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Second Generation health care puts a squeeze on space in the Downtown Eastside

The Portland Hotel Society's Coco Culbertson is concerned about changes to health-care in the Downtown Eastside coming at the expense of non-medical programs that are often preferred by clients distrustful of larger institutions. Travis Lupick photo.
The Portland Hotel Society’s Coco Culbertson is concerned about changes to health-care in the Downtown Eastside coming at the expense of non-medical programs that are often preferred by clients distrustful of larger institutions. Travis Lupick photo.

David Ogilvie has created artwork since his childhood, but it wasn’t until he was 66 years old that he sold his first drawing. At a café on Main Street, the artist gave credit to Gallery Gachet, a space on Cordova Street near Columbia.

“The modest success that I’ve gained has been at least partly due to them,” Ogilvie said. He recounted that in 2015, Gallery Gachet gave him his first proper exhibition and, soon after, the Capilano Review made an offer for a series of his work.

Ogilvie said it can be hard to explain the difference this made in his life, and similarly difficult to explain the health benefits that Gallery Gachet provides to the Downtown Eastside. But he argued that its impact on mental health in the community is significant.

“Without Gallery Gachet, I don’t think I would have gotten this far,” he said. “I might not have made it at all.”

For 22 years, the gallery has operated with support from the provincial health ministry. But in September 2015, Vancouver Coastal Health (VCH), the regional care provider in charge of that money, eliminated Gallery Gachet’s $132,000 in annual funding.

The cut was the first of many moves VCH has begun as part of its “Second Generation” strategy for health care in the Downtown Eastside. The plan is described by VCH as no less than a “system transformation”. As the name Second Generation suggests, it represents the most significant revision of health care in the Downtown Eastside since VCH’s inception in 2001.

Already five years in the making, Second Generation entered an implementation phase last February. That is scheduled to continue through to October, with an official launch planned for the following month.

What’s at stake is almost $60 million that VCH spends every year on the health of Vancouver’s most marginalized residents, those of the Downtown Eastside.

A September 3 VCH media release lists a host of new mental-health and addictions services planned as part of Second Generation. That document and related materials describe a renewed emphasis on clinical services and integrated care delivered with a low-barriers approach that is heavy on peer involvement. The release warns that programs not falling within this focus on clinical applications may be discontinued.

“VCH contracts without a clear health mandate or those offering stand-alone services without formal connections to health care services may not be renewed,” it reads.

Critics of the plan argue that such a tight focus on medical and psychiatric programs will come at the expense of services that, though less formal, are no less beneficial.

Ted Bruce was interim executive director of the Portland Hotel Society for 14 months before he retired in August 2015.

“There is a need for clinical services but there is also a need to balance the clinical services we provide with some of those other, softer, support systems, which are just as important,” he told the Straight.

Portland operates Insite, North America’s first supervised-injection facility, plus 19 social-housing projects throughout the Downtown Eastside.

“What’s important to any population—and, particularly, these folks—is social inclusion, the ability to build community amongst themselves, and the ability to support each other,” Bruce explained. “The kind of programming that has long-term vision—of not just a clinical service but services that build inclusiveness and community—it’s a very important. But that’s often what is not happening when there is an emphasis only on the clinical.”

Bruce stopped short of direct criticism of Second Generation but added: “There are some things that VCH needs to think long and hard about.”

VCH’s chief medical health officer, Dr. Patricia Daly, is quoted in the September release acknowledging that the transition may encounter resistance.

“This is just the beginning of a long-term strategy for change in the Downtown Eastside that will evolve over time,” she said. “We know not everyone will agree with the changes being made, but as health care providers we know that services in the Downtown Eastside can be improved”.

Three organizations lost in the shuffle

Gallery Gachet was the first nonprofit to lose funding.

On April 7, VCH announced that a second organization would be dropped in the shuffle: the Drug User Resource Centre (DURC), a drop-in across the street from Oppenheimer Park that the Portland Hotel Society has run since 2003. DURC previously received $634,000 a year from VCH.

On May 13, in an email to the Straight, VCH named a third: ARA Mental Health, which offers advocacy services for people with mental-health challenges in a building at Pender and Beatty streets. The organization, founded in 1996, has received about $220,000 in annual government funding the past few years.

VCH has extended support to both DURC and ARA to continue operating while they seek new sources of funding, but only through to the end of this summer.

To be sure, VCH services in the Downtown Eastside are expanding by a number of measures. The clearest of these is funding. VCH has said it is increasing what it spends in the neighbourhood by $4 million a year, bringing the annual total to $59 million. There are also extended service hours coming to a number of existing clinics and an entirely new addictions-treatment centre tentatively planned for Powell Street.

Of course, Gallery Gachet’s take on Second Generation focuses on the money it lost to allow for those programs to expand.

“The pattern that I would say seems to be becoming clear,” said Cecily Nicholson, the organization’s financial administrator, “is that there is a lack of attention to preventative means, social, and tertiary services—services that are not directly clinical but are also completely necessary.”

She described Ogilvie’s story as typical of the gallery’s membership, many of whom struggle with mental-health challenges.

“Like the fellow who just brought in his sculpture last week,” Nicholson said. “These are people who are isolated in SROs—very poor housing conditions—but with wall-to-wall art in their rooms. And they have not been able to share it. That is a common narrative.”

She warned that as VCH moves to fill gaps in its system, it is this population that’s at risk of falling through new cracks that open up.

