The Fix

A new way of thinking about the intractable problem of injection drug use

Illustration by Byron Eggenschwiler

Illustration by Byron Eggenschwiler

Matt slumps down in the faded leather chair across from me, his eyes barely open.* We are in a small office at the headquarters of the Vancouver Area Network of Drug Users (VANDU), in the Downtown Eastside, a neighbourhood that serves as a kind of open-air market for as many as 5,000 injection drug users. Matt apologizes: he shot heroin moments before the interview, and he hopes he can keep his nodding off to a minimum, which he does. In his uniform of baggy pants and a straight-brimmed baseball cap, he looks the part of a street-level dealer; the deep lines that score his thirty-six-year-old face suggest that he has also been battling addiction for a long time.

I begin by telling him that I work as an epidemiologist, researching HIV and addictions, up the road at St. Paul’s Hospital. “They know me quite well at St. Paul’s,” he says. He spent almost five months there being treated for endocarditis, an infection of the heart often caused by injecting with dirty needles, which led to a couple of heart attacks and culminated in open-heart surgery. “I dealt with the addictions people quite a bit, and the methadone guy. I had quite the team that worked on me there.” He says it with a sort of pride, as if being treated in a hospital were a luxury.

He grew up in a small town in British Columbia’s Rocky Mountains known for its wildly expensive ski resorts. While he describes his upbringing as good (“Mom and dad. Two sisters, two brothers. Dog. Cat. All my siblings, they work, and they’re married and have kids”), it is clear that from a young age he suffered from severe depression. By thirteen, he had dropped out of school and was smoking and dealing drugs. “It was just for the escape—and the popularity. I liked the idea of going down the street and everybody knowing who I was,” he says.

Three years later, he found his way to one of the BC Interior’s few urban centres, where he gradually replaced marijuana and cocaine with crystal meth and heroin. “I was about eighteen when I first started doing heroin,” he says. “I liked it. I liked it too much. Because it brought me down off of the cocaine.” Still, despite his intensifying use, he refused to inject. I ask him why. “The fear,” he answers. “The fear of getting wired, the fear of people looking down on me for being a junkie.”

That fear persisted into his early twenties, when he started working for and partying with the Hells Angels and became involved in a homicide. “The guy I killed molested a seven-year-old girl who was the daughter of a Hells Angels member,” he explains. “We tied him to a chair and beat him for two weeks. In the long run, he died from his injuries.” He pauses. “I actually walked in on it already happening, in the basement of a place I was at. I was told that if I didn’t help, then I’d be the next party tied to that chair.”

He was sentenced to twelve years in a BC federal penitentiary. There, he started hanging out with a group he knew from his early days of using and selling, inmates who had learned to inject in prison. At first, he abstained. “I’d be having a cigarette or a cup of coffee, and they’d be getting high. I’d be able to sit with somebody while they did their dope, and not do dope.” After three years, though, traumatized by his crime and haunted by nightmares that made him fear falling asleep, “Finally,” he says, “it was like, Can I have some of that? ”

Matt is one of about 100,000 Canadians who have tried injecting themselves with drugs, typically cocaine, heroin, or other opioid derivatives such as OxyContin or Dilaudid, though the rate of amphetamine injection—and crystal meth specifically—is on the rise in some Canadian cities. While many drugs are harmful, injecting them into the bloodstream heightens the risk exponentially. The intensity of the high exacerbates addiction and increases the likelihood of fatal overdose (which remains the number one cause of death for injection drug users in most cities), while needle sharing exposes users to HIV and hepatitis C infection. Beyond the human misery it causes, IV drug use costs Canada’s health care system millions annually. Yet most people who inject drugs are much more likely to meet a police officer or a prison warden in the course of their addiction than a doctor or a nurse. Treating addiction as a chronic illness may be a safe piece of rhetoric across the political spectrum, but in practice we continue to treat IV drug users as criminals.

The war on drugs was launched by Richard Nixon in the wake of the news that tens of thousands of Vietnam veterans had become addicted to heroin overseas. It was then amplified by George H.W. Bush in the heyday of the crack scare in the United States, which firmly established prohibition as the pre-eminent strategy for dealing with drug-related problems across the world. Even the United Nations took up the fight. “Excellencies and friends,” Secretary-General Kofi Annan commenced at a 1998 conference, “allow me to raise my glass in the hope that when we look back upon this meeting, we will remember it as…the time when we pledged to work together towards a family of nations free of drugs in the twenty-first century.”

