Illustration by Bug Cru

One of the big changes in my life as I’ve gotten older has been becoming an insomniac. My brain has decided to forgo the signals that I am asleep and should remain so until an appropriate hour sometime in the waning hours of the dawn, and instead wakes me up around 1 a.m. This time is the sweet spot when nothing good happens, but your defences are asleep. It is when I used to be able to rely on a drink to calm me down and bring me back to being tired. It is when I realize how alive I truly am.

I’ve been sober for a little over two years, a decision I made impulsively one afternoon after a lovely house party where I simultaneously had a lovely time and wanted to kill myself—fight or flight at its finest. It wasn’t too long after that last bout of drinking before the cracks in my dependencies started to show themselves. A friend is playing a show at a bar downtown and your friend group will be there, but also you know it’s a room full of strangers. What are you going to be holding in your hand that will help keep all your anxieties in check? You’ve been invited to speak on a panel about mental health in creative industries and the conversation gets difficult. How are you going to calm your nerves and your heart after an hour of hard questions you don’t have an answer to? These were the types of questions I would ask myself, stray thoughts rattling around my brain desperate for a solution. Drinking, for me, was part of a comprehensive anxiety management system—a toolkit I kept in my closet full of broken tools and the end of a roll of tape, but one I kept telling myself was sufficient to suit my needs. This is all I’ll ever need, I’d tell myself, just me and this rusty hammer with a broken handle against the world.

During a stressful event it is easy to keep one hand on the wheel if the other is holding a whiskey, neat. In 2016, when Donald Trump won the presidency of the United States, I joined in the game that was to take a drink when things looked bleak. I stayed up all night watching that broadcast and had no idea who had won the next day, but I was well aware of the headache and it smelled like I had tried to cook something that was still sitting on the counter. I wasn’t alone in this either; ask anyone where they were that night, and the majority are going to come back with, “I was at a bar,” or “a friend’s house that had projected CNN onto the wall. BYOB.”

I quit drinking in March of 2019, a spring day like any other. I marked the occasion by getting a tattoo on my right arm of a self absorbed harpy gazing longingly at herself in a hand mirror. This was also my first test—with every tattoo I’d had before that I drank a shot of whisky before, just to settle my muscles and nerves to prepare them for the road ahead. Never let anyone experience pain without a suppressant, I’d thought. I had a quad-shot Americano, black, and smoked two cigarettes on my walk to my appointment. Replacing vices with others, just trying to find a new way to feel. That tattoo hurt like hell, but it’s the first one of many that I’ve felt in my bones, every nerve sending a signal to my brain letting me know I was alive and present and experiencing pain, but that it would be okay.

That subsequent summer was my first one living in Toronto, having escaped the Yukon the past winter. The Yukon is where I learned to drink, where I snuck my first quarter bottle of red wine, where I brought my first six-pack of Mike’s Hard Cranberry Lemonade, that my sister had to run and buy for me, to a house party in Grade 12, when I was trying to find a place to belong at the end of my high school career. One of the cool kids on the couch saw me pull the bright red bottle out of my bag and called me a faggot. I dumped all six in the sink as everyone laughed at me, then stole six cans of lukewarm Kokanee from another kid’s bag when he wasn’t looking. “See, now you’re a man,” the cool kid said when I cracked that first can. What I drank was every bit as important as the fact that I did. The Yukon is where I came out and told everyone in my life that I am a transgender woman. It’s where I drank through that first year of being out, when people surrounded me at my office trying to get in the door, calling me slurs and making vague threats before smashing bottles of wine against the locked door. The Yukon is where I drank until I tried to end my life, and took myself to the hospital to keep me safe from my own drunken hand. I told everyone that I was having stomach problems. That seemed easier to explain than I had drank too much and tried to tap out early. The Yukon is where I ran away from the problems that had piled too high for me to see over anymore.

And here I was now, in Toronto, my chosen home. Sober and alive for the first time. I hit my first summer with open eyes, ready to experience the sun and the life I hadn’t lived for 37 years. This was not without its challenges. Every bus stop I walked by had a six-foot picture of a cold mug of beer, cold beads of water running down the side, ensorcelling me with the power of its refreshment. I would duck into any nearby corner shop and buy a tall can of soda water with a high fructose level, or maybe an iced tea. Give me something cold and refreshing that hits me just right, help me forget that I have to fall asleep with my own unfiltered thoughts. But, all the same, every day took me one step closer to learning I didn’t need alcohol to get me through. Every day took me further from the darkness I had left behind that last winter in the Yukon. Here, I could sit in the sun and smile, drink a grapefruit LaCroix and walk home at a reasonable hour without spiralling the entire time. I felt every emotion in every step I took and I understood that I needed to feel them. That I could no longer run or hide from emotional pain, that I had to walk through it.

One year after I stopped having “just one more drink,” the world learned of the dangerous state of COVID-19 and we entered a prolonged state of isolation. Everywhere around me, people were stockpiling toilet paper and whiskey in equal measure. I wasn’t sure I had built a better toolkit to prepare myself for such an unexpected event by then, one that was sure to be filled with new traumas and anxieties, as an uncertain future rolled itself out ahead of each and every one of us.

I watched the numbers climb, and I tried to drink enough coffee in the day to keep my hands from shaking too much, bringing back that old familiar feeling when I would drink brown liquor for days on end, trying to act like nothing was wrong. I began endlessly searching for the right flavour of soda water that would erase my uncertainty of the future. I watched people celebrate Susan Orlean live-tweeting her experience of drinking herself incoherent and felt a twinge of jealousy and regret. I wanted to be able to live so freely, but I knew how dangerous that was. How easily being the fun drunk that cheekily succumbs to alcohol, much to the amusement of everyone around them, becomes the sad drunk that takes themself to the hospital. I stopped sleeping properly and laid awake at night worrying for the future of my partner, our pets, and our life together. I wondered how long we could stay isolated from the people that made us all feel safe and connected. How long could I keep the wolves at the gate?