A state of extreme anxiety

For this article, the Straight spoke with some two dozen people employed by VCH-funded nonprofits and the clients for whom those organizations provide care.

Several people who have spoken to the Straight on a regular basis in the past refused to go on the record for an interview about Second Generation. They cited fears of placing funding in jeopardy. Some pointed to nondisclosure agreements that are now routinely built into contracts with VCH and even applications for VCH contracts.

Those and other conversations revealed a community in a state of extreme anxiety for the changes that are coming.

Coco Culbertson is in charge of housing, community, and peer development for the Portland Hotel Society, one of the few nonprofits that was willing to comment on the record for this story.

She noted that it is still early days in the rollout of Second Generation, and she stressed that service providers don’t yet fully understand how the plan will change health care in the Downtown Eastside.

“It remains to be seen,” she said. “And I think it’s important we stay in discussion with VCH.”

At the same time, Culbertson expressed concern for a focus on clinical services coming at the expense of community programs that she maintained—although perhaps not involving a psychiatrist in a lab coat—do improve people’s health.

“From the PHS Community Services Society’s perspective, nonclinical, nonmedicalized, and noninstitutional approaches to care are at the heart of what we do and why we’ve been successful in engaging thousands of people every day in the Downtown Eastside,” Culbertson said. “I would hope that VCH will continue to value those interventions.”

Marion Allaart is executive director of the Vancouver Area Network of Drug Users (Vandu), a nonprofit founded in 1998 that was instrumental in the fight for Insite. Asked about Second Generation, Allaart’s response was representative of other nonprofit employees who only spoke off the record.

“We’ve been expecting them to come for us for a long time,” Allaart told the Straight.

Service improvements throughout the community

VCH’s mental-health and addictions programs in the Downtown Eastside are overseen by Andrew MacFarlane, operations director of community health services (inner city–east). In a wide-ranging interview at VCH headquarters at West 6th Avenue and Cambie Street, he began by outlining the problems that VCH aims to address with Second Generation.

“We’ve, historically, not been great about being low-barrier and accessible for vulnerable people,” MacFarlane said. “Between 9 a.m. and 4 p.m. doesn’t work for a lot of people that have chaos in their lives.”

To that end, MacFarlane said, VCH is extending service hours and expanding programs at three existing clinics: at 59 West Pender Street, 569 Powell Street, and 330 Heatley Street.

At those locations, he said, doors will soon be open 12 hours a day, seven days a week.

A second complaint VCH heard in its consultation phase for Second Generation was of a system heavily burdened by its complicated structure, where services are isolated from one another in ways that prevent many mentally ill people from receiving care.

“We had programs that were really siloed,” MacFarlane said. “If you saw a mental-health clinician somewhere, then you had to walk somewhere else to a primary-care doctor, who may or may not be in the loop on what is happening with your mental-health treatment.”

To address that problem, new “integrated health-care teams” will deploy at those three locations and others to offer more holistic care, he continued.

“We have a model that we’re implementing that is about having one care team that is really interdisciplinary with a single care coordinator at the centre of it,” MacFarlane said. “Each client will have a designated care coordinator, which will provide a single point of contact for other care providers and agencies.”

Second Generation will also bring a whole new point of access to the Downtown Eastside: the Railtown Centre for Addictions (a working title that could change). VCH declined to reveal a location for the building but multiple sources told the Straight it will likely open on Powell Street east of Oppenheimer Park. VCH will run the centre itself (as opposed to contracting it to a nonprofit). It is scheduled to open this fall.

MacFarlane described the Railtown Centre as a low-barriers medical hub for people with addiction issues.

“This includes an interdisciplinary team, an on-site physician, pharmacist, nurses, and evidence-based psychosocial supports such as social workers, counsellors, peers, and financial workers,” he said.

He noted it will also involve a drop-in component that, crucially, will allow people to connect with addictions services without having to make an appointment or work their way up a wait list.

Through all of that, MacFarlane maintained that harm-reduction programs such as needle exchanges will continue to be a “core competency” of VCH’s work in the Downtown Eastside.

He said that Insite, the city’s only low-barrier supervised-injection facility, has already seen its hours shifted to open earlier in the morning. MacFarlane added that VCH also hopes to soon see supervised injection occur at additional locations. “We are actively pursuing approval to go ahead with that,” he said.

Feedback falling on deaf ears?

For Second Generation, VCH conducted an extensive consultation process that lasted longer than two years.

It commissioned three lengthy papers that presented Downtown Eastside residents’ views on what they want for the community. Today, VCH points to those documents as evidence the Second Generation rollout is following the advice of the people it serves.

At the daily street market on the unit block of East Hastings Street, the Straight asked one of those papers’ authors, Ann Livingston, if Second Generation’s implementation fits with the community feedback she presented in her report.

“Hell, no,” she replied. “I don’t think they’ve looked at it at all.”

Livingston, a cofounder of Vandu, argued that Gallery Gachet and DURC, though not perfect, made people feel welcome and a part of decisions related to their care.

“The things that make the most difference in people’s lives is being welcomed, having autonomy, and having power,” Livingston explained. “Trauma-informed services should be accessible. People should feel welcome. They shouldn’t have to buzz to get in; they shouldn’t have to be a client; they shouldn’t have to give their name….That’s a model for trauma-informed services. But that seems to have been dropped.”