Forty years later, the war on drugs has little to show for itself. Ironically, Annan himself has become a leading voice for a public health approach. The drug-free world was a mirage, as the United Nations Office on Drugs and Crime now pegs the annual value of the global illegal drug trade at $350 billion (US), more than four times that of Canada’s entire energy sector. Because they are prohibited, drugs are an extremely high-value commodity. Unfortunately, they are also incredibly low volume. Consider that in 2010, the Mexican government estimated that illegal drugs made up 8 percent of all trade between Mexico and the United States but only 0.004 percent of total trade volume. To put it another way, all of the drugs needed to supply the US for 2010 would fit into about sixty trucks, a tiny fraction of total cross-border traffic.

In the shadow of this Sisyphean effort to control the expanding supply through drug busts, intelligence stings, aerial eradication of drug crops, military action against cartels, and street-level crackdowns on users, an international network of scientists has been circling closer and closer to the reasons why some people lose themselves in addiction. We now know that childhood sexual abuse and other forms of trauma, along with poverty, homelessness, involvement in the drug trade, incarceration, and mental illness, are all implicated in addiction. The much higher incidence of injection drug use among Canadians of Aboriginal ancestry, for example, reflects their ongoing intergenerational trauma, cultural genocide, and endemic poverty. Therein lies a problem: Knowing what the issue is doesn’t make it easy to fix. How do you eradicate poverty? How do you undo trauma?

During our interview, Matt appears alternately at the mercy of his addiction and hopeful that he can recover from it. At one point, he mentions a new girlfriend who has vowed to help him kick his habit. In these moments, faced with such unrelenting will, I find myself deeply frustrated with the slow pace of scientific discovery and the punitive approach we are stuck with in the meantime, because it means that people like Matt often have little or no support. Perhaps it is because the factors leading to injection drug use seem so intractable that our response has been so inadequate. However, if we dig a little deeper within populations that exhibit risk factors, if we ask those who are addicted to share their experience, we start to notice something curious. In Matt’s case, it is that despite dealing drugs as a teenager, experiencing massive trauma, and going to jail, it was not until he was surrounded by other injectors that he took the plunge.

Sitting in the same back office at VANDU, with the sounds of a raucous community meeting next door filtering through the walls, Allison’s answers to my questions come in waves—a rush of words that peters into silence, her eyelids fluttering open and closed. The wispy twenty-one-year-old from back east apologizes, explaining that she, like Matt, has just injected. “I came out here to get clean,” she adds with a quiet, hesitant laugh.

She grew up with her mother and six siblings in a town near the Windsor–Detroit border known for high rates of illicit prescription drug use. She, too, started using at age thirteen. “I was depressed,” she says, “and the guy I was with would sneak off and sniff Percs.” (Percocet, a relatively mild prescription narcotic.) “Even though I was against it at first, I didn’t like him leaving me all the time.” So she joined him, and a year later she was sniffing OxyContin, a much more powerful prescription narcotic.

According to the US-based Monitoring the Future study, a long-running survey of youth drug and alcohol use, 15 percent of American grade twelve students reported using a prescription narcotic like Percocet or OxyContin in 2012, while fewer than 1 percent of them had escalated to injecting heroin. These statistics support an emerging consensus that the gateway theory—which states that soft drugs like alcohol or marijuana inevitably lead to increasingly intense forms of drug use—is simply wrong. Instead, research by scientists such as Élise Roy, chair of addictions at the Université de Sherbrooke and a global expert on injection drug use, suggests that an entirely different phenomenon may be at work.

Roy is investigating the complex set of factors that leads to initiation—the first time someone injects drugs. During two decades of field research with Montreal’s street youth, she has collected a body of evidence that not only refutes the gateway theory, but dismantles the stereotype that injection initiation is an irrational, drug-fuelled decision made in the heat of the moment. Rather, it is typically the culmination of months—or years—of consideration, in proximity to injectors. “They’ve seen injectors, particularly young ones, who seem to enjoy the hit and don’t have too many bad consequences, because they are new users,” Roy says. “These youth become désensibilisé and begin to think injecting is without risk,” she explains. “They are good role models for those who are curious about it.”

Moreover, she has come to think of the months before and after someone first injects as a period of incubation. Generally used in scientific research on pathogens, the incubation period is defined as the gap between initial exposure and the first appearance of symptoms. For instance, it takes one to four days for flu symptoms to emerge after the virus enters the body and starts attacking the lungs. The incubation period for chicken pox, by comparison, is fourteen to sixteen days. For HIV, the period can last from three weeks to three months, while AIDS symptoms may not develop for years—particularly alarming given that during this time, HIV-positive individuals may not know their status and can unwittingly pass the virus along to others in their networks, through sexual contact or shared injection equipment.

