The Fixer

Are we ready for a rad­i­cal ap­proach to ad­dic­tion that in­cludes ex­per­i­ments with psychedelics, de­crim­i­nal­iz­ing drugs and chal­leng­ing the idea that re­cov­ery equals so­bri­ety? Maybe not yet. But Dr. Evan Wood, head of the new B.C. Cen­tre for Sub­stance Use, is

Vancouver Magazine - - News - by Bruce Gri­er­son pho­to­graph by Pooya Nabei

Dr. Evan Wood has a con­tro­ver­sial idea for treat­ing the fen­tanyl cri­sis—fight drugs with drugs. Are we ready for his rad­i­cal plan?

“I’M GO­ING to be the least com­pelling speaker you’ll hear tonight,” Dr. Evan Wood tells me as we pull up in front of the Anvil Cen­tre au­di­to­rium in New West­min­ster. Peo­ple are al­ready trick­ling in for tonight’s event, Re­cov­ery Speaks, fea­tur­ing in­spir­ing per­sonal tales of so­bri­ety on the other side of hellish ad­dic­tion.

Wood holds afist­ful of ti­tles—in­clud­ing pro­fes­sor of medicine at UBC, Canada Re­search Chair in In­ner-City Medicine and head of the prov­ince’s newly es­tab­lished re­sponse to the opi­oid cri­sis, the Bri­tish Columbia Cen­tre for Sub­stance Use (BCCSU). He’s giv­ing the key­note ad­dress tonight—and he’s go­ing to have to thread the nee­dle.

Many of the at­ten­dees here are part of the “re­cov­ery com­mu­nity”—their jour­neys in­volve get­ting clean largely via the 12 steps. The path in­volves fierce per­sonal reckoning and sur­ren­der to a higher power un­til the de­mon slowly loosens its grip and you get your life back, though with eter­nal vig­i­lance and ab­sti­nence as part of the deal.

“Twelve-step fa­cil­i­ta­tion ther­apy,” hatched some 80 years ago by the Amer­i­can Bill Wil­son (or sim­ply Bill W., as he’s known in AA cir­cles) and Dr. Robert Smith, is still the pre­vail­ing model for treat­ing ad­dic­tion, both in the U.S. and in Canada. It’s tra­di­tion­ally a cold­turkey ap­proach: just you and your god and the dark night (with your sup­port group on call). Wood’s own view is that there’s a less tor­tur­ous and more ef­fec­tive strat­egy. Re­duced to a bumper sticker, it might read: Get off drugs with drugs.

It sounds like pret­zel logic: drink your way to so­bri­ety. Use to get clean. Yet this is the chat­ter on the fron­tier of ad­dic­tion medicine—an emerg­ing field pro­mot­ing ev­i­dence-based strate­gies to treat ad­dic­tion in­stead of the en­trenched old ways, no mat­ter how beloved they might be.

Ab­sti­nence, the ev­i­dence in­creas­ingly sug­gests, doesn’t work for many peo­ple. More than 80 per­cent of those who try it will re­lapse, some stud­ies show.

The ris­ing death toll in the fen­tanyl epi­demic means it’s never been more ur­gent to come up with some­thing that works more re­li­ably—and to quickly clear a leg­isla­tive path for it.

The new think­ing, Wood’s think­ing, is that, far from be­ing a kind of de­fect of the psy­che, ad­dic­tion may in fact be an evo­lu­tion­ary in­her­i­tance—a deeply hu­man trait that turns out to be ill fit­ted in some ways to the mod­ern era. Wood is ex­plor­ing phar­ma­ceu­ti­cal treat­ments for ad­dic­tion, pi­o­neer­ing an ap­proach where ab­sti­nence isn’t nec­es­sar­ily the end goal, and even us­ing com­mon street drugs to tem­per its ex­pres­sion.

All of this would seem to cast him as a fox in the hen­house here. And yet Wood is given awarm setup by the man who in­vited him here tonight, Mar­shall Smith, a for­mer top B.C. gov­ern­ment bu­reau­crat whose own lost-now-found story is as dra­matic as they come.

Ten years clean after a bru­tal co­caine ad­dic­tion that left him un­em­ployed and liv­ing in a ship­ping con­tainer, Smith is now in full re­boot. He runs a non­profit re­cov­ery cen­tre on Van­cou­ver Is­land, co­or­di­nates th­ese speak­ing events and serves as a se­nior ad­vi­sor at the BCCSU, a $10-mil­lion provin­cially funded net­work aimed at de­vel­op­ing an ev­i­dence-based frame­work for ad­dic­tion treat­ment. Part of the man­date is to tap the “lived ex­pe­ri­ence” of users to de­velop ef­fec­tive new strate­gies, which is where Smith comes in. Wood hired him after he re­al­ized Smith’s cred­i­bil­ity and charisma could help shape the evolv­ing nar­ra­tive of ad­dic­tion treat­ment in B.C.

