True Currency in a Bankrupt World: A Discussion of Approaches to Substance Use
“The only true currency in this bankrupt world is what you share with someone else when you’re uncool.” – Lester Bangs (Spoken by Phillip Seymour Hoffman in the movie Almost Famous)
Let’s talk about something un-cool to talk about in most circles – substance dependency. So much has been talked about the death of Phillip Seymour Hoffman. Insights like this one from Russell Brand talked of how the death was inevitable in how drug laws are created and enforced. This one from the Washington Post suggests the death points to a broader opioid epidemic. Counter point to this mourn-ography (as Brand puts it) look at the sensationalism and mockery of Rob Ford, known in Late Night circles as “Toronto’s Crack Smoking Mayor”.
In the former (Hoffman) people see tragedy; in the later (Ford) people see buffoonery. A respected actor with a rather large body of work is a loss; the mayor of North America’s fourth largest city using drugs is spectacle.
As I have blogged about previously, required abstinence is not the way to go. There is not a strong relationship between sobriety and housing retention. It has been suggested, however, that somehow it means I encourage or promote drug use. I don’t. I believe the evidence that security of housing is helpful for assisting people in reducing or stopping their substance use. And, I believe in a four-pronged approach to helping programs and communities address the matter of drugs more holistically:
Education
Enforcement
Harm Reduction
Treatment
On the matter of education, I think we need to broaden awareness of what drugs are prevalent in which communities. We need to, from a young age, increase awareness of substances and their impacts without a simplistic “Just say no” approach that glosses over the pervasive and entrenched position that drugs have in our society. I would also urge people to become more educated on the broad range of evidence that supports different approaches to addressing substance use in communities.
For example, take a look at the research findings from InSite – the Safe Injection Site in Vancouver. There will always be a place for enforcement when it comes to drugs, but I think as a society we need to ask ourselves about the best approach to doing so. I really like this piece by Erik Luna where he quite rightly outlines that mandatory minimums do not meet the generally accepted criteria of law – meeting neither the goals of punishment nor consequentialist goals of deterrence.
So where is the place for enforcement? When organized crime is attached to the drug trade, that is an obvious one to me. When minors are impacted, that is argument for another. When any individual is exploited by the drug trade, including sexual exploitation, I believe that is another reason for enforcement. Punishing the substance user? That is in essence punishing someone for having a health condition.
If we take criminality of the drug discussion out of the equation (which I appreciate is difficult because of how interwoven the drug trade is to often harmful and dangerous criminal behavior), we can look at substances from a health perspective. And when we embrace that perspective we can more clearly see the opportunities for harm reduction and treatment. There is a place for both. It is not either/or.
First, let’s consider harm reduction. While harm reduction is interpreted and considered from many different perspectives, I would urge people to consider it from a person-centered point of view within a broader societal context. (Person focusing outward, not society focusing inward.) Harm reduction aims to decrease adverse health, economics and social consequences of substance use without requiring abstinence or cessation of any sort. Harm reduction is achieved through action and policy. Harm reduction considers the broader needs and impacts of substance use on society when supporting the individual. Through harm reduction, we should expect to see fewer interactions with emergency health services and police as a result of drug offences. We should expect to see fewer upset communities and neighbors as a result of behaviors that stem from substance use. We should see improved health and less destructive behaviors on the personal level. It is absolutely incorrect to think that harm reduction embraces use at all costs. It is a myth to think that all harm reduction efforts are a guise to legalize all substances in all forms. It is also incorrect to think that harm reduction enables use, as the evidence demonstrates that the likes of wet housing debunks the enabling hypothesis when you look at rates and types of substance use, and further evidence shows that people are more likely to decrease or stop substance use once they have security of housing. I believe that housing in and of itself is often a form of harm reduction.
Now let’s consider treatment. When treatment is mandatory in order to use a service or access housing, then housing or service becomes the reward of treatment. The problem with this, as I have discussed in other blogs – and as you can research yourself in the evidence – is that rates of treatment success are low. It isn’t that we shouldn’t encourage people to seek treatment and support people that do – we can and we should – but we should never require treatment in order to access housing or services. When treatment is considered we must also do so patiently and from an informed perspective. Treatment is not one size fits all – a treatment that worked for one person is not guaranteed to work for another. The scope and style of treatment should be matched to a person’s experience and personality. Treatment should make sense relative to a person’s housing situation and her/his social network. Treatment comes with a range of emotions – from guilt of needing it to elation of how it helps curb substance use. When treatment doesn’t work out there can also be a range of emotions. And we also need to have informed discussions about treatment with people that may want it or benefit from it, rather than jumping on a treatment bandwagon just because the person is upset with their substance use or is trying to placate someone else by going to treatment.
Substance dependency may be un-cool to talk about. But it is a conversation we need to have if we are truly going to offer a range of approaches to properly confront a complex social issue. And as un-cool as it is to talk about, if we don’t talk about substances when we talk about housing for people with complex and co-occurring issues, there will be a large number of people remaining homeless for no reason other than they didn’t fit a pervasive view of substance use and what should be done about it, rather than considering a range of approaches.