Allison initially felt ambivalent about injection, even as she watched many of her friends try it. “I was interested in doing it,” she says, “but I was also scared of needles.” Slowly, in the context of an unusually intimate exposure, her attitude changed. “It’s such a small town,” she explains, “that I hooked up with older people, and they would hang out with my grandma, which is weird, because they weren’t any older than twenty-five, and she was in her fifties or sixties.” As far back as Allison can remember, her grandmother used drugs. “She acted like a teenager, kind of, but a druggie teenager, a crackhead.” Occasionally, she would show up at Allison’s mother’s house to evade an abusive boyfriend. By the time Allison was sniffing Percocets, her grandmother’s apartment “was the best place to get high.”

When Allison broached the subject of injecting, her grandmother said, “Don’t do it. You’re going to regret it.” But one day, Allison simply showed up at the apartment with pills and needles. “I had thought about doing it before and had told her I was going to do it, but it was also kind of a random thing,” she says. “I just knew I was going to do it.” Her grandmother ushered her in, tied off her arm, and injected her with crushed-up OxyContin pills. When I ask Allison how her grandmother reacted after it was over, she replies tersely, “Like it was nothing.”

From the work of Roy and others, we are starting to understand that while epidemiological commonalities such as poverty and trauma create vulnerability to drug abuse, they cannot entirely explain why someone would take the almost inconceivable step of sticking a needle in her arm. Meanwhile, research on social networks has steadily advanced, offering us some insight into the process by which individual decision making tends to mirror the values and interests of the people we spend our time with. Social networks intensify collective behaviour, reinforcing commonalities and subtly shaving away differences, while working to exclude those who are not sufficiently similar. That double feedback loop, which falls under the rubric of theories of social contagion and social control, is what makes city dwellers love the same sports team, or leads to a striking consistency between your values and those held by your Facebook friends. It also explains why, at one point not so long ago, almost everyone smoked cigarettes.

If you are a non-smoker, the idea of smoking, the smell of it, watching others do it, is often revolting. But if you have ever spent a substantial amount of time with smokers, you know that revulsion can eventually give way to acceptance. Imagine, then, cohabitating with a family of smokers, or socializing only with friends who smoke, or living in a neighbourhood or even a city filled with smokers. It is easy to imagine how acceptance would eventually give way to something even more insidious: the niggling feeling that it is only a matter of time before you, too, inevitably start to smoke.

In the first half of the twentieth century, when just about everybody ended up trying a cigarette at some point and the tobacco industry had a vested interest in keeping it that way, social norms that made smoking desirable were pervasive. Even when the link between lung cancer and smoking was scientifically proven in the early ’50s, and reconfirmed every few years after that, people continued to smoke. In the US, per capita cigarette consumption actually increased, as tobacco companies ramped up marketing efforts. Then, in the late ’60s, the American government invested heavily in anti-smoking ads, and, in conjunction with a doubling of the cigarette tax in 1983, attitudes toward smoking started to shift, and its prevalence declined. The first lesson here is that evidence is not enough to stop people from doing things they know might kill them. The second is that changing the social milieu just might.

Perhaps the most surprising fact about the phenomenon of injection initiation is the almost complete absence of measures to prevent it; in fact, there is exactly one scientifically evaluated program brought to scale in existence. Break the Cycle is the brainchild of Neil Hunt, a maverick scientist based in the United Kingdom. After piloting the program in Kent in the late 1990s, he exported it to the heroin-swamped central Asian countries of Uzbekistan and Kyrgyzstan, which border Afghanistan to the north, along the massive illicit trafficking routes that deliver Afghan heroin to a community of almost two million Russian drug injectors. Crucially, Break the Cycle works directly with those who have already started injecting—the potential initiators—rather than with those at risk of beginning to inject.

Once established injectors have been identified through street outreach and referrals from treatment centres, they are invited to a “motivational interview,” during which they are asked about their own first hit, the circumstances in which they now shoot up, and times they may have directly aided a first-time injector. The idea is to impress upon them the key role they play in determining whether other, often younger, users make the decision to inject. In principle, by the end of the intervention participants will be prepared to warn potential users about the harms of injecting and, perhaps more important, to say no to those who persistently ask to be initiated.