What I learned from these nights of being awake is how important the hard emotions are in our lives. My brain doesn’t stop working at night, but I am aware and cognizant of that. I can spend the endless hours awake wondering why I am feeling anxious, where my depression and fears are coming from, and rational ways I can try and manage them the next day. I think about how hard everything is, and how I am sure we will see the other side, but how no one knows what shape we will be in when we get there. I think about who I am, really, now that I’m not that scared person running from their problems but living deep in them. I lie awake at night, sober as the day is long, and sneak into the bathroom to cry so I won’t wake anyone up. My bare feet on the cold and rough concrete floor, every nerve sending a signal to my brain letting me know I am present and experiencing pain, but that it would be okay. When my defences have been done away with, and in the hard hours of an insomniac’s night, I realize how alive I finally am.

In Mildred Grace German’s piece Stigma Kills, the artist aims to depict how mental illness and addiction can affect anyone, regardless of their background or location. The artwork was inspired by the ongoing battle for social justice in Vancouver’s Downtown Eastside, where German lives. The piece was on display at the University of British Columbia as part of a student art show exploring the impact of the opioid crisis from a youth perspective.

It was the second day of the Calgary Stampede, a 10-day bonanza of cowboy-themed festivities in the Canadian province most stereotyped by its beef, oil, and country music. Nearly every local business had shut down for the week. “It’s our biggest holiday. You just don’t mess with the Stampede,” Calgary-born Mandy Alston tells me nearly a year later.

The 27-year-old has worked in the hospitality industry for the better part of her adult life, and most of her friendships were established in restaurants, bars, and while hosting corporate events.

That day last July, Alston had just been given a case of Prosecco by one of her distributors and was getting ready for an engagement party. Then she got a call. Her boyfriend suggested she not come; it was a friends-of-the-family–only event. When Alston later found out her partner was there with another woman, things unravelled. The affair had been going on for months. She had been betrayed not only by her partner, but by her friends who lied on his behalf to cover up the liaison. “These were people I had known for seven years… I was devastated.”

Alston’s coping mechanism was to self-medicate with alcohol and drugs. She started to spiral, losing weight. “I would essentially wake up and start drinking. I couldn’t even tell you how much cocaine I would do in one day,” she remembers. “I was a mess.”

In Alston’s industry, there is little talk about research-based solutions to addiction or behavioural interventions for mental health. Friends would respond to everything by suggesting a drink or a line. “It’s a supported addiction,” she says.

Alston was teaching spin classes while running restaurants and working for clients, so she felt she had to hide her vulnerabilities. Cocaine, she says, helped her remain positive around others. She could still be the happy, peppy person that everyone knew. “No one had to know that I was going through pain,” she says.

The first time Alston used cocaine was with her ex on vacation in Mexico on New Year’s Eve. She started to work in nightclubs more often, planning and hosting events. “Cocaine was readily available. At first I didn’t like that because I couldn’t sleep,” she says. She stopped doing it for a while, but she then figured out what she calls “the balance.” “It was a quick line here and there and with that came a drink. I would do a line and think, ‘Now I need a drink,’” she says. “The habit formed so fast that I thought, ‘Wow, I’m in this,’” she remembers.

We know that while trauma resides at the roots of addiction, another aspect that holds incredible power is when learning mechanisms go wrong. This is often understood through the field of neuroplasticity. “Cells that fire together wire together,” wrote Donald Hebb, a Canadian neuropsychologist working on associative learning at Harvard University, in 1949. Marc Lewis, a neuroscientist who considers addiction a brain malfunction rather than a disease, has written similar findings extensively. “The more you repeat a behaviour, the more likely your brain is to produce a reward in response to that behaviour. With each repetition, activated synapses become reinforced or strengthened… and alternative [less-used] synapses become weakened or pruned,” he wrote. “Repeated patterns of neural activation are self-perpetuating and self-reinforcing: they form circuits or pathways with an increasing probability of ‘lighting up’ whenever certain cues or stimuli [or thoughts or memories] are encountered.”

In healthy brain functioning, highly pleasurable “rewards” are experienced in the limbic system—the brain’s more primal, impulse-driven centre—and rational thoughts about responsibilities and consequences happen in the prefrontal cortex. In addiction, the former overrides the latter: the decisions made in the rational system of the mind are vetoed by the reward-driven system of the mind.

The good news is that many in the field of addiction and mental health are beginning to understand this and are working toward solutions that help take back the prefrontal cortex’s control. Medication-assisted treatment (MAT) programs are on the rise, and could be a solution for many. MAT combines psycho-social interventions like cognitive behavioural therapy (CBT) with medications that are offered on a 30- to 60-day plan to reduce the endorphin reward. This lessens the reward-seeking drive so the brain can go back to commanding our actions rationally.

What’s thwarting the success of these programs, however, is an after-effect of the opioid overdose crisis. Echoing failed policies of the drug war, calls for banning all pharmaceuticals are counter-productive and even dangerous. But the hysteria surrounding pharmaceutical intervention is understandable and expected, says Elliot Stone, CEO of Alavida, a MAT program based in Vancouver. “People are upset about [others] dying and opioid addiction is a very serious thing, so it’s a natural [response],” he explains. “With alcohol, someone tells you that you have a problem, then you have a chance to get better.” But with opioids, he says, “you die, immediately in many cases. It’s human nature that people are focusing on this.”

I asked Stone, whose program focuses on alcohol addiction, if he felt alcohol had been lost in the dialogue on addiction given the current news cycle centred on opioids. “I don’t think alcohol is getting the attention it should,” he says. “But I think it’ll come around. Mental health is starting to be appreciated, and there’s a general movement in the right direction. It’s just going to take time.”