Support for change

Livingston and other Downtown Eastside residents interviewed for this story also raised serious questions about the first big winner in the funding shuffle that’s come with Second Generation: Lookout Emergency Aid Society. She criticized the group’s record on harm reduction in Surrey, where it previously operated as Keys Housing and Health Solutions under the direction of Fraser Health Authority. Livingston took issue with restrictive hours for harm-reduction programs and a past requirement for needle exchange to happen on a one-for-one basis (since abolished).

When DURC lost $634,000 in annual funding from VCH, Lookout gained about $200,000 to allow it to extend hours and expand services at a drop-in centre called LivingRoom, located on Powell Street just east of Oppenheimer Park.

In a telephone interview, Lookout’s executive director, Shayne Williams, defended the organization’s harm-reduction services in both Surrey and Vancouver. He said harm reduction will also be a big part of expanded programs at LivingRoom, though he added it was too early to say exactly what shape those will take.

Williams did, however, note the new LivingRoom will fit with VCH’s stated emphasis on clinical applications. “It certainly won’t be hardcore clinical,” he said. “But the focus will be to be proactive. To help folks get connections to care, to VCH services, to other, more clinical services, and to be that kind of entry point for folks.”

Stephen Finlay is executive director of ARA Mental Health. Despite VCH eliminating funding for his organization, he was largely supportive of Second Generation.

“For many years, everybody has complained—and rightly so—that clients get shuffled from door to door,” he began. “Vancouver Coastal Health listened to that. And they are trying to set up this service so that there is less of that.”

Discussing cuts to his organizations and others like Gallery Gachet and DURC, Finlay alluded to an issue larger than VCH. He pointed out that the health-care provider no longer receives annual budget increases like it once did.

Budgetary constraints

A review of VCH’s annual reports shows Finlay is correct.

In 2009, the B.C. Ministry of Health gave VCH a seven-percent increase to its total operating budget. Since then, there’s been a downward trend in the amount of annual increases. In 2010 and 2011, the increase was three percent each year, then four percent in 2012, two percent in 2013, and three percent in 2014. Then, in 2015, provincial contributions to VCH were reduced by one percent from the previous year.

Since 2010, the change in ministry funding for VCH has averaged plus–two percent per year, barely keeping up with inflation, let alone costs associated with new technologies and aging baby boomers.

Asked if this situation has put a squeeze on services in the Downtown Eastside, VCH’s director of strategy deployment, Natasha Golbeck, remained upbeat.

“We’re always challenged in health care to do more with less and to be increasingly efficient and thoughtful about where we spend resources,” she said. “We are not doing more with less; we’re doing more with more.”

Pressed on whether or not VCH is preparing to eliminate funding for other programs beyond Gallery Gachet, DURC, and ARA Mental Health, Golbeck responded: “The things that are going to be lost have already been lost. At this point, we have made the reallocations that we’ve needed to make.”

The Ministry of Health did not make a representative available for an interview. Quoted in a VCH media release, minister Terry Lake threw his weight behind the Second Generation.

“Change is never easy, but we know it’s desperately needed in the Downtown Eastside,” he said. “Many residents increasingly struggle with chronic conditions and changing addiction issues, but a lack of integration between health services creates barriers to accessing treatment. I applaud Vancouver Coastal Health for making the changes needed to improve patient care in this neighbourhood.”

Losing space

DURC, expected to close by the end of the summer, is a low-barriers community centre that serves as a safe space for alcoholics and people addicted to hard drugs, including stimulants such as methamphetamine and crack cocaine. It offers laundry and showers plus harm-reduction services such as a crack-pipe vending machine and a managed-alcohol program that lets severe alcoholics brew their own beer.

Each Friday afternoon, the managed-alcohol program convenes at DURC for a regular meeting called the “Drinkers Lounge”. What’s said there is usually confidential (as with Alcoholics Anonymous meetings), but the group permitted the Straight to attend on April 29 on the condition that names be withheld.

Participants explained how the program saves people from drinking Listerine and hand sanitizer across the street in Oppenheimer Park. The homebrew they make at DURC is safer, and the Friday meetings allow DURC to connect members to health services, including detox and rehab.

The April 29 meeting began with a roll call of the 35 people in attendance. Next there was a round of happy birthdays, followed by a reading of the group’s rules and mandate. To conclude the meeting’s opening, people were asked to stand for a moment of silence and invited to recite the names of friends or family who had recently passed away or gone missing. One by one, 16 names were called out.

Moving to an open discussion, the topic of the day was DURC’s pending closure and VCH’s reallocation of funds to the Lookout drop-in centre called LivingRoom.

“Where are we going to go?” asked a man in the back. “The City of Vancouver doesn’t want us on the streets around here. They don’t want us in the park. They’re doing this to get rid of us.”

Liz Evans founded the Portland Hotel Society in 1993 and served on the organization’s executive management team for 20 years before she resigned in 2014. She declined to speak specifically on Second Generation, but expressed concern for marginalized people losing the spaces where they feel comfortable.

“If you’re living in a tiny SRO room, 120 square feet, where all you have that’s yours is a sink and a fridge, then having a café to sit in is meaningful,” she said. “And it just feels like space is being lost.”

On May 6, the Portland Hotel Society’s interim executive director abruptly stepped down. Pending the appointment of a new leader, Coco Culbertson is acting as a spokesperson for the organization.

She voiced concerns about the pace with which the Downtown Eastside is changing but maintained that it has learned to take care of itself.

