Introduction

In a beat-up old hotel, Mark Townsend watched one of his tenants, a woman named Mary, crawl up the stairs, so crippled by the symptoms of withdrawal that she couldn’t lift her body to walk. It was 1992, Townsend recalls, and doctors required a thorough examination and patient history before they would prescribe methadone to someone addicted to drugs. Often that took several days.

“How can we make this woman’s life bearable?” he remembers thinking. The rules were wrong, Townsend decided. He found a doctor who put Mary on methadone immediately. They broke the law. That still didn’t solve Mary’s addiction to heroin; she would struggle with that for many years. But they addressed her immediate pain and made her well enough to fight another day.

Like Townsend, activists, health-care workers, and some politicians in cities across North America are realizing they will have to break and rewrite the rules on how society addresses addiction. The continent is in the grips of an overdose epidemic. In 2016, there were an estimated 60,000 fatal drug overdoses across the United States, up from less than 15,000 twenty years earlier. More than sixty percent of 2016 deaths were attributed to heroin and similar drugs like OxyContin and fentanyl. For people under the age of fifty, an overdose associated with an opioid is now the number one cause of death in the United States. Heroin has reached the middle class and suburban America. At the same time, public opinion is turning against the “war on drugs.” Many policymakers are beginning to look at addiction as a health-care issue as opposed to one for the criminal justice system.

One Canadian city has seen this sort of crisis before. In response, a grassroots group of drug addicts waged a political street fight for two decades to transform how Vancouver treats its most marginalized citizens.

Beginning in the early-1990s, activists pushed the city to adopt a “four pillars” approach to addiction. Authorities would continue with the pillars of prevention, treatment, and enforcement, but also deploy a series of complementary programs described as harm reduction. The city defined it like this: “The principles of harm reduction require that we do no harm to those suffering from substance addiction, and that we focus on the harm caused by problematic substance use, rather than substance use per se.”

In Vancouver, the municipal government accepted that it could not immediately help every addict stop using drugs. Therefore, for those people who had failed to get clean, or who simply were not ready for that step, it would attempt to make drug use less harmful.

Inherent in harm reduction is an understanding that it is not necessarily the drugs themselves that do the most damage to a user, but that the laws and systems of prohibition, which make drug procurement and possession illegal, are what hurt people the most. When a person addicted to cocaine injects with a dirty needle, it is not the cocaine that poses a risk of infectious disease but the syringe. So why not make a clean needle available? Yes, the risk of overdose remains, as does the much larger issue of the addiction itself, but the potential harm of an infectious disease is removed. When someone uses heroin in an alley, hurriedly injecting for fear of police, it is not the drug that causes them to rush and miscalculate their dose, possibly leading to an overdose. It is their fear of persecution. If they were offered an injection site where they could take their time and use under the observation of health-care professionals, the risks would be reduced. Again, the addiction remains. But if they overdose at an injection site and a nurse is there to monitor them, they lived to make another attempt at long-term treatment.

Harm-reduction strategies are about keeping people alive and as healthy as possible until they can arrive at a place in their life where treatment or abstinence will work for them.

Today, there are dozens of cities across North America at the point where Vancouver was in the 1990s. Toledo, Miami, and San Francisco, for example, have sprouted activist groups that are working with health-care professionals to slowly warm public opinion to this issue.

“Ninety percent of new heroin users are white. A rising number are middle class or wealthy,” a US official told “Frontline” on PBS in 2016. “It’s been true throughout American history that when drugs penetrate into the middle class—the white middle class—politicians panic much more than they do when the drugs are concentrated in poor neighborhoods. It’s not fair and it’s not right, but that is the kind of country that we are living in.”

Jurisdictions across the United States are looking to Vancouver’s example with increasing interest. One of the founders of Vancouver’s harm-reduction movement, Mark Townsend, spent April 2016 in New York, helping the city expand needle-exchange programs. In October 2016, a delegation from Seattle visited North America’s first supervised-injection facility, Insite, in Vancouver. In early 2017, former BC coroner and mayor Larry Campbell was in Sacramento helping lawmakers draft policies that would allow for the establishment of supervised-injection facilities in California. Interest in Vancouver’s model has grown with the increasing severity of America’s opioid problem.

Fighting for Space is about people who slipped through the cracks. It is about those who have suffered the consequences of addiction and prohibition and who didn’t have family or friends to help them get back up. It is about those who, for a myriad of reasons, failed with treatment and rehabilitation. It tells their stories and explains harm reduction for communities that are struggling with overflowing jails, crimes fuelled by desperation, and people left in the streets to die.

It’s also about the activist movement that fought for harm reduction in Canada, which came out of a small neighborhood in Vancouver called the Downtown Eastside. It’s only about ten square blocks and has long held notoriety as the poorest urban neighborhood in the country. But in the 1990s, its residents banded together to demand a say in drug policy.