Stone’s program combines evidence-based practices in two worlds that he believes are closely related, but that don’t often intersect: the world of psychotherapy and the world of medicine. On the medical side, Alavida uses the opioid antagonist Naltrexone, which partially blocks opioid receptors so that they can’t fully deliver the pleasure they normally do. “[These medications are used] as a tool to essentially retrain the brain and to make the process of paring down your drinking easier from a biological sense,” he explains.

When you don’t get the neurochemical reward, then you aren’t as inclined to seek the substance that delivers it. “If [we’re] able to block that reward for a period of time in specific circumstances, it can pull someone out of that compulsive cycle and give them a bit of space to make decisions,” Stone explains. And that space is where his program really doubles down on the psychotherapy aspects like CBT, motivational interviewing, and traditional therapy.

Because her case was less severe than many addicted to alcohol, on her own, Alston was able to figure out how to achieve some of the components that successful treatment plans like Stone’s and other MAT programs incorporate. She moved from Calgary to Vancouver to get away from her triggers that set her reward-seeking behaviour in the driver’s seat, and sought out relationships that didn’t expect her to be happy and peppy all the time, or those who suddenly became too busy when things got tough. People who, when she’s going through a rough patch, don’t just resort to buying her a shot. “I’m cooking dinners, I’m being honest, and I’m enjoying my life,” she tells me happily.

“I’m out of my ‘darkness place.’”

Photo material republished with the express permission of: National Post, a division of Postmedia Network Inc.

One Friday in late January, a photo on Facebook had Debra Selkirk in tears. Weeks earlier, she’d received a desperate email from a woman in the U.S. The woman’s 30-year-old sister needed a new liver, but she had to be alcohol-free for six months before she could get a transplant. The question was: Did she have time to wait? Selkirk quickly sent over a list of American transplant centres and a doctor who would waive the waiting period. Now, as Selkirk scrolled through her feed, she spotted a picture of the two sisters together—post-transplant. “I helped with that,” she sighs.

Selkirk’s name made headlines a few years ago when she fought that very six-month policy in Canada. Her husband, Mark Selkirk, died in 2010 just two weeks after he was told he wasn’t eligible for a transplant—he’d only been alcohol-free for six weeks.

While there are U.S. transplant centres who don’t follow the policy, it’s much more consistent in Ontario, where Mark was being treated, and across Canada. Proponents argue that those who haven’t been alcohol-free long enough are likely to relapse after surgery, or that patients are likely to get better over the six-month abstinence period (and possibly avoid the need for a transplant). But Selkirk says it’s discriminatory and misguided. She often cites medical research, such as a University of Pittsburgh study that found that only six percent of liver transplant patients who once misused alcohol relapsed each year, and only two-and-a-half percent returned to heavy drinking. That, and other studies, conclude abstaining from alcohol has only a moderate impact on transplant success. In 2015, Selkirk filed a constitutional challenge to change the rule in Ontario.

Last September, after more than two years in court, the Trillium Gift of Life Network, the agency that runs the province’s transplant network, agreed to launch a three-year pilot that would eventually waive the requirement for all patients. While the policy remains unchanged for now, the agency will watch participants’ progress and determine whether to alter the criteria. Selkirk believes the pilot will succeed, and hopes the outcomes will convince other provinces to change their policies. The program begins in August, but other cases have already popped up in the news. Last fall, Cary Gallant was scheduled to ask a judge for an injunction to force authorities to put him on Ontario’s transplant list. And in December, Indigenous rights activist Delilah Saunders’s story spread after she, too, was denied a transplant.

Selkirk has been watching these stories, and offering support where she can. As her court case wrapped up, she realized she wanted more than a legal battle that would end. Patients still need so much support, she says. “I just started to have a million ideas, like I should do this, and someone should be doing that.” And so, in October, she began narrowing down the mandate for the Selkirk Liver Society.

She wants to encourage a holistic approach to treatment where patients manage their disease with the help of not just a liver specialist, but a nutritionist and other health professionals that they can periodically visit all in one day. She also wants to reshape public perception starting with the media, and she’s asked the Canadian Press to finalize their decision to replace words like “drunk” and “alcoholic” with “person with an alcohol use disorder” in their style guide. And, long term, she wants to support people through the process of transplantation by making things like accommodation easier. Paying to stay in Toronto for six weeks during the surgery and recovery process, for example, can be an extra burden on families—especially when a spouse or partner has to be away from work for so long. She hopes to set up more affordable short-term housing where families can stay.

There’s a lot to be done, but Selkirk says she’s found her calling. “I’ve never loved what I do,” she says. “I just always wanted to go home to Mark.” These days, Selkirk occasionally gets a message from another stranger watching a family member suffer, and she’ll channel her passion into that. Soon, she says, they’re texting like they’re best friends

In Aaron Goodman’s The Outcasts Project, the photojournalist captures opioid users from Vancouver’s Downtown Eastside in their day-to-day lives as they participate in the North America’s first heroin-assisted treatment program. Above, subject Johnny is photographed as a nurse aids in self-injection at Vancouver’s Crosstown Clinic. “The reason why I do the dope is different from why a lot of other people do it,” he says. “They do it to get high, I do it to help with some pain issues I have. I don’t want people thinking, ‘You know, these guys are going in there taking our tax dollars and doing heroin and getting high, look at them. You know, they’re nothing but detriments to society.’ Well, I’ll tell ya, it’s saving my life.”

Pacing frantically around her living room, Audrey yelled at herself in frustration: “Just put down the fucking phone!” It was mid-February and, having been sober since New Year’s Day, Audrey, 35, whose name has been changed to protect her privacy, decided to see a show with friends at Toronto’s Danforth Music Hall. After getting ready with the band’s album playing and “just one” drink in hand, she became consumed by an inner battle between the urge to dial her dealer for the drugs she usually took when going out with friends, and her long-term desire to kick the habit.

Audrey had been a heavy drinker since her early 20s. Over the past decade, she developed a compulsive drive toward cocaine, even knowing that it can sometimes be laced with fentanyl. “It scared me at first,” she says, “but I just don’t read those headlines anymore.”