It was nuts, both men re­al­ized, to present them­selves as ad­ver­saries—pen­ning op­pos­ing opeds in news­pa­pers, pit­ting harm re­duc­tion against ab­sti­nence-based re­cov­ery—when all that did was make the en­tire ad­dic­tion-medicine space ra­dioac­tive to politi­cians and po­ten­tial fun­ders. “We clearly came from dif­fer­ent per­spec­tives, we clearly came from dif­fer­ent per­sonal ex­pe­ri­ences and we clearly rep­re­sented dif­fer­ent con­stituen­cies of sub­stanceusing peo­ple,” Smith says. “But . . . we were in ab­so­lute agree­ment that the sys­tem we have now is fail­ing peo­ple at best and killing peo­ple at worst.”

Wood steps up to the lectern with­out notes. Be­spec­ta­cled and self-con­tained, he has the air of an un­cle about to give a toast at Thanks­giv­ing din­ner. He tip­toes through a de­cent joke be­fore quickly es­tab­lish­ing a sen­si­tive, com­mis­er­at­ing tone that finds com­mon ground with Smith. “The sys­tem of ad­dic­tion treat­ment in Bri­tish Columbia isn’t bro­ken,” he says. “There. Is. No. Sys­tem.” Suf­fer­ers are left alone to fig­ure out their op­tions amid a Wild West cli­mate of murky reg­u­la­tions and an ab­surd cir­cum­stance where opi­oids are pre­scribed to peo­ple who don’t need them and with­held from those who do, one in which re­hab­bing users are dis­charged from detox with ahand­shake and di­rec­tions

"Inside ev­ery ad­dict is a seeker who got on the wrong track."- Carl Jung

to the bus stop, and where wait-lists for re­hab fa­cil­i­ties can be months long. Ev­ery story he’s hear­ing, in this room and out there in the world, Wood says, ev­ery scrap of data he’s gath­er­ing, will go into the bat­ter of this new thing they’re cook­ing at the BCCSU.

He gets as­tand­ing O.

INTHE GI­ANT’SSHADOW

I FIRST MET Wood, 43, in his up­stairs of­fice at St. Paul’s Hospi­tal, tucked away from the emer­gency room, where fa­tal opi­oid over­doses have be­come an al­most daily oc­cur­rence.

His eyes were red be­hind his spec­ta­cles: too many short nights in arow. He was wear­ing a crisply cut suit in banker’s blue—the bet­ter to con­vene high-level meet­ings with se­nior staff of health agen­cies, con­vey grav­i­tas in me­dia in­ter­views and beat the bushes for fund­ing. That suit, and his quiet, squeaky-clean in­ten­sity, evokes Eliot Ness, the fa­mous Pro­hi­bi­tion-era Chicago crime fighter. Only their mis­sions are ex­actly back­wards. Wood is at war against the War on Drugs and all it has wrought—from ram­pant gang vi­o­lence to a lethally toxic drug sup­ply. He’s less in­ter­ested in bring­ing drug crim­i­nals to jus­tice than he is in restor­ing jus­tice by de­crim­i­nal­iz­ing drugs.

But pol­i­tics are not his of­fi­cial brief. As head of the BCCSU, Wood’s lofti­est goal is to change the way we think about ad­dic­tion. To make us un­der­stand it as a kind of con­ta­gion—al­beit a so­cial rather than vi­ral one. The best strat­egy to sup­press an out­break? De­ploy mas­sive re­sources at mul­ti­ple lev­els all at once. Toss a blan­ket over the fire so that it sends out no sparks.

Wood’s job one is to wran­gle those re­sources and chan­nel them to­ward an ef­fec­tive treat­ment model. That means train­ing doc­tors and nurses who work with ad­dic­tion suf­fer­ers on which drugs work best to curb crav­ings and ease with­drawal, when to use them, and how to wean folks off them where ap­pro­pri­ate. It means lay­ing out clear op­tions for users who want to get clean and mak­ing sure they have ac­cess to them. Right now, it means host­ing lots and lots of meet­ings with ad­dicts and their fam­i­lies, the peo­ple whose voices most need to be heard.

Wood’s cur­rent po­si­tion is an evo­lu­tion of his ca­reer at the fore­front of pub­lic health and epi­demi­ol­ogy, but he be­gan by tack­ling ad­if­fer­ent scourge.

He grew up in West Van­cou­ver, raised by his so­cial­worker mother. His fa­ther was an in­ven­tor who de­signed marine nav­i­ga­tion sys­tems and who sep­a­rated from his mother when Wood was two.