Break the Cycle is premised entirely on the transformational power of social networks. Its philosophy defines exposure to established injectors as the fulcrum upon which decisions to inject rest, and sees the behaviour of those who are considering it, regardless of how much they have already experimented with drugs, as modifiable, even up until the last minute. Allison’s story certainly supports this theory. When I ask her whether she thinks she would have begun injecting if she had not been surrounded by injectors, in particular her grandmother, she is emphatic: “No, I wouldn’t have done it, because I was scared. I couldn’t even touch needles. I couldn’t look when people injected me, because I’d get so scared and freak out. So I wouldn’t have known how to do it.” Hunt, meanwhile, touts data showing that those who complete the Break the Cycle intervention report significantly fewer instances of helping others inject for the first time.

Of course, quantifying the number of injection initiation events an intervention can help avoid is a complex scientific puzzle, not least of all because of the potential for unreliable reporting. No matter how well intentioned Hunt and his participants may be, and no matter how well they have done in evaluations, it is easy to imagine a variety of real-world scenarios in which all of the behavioural training in the world might be moot: for instance, if a user going through withdrawal were offered free heroin in return for helping a friend inject for the first time. Most scientists and policy-makers have resigned themselves to the fact that, more often than not, the cold calculus of addiction trumps voluntary behavioural change.

Twenty-eight-year-old Adam is impeccably polite and well dressed, in a leather jacket and crisp jeans—a far cry from the caricature of the junkie that holds sway in our collective consciousness. In the course of our interview at VANDU, he reveals that he never really had a father, while his mother’s drug binges were so extreme that he uses them as markers in his own trajectory of use. Growing up in Winnipeg, he experimented with a slew of drugs, eventually turning to cocaine, which he describes as a “door opener”—a way to meet people who otherwise ignored him. At eighteen, he first tried injecting, with crystal meth, not because of his erratic childhood or his history of drug use, he says, but because he dreamt of being just like his idol.

“The way I learned to inject was reading the Kurt Cobain biography,” he explains. “The book said, he put the needle in his arm, pulled the plunger back, and saw the crimson red…So I realized that’s probably how you do it, and I tried it myself.” Soon after his first injection, his mom skipped town unannounced, and his friends, previously game to party, suddenly stopped calling. Without any money, he decided to head west, first to Alberta and the oil sands, where he made tens of thousands in a few short months and blew it on a crystal meth binge, and then on to Vancouver, where, on his very first night, he finally injected heroin, just like his idol.

When I ask him about his experience initiating others, he becomes uncomfortable. He never has, he says at first. Except there was this one guy—a good friend, it turns out. “First time he asked, I didn’t want to be a part of it,” Adam says. “You never give someone down for the first time—it’s a rule on the street—and you don’t inject someone for the first time. You don’t want to be the first person to do that for them.” With his friend, though, he felt his resolve weaken: “He was begging me, and I felt really bad.” He had been injecting in front of this guy (who was then exclusively smoking crack) for months. “I’d be a hypocrite if I said he couldn’t do it. Plus he shared his rock with me.”

Like Allison’s grandmother, Adam found ways to rationalize. “If I said no to him, he would just get someone else to do it, or he’d learn it himself,” he explains with a sigh. “I figured I’d show him what I knew, which I thought was safe. You know, bevel up, tie it on this way, the basic safety stuff.” But the episode scarred Adam. He shakes his head: “He’s looking rough now.” The friend’s use quickly spiralled out of control, and he is now homeless. “Knowing what I did, and seeing what happened to my buddy,” Adam says, “no one could pay me enough to do that again, because it can ruin somebody’s life.”

The reality, however, is that he continues to move within social networks made up primarily of drug users, so even if he manages to turn away would-be injectors and their offers of free drugs, he will still be modelling injection every day. Ultimately, if we want to prevent the transmission of Adam’s behaviour to non-injectors, we must prevent any kind of exposure—another seeming dead end.

Except, perhaps, in the context of a new approach to preventing HIV transmission, developed by Julio Montaner, director of the BC Centre for Excellence in HIV/AIDS in Vancouver (full disclosure: I work there). The idea is that if everyone in a community of HIV-positive individuals gets access to treatment, the level of the virus in their blood will decrease, most often to an undetectable level. For someone trying to manage his or her HIV, this is great news, because it becomes a chronic condition rather than a death sentence. But it also benefits the entire community, since the chance of that person infecting others—even when sharing a needle or engaging in unsafe sex—becomes infinitesimally small. Treatment as Prevention has been adopted as an official guideline for controlling HIV epidemics at the highest levels, and the program is slowly being implemented in parts of the world facing large HIV epidemics, such as China.