Audrey was the lead programmer at a Toronto tech firm, yet her personal life was unravelling. Her husband wanted children on the condition that she stop taking drugs for at least a year, but she had struggled to pass a month. Some days, Audrey found herself sniffing cocaine before breakfast.

That night in Toronto she cracked and called her dealer, instantly easing her anxiety. But feelings of guilt and defeat returned the next day. “I was so mad at myself. I’d been sober for over a month,” she says. “It’s like another person takes over.”

Like millions of other Canadians, Audrey has an addiction. By definition, addiction is when we compulsively engage in rewarding acts, even when we understand the adverse consequences. One can become addicted to many things: alcohol, cigarettes, gambling, sexual activity, shopping, junk food, even work. In non-compulsive amounts, some of these can be good for you. It’s only when they’re incessantly sought out, despite knowing the negative repercussions, that use becomes addiction.

The current answer to addiction is based on outdated assumptions and disproven theories. If we believe that narcotics on their own cause addiction then it makes sense to criminalize drugs; but a four-decade-long War on Drugs has done little to curb the problem. More people have been jailed for possession and profiteering than ever before, though addiction is rising in lockstep with an epidemic of overdose deaths.

If we believe that genetics alone causes addiction, then it makes sense to prescribe the disease away with pharmaceutical responses. But no specific gene can be pointed to as the cause of addiction, and no pill can cure it. Current medical and public policy approaches largely believe addiction is a problem to prescribe or jail away. Yet the roots of why people become addicted must be tackled to find lasting solutions.

Dr. Gabor Maté, a Vancouver physician and renowned addictions author, has long advocated for deeper comprehension. “If we’re going to understand addiction,” he says, “we first have to understand what it is that the person gets out of it.”

Addictive acts and substances activate neurochemicals known as endorphins, our brain’s natural opiates. By acting on the brain’s reward centres, opiates—both natural and synthetic—calm the body and mind. After consistent repetition of the behaviour, stimuli such as smells, sights, and sounds associated with the endorphin-releasing act trigger dopamine in the brain.

Dopamine is a neurotransmitter responsible for increasing energy, heightening drive, and narrowing focus. For Audrey, stimuli that typically preceded taking drugs—drinking and listening to music before a concert—triggered dopamine that focused her drive to obtain cocaine.

“If I were to start using heroin, the first time I did it…I wouldn’t get high until the heroin hit my brain,” says Dr. Alexander Goumeniouk, emeritus pharmacology professor at the University of British Columbia. “But the fiftieth time, I’d be high before the heroin even got in my arm.” Repetition facilitates the release of these compounds, Goumeniouk says. “There definitely is a behavioural component to addiction.”

We weigh consequences in our brain’s prefrontal cortex, the place where Audrey tells herself to stop using coke. But the brain’s reward centre can easily overpower the prefrontal cortex’s commands if cued by external stimuli—even something like a song. Stress can also trigger the reward centre to overpower the rational prefrontal cortex.

Maté often tells audiences on his speaking tours that the real question is not “why the addiction” but “why the pain.” If we’ve experienced stressful life events, we are more likely to reach for substances that release feel-good endorphins. “The first time I did heroin,” a sex worker told Maté, “it felt like a warm, soft hug.”

An overreactive nervous system and its need for soothing both stem from trauma. During childhood, abuse and neglect affect the brain and nervous system’s development, amplifying stress responses in adulthood.

When asked about her upbringing, Audrey disclosed she had been neglected as a child. Her father left when she was very young. “The new man my mom married was verbally abusive; a pretty angry guy,” she says. This abuse frayed her nervous system. “I think that’s why I can’t connect with others without being high.”

While data suggests that 80 percent of those in rehab centres have some trauma, childhood or otherwise, Goumeniouk’s experience puts that figure at 100 percent. Despite his own field trying to solve addiction with pharmaceuticals, he’s quick to note the effects of trauma on addiction, calling it an “underappreciated component of addiction-ology.”

In addition to childhood trauma, isolation is another crucial factor in determining the chances of addiction. Social and economic exclusion leaves the brain in the absence of environmental conditions required for healthy neurochemical activity.

Maia Szalavitz, a neuroscience author and reporter for the New York Times, often writes about the importance of connection for brain health. “You could define addiction as falling in love with a drug rather than a person. The same kinds of brain systems and chemicals are involved,” she says. The underlying message, Szalavitz notes, is that if people are alienated, traumatized, and desperate for a solution, simply taking away a drug doesn’t solve the problem.

But the way we’ve set up society works against “making warm and reliable connections,” she says, which are crucial for relieving stress. “When you have inequality, you have competition,” neither of which are useful in helping people get the social support they need.

“There’s a very universal human desire to be included, to be social,” says Chris Arnade, addiction and poverty journalist with the Guardian. Drugs perform many tasks, he says; beyond numbing pain, they provide someone with a social network. “It may not be the social network that you or I may approve of, but on the streets, they have family, often for the first time.”

If addictive substances soothe us, calming troubles stemming from childhood trauma or social isolation, then society must tackle addiction at those roots. To create more affection and inclusivity, we need a deeper awareness of the lasting effects of childhood abuse and the isolating effects of stigma and disenfranchisement left over from the drug war.

With so many advocating for an addiction approach focused on mental and physical health, rather than a punitive or strictly pharmaceutical response, it’s time we accept the research and activism that prove we must tackle addiction at its roots.

UPDATE (02/14/2018): Some of the language in this story has been updated to better reflect vocabulary standardly used around addictions.

More information on the Outcasts Project can be found at outcastsproject.com.

Cheryl prepares to use drugs in her apartment in Vancouver’s Downtown Eastside.

We need for you people to see that we’re not stereotyped monsters. We’re people just like you, just with an addiction. Something that we do a little bit more than others… When you look at this, take it with a grain of salt, because it could be your own daughter, it could be your own son out there doing exactly what I’m doing, but they had the door closed.