Wood ap­proached the med­i­cal-health field in a grad­u­ally tight­en­ing cir­cle. In an un­der­grad ge­og­ra­phy de­gree at UBC, he did a term project that in­volved map­ping the spread of HIV, which nudged him to pur­sue med­i­cal ge­og­ra­phy—a sub­field that looks at air­borne and vec­tor-borne ill­ness. He ap­plied for asum­mer job at the BC Cen­tre for Ex­cel­lence in HIV/AIDS, where he quickly dis­tin­guished him­self as apro­tégé of Dr. Julio Mon­taner. Hired as a ju­nior re­search as­sis­tant, the young Wood churned out aprovoca­tive pa­per so quickly that Mon­taner read about it in the news­pa­per he opened on a flight later that same sum­mer. After Wood knocked off a PhD in epi­demi­ol­ogy in 2003, he be­gan pub­lish­ing at a fu­ri­ous rate. He and Mon­taner would go on to co-au­thor dozens of in­flu­en­tial papers, in­clud­ing two humdingers—one pub­lished in The Lancet that helped shape the con­ver­sa­tion around AIDS treat­ment in Africa and another on anti-vi­ral drug strat­egy, pub­lished in The Bri­tish Med­i­cal Jour­nal, that was dubbed Sci­ence mag­a­zine’s 2011 sci­en­tific break­through of the year.

In 2005, Wood and his col­league Thomas Kerr—an epi­demi­ol­o­gist and now co-di­rec­tor of the BCCSU— found them­selves al­most sin­gle-hand­edly try­ing to save InSite, Canada’s first su­per­vised drug-in­jec­tion site, from a court chal­lenge by the Harper gov­ern­ment, which ve­he­mently viewed drug use as a crim­i­nal mat­ter. The bat­tle went all the way to the Supreme Court, with Wood and Kerr ar­gu­ing ev­i­dence should trump moral­ity when it came to re­duc­ing the risk of dis­ease trans­mis­sion and over­dose.

In the end, their ef­forts en­sured one of the world’s most high-pro­file ex­per­i­ments in harm re­duc­tion, one that has since be­come a global model in pub­lic health, was spared the knife.

In the mid-aughts, Wood in­ter­rupted his progress in HIV/AIDSre­search to go to med school,think­ing he would have more im­pact as aphysi­cian. He blitzed through the Univer­sity of Cal­gary’s com­pressed cur­ricu­lum, putting him­self in the com­i­cally in­tense po­si­tion of be­ing a pro­fes­sor at UBC while a med stu­dent in Cal­gary. He com­pleted his MD in two years and nine months.

Upon­re­turn­ing toVan­cou­ver,how­ever,Wood dis­cov­ered the fire he was now­dou­bl­yarmed to fight was nearly con­tained. The death rate from AIDS was down 80per­cent, as was the num­ber of new HIV­cases.Wood piv­oted to ap­ply his harm-re­duc­tion strate­gies to another is­sue af­fect­ing the same at-risk com­mu­ni­ties he’d come to know through his work with­Mon­taner. Heemerged as a leader in ad­dic­tion medicine around 2010, just as a drug called fen­tanyl be­gan to show up on city streets, ig­nit­ing yet another pub­lic health cri­sis and thrust­ing the is­sue of ad­dic­tion into the spotlight.

WHATHUMANS DO

in the lobby of the Anvil Cen­tre, dur­ing in­ter­mis­sion at the Re­cov­ery Speaks event, a woman named Lynn but­ton­holes Wood. Her 23-year-old son is in treat­ment, bat­tling a heroin ad­dic­tion. He’s been in an ab­sti­nence­based treat­ment fa­cil­ity for sev­eral months and is due home soon.

Wood lis­tens si­lently, rab­bini­cally. (Pri­vately, he is a lit­tle worried about this young man, who is about to be sprung loose, his tol­er­ance low, onto aland­scape mined with fen­tanyl and car­fen­tanil. “Any­one in that po­si­tion is just a sit­ting duck for a fa­tal over­dose,” he tells me later.)

Wood al­lows that some peo­ple do man­age to get clean all at once just be­cause they de­cided to, over­rid­ing prim­i­tive in­struc­tions from a brain that has ac­tu­ally been rewired, by trauma or stress or crush­ing cir­cum­stances, to crave so­lace. But it’s clear which side he be­lieves the sci­ence tips to­ward. The data doesn’t sup­port ab­sti­nence as Plan A.

Lynn tells Wood she has dis­cov­ered a book tout­ing a phar­ma­ceu­ti­cal “cure” for al­co­holism. You sim­ply take a drug—an al­co­hol an­tag­o­nist—an hour be­fore you plan to im­bibe, and it whisks the re­ward off the ta­ble. So a drink is just a drink, not at­icket any­where, and you stop at one or two. Even­tu­ally the thrill is gone. You can drink so­cially with­out fear of drink­ing to ex­cess—then ta­per down to com­plete so­bri­ety, or not. There’s ev­i­dence the drug works for opi­oids too.