“This community has always had a strong voice when it gets together,” Culbertson said.

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This article originally appeared in print and online at Straight.com on May 21, 2016.

Health Canada proposes regulation change to permit prescription heroin for severe addicts

At Crosstown Clinic in the Downtown Eastside, Dr. Scott MacDonald oversees patients with severe addictions who are given prescription heroin and hydromorphone to stabilize their lives. Travis Lupick photo.
At Crosstown Clinic in the Downtown Eastside, Dr. Scott MacDonald oversees patients with severe addictions who are given prescription heroin and hydromorphone to stabilize their lives. Travis Lupick photo.

Canadian doctors could soon be allowed to offer patients prescription heroin as a method of treatment for a severe addiction to opioids.

Today (May 13), Health Canada proposed a regulatory change that would let doctors apply for special access to the drug, also called diacetylmorphine, and offer it to patients as they see fit.

“A significant body of scientific evidence supports the medical use of diacetylmorphine, also known as pharmaceutical-grade heroin, for the treatment of chronic relapsing opioid dependence,” reads a Health Canada media release.

Since December 2014, a small group of specific patients has hadaccess to prescription heroin at a clinic called Crosstown in Vancouver’s Downtown Eastside.

Three times a day, 110 patients can visit the clinic at set times and receive an intravenous dose of heroin under the supervision of nurses. The treatment is paid for by taxpayers and operates under Providence Health Care, the regional authority that also runs St. Paul’s Hospital.

The 110 people are only allowed access to the drug via a court injunction. They are previous participants in a clinical trial. Upon that study’s conclusion, they were essentially grandfathered into the program pending the resolution of a legal challenge.

If the proposed regulatory changes pass, it would eliminate the need for that legal challenge and open the door for people outside of the group of Crosstown patients to gain access to prescription heroin via their doctors.

A consultation period of 30 days is now underway.

Dr. Scott MacDonald is the lead physician at Crosstown Clinic who oversees the heroin maintenance program there.

“This is good news,” he said in a telephone interview. “There are going to be more people having access to diacetylmorphine as a safe, effective, and cost effective treatment.”

MacDonald however added the proposed regulations are only a “good first step”. He noted the bureaucratic requirements for a doctor to prescribe heroin would remain arduous.

The idea behind heroin maintenance is harm reduction, MacDonald explained.

He pointed to studies that show patients enrolled in a heroin-maintenance program will have less negative interactions with police, greater access to medical treatment, and a new degree of stability that can help them improve other areas of their lives, such as housing and family relations.

“These people are involved in a chaotic lifestyle and an illicit drug trade that supports organized crime and general chaos for the community,” he said. “It is important that we engage everybody in care that is using illicit opioids. We need all the tools in the tool kit, whether that is methadone, suboxone, hydromorphone for some, and diacetylmorphine or prescription heroin for the small number of people that need that.”

The treatment is only recommended for chronic addicts who have previously failed with traditional forms of rehabilitation such as abstinence and methadone.

For the 110 patients receiving prescription heroin at Crosstown, the average number of years they have been addicted to opioids is 26.6 years. The average number of times they have failed with a traditional treatment is 11.4.

MacDonald estimated that if heroin maintenance could be administered without bureaucratic restrictions, the number of Vancouver residents for which the treatment would be appropriate would not exceed 500.

The court challenge was launched in March 2014 when Providence Health Care and five long-time heroin addicts filed a lawsuit against the Canadian government in an effort to secure diacetylmorphine as a legal means of managing addiction.

That action was in response to a regulatory change that former health minister Rona Ambrose enacted in October 2013. That month, she closed what she described as a “loophole”, barring clinicians from applying for special access to administer drugs such as heroin, cocaine, and ecstasy (MDMA).

Canadian doctors had never prescribed those drugs on a regular basis. But at that time, Vancouver’s heroin-maintenance program at Crosstown was gaining attention. Doctors were also beginning to write diacetylmorphine prescriptions for patients who had cycled out of the academic trial, and moving to make the treatment available to addicts who were not enrolled in earlier studies.

Doug King is a lawyer with Pivot Legal Society, the group representing the five plaintiffs in their lawsuit against the federal government. In a telephone interview, he said the regulatory change could lead the group to drop its court action.

“We’re happy,” he told the Straight. “We expect we’ll get the change in regulations that we are asking for in our lawsuit, and that will, essentially, be a victory for us.

“The point of the lawsuit was to nullify the regulation change that was made by the Conservative government and bring it back to the way it was,” King continued. “And that is essentially what they are doing here.”

Libby Davies was the member of parliament representing Vancouver East from 1997 to 2015. During those years, she repeatedly called for the government to legalize heroin as a means of reducing overdose deaths and improving the lives of addicts.

In a telephone interview, Davies placed the benefits of prescription heroin in the context of recent deaths attributed to fentanyl. She noted that drug, which is often sold as heroin but is much more dangerous, is killing an average of 64 British Columbians every month this year.

“People don’t know what they are taking,” she told the Straight. “So to have a prescribed program where people are in the health-care system, to me, that is the critical thing.”

B.C. Health Minister Terry Lake voiced his support for Crosstown’s heroin-maintenance program in a release back in October 2013.

“We have to think outside of the box sometimes,” he said. “I know that the thought of using heroin as a treatment is scary, but I think we have to take the emotion out of it and let science inform the discussion.”

