Getting better in Vancouver: Part 1
A first-person account of navigating substance use services in Vancouver
It’s a gloomy February morning in 2021 as I wait for the intake coordinator at Onsite detox, one of three withdrawal management programs funded by Vancouver’s regional health authority.
After my orientation, I surrender my clothes/blankets/pillows/backpack to be washed and dried on high heat (a practice meant to kill bedbugs, cockroaches and other stowaways). They give me clothes to wear as I wait: cardboard slippers, a stiff rectangular top, a coffee-or-blood-stained waffle knit robe, and pajama pants so big I hold them up when I walk.
On day one, the uniformity of institutional “addictions care” renders us ageless, sexless, genderless; without futures or pasts; with no hobbies or favourite plants; without kids, (play)mates or pets.
After day one, many of us will wear combinations of our own clothes and those provided to us. For example, I pair a the waffle robe with my (comfy) cotton t-shirt and leggings (because robes have pockets, good for storing my phone and extra tea bags).
For those with minimal apparel (because they’re unhoused, or they’ve been robbed), detox-issue clothing is a must.
Operated by PHS Community Services Society, a non-governmental organization known for providing harm reduction-oriented services (like Insite), Onsite is the only Vancouver detox that provides each resident with a private room and washroom — a feature they call “detox with dignity.”
A large common area doubles as a dining room and activities space. Onsite hosts three or four activities each day, for those who can or want to participate.1 Activities include: art, yoga, meditation, acupuncture, drawing and reading.
There’s a flat-screen TV for watching local cable. And VHS tapes crowd the single bookcase, as if someone donated their beloved analogue video collection – Moonstruck, Fast Times, The Dead Zone, The Warriors. But the VCR player is broken.
Smoking cigarettes is allowed on a patio overlooking the back alley.2 We watch people buy drugs, get high, pass out, overdose. We listen to screams and sirens. We watch good Samaritans (usually other people who use drugs) give mouth-to-mouth, or Narcan, until paramedics arrive (if they arrive).
Onsite is also the only withdrawal management program in Vancouver that allows residents to smoke weed (for pain relief, and, I’m sure, scads of other reasons — most of which are unknown to me, because I don’t smoke pot).
Once settled, we are lovesick strangers, our minds and bodies at various stages of separation. I liken the (certain aspects of the) pain of withdrawal to what it’s like to break up with a lover I am crazy about — absolutely bananas. Maybe a Siamese twin, or a regular twin. The pain — it’s severity — will depend on the attachment. How heavy is the yolk? How sticky the connection? How tight is the bond between substance and receptor?
The word “detox” is actually a misnomer. Programs like Onsite are not actually designed to rid our bodies of all chemicals and toxins. While the idea is to rid us of street drugs, like opioid analogues, withdrawal management programs prescribe (controlled and regulated) opiate substitution meds — like methadone, still considered, by some doctors, to be the gold standard of opiate use disorder (OUD) treatment.
When locked up together — disarmed and defenceless — some of us make friends or acquaintances with another person who (ideally) shares some of our interests; someone who isn’t (at least, at first) obviously irritating.
This is natural, at least for me.
When I’m naked, raw and disconnected, I make wobbly bonds with one or two others. So I’m not alone. So I’ve got at least one other person to walk with, along the pathway through confusion, terror, and a type of grief stuck inside me like a shipwreck.
Friends, families and other lovers often believe that total deprivation from any/all drugs is step one in recovery from drug use.
I don’t believe that the drugs, themselves, are the problem. (Sorry, Manson — you can like, or not like, the drugs, but they can’t like you back.) Instead, I believe in drug-related harms.
When looking for someone/something to blame, I get how tempting it is to anthropomorphise the very substances that seem responsible for so much suffering, pain and grief. This is what happens when we live in a culture of denial around death and accountability.
Harms, in my opinion, can be drug-related, but I would not say they are caused by drugs — that would be an over-simplification, letting a great many of us (parents, teachers, doctors, policy-makers and our provincial/municipal/federal governments) off the hook.
Drugs, by definition, are medicinal and/or chemical substances that produce physiological effects when consumed by living organisms (like humans). Drugs are objects, incapable of free will and personal autonomy. As objects, they lack opinions, memories, motor skills, internal organs; the ability to reason, to feel shame, elation, anger, grief.