A drug addict’s world is not just the drugs, it’s how they get them, what you gotta’ do to get them. Sex trade, you know. Stealing, killing, whatever it might take just to get that extra dollar to get that extra fix so you can feel numb for the rest of the day. Not necessarily it’s always that, but in my life, I just want you to know that I’m struggling and I need that extra help.

Cheryl cries in the yard of a church where her father’s funeral was held.

I hope the people see through this [essay] all the points, all the emotions and desires, needs, and wants that we need, that you can help us down the road be able to successfully show our governments that people need the extra bit of help because we can’t do it on our own.

Cheryl self-injects her medication at Providence Health Care’s Crosstown Clinic in Vancouver.

I want to show the people that this place is where we get our injections for our heroin opiate program, just show them that we need these places so heroin addicts can get off the streets. Heroin can be contaminated with many different poisons out there that can severely give us infections, because they put hog dewormer in the heroin on the streets. The clinical heroin here, there’s no bad chemicals or poisons in the drug. It helps us through the day, takes our aches and pains away, everything that heroin used to do.

In other places of the world, they had this study and it’s helped them, that’s why they brought it to Canada, here to [British Columbia]. And for us, the people who are in it, we’re so lucky and should be so grateful to have such a great program.

Cheryl paints her nails prior to a court appearance for a sexual assault she experienced.

I’m sure there’s hundreds of photos that could show my life different. But my life today is a recovering heroin addict. I’m 124 pounds. I used to weigh 97 pounds. There’s so many good things, and positive ways of looking at my life. If a picture could show all that emotion in one? That would be great, but it won’t and that’s all that my voice could tell you.

Cheryl self-injects drugs in her apartment in Vancouver’s Downtown Eastside.

I think that people see a girl looking in the mirror, looking in fear, like what is she doing with the needle in her neck, sticking in her neck, that’s a pretty dangerous site to be injecting. But that’s the reality of that picture. It’s me being all strung out on dope, trying to get that shot into me, and it’s filled with blood and I’m trying to plug it into my vein cause I need that drug that’s in there so I can get off and get high, numb whatever pain I’m going through in that moment.

I was all fucked up on drugs that day, yeah. It shows my emotion, my fear, my determination. [I wish the photo had] maybe a little bit more light… Just to show it’s hard to inject into your neck like that. Just to show the picture more. To see what kind of struggle it is to inject in your neck. And to show maybe just a little bit more emotion to the people just to show what and why I’m doing that to myself.

Cheryl returns to an alley in Vancouver’s Downtown Eastside where she lived for several years.

People viewing this photo might see some young girl, downtown, in a back alley. Looks like it’s a rough alley. A young girl, maybe she’s strung out, or maybe she’s determined to find drugs or who knows what they see in this photo. They just see a young girl smiling and looking down the alley.

Yeah, it shows all of me. I just hope the people see me in this photo—that I’m a striving, struggling drug addict. That I’m trying to better my life.

A woman, Cheryl, self-injects at Vancouver’s Crosstown Clinic. From Aaron Goodman’s The Outcasts Project.

Except for a long line at the barbecue, where hungry older folk wait for a free meal, most people have left Oppenheimer Park for the day. But not Jim McLeod, who’s clutching a hot dog wrinkled with the cold, so engrossed in telling me his story that he’s forgotten about his dinner. It’s late February and we’re standing in Vancouver’s Downtown Eastside, the epicentre of Canada’s overdose crisis, talking about harm reduction—two words very much in vogue.

“You don’t bounce back from torture,” McLeod says almost casually, wind whipping tendrils of his long hair into a frenzy. He tells me that past trauma has much to do with his morphine use today. “I’m wired to it,” he says. “I use it daily because I’ve had physical pain most of my life.”

At 14, McLeod’s foster father threw him into a doorknob. The impact permanently damaged his spine. Years later, his best friend suffered a psychotic episode and nearly beat McLeod to death, confining him to a room for hours at gunpoint. “I was worked head to toe with the claw of the hammer, tearing strips out of me,” he says. McLeod rolls up his sleeves, revealing a scar that runs from elbow to wrist, the stitch marks still visible—like slashes of red ink from a pen. He gestures to his knees, pointing to places the hammer punctured his body, creating wounds that never quite healed. “I’ve suffered the kind of violence most people don’t see, unless it’s on TV.”

McLeod gets his morphine from the streets, relying on dealers rather than doctors to manage his pain. But he considers himself lucky. The morphine he takes comes in an uncrushable pill, making it hard to adulterate. He can always tell if someone’s been sneaking in additives.

It’s impossible to know what’s in other drugs. Fentanyl, a painkiller so powerful that only a few sand-like grains are needed for a lethal dose, has breached the illicit opiate supply. It’s found in everything from heroin to fake Oxycontin pills. Stimulants such as cocaine and methamphetamine aren’t safe either: One Vancouver journalist reported being offered “knock-down jib,” or laced meth, by a street dealer, while fentanyl-laced cocaine hit partiers in Ontario and B.C. last year. A 2016 Vancouver-based study found fentanyl in 86 percent of drugs tested.

In B.C, lives lost to drug overdose nearly doubled over the last two years. In 2016, almost 1,000 people died. In the same period, Alberta saw 343 fentanyl-related fatalities, a three-fold rise in only two years. That’s comparable to diabetes, which consistently stars in the province’s top-10 lethal causes list. Eastern provinces aren’t exempt, either: According to reports, drug-related deaths in Ontario have more than quadrupled since 2000.

But McLeod doesn’t hold manufacturers, dealers, or poor policing accountable for the spike in overdoses. The problem, he says, is a system that doesn’t recognize the social determinants of addiction, the many faces of pain. “If they would actually legalize and regulate drugs, it wouldn’t just end the crisis,” says McLeod. “It would almost end overdoses, period.”

