Unconditionally safe: how the drug using community helps each other when healthcare services fail

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Content warning: This story mentions drug addiction.

In the heart of Boston, between warehouses and industrial parks, lies the Mass and Cass neighbourhood. Often seen as a drab area by most locals, Brendan Little describes it as a place that “wasn’t designed for people to be there.” And yet, it’s become and continues to be home to a strong community of people who live in encampments, and many of whom use drugs. 

When Little was growing up in Boston, in a particularly dysfunctional family, he found solace in the streets — in areas like Mass and Cass. He found a community of kids in the downtown area who, like him, revelled in punk rock music. There were people from all walks of life, different backgrounds, and different ages, who came together as a refuge for each other. Little says that the streets became a kind of salvation for him to escape the stress he felt at home. 

Around the same time, Little also started to use drugs and got into trouble with the law. He would often be court-ordered to juvenile detention or social service treatment centres. Little’s early teen years were a tumultuous time when he was in and out of many institutions, recovery programs, in between living on the streets. But it was always the latter where he felt most comfortable. 

Little recalls sleeping below underpasses, bridges, tunnels, or on the sidewalk — most of the time, he would rather be there than at home. He felt safer; he had his chosen community with him.

“If you’re on the street, and you’re sleeping in a tunnel, there’s something calming about that because there’s nowhere else to fall,” says Little, adding that while there were, of course, hardships, struggles and horrible moments during this time, there was still comfort in having people around who would accept him unconditionally. 

“You’re drunk or high or you’re dirty, and somebody’s still giving you a hug, sharing a cigarette, helping you out with a problem or just laughing with you,” says Little. It’s almost like this dare or test, [to see] how low you can go, in society’s eyes, and still have your people — there’s something kind of safe about that.”

Years later, Little is a harm reduction advocate, and a former policy director at the Boston Mayor’s Office of Recovery Services. He advocates for the unconditional love, the kindness, non-judgement, and acceptance he experienced as a teenager to be embedded within addiction and prevention services for drug users. In institutions that often rip drug users away from their only community and present abstinence as a prerequisite for care, Little pushes for recovery services that are non-judgemental and let drug users decide what help they actually need. 

Using technology to strengthen existing community supports 

One organization based in Vancouver has digitized peer support systems for easier access. Using the strong networks that already exist with drug-using communities, Brave Technology Cooperative (or Brave) is built by drug users and for drug users to prevent overdoses through digital tools. The team has created a phone app, a wireless smart button, and a radar sensor that allows someone using drugs to reach out to a community member for help if they are at risk of an overdose. 

When starting up with Brave, the team tried to meet with as many drug users as possible and find out if they had access to technology. For those who did, they asked them if they would use the technology to keep themselves safe and what it would take for them to feel safe using it. 

“Being able to move through those communities to ask those kinds of questions required us to use my expertise and my knowledge of what it means to move inside of a stigmatized community,” and “find people who were trusted nodes within the community,” says Oona Krieg, chief operating officer with Brave Technologies Cooperative and co-founder of the National Overdose Response Service.  

Brave Technology essentially activates the existing drug user community support and uses it as an overdose prevention tool. 

“What we were missing from the overdose prevention and response piece was that moment of being able to identify the when and where of an overdose and send nearby help,” explains Krieg — as it stood, their only option was calling 911, which many people don’t feel safe doing.

When someone uses Brave, whether it’s through the phone app or the smart button, they’re connected anonymously to a trained support volunteer who will chat with the caller and come up with a rescue plan. The caller also has their location and emergency contacts listed on their profile, which is only released to the supporter for a short period of time if the caller becomes unresponsive. 

Most people have some sort of informal emergency system in place already — whether that’s asking a neighbour or roommate to check in on them. But it’s not possible to always keep tabs on someone who is using, says Krieg. Brave just allows drug users to push a button when they need help and get someone to check in on them, says Krieg. 

In this way, Brave is not only an overdose prevention and response tool, but also a method for someone using drugs to transform their own home into a supervised consumption site by allowing someone to come in and check on them.

People need options, says Krieg. People can download three different apps just for a food delivery service, but emergency services are incredibly limited for drug users. 

“We’ve just simply systematized processes that are already existing in the community by creating that purposeful flow of information in between any emergency event and the response. And it’s that critical activation, where you’re able to get help that might just be on the other side of a wall,” says Krieg. 