By this logic, drugs exist to be consumed. Are we to believe this is some kind of cosmic fuck up? A lesson in moral restraint?
To consume (a food/substance/object/feeling) is to use, spend, eat, drink, and/or engage with it. Consumption is neither good nor bad; it requires personal interpretation, or context. However, drug consumption is still commonly viewed as inherently negative.
Remember when Shane, from Degrassi Jr. High, takes acid at a concert? He ends up with brain damage — a cautionary tale relating the dangers of drug use.
Want to read more about how TV and movies influence our beliefs about drugs use? Visit our sister site, WHERE’S THE HARM (WTH).
And stories about drug use have hardly changed since the 1980s. Like, when is the last time we met a TV character who uses drugs and doesn’t get (somehow) punished for it (until and unless they face the consequences of their actions and “clean up”)?
Consequences are often thought to be the result of an action or behaviour that is viewed as unwise or unforgivable within a given culture or community. But in truth, consequences aren’t actually defined as having negative attributes; a consequence is a result (full stop).
In the West — and around much of the world — many of us still assume drug use is a dangerous and undesirable (if not immoral and fatal) activity, responsible for devastating consequences to individuals and communities. And people who use drugs are the obvious scapegoats. The only way to prevent such devastation, we reason, is to abstain from all drugs, and support — even enlist in — the war on drugs. No more drugs, no more problems, yes?
The story about the war on drugs is powerful. But if we examine it for what it is — a harmful mythos, at best — we may discover prejudice in place of truth.
We may discover that this drug war is actually a “war on drug users”; a war on people with disabilities; a war on the poor; a colonial/racist war, responsible for the mass incarceration of black, Aboriginal and Latino people.
Furthermore, when we read about drug use — in books, newspapers and on government websites — we actually learn more about the writers’ or publications’ ideological positions (and biases/prejudices) than we do about drugs and people who use them.
In fact, I will argue that our public (and private) news and radio stations still have difficulty reporting on drugs and drug use, often resorting (whether intentionally or not) to familiar clichés, and beliefs unsupported by living experience or empirical evidence.3
Does this mean that drugs aren’t harmful? Of course not. All substances have side-effects, and some folks are allergic to ingredients in psychoactive drugs. (By this logic, nothing is ever inherently safe.)
And every human has a vice — or many. Some are more or less socially accepted (like shopping and over-working); others are misunderstood (like hoarding or not eating). Using so-called hard drugs (like fentanyl or crack-cocaine) is often vilified.
To vilify is to defame, slander and speak ill of a person, object, movement, religion. As in, this person or thing is vile. So, when a person uses hard drugs (or even just regular drugs, the kind viewed as “gateways” to harder drug use), they are often shamed and criminalised.
But what about when the drugs we use are not what they appear to be? Like when fentanyl overtook heroin, and then opioid agonist-resistant benzo analogues (most of which we can’t detect using standard drug checking technology) found their place in the market.
One major problem with benzo dope is that OAT medications cannot relieve the drug consumer of their benzo-related withdrawal symptoms. And these consumers are people who are unknowingly consuming what I can only describe as poison.
It’s okay to be afraid of drugs (even, to hate them), as long as we don’t underestimate the complexities underlying a person’s (and our own) drug use. As long as we remember that using drugs is an attempt to change something — an environment, a traumatic memory, physical/emotional pain and discomfort, guilt, grief, boredom, purposelessness, housing and job insecurity, and other markers of human suffering and experience.
And harms, once defined/identified, are rarely (if ever) easily resolved.4 We can’t just alter or extract a drug causing harm; doing so poses other risks. Sometimes, what we identify as the cause of a problem is actually one tool (or many) that’s keeping us alive.
In 1987, the American Medical Association (AMA) recognized addiction as a disease. Although the disease model of addiction would become (and remain) controversial, it introduced a medical explanation for what was (and often still is) deemed a predictable negative consequence of poor decision-making.
People who use drugs have long been stigmatized as amoral actors, bad apples, selfish parents, rebellious daughters, predators, sinners, narcissists and hedonistic libertines.
If you have it, you’re fucked. If you try to stop it, you’re in denial that you’re fucked.
When substance use is viewed as a choice — rather than a result of something that precludes the decision to use — it’s easy to conclude that drug use is a behaviour that can, and should, be stopped.
Human willpower is a seductive concept. Our ability to choose is this thing that separates humans from animals, and cements (we believe) our superiority over nature. If we can start it, we can stop it.