Health Canada’s May 13 release notes prescription heroin has been available in other jurisdictions for some time, including Germany, the Netherlands, Denmark, and Switzerland.

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This article originally appeared in print and online at Straight.com on May 13, 2016.

B.C. RCMP officers at centre of sharp rise in fatal police shootings

The family of Naverone Woods, a 23-year-old First Nations man who was fatally shot by transit police, is still waiting for answers about why guns were used.
The family of Naverone Woods, a 23-year-old First Nations man who was fatally shot by transit police, is still waiting for answers about why guns were used.

December 28 marks one year having passed since the death of Naverone Woods, a 23-year-old First Nations man who was shot and killed by transit police at a grocery store in Surrey.

On the phone from Hazelton, B.C., one of two Interior towns where Woods grew up, sister-in-law Tracey Woods said the family is still waiting for answers.

“We just want to have some kind of closure,” she explained. “And to know that there was an investigation done, that this case wasn’t just pushed aside.”

Tracey, whom a neighbour described as “like a stepmother” to Naverone, said she has questions about what efforts were made to deescalate the situation before force was deemed necessary, and why guns were used at all.

“We always compare it to a big grizzly bear that they will shoot, put to sleep, and relocate,” she continued. “How come they couldn’t use a Taser or something rather than drawing their weapons?”

Woods was the eighth British Columbian to die in a police-involved incident in 2014, according to a database maintained by the Georgia Straight. So far in 2015, that number stands at 11, the most for any year since 2009.

Last February, the Straight reported that a stark pattern emerged from an analysis of dozens of deaths involving B.C. authorities dating back to 2007: of 99 police-involved deaths investigated by the B.C. Coroners Service or scheduled for investigation, 90 percent involved a mental-health component, substance abuse, or both.

Now a review of that database updated for 2015 reveals another pattern: as deaths have increased, so has the frequency with which guns were involved in those incidents.

In 2015, there were seven fatal police shootings in B.C. That was up from five the previous year, two in 2013, four in 2012, five in 2011, three in 2010, and seven in 2009.

Six of those seven shootings in 2015 involved the RCMP. That compares to two during each of the years 2014, 2013, and 2012, and four in 2011, three in 2010, and five in 2009. Fatal RCMP shootings were geographically dispersed across the province. One exception is Surrey, where RCMP officers have shot and killed seven people since 2009.

Josh Paterson, executive director of the B.C. Civil Liberties Association, said that, to an extent, the data simply speaks for itself.

“These numbers suggest a doubling of police-involved deaths in the last three years in B.C.,” Paterson told the Straight. “The number of people shot and killed by the RCMP have risen to the highest level in over 10 years. While these numbers don’t allow us to draw a conclusion as to why this is happening, they raise an alarm and require us to ask hard questions.”

The B.C. RCMP and the B.C. Ministry of Justice refused to grant interviews.

Steve Schnitzer is the police-academy director for the Justice Institute of B.C. He called attention to courses that focus on crisis intervention and deescalation tactics and how best to respond to emergencies involving a mental-health component. Those lessons were made mandatory in 2012 following the 2007 death of Robert Dziekański at Vancouver International Airport and the subsequent Braidwood Commission of Inquiry.

“That is a policing standard now,” Schnitzer emphasized. “It [training] changed significantly after the Braidwood commission report came out.”

Statistics compiled by the coroner’s service suggest that there is still room for improvement. According to the organization’s annual report for 2010, just 40 percent of coroner’s recommendations related to police-involved deaths were adopted by the agencies involved in those incidents (2010 being the most recent year for which such statistics were included).

Doug King, a lawyer with Pivot Legal Society, said there is one factor that can make all the difference in how a police encounter plays out: time.

“There is a huge correlation—based on our work and what we see—with police-involved shootings and first responders,” he said.

King explained that when police officers fire their guns, the weapon is almost always discharged by an officer who was first on the scene and during the first few minutes of a confrontation.

“To me, that indicates there needs to be better training and a greater emphasis on what someone can do to contain an individual until help can arrive,” King said.

The death of Naverone Woods remains under investigation by the Independent Investigations Office of B.C., a public body created in 2012 to examine police incidents involving death or serious harm. Once that review is complete, the case will likely proceed to the coroner’s service.

King said that investigation is one of three he’ll be watching in 2016.

The second, he continued, is that of Phuong Na (Tony) Du, who was killed by Vancouver police at the corner of Knight Street and East 41st Avenue in November 2014. The third is Hudson Brooks, a 20-year-old male who was shot by Surrey RCMP in July 2015.

“These three shootings are all really problematic, from what we’ve heard, and really beg explanations,” King said.

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This article originally appeared in print and online at Straight.com on December 23, 2015.

Methadone patient alleges discrimination and targets the B.C. government with a class-action lawsuit

Laura Shaver, a member of the Vancouver Area Network of Drug Users (Vandu), has opened the door for a class-action lawsuit against the B.C. government for allegedly discriminating against methadone patients. Travis Lupick photo.
Laura Shaver, a member of the Vancouver Area Network of Drug Users (Vandu), has opened the door for a class-action lawsuit against the B.C. government for allegedly discriminating against methadone patients. Travis Lupick photo.

An advocate for recovering heroin addicts has taken the first step in a potential class-action lawsuit against the Government of British Columbia.

“I want to help everybody in the Downtown Eastside who is on methadone and who has to pay this,” Laura Shaver told the Straight.