They called for harm-reduction services to provide the stability, space, and time that some people need to find treatment services that might help them eventually control their addiction. It’s a simple yet revolutionary idea: that everybody deserves a home regardless of their drug abuse or destructive behaviour, and that an addict is a human being who should be treated with dignity.

Despite officials' reluctance, a conversation about harm reduction is being forced on North American governments by an unprecedented increase in opioid addiction and an almost-unfathomable spike in overdose deaths.

Chapter 1: Toledo, Ohio

Matt Bell was in a coma for five days. He woke up in a hospital in downtown Toledo, Ohio. Although disoriented, he knew where he was and that he’d overdosed to get there.

“Fuck,” Bell remembers thinking as he opened his eyes. “I messed up again.” It was November 2014.

After another two days at ProMedica Toledo Hospital—while his body learned how to walk again—Bell was ready go home. He grabbed the bag that the hospital had stuffed his possessions into when he arrived, and his girlfriend drove him home. As he was unpacking his things, he found a business card. “Lucas County Sheriff’s Office,” it read. Bell moved to throw it in the trash but then slipped it into his wallet instead.

Bell had been a freshman at the University of Toledo. He’d graduated high school with a straight-A report card and received a full scholarship for baseball. Major League teams, including the Baltimore Orioles and Toronto Blue Jays, were already scouting him. How he found himself waking up from a heroin overdose in a Toledo hospital is a story that will sound very familiar to thousands of opioid addicts across North America today.

“I hurt my shoulder,” Bell begins. “They did surgery, then gave me ninety Percocets. And that’s all she wrote. I abused Percocets to an extreme,” he continues. “And then somebody introduced me to Oxy[Contin] because those were stronger. I started doing Oxy. That became a $400-a-day habit. And then it went to heroin.”

In the eight years between his first time using heroin and the five days he spent in a coma at ProMedica Toledo Hospital, Bell tried and failed at rehab twenty-eight times. He was arrested thirteen times in four different states. He previously overdosed twice. Once he found himself in a back alley, where his dealer had dragged him and left him to die. The second time was at his mother’s house, where Bell woke up covered in vomit. Bell’s third overdose, in November 2014, was the one that came closest to killing him.

There were 2,744 drug-overdose deaths in Ohio that year, placing it among the top five states in America for drug fatalities.

Twenty-seven hundred deaths is triple the roughly 900 fatal overdoses that Ohio saw one decade earlier, in 2004. Since 2014, the number has continued to climb, to 3,310 in 2015 and then to an estimated 4,000 deaths in 2016. In June 2017, NBC News reported that based on deaths during the first five months of the year, Ohio’s Montgomery County coroner predicted the state will see 10,000 fatal overdoses in 2017. That’s more than the entire country recorded in any given year during the early-1990s.

The overdose crisis that Ohio is experiencing is part of an epidemic playing out across the United States and Canada. In the 1980s, there were less than 10,000 drug-overdose deaths in America each year. Twenty years later, that number had grown to 30,000. In 2017, it’s projected that America will see some 60,000 people die of a drug overdose, according to a comprehensive analysis by the New York Times.

The very day that Bell checked himself out of that hospital in downtown Toledo, he was using heroin again. After another nine months on the drug, he put a gun in his mouth.

He was tired of heroin and tired of the hustle it kept him on. Tired of waking up every morning in a panic over where the next fix was coming from, scheming every day for enough money to keep withdrawal at bay. He was tired of being an addict.

Then, with the gun in his mouth, he remembered the card in his wallet.

“I wasn’t even supposed to be around a gun,” Bell remembers thinking. “I had two active felony warrants in two different states. I had drugs and I had paraphernalia. But I called [the sheriff’s office], and they took me to treatment instead of to jail.”

Bell ended up at Zepf Recovery House, where he spent the next ten days going through detox and then beginning down the road to long-term recovery. At Zepf, he got to know a few guys who were in there for using the same drug, and they grew close. Before each group-therapy session, Bell and these four other men would form a circle, put their hands in the centre, count to three, and then break, raising their hands in the air like a baseball team does before taking the field. “One, two three—Recovery!” they’d shout. Then they’d get on with their group-therapy session.

“It was a joke,” Bell says. “We were feeling like shit and we were just trying to do anything to make each other feel better.” But the nickname “Team Recovery” stuck.

Society doesn’t make life easy for people coming out of recovery for a drug addiction. Most job applications have a box you have to tick if you’ve ever been convicted of a felony, and a lot of former drug users have. They tick that box and then seldom receive a call back. Meanwhile, a lot of an addict’s friends are often still on drugs, which makes reconnecting with them a bad idea for anybody who’s trying to stay sober. It all makes for a lot of free time.