How harm reduction and peer supports save lives 

Simply put, harm reduction practices aim to minimize the harms associated with using drugs. Some common harm reduction services include needle exchange programs (which provide drug users with clean needles) and safe injection sites (where people can use illicit drugs with medical supervision). Programs such as these not only provide people with safe supplies and a secure place to use drugs, research has also shown that harm reduction programs prevent overdose deaths. 

While critics of harm reduction sometimes argue that this approach enables people to continue using drugs, harm reduction advocates say that the goal needs to be keeping people safe and alive, regardless of their chosen lifestyle. 

Many experts are calling the overdose crisis a serious public health crisis which should and must be taken as an emergency. Yet, even though the pandemic has severely worsened the overdose crisis, the urgency given to COVID-19 is incomparable to the opioid epidemic, in terms of public attitude as well as policy changes. 

Between January 2016 and September 2021, there were 26,690 apparent opioid toxicity deaths in Canada (to put that into perspective, COVID-19 has taken about 39,500 lives since 2020). The first year of the pandemic alone saw a 95 percent increase in opioid toxicity deaths (from April 2020 – March 2021) according to Statistics Canada. Deaths have remained high since, and the report also shows that the overdose crisis has worsened during the pandemic, due to several factors including rise in drug toxicity levels.

To those in the drug using community, the crisis is obvious. And they’ve taken matters into their own hands, as this community has done for decades. Peer support networks, whether through community service organizations or tent encampment communities, can and do serve as a vital tool in harm reduction support. Through non-judgement and understanding, they keep each other safe in a way that professional medical services usually don’t. 

Examining the vast gap within professional medical services for drug users

The healthcare system isn’t designed to welcome everybody. Medical practitioners hold biases like everyone else — which include stigma against those who use drugs. 

Shoshana Aronowitz, an associate professor in the nursing faculty at the University of Pennsylvania, has been working within the harm reduction movement for most of her career. It was during her first nursing job in a methadone clinic in Vermont, when she started to understand the depths of how treatment systems and healthcare fail drug users. 

Drug users often face intense stigma within healthcare and community services which include people being rude to them, and treating them poorly. It also means that drug users are not getting the care they need, Aronowitz says. 

For example, when drug users seek care in a hospital, they usually don’t receive adequate pain control (because of the assumption these medications might fuel a drug addiction, or because they’re simply not taken seriously), which Aronowitz says is a huge issue. People also leave early because they aren’t getting good withdrawal treatment, not being allowed to go outside, and generally feeling lonely.

Treatment options also tend to be hard to access, inflexible, and end up being quite difficult for people to succeed in because they usually position abstinence as the only acceptable goal; and these gaps in the system are for those who are actively seeking substance use treatment. 

For drug users who don’t want treatment, don’t want to stop using drugs, and are just seeking healthcare in general, the stigma is ever deeper, says Aronowitz:“Healthcare providers think, ‘you’re doing this to yourself; why should we help you?’” 

And so, knowing the stigma they will face, drug users often avoid getting care altogether.

“Our treatment systems can be really traumatic for people and don’t really afford a lot of autonomy or options for people. It’s very much like, if you want care, you have to do it in this exact way,” says Aronowitz. And that one way is, more often than not, maintaining abstinence from all substances. 

Krieg also explains that someone who lives in poverty and uses drugs has a lot to fear in being involved with institutions when they’re in need — potentially losing their children, their house, their livelihood, or being incarcerated. That’s why many drug users turn to their peers for support, rather than emergency or community services. 

“The drug-using community that lives below the poverty line have a lot of shared spaces, and the community has always watched out for each other,” says Krieg. “It’s that expertise of how communities keep themselves safe which actually reduces harm overall.”

She continues: “Harm reduction, as an institution, is about diverting poor people, criminalized people, and racialized people from the hospital.”

Pushing for abstinence alone isn’t enough — drugs users need agency to decide what is best for them

Even when healthcare or recovery centre settings use harm reduction strategies, the assumed outcome is that people will and should stop using completely. And while for some people, that is the goal, it isn’t for everyone. 

Those who want to continue using drugs face major stigma because care providers see their choice to use as a moral failure. Yet, the choice to use drugs and self medicate is socially acceptable when it comes to other substances that are regulated. 

People use drugs everywhere throughout the entire social fabric, but not everyone is at risk of dying from an overdose, says Krieg. There’s a massive gap in the way the general population thinks about their own drug use versus drug users living under the poverty line, with a high risk of overdose. 