According to a notice of civil claim filed today (November 4) in the B.C. Supreme Court, Shaver entered into an agreement with the province that results in a monthly deduction from her social-assistance payments (commonly referred to as welfare).

The claim alleges Shaver entered that agreement while under duress, and that the nature of that agreement amounts to discrimination on the basis of a disability.

None of the allegations included in the lawsuit’s notice of claim have been proven in court. The province has yet to file a statement of defence.

The lawsuit pertains to a group of people who are both enrolled in the province’s methadone maintenance program (MMP) and who receive social assistance under the B.C. Employment and Assistance Act.

The claim explains that as one of those people, Shaver was asked to enter into a “fee agreement” with the Ministry of Social Development before her physician would prescribe her methadone, a form of an opioid-substitution therapy favoured in B.C. for the treatment of an addiction to heroin.

“Ms. Shaver signed the Fee Agreement unwillingly and under duress to gain access to necessary medical treatment,” the notice of claim reads.

That fee agreement preauthorizes the provincial government to deduct an amount from Shaver’s monthly social-assistance payments and provide that money to the private clinic where she is prescribed methadone.

“The Fee Agreement purports to allow the Province to deduct $18.34 from Ms. Shaver’s social-assistance payment per month despite the Province’s implicit understanding and awareness that Ms. Shaver has no resources to cover that cost and that going without methadone was not a practicable option for Ms. Shaver,” it continues.

The notice of claim states that because the fee agreement in question is only applied against methadone patients, the monthly deduction from Shaver’s social-assistance payments amount to a violation of Section 15 of the Canadian Charter of Rights and Freedoms. It states that every citizen is equal before the law and ensured equal treatment regardless of any mental or physical disability.

The Straight has requested an interview with the Ministry of Social Development and Social Innovation. This article will be updated if a representative is made available.

Shaver, who is also a member of the B.C. Association of People on Methadone and the Vancouver Area Network of Drug Users (Vandu), is represented in her legal challenge by Jason Gratl, a Vancouver-based lawyer.

“From a legal point of view, the signature on patients’ consent forms—the signature on the forms consenting to the payment—was obtained by means of duress,” he said.

Gratl conceded that to many people, $18.34 a month won’t sound like a lot of money. But to those on welfare, it can account for a noticeable fraction of their budgets.

“The ministry and the prescribing doctors are forcing people to choose between necessary medical treatment and food,” he argued.

In B.C., the maximum amount of monthly income assistance for a single employable person is $610, which includes a $375 shelter allowance .

Gratl said that he wants the legal challenge to result in the province refunding money to any patient enrolled in the methadone maintenance program who saw money deducted from their monthly social-assistance payments.

“There is no legal authority allowing for such deductions to occur,” he said. “Those services are medically necessary.”

The B.C. Supreme Court has yet to certify the claim as a class-action lawsuit. Gratl told the Straight he is confident it will receive that classification and advance in the near future.

According to a May 2014 B.C. government report, in 2012-13 there were 14,833 patients enrolled in the province’s methadone-maintenance treatment program.

That document states that to keep one patient in opiate substitution therapy, it costs B.C. approximately $3,268 per year.

If the government were to stop its monthly deductions from cheques like Shaver’s, that number would grow to approximately $3,488 per year.

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This article was originally published online at Straight.com on November 4, 2015.

Addiction is not a disease, Toronto neuroscientist Marc Lewis argues in The Biology of Desire

It has been very useful for western society to classify addiction as a disease, according to Marc Lewis, a Toronto neuroscientist. That has let drug users understand their cravings as something that can be dealt with within existing health-care systems. It has also allowed doctors to treat addiction with pharmaceutical tools like methadone and permitted policymakers to spend money on drug-rehabilitation programs the same way governments fund research for conditions such as diabetes.

On the line from the Netherlands, where he teaches developmental psychology at Radboud University, Lewis conceded that the conception of addiction he proposes in his new book, The Biology of Desire: Why Addiction Is Not a Disease, risks upending all of that.

“The criticism that I’ve gotten says that if you stop calling it a disease, if you take away our health-care system—the institutional network that we have for dealing with addicts—that addicts won’t get treated,” he told the Georgia Straight. “That is a valid concern, but I think it is shortsighted.”

Lewis will present a long-term alternative when he travels to Vancouver on August 4 for an event, organized by the Portland Hotel Society, that is timed to coincide with the Canadian publication of his book.

In The Biology of Desire, he argues that addiction is not a disease but a learned habit, a normal process of the brain’s development, albeit a destructive one.

“The repetition of particular experiences modifies synaptic networks,” he writes. “This creates a feedback cycle between experience and brain change, each one shaping the other. New patterns of synaptic connections perpetuate themselves like the ruts carved by rainwater in the garden. The take-home message? Brain changes naturally settle into brain habits—which lock into mental habits.”

In easily digestible anecdotes, Lewis presents the lives of characters like Natalie, a university student who slowly transitioned from prescription opioids to heroin. Alternating real-life stories and descriptions of neurological changes happening at a molecular level, Lewis delivers step-by-step explanations of the ways that physical actions involving drugs impact the brain to create feedback loops. Over time and through repeated behaviour, those effects change how the brain functions.

For example, dopamine uptake to the striatum—the part of the forebrain that receives input from the cerebral cortex—evolves to prioritize short-term rewards over long-term planning. At the same time, synaptic pruning results in a loss of communication between different brain systems that regulate self-control.