The disease model helped destigmatize the addiction problem — sort of. Those who accepted it could sympathize with those afflicted, even as they condemned (what they saw as) the symptoms of addiction (like isolating, lying, stealing, giving up).
How many times have we heard parents’ desperate cries: “What happened to our beautiful baby, who gave us so much happiness and joy? I don’t even know him anymore.” An accusation like that points fingers at the child. Did the family ever stop to think that maybe they never actually knew their child? Maybe, what they saw — the future they envisioned for their child — was a projection?
While the “choice” theory of addiction places blame on the individual, the medical classification creates a kind of hopelessness.
Crackdown podcast’s editor-in-chief, Garth Mullins, describes being told by a doctor that his substance use was evidence of a “chronic relapsing condition.” While the symptoms of his addiction could be treated or managed, he was told, it could never be cured.
Far from empowered by this explanation, we can imagine that young Mullins felt his inability to quit drugs as lack of control — over his body, his future, his fate. I imagine this was almost like being told that he had a later-stage form of cancer: the kind that might be managed (for a time), but will only ever kill him in the end.
And management of drug-related symptoms is far from a cake walk. If the only solution is abstinence from all drug use (including alcohol), dopesickness is imminent, and crippling. Not even a steady/gradual reduction in use is advised or acceptable, according to twelve-step-based groups like Narcotics Anonymous (NA) (which was modelled after AA for folks who felt like drug users needed a twelve-step group of their own).
You can read about NA and twelve-step until the cats come home. You may notice that many of its online sources are hosted by for-profit addiction recovery foundations and private or public programs, including detox centres. Please read what they publish with a critical lens.
BC offers a variety of medical/clinical, residential and outpatient programs designed to treat folks with substance use disorders (SUDs). But provincial licensing standards for residential care programs are rather general and nonspecific, focusing mostly on operational requirements around occupancy limits, staffing coverage, emergency preparedness, and dietary needs and restrictions.
Oddly, there don’t seem to be any requirements relating to program content or therapeutic approaches to care. It is as if licensees are free to design substance use services however they want to.
So, what qualifies them as experts? In BC, counselling is still an unregulated profession — despite demands that the province create a regulatory college to legitimize the counselling profession and protect vulnerable clients from neglect and trauma/abuse.
“Government regulation occurs when the provincial government grants certain rights and responsibilities to a profession through legislation in exchange for the profession regulating its members in the public interest.” — The Federation of Associations for Counselling Therapists in BC (FACTBC)
So. While therapy is typically a go-to recommendation for treating substance use and mental health conditions (by doctors, employers, insurance providers, family members, etc.), BC’s counselling profession is not governed by a regulatory authority.
Membership with a professional association (like FACTBC) has accreditation requirements, which lends credibility to clinical counsellors who become members. Good. Great.
Except that a professional association membership is not required to practice therapy in BC. This means that your therapist is not required to have a masters or doctorate degree. Orrrrrr… ANY education/training if they don’t wanna.
You heard me. Today, in British Columbia, Canada, any person can provide counselling services. And residential substance use centres are free to operate as long as they meet (IMO) skimpy and rather unimportant standards (given they are tasked with treating people who are in legitimate and complex degrees of physical/psychic pain).
But we don’t hear about this on TV, do we? Instead, what we hear are pleas from friends and family members that the person using drugs attend counselling, or twelve-step meetings.
Many people who use drugs as a coping tool suffer from trauma and PTSD (often due to a prevalence of childhood abuse/neglect, which can be evaluated using the adverse childhood experiences — aka ACEs — questionnaire).
It’s not uncommon for people entering treatment to have anxiety/depression, personality disorders, and other mental health conditions; chronic pain, learning and/or physical disabilities, difficulty managing emotions (like anger, shame, fear). After all, there are reasons (many, many reasons) a person uses drugs to cope.
It’s not uncommon for these folks to lack family support, have trouble meeting basic human needs (like housing and nutrition), or inability to pursue higher education.
Some folks come from the carceral system, or are mandated by the court to attend treatment (a practice that isn’t generally recommended by clinical professionals — we can’t force people to get better).