Krieg adds that people who use ecstasy on the weekends, take depression or anxiety medication, or smoke weed, have access to a safe supply that helps them cope in one way or another. If someone goes to a brewery, they’re essentially getting a safe supply at a safe consumption site. 

“People think drug use is inherently harmful when really, a lot of the risks and harms associated are because it’s criminalized, and prohibition and the war on drugs makes people unsafe. It’s not always the substance-use itself,” says Aronowitz. 

When it comes to treatment options (outside abstinence) for drug users, they are hugely limited. Traditional recovery services work for some people, but can be very damaging for many, says Little. “There should be multiple options of how people want to pursue their recovery or pursue their path to housing.” 

Often, traditional recovery means that a person is in a space without their community and are held to impossibly high standards where if they slip up once, they are kicked out. It’s hugely problematic, says Little, especially because people who are on the streets are highly traumatized, and have not been shown genuine care from their families.

Harm reduction services, like Brave, give people options. Options like using drugs safely while still going to work, and maintaining their lifestyle. Unconditional care for people who use drugs means accepting their chosen lifestyle — something that peer support does best. 

When a support worker from Brave helps out a person who was at risk of overdosing, they won’t try to push them into a recovery program afterwards. They first and foremost try to keep the person alive and safe above all else. 

Embedding peer support and harm reduction into care services 

Many people who are using drugs feel a deep mistrust towards institutions and systems that have caused intergenerational trauma for them, says Krieg. But they will trust someone who comes from the same walk of life, speaks the same language, and understands them.

“The reason there’s peer support is because of stigma and lack of services,” says Gord Garner, vice president of strategic partnerships at Community Addictions Peer Support Association (CAPSA), an organization that advocates for harm reduction and improved substance use healthcare. “When people don’t go to health centres . . . they learn from their companions — and so that’s where people turn to when they’re struggling, because they’re rejected from the healthcare system.”

At CAPSA, Garner explains that they have a peer support group called ‘All People All Pathways’ which is a peer-facilitated group session that allows anyone to join and share their experiences and challenges around substance (drugs and alcohol) use. It doesn’t require people to pre-diagnose themselves with any condition — anyone can join to talk about their relationship with substances. 

Peer support within a traditional healthcare setting, Aronowitz says, could mean a drug user going to the hospital with someone they trust, someone from their community. As a member of the grassroots harm reduction group, SOL Collective, Aronowitz explains that when the group is doing community outreach work and come across someone who is seeking medical care, a team member will go with them and advocate for them at the hospital. 

“It’s really shitty that this is true, but I think people are often treated better if they’re with someone [else], especially if [they’re] a healthcare provider,” says Aronowitz. 

People need to be allowed to show up as they are to spaces like housing shelters and care centres, instead of being forced to abide by a list of rules like a no drug policy, or not being allowed to go outside. 

Little says that low-threshold overnight spaces are a game changer. Unlike most spaces for people experiencing homelessness, people aren’t under high surveillance, won’t be subjected to bag checks, and can drop in and out of the space as they need. In places like Boston, these kinds of services are becoming more common.

“They can bring their community with them,” says Little. In these spaces, people can bring whatever is it that calms them down — their partner, their friend, their dog, their drugs, anything that helps them feel comfortable. 

“I think that the key is to allow people to have their community in whatever way you can do that…and how they define community, not a manufactured community that you dictate is their community; something that they feel is theirs,” says Little. 

Unconditional support can be transformative for people

By the time Little was 18, he already tried a number of treatment programs (which he was forced into by court-ordered mandates), but they never seemed to work for him. Meanwhile, a friend of his started going through a 12-step recovery program. 

Little told his friend he thought programs like that were nonsense and cult-ish, and he would never try something like that again. His friend, in turn, met him with compassion and understanding, saying, “It’s okay, it’s not for everyone,” recalls Little. 

The two continued spending time together, and playing music together — something Little cared about deeply. One day Little remembers asking his friend for money, and he made up a lie about why he needed it. “[My friend] went to the ATM and gave it to me, fully knowing that I was gonna spend it on drugs, and didn’t judge me.”

Little’s friend never forced recovery on him. He never imposed his solutions on Little, never asked him what he was going to use the money he borrowed for, never suggested he should check himself into recovery. He showed up with kindness, and supported his decisions unconditionally.

“Guess who I called the day I woke up and I knew that I really wanted to get help?” 

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