“When we got out, we were bored,” Bell recounts. “Let’s go down and hold signs on Cherry and Summit,” someone else suggested.

Cherry and Summit is a busy intersection in Toledo where panhandlers sometimes congregate. The idea was to break the stereotype of a heroin addict as an unwashed homeless person standing on the side of the road asking drivers for drug money. Toledo is part of America’s Rust Belt. The region was devastated by North America’s loss of factory jobs. Then, in the early-2000s, prescription opioids swept into town. Heroin followed shortly after. In Toledo—and right across North America—addiction was a disease affecting families. Team Recovery wanted families to be able to talk about it. Just like the homeless addict people imagine when they think of heroin, Bell and the guys decided they would go down to the intersection of Cherry and Summit and hold cardboard signs. But instead of asking for money, they would give it away.

“Honk if you hate heroin,” one of their signs read. “Heroin’s killing our town,” read another. And a third, “We used to take, now we give.”

Into the hand of each driver who stopped to chat for a second, they handed a one-dollar bill. “Completely flipping the stereotype,” Bell explains.

People loved it.

Just about everyone who drove by Team Recovery that day knew someone who was struggling with an addiction. Many had already lost someone. Stigma prevented them from talking about it, Bell remembers thinking, but everyone knew what was going on.

The guys had created a Team Recovery Facebook page a few days earlier. It only had twelve followers, but nobody cared. It was just an inside joke and an easy way for the guys to stay in touch. If it spread a little awareness about addiction and recovery, that was a bonus. The evening after they’d taken signs down to Cherry and Summit, Bell uploaded a few photos to the Facebook page. The next morning, when he woke up and logged online, the pictures of the guys and their “Honk if you hate heroin” signs had more than 200,000 likes. In February 2016, Team Recovery decided it wanted to organize something bigger.

After they put the word out on social media, more than a thousand people gathered in the parking lot outside Zepf Recovery House one chilly afternoon. There was free food, coffee, and hot chocolate for kids. It was a family event. They had a bouncy castle and face-painting stations. On a small stage, politicians, police officers, and recovering addicts spoke about a need to break the stigma around drug use in Toledo.

A journalist with a local newspaper reported that the head of the Toledo Police Department was there that afternoon and stood on the stage to say that it was time Ohio take a new approach to addiction. “Chief Kral called the heroin addiction a ‘public health crisis’ and said, although it might seem counter-intuitive to some, the police department is ‘moving away from putting everyone in jail to putting the right people in jail,’” the article reads.

From Zepf Recovery House, the crowd marched down Collingwood Boulevard, making a public call for government action on Ohio’s overdose epidemic.

The city had never seen anything like it, Bell remembers. Toledo is a conservative town, and people seldom spoke publically about a friend or family member’s drug problem. If somebody died of an overdose, that was never mentioned in the obituary. The February 2016 rally began to change that.

Team Recovery grew from there. They established a twenty-four-hour hotline for help accessing treatment services as well as for people who called just to talk. They launched an education and prevention campaign, visiting more than fifty high schools and speaking with more than 27,000 students in the first year. Team Recovery now holds twice-weekly support groups for the families and friends of people who are struggling with an addiction or who have lost someone to drugs.

In mid-2016, Team Recovery partnered with Ohio Mental Health and Addiction Services to teach overdose response. Its family-support groups usually meet at a church, and at the end of those meetings, attendees can stick around to learn how to use naloxone (the generic name for Narcan), a prescription drug that reverses the effects of an opioid overdose.

“In Lucas County, we’ve put out more Narcan than the health department, all pharmacies, and every other facility combined,” Bell says. “And it’s confirmed that some of these kits have saved lives.”

Bell won’t call it harm reduction. He emphasizes that Team Recovery focuses on abstinence-based treatment. They don’t even encourage widely-accepted opioid-substitution therapies such as methadone.

“We realize that everybody has their own path, but the way that we got clean and sober was through twelve steps,” he says. “Harm reduction is not our purpose. Yes, it will stop the spread of disease and it will stop people from sharing syringes and all that stuff, but we think that getting somebody clean and sober will stop those things too. “I can’t actually support any kind of needle exchange,” Bell continues. “I just can’t wrap my head around it. I get that it works in other places and I know the data behind it ... but that’s just not in our mission. In Ohio, it would never happen.”

Few people involved in that February 2016 march down Collingwood Boulevard had ever heard the name Bud Osborn. Bell concedes that he never had. Osborn grew up in Toledo. Many years later, in Vancouver, Canada, Osborn was a key figure in a grassroots movement of drug users who transformed how Canada responds to addiction. He helped pioneer North America’s first harm-reduction programs, expanding needle exchange and eventually establishing the continent’s first supervised-injection site.

Some thirty years before Team Recovery existed, Osborn arrived in Vancouver, in a rundown part of the city called the Downtown Eastside.