics and personal histories as yet to see if there might be a path away from this.
Thanks for the reply BTW.
I have no problem with Mike Johnson’s comments. I think they are good. And I did not interpret them as an attack on Marc.
Should read the PROVE studies, just one base of support. HAT is very much needed here in the USA as well. A certain sub pop of addicts need it to begin to stabilize so they can eventually have productive lives. Greed, lies, punishment & shame are not needed, needless to say. When the laws create more harm & problems than they prevent, its time to change the laws.
Veering from either side of the median at some level, is what got us into addiction in the first place. Yes, there are marginalized populations everywhere, and everyone deserves attention and inclusion, whether their marginalization is self-induced, societally induced, or life induced. It’s the human condition. The “not turn away” phrase is critical to the compassion needed in all of this. I think that is a given. People in power are often flagrantly avoiding it. I think Marc’s post is in line with this, and we are getting side-tracked here. Changing the commonly held views on addiction will do a lot to alleviate and ameliorate this situation although the way humans get things done, it may involve geologic time. I think Marcus’s take on this is realistic.
Interpretation of rhetoric is largely rhetorical…and political. When it gets to the level of correcting people’s spelling, it’s clear tensions are high. I am kinda confused and distracted by this. Can we get back to talking about addiction?
Seems to me we are missing the point here. Marc is writing and we are blogging/responding to what he as aptly renamed ” Understanding Addiction”
Why? Because to understand is to deal with it in an effective manner . And the only way I can see to do that of all that has been tried( and failed..and here I mean ” treatment”) , is to prevent it to the greatest degree possible .
Homo sapiens are, by nature, both curious and fearful- both evolutionarily derived to improve fitness to survive. We cant do without it without completely re-engineering the hind and mid brains.
Of course then many of us creatures will try one or more possible substances that alleviate the suffering of the normal human condition.
The majority of those who do, do not get into trouble; and the majority of those who drift into “problematic” use get themselves out of it- what we call ” natural recovery”
Our current focus on the problem is on the extreme end of severity of the problem.. largely driven by the mis-guided disease model and its resulting War on Drugs just like the War on Cancer and the War on Poverty etc etc.
I have huge compassion for the unfortunates who end up in places like Downtown Eastside… and talent has nothing to do with it . But we are looking at the wrong place to find solutions.
We need to look at the other end of the spectrum. Questions like how and why does natural recovery occur. Why do some even in fairly advanced stages like I was , finally make the choice to change. How do we help people to develop self-empowerment skills to facilitate that
And finally , how do we educate each other adequately and early enough to decide to change when it is still relatively easy rather than near impossible by the residents of Vancouver.
The answers to all that are tough , complex, and have many variables. The way to start however is by asking and reframing the questions .
Excellent thoughts, Bill. I see it much the same way… I’m finally reading Chasing the Scream….and loving it. What a masterful piece it is.
Despite the moving and illustrative prose, I was still left with a sense of hopelessness, that of enabling and perpetuating the darkness of the status quo. I understand that this might provide the lesser of evils.. but evil nonetheless.
What resources are provided and where is the empathetic encouragement break the destructive cycle and offer hopeful alternatives to that bleak existence ?
I also agree that while shame is often a tool of self immolation, It can also offer with a change of perspective a useful tool to empower change depending on how it’s internalized.
Hi Ron. I felt the same hopelessness. Very much so. It was nowhere stronger than when watching the people shoot up in those booths. They weren’t awash in joy and peace. Rather, they looked like starving animals that had finally gotten to eat.
This is the whole issue with HR, isn’t it. I don’t have an answer. But I asked a lot of questions. The floor above the injection room was a residential rehab facility. I kept asking things like…How many of these people are likely to stay clean after they leave here? Russ, my host, let me know in various ways that very few would and that wasn’t really the intention here. The intention, as I wrote, was to provide a respite, a break from the chaos.
Re shame, I have also waffled on this issue publicly and privately. My present sense is that remorse, frustration, and similar emotions can be very productive in the way you say. But the chance of shame being “internalized” in a useful way is about the same level of odds as these poor folks getting off drugs.