These changes are not the result of a disease or dominant genetic predisposition, Lewis maintained, but are the predictable results of behaviour patterns and environmental impacts.

“When people talk about an addiction gene or a cluster of genes for addiction, it is just not right; it is just not scientifically valid,” he argued. “What I wanted to do is to launch an alternative based on the science, and on the neuroscience in particular, as well as the stories of addicts.”

Lewis, whose 2012 book, Memoirs of an Addicted Brain, lays bare his own past struggles with drugs, said that as long as we continue to incorrectly describe addiction as a disease, we prevent society from developing an understanding that allows us to more effectively help people get better.

His work makes a strong case for a paradigm shift, but The Biology of Desire presents no silver bullets.

“Whether you see addiction as a disease or as a learning phenomenon, it isn’t clear exactly how you fix it,” Lewis said. But, Lewis added, the first step must be acknowledging that addiction as a concept is something more complicated than a disease.

Marc Lewis will speak at 7 p.m. on Tuesday (August 4) at the Goldcorp Centre for the Arts at SFU Woodward’s.

The article originally appeared in print and online at Straight.com on July 29, 2015

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Vancouver study finds supportive-housing policies fail to curb drug use

B.C. Housing CEO Shayne Ramsey recent led a tour of various supportive-housing sites around the Downtown Eastside, several which fit into a Housing First strategy the province has adopted in partnership with the City of Vancouver. Travis Lupick photo.
B.C. Housing CEO Shayne Ramsey recent led a tour of various supportive-housing sites around the Downtown Eastside, several which fit into a Housing First strategy the province has adopted in partnership with the City of Vancouver. Travis Lupick photo.

SFU associate professor Julian Somers describes himself as a big fan of Housing First, a social policy wherein homeless people who struggle with a mental illness or addiction issue are given a room as the first step in getting their lives on track. But Somers told the Straight that a study he conducted suggests there’s one area where the benefits of Housing First may hit a wall.

“The model that we implemented based on Housing First doesn’t, on its own, have an impact on problematic substance use,” Somers said in a telephone interview. “I think one of the chief implications would be that we need to strengthen the quality, availability, and diversity of addiction treatment.”

Somers described his latest paper—which saw publication July 16 in the academic journal Addiction—as the first to quantifiably test this aspect of Housing First.

For two years, researchers followed 497 Vancouver residents who were both homeless and diagnosed with a mental illness. A control group of 200 was marked “treatment as usual” and not given a room, while 297 people were provided with independent housing plus support services such as mental-health care.

When researchers compared the two groups’ drug-use habits, it was found that Housing First “did not reduce daily substance use compared with treatment as usual”.

Somers emphasized that these findings do not detract from previous research concluding that Housing First’s benefits justify its costs. (A 2014 Mental Health Commission of Canadareport, for example, states that when the same group of people described above entered the Housing First program, the result was fewer visits to the emergency room, fewer interactions with the justice system, and “significant and meaningful improvements in community functioning and quality of life”.)

Somers added that this month’s findings related to drug use do not address cause and effect.

“Addiction treatment, period, is really hard to come by,” he explained. “The finding may really be related to the broader observation, that if you have an addiction in Vancouver and you are well-employed and wealthy, you may still have a problem getting adequate treatment.”

Vision Vancouver councillor Kerry Jang defended Housing First while acknowledging there are limits to its benefits.

“We’ve always known this,” he said on Somers’s findings related to drug use. “His research has demonstrated that Housing First is a necessary but not always sufficient condition to help somebody get off the street.”

For that reason, Jang stressed, a number of supportive-housing sites the city has developed with the province not only provide people with a room, but also include support services such as rooms reserved for at-risk youth and mental-health care services.

“It’s more and more common that the folks in our housing are the most ill,” he said. “They have a mental health and addiction problem. Concurrent disorders. And those guys can be expensive and difficult to treat. But they can be treated.”

This article was originally published at Straight.com on July 25, 2015.

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Johann Hari’s Chasing the Scream looks to Vancouver for a start to the end of the war on drugs

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On the cover of Johann Hari’s Chasing the Scream is a man in the shadows holding a pipe and a lighter to his face. The camera is angled up toward the trees and sky behind him. To most people, it’s a shot that could have been taken anywhere. But to residents of Vancouver, it’s an image that will likely look familiar. It’s Gastown, where one of the most affluent areas of the city blends into a neighbourhood best-known for drug addiction.

There is a lot in Hari’s 2015 book about prohibition and the drug war that will feel familiar to Vancouver readers. Hari spends more than 50 of the book’s 300 pages in our quiet city.

With fascination and compassion, he recounts the stories of some of the Downtown Eastside’s best-known characters, unearthing intimate details that even some seasoned Vancouver reporters might be surprised to learn.

The life of the late Bud Osborn—who passed away in May 2014—is recounted, beginning as far back as the Insite founder’s childhood in Toledo, Ohio. Osborn’s early experiences with family trauma are tied to his later struggles with alcohol and then heroin addiction. And those in turn are tied to his days in the Downtown Eastside, where he went on to pioneer harm-reduction programs and eventually help get North America’s first and only supervised-injection facility off the ground.

Portland Hotel Society cofounder Liz Evans is interviewed about her time as a young nurse. She pushed for a new kind of social housing in the Downtown Eastside where tenants were guaranteed a room they could keep regardless of day-to-day struggles with addiction or a mental illness. (Today, the City of Vancouver calls this “housing first” and places it at the centre of strategies to reduce street homelessness.)