Pioneered in BC, the strategy focuses on expanding access to HIV rapid testing, as well as antiretroviral treatment for all eligible HIV-positive individuals, which requires a large upfront investment in medicine and outreach to at-risk populations, such as injection drug users. Results suggest that the investment has been very cost effective. While annual statistics for new HIV cases in other provinces have remained essentially stable or increased, the number in BC has decreased by more than half since it peaked in the mid-’90s, and Montaner is bullish about the project’s prospects. “We’re pushing back HIV to levels we’ve never dreamt possible,” said the native Argentinian during a 2011 TEDxSFU talk in Vancouver. “Death related to AIDS is [also] going down, and we have every reason to believe that with this aggressive approach we will reach a point where AIDS will not be anymore a significant problem in our province.”

Now, consider all of this in the context of another transmissible condition, namely injection drug use. What if we could reduce the overall number of injectors in a network of users by increasing addiction treatment? Borrowing the logic of Treatment as Prevention, we might manage to reduce the exposure of prospective injectors to established ones. This might in turn reduce the social pull—that sense of inevitability—that drives young users to seek out injecting. On the flip side, people like Adam, or Allison’s grandmother, or any other injector battling addiction would be freed from having to justify a bad decision to inject someone else, because the decision simply would not exist.

It is a simple theory—often the best kind—in need of scientific evidence. Testing it would require our governments to redirect investment from mass incarceration, street-level crackdowns, and other strategies of prohibition toward treatment. For this to happen, we will finally have to confront the ongoing stigma perpetuated by the war on drugs. Despite mountains of evidence to the contrary, addiction continues to be widely conceptualized as a moral failing that only punishment can correct.

There are other challenges, too. Methadone, buprenorphine, and a small number of other prescription opiates are the only drugs clinically proven to manage heroin addiction (mitigating symptoms so the individual can lead a more stable and healthy life), and none is 100 percent effective. Meanwhile, no viable clinical treatment options exist for the millions of cocaine and amphetamine users worldwide, although, with the right kind of support, pharmacological advances could be made within a matter of years.

Finally, there are the vagaries of addiction itself. The intensity of symptoms can vary from day to day, month to month, person to person. Attempts to force users into treatment have been a dismal failure, not to mention ethically questionable. It should seem obvious, but it is worth repeating: people have to be ready to recover, and the window of opportunity can be very small. That is why we need to scale up public health services such as supervised injection sites, which not only reduce non-injectors’ exposure to injecting, but offer established injectors a point of contact with health professionals, increasing the likelihood that they will go to treatment.

Of the three young injectors I interviewed for this article, Adam is the closest to stabilizing his addiction. He has enrolled himself in methadone maintenance therapy, and he is moving into a bachelor apartment, a step up from the couch surfing he has been doing for the past few months. He admits, however, to occasionally still using heroin, and he finishes a diatribe about the dangers of crystal meth by admitting that he has a small Baggie of it on him.

“It’s hard to get out of here,” he says of the Downtown Eastside, but he could be talking about any network of drug users, on behalf of anybody trying to recover. “It traps us.” That is because, for Adam and many others who inject drugs, beyond the daily struggle for survival and self-medication, using is wrapped up in their sense of identity, and in the choices they make about where they live and who their friends and lovers are. Treatment and recovery are so hard precisely because they often require that people deracinate themselves from a community of their peers, right when they most need love and support. When I ask whether in a perfect world he would move someplace else, Adam shakes his head: “Maybe I’d live a little out of the area, but not too far. Everything I know and everything I am is down here.”

While treating injection drug use and addiction is a battle on par with the global fight to tackle HIV, it is not impossible. Indeed, in a Vancouver-based study I co-authored, (published earlier this year), we found that since 1996, 48 percent of participants—all people who inject at baseline—reported that they had ceased injecting by 2010, and that those enrolled in methadone programs were significantly more likely to do so. If effective treatment can be extended to all those who might need it, at the very moment they feel ready to try it, we may just start seeing the beginnings of a new feedback loop, in which less exposure to injecting starts to reduce the number of new cases, which results in less exposure, and fewer new cases, until we reach a point where injection drug use will no longer be a significant problem in our country. It all starts with helping someone like Matt, who could turn out to be the fulcrum upon which our efforts succeed or fail. “I’ve saved a few lives and taken a few lives,” he tells me at the end of the interview, his voice shaking. “I don’t want to do that again. My soul can’t take much more of it—I know that.”

This appeared in the September 2013 issue.

Dan Werb
Dan Werb, PhD, is an award-winning writer and epidemiologist whose work has appeared in the New York Times, Salon, and elsewhere. He is based in Toronto and San Diego.
Byron Eggenschwiler
Byron Eggenschwiler has done artwork for the New York Times, the Wall Street Journal, and GQ.