‘starving…. ‘… to death seems to match some observations on the street. Many of these people are slowly dying or being done to death by their addictions and without the drive they are getting from their brain to get more drugs they would collapse in many cases. The drugs are holding them up as well as the desire for more drugs.
If there is such a category as life instinct or death instinct it is being over ridden in some cases by drugs.
These people dying on the streets are overlooked on the basis that they are addicts and not glaring health emergencies.
People not seen to be addicts would not be allowed to starve to death as in the Soviet times in Ukraine and elsewhere.
The point is that the guards, the wire, and the crematoria are rolled up inside the habit which imprisons many people.
I don’t think we’re likely to change the overarching attitude problem in the US, because it’s due to the top-down hierarchical structure of everything in this country– businesses, prisons, schools…
I agree with Marc that shame alone will not help because it is driven by frustration and resignation with the inability to stop. However, shame coupled with a better understanding, maybe even anger at the addiction and its detrital byproducts, may bolster a motivational force to persevere at recovery.
I facilitated a meeting yesterday at a hospital program for homeless HIV positive persons with addictive disorders. A resident had OD’d in the parking lot during the night, and his good friend who’d warned him not to inject into his PICC line was at the meeting. The group meditated, then consoled each other, talked about their understanding of addiction and the devastation it had wrought in their lives. We also did the same for recovery, and did some exercises to help group members tease out just what recovery meant to them. We talked some about willpower, “ego fatigue” and “now appeal.” The grieving resident left with an understanding of his addiction he didn’t have before– its neuropsychological underpinnings,and that there might be a behavioral way to thwart them. He seemed animated and motivated and asked me not to erase the whiteboard as he left.
Change happens through compassion, hope and commitment. And it happens at the street level.
I think the ability to view the proverbial “Forest through the trees” is an essential aspect of recovery in order to disengage the addiction along with its concomitant shame from the addict. Much like clarifying the difference between guilt and shame as in I make mistakes, but I am not one.
When one takes the view that I am not necessarily an addict but I do have an addiction, the story seems to lose a lot of its power along with hopelessness.
That is why i love this blog. Although based on the premise that addiction is demonstrably NOT a disease neurophysiologically, I CHOOSE not to treat it even casually as a disease in the vernacular and certainly DO NOT proclaim myself as one in meetings thereby distancing myself from a judgement of my shameful story.
I should have emphasized my opinion of the power of how shame is externalized rather than internalized as a vehicle for empowerment though the net sum is similar.
Matt, I think your story may illustrate my point as perhaps the power of one addict being able to clearly see the misery of their addiction mirrored in the unfortunate misadventure of another might just provide enough distance for a wake up call. In retrospect I feel strongly that If I had been shown a video of myself mumbling incoherently, crawling and foraging on carpets and peering out windows, I would have likely arrested my addiction a lot sooner via the disconnect of myself as the viewer vs. the disgusting behaviors of the addict on the screen.
BTW..those fleeting moments of epiphany and catharsis and how and when they occur have always fascinated me for the clarity and resolve they often impart and whose powerful recollection lasts long into the recovery process
I like your characterization of the difference between guilt and shame, and the difference between having an addiction and being an addict. Instead of an incorporation, there is still the subject-object relationship, where addiction is something to remove or move away from. To internalize THAT conceptualization can be very empowering, as you imply.
As for the story, I agree that the wet-fish-in-the-face wake up call of personalized tragedy so close to home can move someone in the right direction. However, it can also be short-lived if not sustained. I did see a video and hear a tape of myself drunk once, and although horrifying, it didn’t stop me. But if I saw or heard them now, I’m sure I’d want to vomit. Somebody with a better self-concept might have had more staying power.
If there were a drug we could distill that imbued us with the sentiment of the complex emotion of catharsis, epiphany, clarity and resolve you describe, the healing apperception would be such that we could all brush our palms together and go home. Very nicely put. Thanks, for this, Ron
Thank you Matt for your time and the validation..Its important for me to learn from others to ensure that I continue on the right path and what and how I perceive my relationship to addiction is both constructive and productive.
And of course Marc..I remain grateful