There are also folks who seem better equipped to learn how to stop using drugs as a coping mechanism for stressors they feel unable to handle. Perhaps these folks have employment, family, friends and other markers of privilege and/or community support. And yet, many can’t stop using lethal street drugs — they’ve overdosed more times than they will admit, they worry about being judged by their friends, and — for a variety of reasons — they may feel insecure, frightened, angry, confused or suicidal.
Do we really think that any person who calls themself a therapist is qualified to care for the individuals I’ve just described? Are they qualified to practice CBT or talk therapy if they’ve never studied or trained?
Then again, substance use care facility licensees are not even required to hire counsellors. So, what the heck. Welcome to the wild west of substance use care in British Columbia, Canada.
In BC, there are residential recovery programs that use the twelve steps as their only/main curriculum. I have heard (and I assume) that employees working for such programs tend to be well-versed in the twelve-steps and traditions, faithfully attend AA or NA meetings (in addition to their “home group”), have experience coaching sponsees, and have abstained from drugs/alcohol for quite some time.
I’ve heard that twelve-step groups are sometimes helpful. But I cannot condone any program that asks its members to find God (any God) or else they won’t recover.
I cannot approve literature that stubbornly (and to this day) uses male pronouns to refer to God.
But if would-be members are hesitant to adopt (what totally sounds like) a Christian solution to a medical issue, they are welcome to find or create a “higher power” of their own.
“Do you believe that life on Earth is all there is?” the twelve-stepper asks. “No…” replies a skeptical newbie. “Then you must believe in a force greater than yourself. Yes?”
And yet, here they were, so convinced that twelve-step might be the “only way” that they would rather alter what little they could about the program, and ignore what they couldn’t. Just for a chance at recovery.
Sadly, individuals who can’t (or won’t) submit to a higher power, cannot complete the program. The implication is that such people are doomed to repeat the addictive cycle in perpetuity (reminding me, again, of Garth Mullins’ incurable “relapsing condition.”)
And still, despite my protests, I have attended twelve-step meetings. I even had a sponsor.
As an injured person in the 2010s, using (hard) drugs in Vancouver (because they felt good/relieved my pain/plugged up that dreaded — and universal — soul hole), I longed for a solution that evaded me.
And even in my longing, I found mixed feelings so twisted, knotted, and gnarled they were just impossible to resolve. Why SO many barriers? Like, finding God?? Way to turn a deeply personal/individual journey into some pesky step that demands complete and immediate surrender.
In my search, I found twelve-step groups chaired by (what appeared to be) conflicted progressives — desperate to stop the pain attributed to their drug dependencies. Athiests, sex workers, young communists, artists, feminists, gays.
To be crystal clear, the twelve steps and traditions were not written with lefty queer-femme weirdos in mind. And yet, here they were, so convinced that twelve-step might be the “only way” that they would rather alter what little they could about the program, and ignore what they couldn’t. Just for a chance at recovery.
I admired the way these progressive weirdos defaced their Big Books by crossing out words they refused to read; replacing the “he/him” pronouns with “she/her and/or “they/them”; whiting out references to “God” (aka “Him”) and naming, instead, the Creator, a spirit animal, or ancestor.
And chapter eight, “To the wives,” never failed to create discomfort. Some of us read it, sarcastically; others skipped/changed the (in their opinion) most offensive sentences/words; and others abstained from reading chapter eight altogether.
During the sharing portion at these meetings, there was much discussion and debate. I heard many women express anger at twelve-step and its founder. “I haaaaaaaate Bill,” one woman said. He was a womanizer. He was a sex addict. Those who could, somehow found a way to reconcile their cognitive dissonance.
Not all residential treatment programs use twelve-step as their curriculum. But, in Vancouver today, all programs use complete and total abstinence as the only (or main) measure of success. If we can abstain from using drugs, we can graduate and (ideally) live happy/sober lives. And maybe that’s the problem.
These programs are designed by people who don’t use drugs. They are designed by people who have no idea what it feels like to be physically reliant on a dangerous street cocktail; to be so dependent that not taking it is not an option.
These programs are created by people who have no idea what it feels like to try and try again (to get better, even if it’s only slightly better than the day before), only to be told that every failure is our fault.
In detox, we don’t need to worry (yet) about committing to an ideology or a spiritual/religious path that may or may not keep us drug-free. In detox, we focus (mostly) on physical stability. “The easy part,” some say, seeming to ignore the mind/body connection.