Hari also gives considerable space to Bruce Alexander, a psychologist and adjunct professor at Simon Fraser University. Alexander once elicited scoffs for challenging widely accepted theories related to chemical addictions. His innovative research has since changed the ways we understand fundamental concepts about the disease, Hari writes (and recently discussed in Vancouver during a TED talk last June).

Finally, there is Dr. Gabor Maté, a physician who was once a fixture in the Downtown Eastside and whose work obviously had a great influence on Hari.

“I find myself walking in circles through the Downton Eastside after one of my conversations with Gabor, past addicts who are half collapsed on the street,” Hari writes. “They are wearing the exaggerated stage makeup of the street prostitute, or hawking drugs or random items they have discovered in dumpsters—old VHS tapes and half-broken shoes. They shout and holler, at me, and at the world.

“I picture the look of judgement on the faces of people who stumble into this neighbourhood by mistake. I can see them now. The people from stable families, who glance at addicts and shake their head and say, ‘I would never do that to myself.’ I feel an urge to stop them and wave Gabor’s statistics in their face and say—Don’t you see? You wouldn’t do this to yourself because you don’t have to. You never had to learn to cope with more pain than you could bear.”

Hari presents the city as a progressive example of how other regions might take their first steps toward legalization. One not as far along as Portugal or Uruguay, but a city ahead of any other in North America.

“Vancouver had given me an itchy sense of hope,” he writes as he ends his time here. Optimism might not be the feeling many take away from a walk through the Downtown Eastside. But Chasing the Scream is a work that flips a lot of notions on their heads.

It’s a thoroughly researched takedown of just about every argument there is in support of the war on drugs. At the core of Hari’s case is one simple point: even the most addictive of illicit drugs are more harmful to people when they remain illegal.

Driven almost entirely by anecdotal narratives and in-depth character profiles, Chasing the Scream tells the story of the drug war as it plays out on the ground.

He begins with the cop, the robber, and the addict caught between them.

There’s Harry Anslinger, a Prohibition-era officer of the U.S. Treasury Department who Hari presents as the prototype for fanatical executors of the drug war. His opponent is Arnold Rothstein, a ruthless and brilliant New York gangster who caught on early to the potential for wealth and power created by a government ban on something so many people desire. Billy Holiday is the tragic consequence of the system created by those opposing sides. It isn’t heroin that defeats her but authorities’ persecution of her addiction to the drug.

From there, Hari hops around the globe, from blood-filled streets in Ciudad Juárez to a prison where women are locked in solitary confinement in the desert of Arizona to government-funded rehabilitation programs in Portugal.

There are omissions. There is scant attention paid to politics or even Washington’s most influential players in the war on drugs. Former U.S. presidents Richard Nixon and Ronald Reagan, for example, barely receive a mention. The war’s greatest villains, such as Pablo Escobar and Manuel Noriega, are similarly ignored. Racial elements also receive less attention than they deserve, though on that topic, Hari refers readers to Michelle Alexander and her exceptional 2010 book The New Jim Crow (a work that cannot be recommended highly enough).

But what Hari does cover with Chasing the Scream, he covers exceptionally well. It’s a book with the power to change entrenched views and policies that reads so quickly I could hardly put it down.

It’s also worth noting that Hari is realistic. He’s looked at the data and accepts that the use of some drugs will increase after legalization. (Drug use, but not necessarily harmful drug use, as he goes on to explain.) It also might be telling that he describes Vancouver’s Downtown Eastside with such positivity; perhaps that should serve as a warning that ending the drug war will involve measures not always so easy to stomach.

This article was originally published at Straight.com on July 18, 2015.

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Drug traffic fuels addiction in Sierra Leone

A version of this article was originally published at Al Jazeera English on January 26, 2013.

Freetown, Sierra Leone – Leaning against a wall, his eyes red and glazed over, Patrick Hindowa described how he spends his days getting high. “I got no job here,” he explained. “Whatever [drugs] I’m going to be able to do, I’m going to do. Because I really don’t have nothing.”

Huddled at the end of a narrow alleyway downtown, Hindowa and two friends shared stories of addiction and life on the street.

“My mother died, my father died,” recalled Bakar Sesay. “Since then – since I was a kid – I chose the street life. Coke and all that.” The 20-year-old said that he has used drugs since he was seven.

The group listed heroin as their favourite, with freebased cocaine a close second. When hard drugs were not available, they turn to marijuana, alcohol, amphetamines, or prescription pills – anything, really. “From the time we wake up, ’till the time we go to sleep,” one said.

Substance abuse has long been a problem for the impoverished West African country. Throughout the 1990s, a civil war gained international notoriety for the role played by drug-fuelled teenagers, who committed atrocities and launched an anarchic attack on the capital. The effects of marijuana, alcohol, and amphetamines contributed to the violence. When the conflict ended in 2002, many combatants returned home addicted to those substances.

In recent years, harder drugs – cocaine and, to a lesser extent, heroin – have become increasingly available, authorities and health practitioners say. They blame West Africa’s growing role as a transit route for the global narcotics trade. Cocaine comes from Latin America and heroin from Southeast Asia, officials explained, and through such countries as Guinea-Bissau, Liberia, and Sierra Leone. The drugs then continue on to Europe and North America.

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