Treat addiction like any other disease: That’s the seemingly radical idea activists like McLeod demand in the face of these fatalities. Calls to set up special clinics, prescribe heroin, and reform prohibition brought McLeod and 300 others to Oppenheimer Park, part of a nation-wide protest organizers called the biggest mobilization for harm reduction Canada has ever seen. The rally doubles as a memorial service; most in attendance clutch wooden feathers scrawled with the names of the dead. It’s not the first time drug users have insisted on their right to equal care. But they’re hoping, in the face of a national crisis, it’ll be the last.

***

Main and Hastings might be Canada’s most notorious intersection. Hotels with crumbling facades hint at a once-thriving entertainment district; many have been converted into welfare housing with patchy hot water and pest problems. Theatres have closed. Walking past these buildings, it’s not uncommon to step around tents fashioned from umbrellas, dodge garbage thrown from windows, or hop over trash cans torn apart by salvagers. The sidewalks buzz with casual drug deals, and residents smoke and inject openly.

The City of Vancouver, to its credit, largely defies traditional approaches to drug use—namely policing, shaming, and abstinence-only services. When I first arrived here last fall, I wondered why nobody was doing anything about the mayhem. I’d see needles in the gutters, people smoking meth under tarpaulin erected on the sidewalks, dealers hawking Valium and codeine at the bus stop. But like anyone else reading the literature, I learned that exhorting drug users to get clean at all costs wouldn’t help those living with severe pain, trauma, or mental illness. All the evidence I could find pointed to embracing the kind of harm reduction that’s blossomed here in the last two decades, such as needle exchanges, low-barrier housing, and cops that turn a blind eye to small-time drug trade.

Perhaps the most convincing data for harm reduction can be found in Portugal, which decriminalized everything from cannabis to cocaine in 2001, effectively ending the drug war. The country saw a drop in drug use, HIV transmissions, and overdose deaths a decade later. While drug use is still punishable by prison time here, Vancouver too has moved away from the “hard on drugs” mentality. On Hastings, unlike elsewhere in Canada, health often comes before penalty.

One activist I spoke to called the Downtown Eastside “a visual living affront to the way mainstream Canadians would like to see themselves,” a place where marginalized populations have come together and formed a thriving community—one with political clout, no less. Among the worn-out buildings and tent cities, it was here in the 1990s where drug users took harm reduction into their own hands, opening illegal injection sites and forming needle distribution teams who would comb alleys to make sure everybody had a clean rig.

Their nose-thumbing resulted in official harm reduction services like Insite, North America’s first “supervised injection site” where clients can legally use their own street drugs. It offers supplies and social workers alongside injection booths, private desks where users shoot up in a clean environment. Nurses have reversed hundreds of overdoses since the service opened in 2003, while HIV infections and crime are down in the area around Insite. Despite the influx of fentanyl, not a single person has died there. “People talk about enabling, but you’re just enabling someone to live longer,” McLeod says. “That gives them a chance to make changes. Dead men don’t detox.”

The federal government seems to be listening to the evidence, but it’s still illegal to open injection sites without a special Health Canada-approved permit. In December 2016, Health Minister Jane Philpott introduced Bill C-37, which would streamline approval so more places like Insite can work their magic across the country. But Toronto, Ottawa, and Victoria are still on the waitlist, and for other communities, the research and surveys required by C-37 to open a site may stand in the way of even applying. “It’s labour intensive, expensive,” says Marilou Gagnon, a nursing professor and founder of a coalition of nurses fighting for harm reduction policy in Ottawa. “Meanwhile, it should just be standard practice.”

I asked Andrew MacKendrick, Minister Philpott’s press secretary, why Health Canada seemed to be sitting on its hands in the midst of these preventable deaths. “We are in a national public health crisis in Canada. Minister Philpott is committed to using every lever at her disposal to combat this crisis, and to working with all levels of government and partners across the country to do so,” MacKendrick said over the phone. “The minister has stood up and said the evidence is very clear: When properly managed and operated the sites save lives.” And while invoking the Emergencies Act, as activists have demanded, would allow Philpott to override these political barriers, MacKendrick says there’s a number of “quite high-profile criteria” to be met before she would consider doing so.*

Having a safe place to use drugs is only part of the solution. Supplying medical-grade heroin means opiate users know exactly what they’re getting and helps severely dependent users lead more fulfilling lives, giving them the time and peace of mind to pursue activities other than drug-seeking. In Vancouver, about 100 patients receive heroin daily from Providence Health Care’s Crosstown Clinic, which opened in 2011. “[It’s] a sanctuary for those people,” says activist and Crosstown patient Dave Murray. “You ask any one of them and they’ll tell you they might not be alive today if it hadn’t been for the clinic.”

Four years after opening, a study out of Crosstown found heroin therapy lowered use of street drugs and crime, allowing patients to get their lives on track without quitting opiates. Canada legalized prescription heroin last year, but advocates say accessibility has yet to catch up to the law. Gagnon, who steadfastly believes in the harm reduction philosophy, warns that some doctors aren’t trained in the science—or ethics—underlying these measures, and may not feel comfortable prescribing heroin to patients. “We can’t expect health care providers to embrace harm reduction across the board,” she says.

Aside from Crosstown, harm-reduction services stop short of supplying the drugs themselves. But activists say that’s exactly what should happen to end the overdose crisis: regulated drugs, accessible to anyone who decides to use them, including those who only indulge recreationally. They’ve floated the idea to Justin Trudeau during his recent pilgrimages to B.C., but unlike cannabis, full regulation of narcotics has proved too radical for him to support. In 2015, Trudeau told a reporter he doesn’t believe harm reduction entails the decriminalization of “harder” drugs such as heroin. “Despite some of the examples around the world, I don’t think it’s the right solution for Canada now or ever,” he said. A year later, Trudeau told the Vancouver Sun that “more work has to be done” to determine whether regulating illicit drugs is the best course of action.