After the harshest and most intense markers of (dope) sickness, we are propped up on opiate agonist medications (also called opiate substitution meds), like methadone, suboxone, fentanyl, hydromorphone, slow-release oral morphine, and more. Except that in BC, where I live, retention on these (so-called) withdrawal management medications is so abysmal that I wonder if we have taken substitution as far as it can go. How can you substitute for poison.
We, the (about-to-be) Detoxified, are promised a unique opportunity — to die and come alive again — to be reborn/remade/reformed, as many times as it takes. To be beautiful again, and loved and educated. To learn the warrior pose, and downward dog; to learn how to breathe and walk tall/chin up.
We might stumble, we’re told (and most, if not all, of us fall). But that’s not what matters. “Doing” is what matters. As many times as it takes; to breathe easier; to discover a well of fun, a piece of pleasure to make it better, to stop the pain, to stop worrying and/or hurting.
In reality, for those of us who survive the five to seven days it takes to “get better” (without relapsing and/or leaving), the results are hit or miss. If we’re lucky, we go directly to a treatment centre (paid for by our families or the Ministry and arranged by case workers who refer us to programs they oversee). If we’re luckier, that treatment centre is at least semi-professional and not half-bad. Some even employ counsellors with degrees in psychology, social work and/or counselling.
The best residential programs (IMO) give us our own bedrooms. The best programs introduce us to a range of support groups — from those based on Buddhist philosophy to those that endorse harm reduction as a compass, a lighthouse in the storm. The best programs are sensitive to social progress and cultural evolution. They don’t tell us what to do or how to survive (because… how could they possibly know?).
Most of us aren’t very lucky. Not in Vancouver. Not today. Yes, we relapse. And we relapse. Again and again, despite stuff we learn about why we hurt and why we use. We relapse because outside these programs, the world is stressful. We lose new friends and supports to relapse, to overdose deaths. If we’re lucky to find our very own drug-free apartment, we soon realize we’re alone in it. And then we get lonely.
Back in detox, from my sickbed, I peek through the blinds at the street that never sleeps. “Rock, powder, down…”: a mating call for the dopamine-deficient (which, is all of us, at this point, right?); for those who never sleep; for those doomed to haunt the same few blocks, forced to face off over some shitty, tattered carcass (what past-life sins had they accumulated?); for those who eat cereal with milk from the store, and pay $5 each, per plastic bowl.
I am grateful for the high ceilings in my private room; for the wall of (single-pane) windows that never open. Mostly, I keep my blinds closed. All day, every night. Except to peek out and think, I’ll be well again one day, I swear I will. By Goddess as my Witness.
Opioid withdrawal has several stages (or symptoms), and each person’s experience is unique. Restlessness is not uncommon. In my case, restlessness is often combined with weariness; I can’t stay still long enough to lie down, or channel my energy into a to physical activity. Yoga (a combination of movement and stillness) can provide some relief. Onsite is (allegedly) the only Vancouver detox centre that provides activities apart from twelve-step panel meetings (where attendees are generally discouraged from sharing about their own stories or feelings — shut up and listen, not matter how batty or rambly or off-topic these sober panelists claim to be).
Smoke breaks are scattered throughout the day, unlike the other detox centres in Vancouver (where smoking is either not allowed — anywhere, at all — or only allowed for limited hours each day). Smoking is not uncommon among people who use drugs (aka PWUD). Centres that restrict smoking usually offer nicotine gum as a replacement — a scary prospect for smokers who find Nicorette essentially useless.
In many ways, this isn’t totally their fault. Substance use is such a neglected area of medicine that BC doctors are allegedly refusing to take the provinces opioid addiction treatment support program (which, I admit, is far from perfect, but at least it enables them to prescribe OAT meds to those who want it).
Remember that drug prohibition creates opportunity in the black market. When Purdue Pharma made a tamper-resistant version of OxyContin, many turned to heroin; and thus the stage was set for fentanyl to dominate the street drug trade, causing a death cascade that, in BC at least, shows no signs of ceasing. And on and on it goes.
I had no idea you were going through stuff like this Reija. Thank you for this incredibly well-written and comprehensive breakdown of the issues with drug-centered care & treatment here. I would recommend this to anyone who still stigmatizes drug-use or drug-users. I want to become a clinical counselor myself, and I pray that things change in the future. We must do better than this.
Great article, its as brutal here in Oakland and San Francisco. You raise a lot of important topics, thank you for continuing to create this content.