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 courtesy of Vancouver Courier/Dan Toulgoet.

As fentanyl rears its ugly head across Canadian communities, the country is trying to mount a counterattack against the deadly opioid. And while cities beyond Vancouver and Toronto wait for government approval to open supervised injection sites, naloxone—the lone antidote in the battle against the ubiquitous street drug—remains scarce, according to a recent Canadian Medical Association Journal (CMAJ) survey. Studies show that death rates drop the more naloxone, which can stop or reverse an overdose, becomes available. In their Opioid Action Plan, the Trudeau government vowed to improve access to naloxone. But so far they haven’t delivered: Fewer than one-quarter of community pharmacies, the CMAJ found, stock the drug.

SURREY, B.C.
Population (2016): 517,887
Fentanyl-related deaths (2017): 139
Pharmacies with subsidized take-home naloxone kits: 0

B.C.’s second-largest city also recorded the second-highest number of fentanyl-related overdose deaths in the province: One of out every 10 deaths over the first 10 months of 2017 happened in the Vancouver suburb. In 2016, a spike in overdoses stunned the city and prompted a Surrey MP to call for an emergency meeting.

GRANDE PRAIRIE, ALTA.
Population (2016): 62,320
Fentanyl-related deaths (Q1-Q3 2017): 18
Pharmacies with subsidized take-home naloxone kits: 13

The fentanyl epidemic is hitting especially hard in Alberta, where hundreds across the province are dying from the drug every quarter. Most fatalities happen in Calgary and Edmonton, but Grande Prairie has the highest rate of fentanyl-related deaths by population, nearly double the provincial average. The alarm bells sounded last June, when seven people overdosed over a 15-hour period.

SASKATOON, SASK.
Population (2016): 246,376
Fentanyl-related deaths (2017): 5
Pharmacies with subsidized take-home naloxone kits: 0

Saskatchewan, where fentanyl-related deaths peaked in 2015, is an anomaly among the provinces. There were just seven fatalities in all of 2017, with all but two of them occurring in Saskatoon. It may explain why Saskatchewan also stands out as one of only two provinces that don’t subsidize the cost of naloxone kits at pharmacies (which sell them for as much as $70). A lone clinic in Saskatoon offers kits for free.

WINNIPEG, MAN.
Population (2016): 705,244
Fentanyl-related deaths (Q1 2017): 26
Pharmacies with subsidized take-home naloxone kits: 2

The fentanyl heat map homes in on Manitoba’s capital, where all but four overdose deaths in the province took place in the first three months of 2017. That puts Winnipeg on pace to record more than 100 fentanyl-related deaths for the entire year. In the first half of ’17, first responders in Winnipeg administered naloxone to 435 people. More than a quarter of those incidents took place in the downtown area.

SAINT JOHN, N.B.
Population (2016): 67,575
Opioid overdose deaths (Q1-2, 2017): 5
Pharmacies with subsidized take-home naloxone kits: 0

New Brunswick is the only other province whose pharmacies don’t have free naloxone kits. The government did, however, announce in November that it would spend $150,000 to supply four non-profit sex clinics with 2,500 kits, one of which is in Saint John. Five people died there in the first half of 2017 after overdosing on an unspecified opioid.

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.

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.

Vancouver’s Insite facility. Photo courtesy of Vancouver Coastal Health.

Ottawa: The feds

“I’ve made it very clear to my department that there should be no unnecessary barriers for communities who want to open supervised consumption sites.”—Jane Philpott, federal health minister