That position strikes Gagnon as a blow to harm reduction work. Other experts agree. “We should have the primary goal to reduce drug-related harm, and we should be open about the best ways to reach this,” says Dr. Jürgen Rehm, director of addiction policy at the University of Toronto’s School of Public Health. Insisting on abstinence as the only form of treatment—think ideology-based 12-step programs like Narcotics Anonymous—means that patients like McLeod, who use street drugs to medicate for pain and past trauma, will inevitably fail.

***

Back on Hastings, I meet up with Karen Ward, a woman in a black hoodie frowning into her cigarette. We’re outside the Vancouver Area Network of Drug Users, a dilapidated storefront converted to a user-run resource centre back in 1998. They hold meetings every week, and have recently been letting users inject in a back room—their own unsanctioned injection site, an emergency measure to prevent more deaths. When we go inside, the front desk is plastered with funeral notices.

Activists like Ward hate the way governments have handled the crisis. She tells me, firmly, that fentanyl isn’t even the problem. “It’s always going to be something. If it’s not one substance panic it’s another,” she says. Vancouver suffered another overdose crisis in the late ’90s, when an influx of potent heroin from Southeast Asia flooded the Vancouver market, leaving 200 dead in a six-month period. The problem repeats itself, Ward explains, and bad policy is to blame. “We expect our roads not to collapse. We expect the food we eat to be safe. We expect the buildings we live in to not fall down,” she says pointedly. “We need to acknowledge that people are using substances for pain, whatever pain that is, and give them the substances in the safest way possible.” Her voice trembles. “But instead we turn around and punish them for it. We leave them to die in the street.”

To date, Canada’s response to overdoses has largely focussed on the emergency medication naloxone, which brings someone back from the brink of death. When a powerful opiate like fentanyl enters the system, it attaches to opiate receptors, which can interfere with respiration. Naloxone works by shoving the opiate molecule off its receptor, allowing the patient to breathe again. But it’s not foolproof, and not everyone knows how to administer the medication. When Jerry “Mecca J” Verge, from Surrey, B.C., was found unconscious in a washroom at his workplace with a needle still in his arm, his colleagues didn’t know how to help, and he couldn’t be revived. Even when naloxone is given in time it can take a while to work, which may lead to oxygen deprivation and irreversible brain damage. “I compare it to somebody on the street bleeding to death and having Band-Aids thrown at them,” Ward says. “We can’t naloxone our way out of this.”

There’s been “a lot of talking and not much doing” on the government’s part, according to Gagnon. “The actions that have really made a difference in this crisis have been done by volunteers on the ground.” She means organizations like the Vancouver Area Network of Drug Users, who defy the law to prevent overdoses, refusing to wait months for bills to crawl through Parliament or for public opinion to shift. “There are ways of responding to the crisis where you can overlook bureaucracy and actually save lives,” says Gagnon. Ward agrees. “We just need someone to have the political bravery to say, ‘Go and do it, it’s the right thing to do.’ Saving lives is always the right thing to do.”

For people like Jim McLeod, who may always use opiates, granting these demands could one day save his life, too. When we part ways in Oppenheimer, I pass under a row of leafless trees, wooden feathers from the rally now tied to their boughs. Almost a thousand of these makeshift monuments dance in the wind, names flashing in the sun. Each one a reminder of a human life lost not to drugs, but to radical policy: prohibition, the biggest killer of all.

* UPDATE (MAY 30, 2017): Since this story was published in our May/June 2017 issue, Bill C-37 has passed, and four supervised injection sites have been approved. This paragraph has been updated to reflect these changes, including an updated quote from Minister Philpott’s press secretary Andrew MacKendrick.

Will your donated change help solve the problem of homelessness? Creative commons photo by Flickr user Alex E. Proimos

By Mary Dirmeitis and Megan Harris

You’re walking down the street when you see a panhandler on the sidewalk, holding out a cup for passersby to give change. You can feel the loonie in your pocket left over from the coffee you bought earlier — but do you give it to the person?

If you live in a major city, or even if you don’t, you’ve likely been in this situation before. The dialogue runs through your head. If you do give up your money, what will the person spend it on? Will they use it to buy something helpful for themselves, like food, or will they use it to feed an addiction? And then your personal debate goes further. Do you have a right to judge how another individual spends their money? Are you only giving to appease your own guilt?

It’s something we think about, and feel conflicted about, and so we talked to organizations who work with street-involved people to get their take on the ethics of giving change. We asked their views on the effects of donating directly to individuals, and how people can best use their limited dollars.

Matthew Pearce, Director General of The Old Brewery Mission in Montreal, says that if you think that you’re doing your bit to help homelessness by donating money to panhandlers, you’re wrong. Small change or daily necessities such as food or clothing may benefit a homeless person temporarily, but it keeps them in their current situation.

“Instead of giving that money, collect it over a little while and make a donation to an organization that provides real services to the homeless, not just food and lodging.” says Pearce. “Most [organizations] now, such as The Old Brewery Mission, have counseling programs to get people off the street.”

With the plethora of organizations across Canada, Pearce says that the people you see panhandling do not need money for food because there are shelters that provide that.

“There’s no reason for a homeless person to be hungry with the services that exist in the cities of Canada. And so they don’t need the money to eat. They don’t need the money to clothe themselves because our shelter and others have clothing depots, and we provide them with clothing, most of it new. So they don’t need it for clothing, they don’t need it for food, and it’s not going to be enough to allow them to pay for an apartment, so it’s not for housing. So then what is that money for?” Pearce asked.

Seren Gagne, a youth support worker at Resource Assistance for Youth (RaY) in Winnipeg, says that homeless youth will seek money to support a drug or alcohol habit, whether we give to them or not. Gagne therefore supports panhandling as an ethical way of getting money.

“Let’s say you’re a drug addict. What are you going to do?” said Gagne. “Are you going to panhandle? That’s a pretty safe way of getting money. What are the other options? Sell drugs, sell your body, assault someone. If you’re going to do that anyway, I don’t think panhandling is that much of a problem. Essentially it’s harm reduction. They’re squeegeeing [a car] or panhandling, instead of committing a crime or possibly selling their bodies.”

Although a correlation between addiction and homelessness does exist, some members of the public do not want to hand over change that might support a bad habit. Others feel that homeless people, as adults, are entitled to make their own decisions about how they live and what they do. Some prefer not to give money, but will hand over food or some other helpful item.

Myron Krause speaks about how gifts — a backpack, say, or a toque — address a short-term need, but do not contribute to eradicating the root causes of poverty. As Executive Director of The Mustard Seed, a non-profit organization committed to addressing the root causes of the the homelessness epidemic in Calgary, Krause sees a lack of safe, affordable housing as the most serious issue.

“When rents start at $800 and up just for a basement suite or one-room apartment, it’s not accessible for a lot of people,” said Krause. “So [with regards to] panhandling, the money we give is probably not going to address the need for people to be able to afford their rent. But we as an organization can use that money to try and create affordable housing and that’s what we’re doing.”

A more valuable thing to do could be to donate your time — for instance, serving at a soup kitchen or volunteering at a shelter. That way, you can see direct results of your work.

“It’s great to volunteer your time,” said Gagne. “That’s better, that’s doing more for yourself, and doing more for other people. You’re not just simply doing the act of handing out money, you’re taking the time to really get to know these people and maybe interact with them on a personal level.”

Pearce believes that confronting the roots of homelessness is the most valuable act.

“It’s hard to see a positive effect [of panhandling] except that it is an opportunity for people in the city to come face to face with homelessness,” said Pearce. “And they have an option then to give money or not. They also have the option to show the person a little bit of respect, look them in the eye, show them they exist. The life of homelessness is a life of exclusion, you always feel on the fringes, you always feel like you’re almost invisible.”

Pearce also spoke about the concept of donating respect. Even if you don’t want to give the change in your pocket, or if you have none to give, look the person in the eye and tell them that. And then wish them a good day and move on.

Giving comes in all forms, whether it’s a small donation, a personalized budget, or necessities for life on the street. And the decision to engage in this transaction is ultimately a personal one. However, the causes for poverty and homelessness are vast and complex, and there are countless organizations to contribute to who have made it their mission to address these causes and eradicate homelessness for good.

Above all, Pearce also says people should not give up hope in regards to helping the homeless. “Keep going,” Pearce said, “Because it will change.”

The evidence in favour of safe-injection sites is overwhelming, but the federal government appears determined to shut Insite down.

Despite ongoing efforts by the Harper government to shut it down, Insite, the Vancouver-based supervised-injection site, is alive and thriving, with over 10,000 registered users and around 800 daily visitors. To Mark Townsend, an Insite representative, it’s a success story that needs to be replicated in other cities.

Established in 2003 as a scientific research project to help marginalized populations struggling with addiction, mental illness, and HIV/AIDS in Vancouver’s notorious Downtown Eastside, Insite operates under a constitutional exemption from federal drug laws and is the only legal supervised-injection site in North America.

Since its inception, Insite has been subject to rigorous, independent third-party research that has lead to highly positive articles in publications ranging from the New England Journal of Medicine [PDF] to The Lancet [PDF]. Results have been nearly unanimous: Insite improves health access for the highest-risk users, reduces costs to the health care system, decreases crime, and improves neighbourhoods.

For Townsend, it is a testament to the narrow-minded, ideology-driven policies of the Harper government that it is still trying to have the courts rule Insite a violation of federal criminal drug law.

The latest round of court battles started in May 2008, after the B.C. Supreme Court issued a landmark decision—that it would be a violation of the charter rights to life, liberty, and security of person for addicts not to have access to harm reduction in the form of a safe-injection site. It is this ruling that the federal government is currently appealing; there is no word yet on when a decision will be made. [UPDATE: The B.C. Court of Appeal dismissed the challenge on January 15, 2010; the government indicated it would appeal to the Supreme Court.]

Townsend is hopeful, though, that Insite will survive both its current battle in the B.C. Appeal Court and the inevitable future showdown in the federal Supreme Court. Still, in light of the government’s intransigence, Townsend insists that what is needed now is more action from Insite’s supporters: the best way to fight for the future of safe-injection sites is, where appropriate, to set up more.

“People need to stop talking, get off their asses, and actually do something,” he says with frustration, remembering how Insite immediately transformed Vancouver’s Downtown Eastside for the better.

The culprit: common hand sanitizers, which have been saturating not only our hands, but also store shelves and public places in the wake of H1N1 paranoia.

Apparently, this widely available alternative to traditional hand washing has another useful function. According to this article published yesterday in The Gazette by the Winnipeg Free Press, an increasing number of addicts are ingesting the extremely high alcoholic content of the product in order to become intoxicated.

Experts say people add salt to the hand sanitizer, which separates pure alcohol from the product with potentially dangerous results.

At one of Winnipeg’s main shelters, workers have confiscated sanitizer bottles and stopped leaving salt out on tables; people have to ask to use it.

Under the province’s Liquor Control Act, an individual found guilty of selling a non-potable intoxicating substance as a beverage can receive a fine of $2,000 to $20,000 or up to six months in jail.

Furthermore, there has been growing concern among the public about the dangers and effectiveness of the popularized product for its intended purpose. This news report, featuring Dr. William Jarvis from the Centres for Disease Control and Prevention (CDC) attempts to alert the everyday addicts; germophobes who dose their hands in the product as often as a chain-smoker takes a drag. Some scientists and healthcare professionals caution that an overuse of hand sanitizer could lead to an immunity to the product, which weakens the body’s ability to combat bacterial infections making people more susceptible to illnesses.

While many of the purported dangers are still speculation, at least one thing’s for sure. The increasing number of sanitizer skeptics, coupled with these two types of potentially harmful additions to the the product leaves the future of “convenient” cleanliness in doubt.