This ap­proach would clearly not be em­braced by most of the peo­ple in this au­di­to­rium. But Wood be­lieves the data shows that you can man­age ad­dic­tion with­out try­ing to hold it at bay through brute ab­sti­nence. It may even be the more hu­mane tack.

“The vast ma­jor­ity of peo­ple who have what we would now call sub­stance-use dis­or­der are work­ing, they have fam­i­lies, they’re go­ing about their life, but they have this com­pul­sion to use,” Wood elab­o­rates later. “They may wish to cut down but have dif­fi­culty do­ing so. They might get with­drawal if they stop. But they’re get­ting along with their lives pretty well.” In the new land­scape of ad­dic­tion treat­ment that he en­vi­sions, “if peo­ple come to a health-care provider, we could of­fer things to help them cut down, or quit, or re­duce their crav­ings.

“This is re­ally part of the hu­man con­di­tion. The old­est writ­ten records show peo­ple us­ing things like al­co­hol. We could have cof­fees in front of us. We could be hav­ing a glass of wine tonight. I mean, this is what hu­mans do.”

And here is where Wood and Smith—not to men­tion the peo­ple who have shared their heart­break­ing but hope­ful per­sonal sto­ries tonight—re­ally do have a com­mon cause. They deeply be­lieve that peo­ple with sub­stance-abuse is­sues ought not to be vil­i­fied for be­ing a lit­tle more demon­stra­bly hu­man than ev­ery­body else. (Smith ad­mits his po­si­tion on ab­sti­nence has soft­ened some­what as the ev­i­dence for harm re­duc­tion has piled up; he now in­cludes sub­sti­tu­tion drugs like Subox­one at the re­hab cen­tre he over­sees.)

In asense, peo­ple prone to ad­dic­tion—and “about 50 per­cent of the bur­den of sub­stance use is ge­netic,” Wood says—are sim­ply exquisitely at­tuned to the prom­ise of re­wards. For most of hu­man his­tory that was a good thing. “Be­ing a good re­ward ap­pre­ci­a­tor,” as the ad­dic­tion psy­chol­o­gist Anna Rose Chil­dress put it, would have made an in­di­vid­ual more, not less, evo­lu­tion­ar­ily fit.

Only in the last 75 years, when con­sumer cul­ture be­gan pro­duc­ing a glut of ir­re­sistible temp­ta­tions, did that trait stop de­liv­er­ing ben­e­fits and start cre­at­ing prob­lems. Now that same quester who was once first to try a new food, a new route, a new mate, is now first to fall hard for the shiny poi­soned bauble.

Not long ago, cer­tain vari­ants of agene called OPRM1 were found to be linked to im­pul­siv­ity and risk-tak­ing be­hav­iour—and apre­dis­po­si­tion for drug ad­dic­tion.

But, Wood ex­plains, OPRM1 is re­ally an at­tach­ment gene. “In rhe­sus macaque mon­keys, hav­ing the gene cor­re­lates to how up­set the ba­bies get when they’re sep­a­rated from their mother.” The gene is thought to work in a sim­i­lar way in hu­mans.

“So here you have this at­tach­ment gene that makes great sense for sur­vival, so you don’t go wan­der­ing off acliff,” Wood says. “But that same gene, if you get pre­scribed Oxycon­tin by your doc­tor—and Oxycon­tin is ex­tremely re­ward­ing—it can just grab hold of you.”

Wood works the room. He is adept at say­ing the right things and leav­ing out the right things. He chats with the pri­vate donor who qui­etly gave $1 mil­lion to his cen­tre and with moth­ers who have watched their chil­dren slip through their fin­gers—griev­ing moms have be­come the face of the fen­tanyl cri­sis. Wood’s own kids, aged 4 and 9, are still too lit­tle to worry about in this re­spect.

There’s some­thing al­most epi­demi­o­log­i­cal about the way he cir­cu­lates, each point of con­tact mean­ing­ful in some hard-to-mea­sure way. If the root of all ad­dic­tion is dis­lo­ca­tion, as are­cov­ery-com­mu­nity adage has it, then an an­ti­dote for ad­dic­tion is con­nec­tion. This is a sec­ond be­lief that both camps share. In­deed, you could say that the se­cret sauce of su­per­vised in­jec­tion sites like InSite is not that they pre­vent sub­stance users from over­dos­ing to death right now (though they in­deed do that) but that they bring users into con­tact with po­ten­tial so­cial life­lines—health pro­fes­sion­als whom they can trust to help them get their lives back on track.

Wood has been wel­comed here. The kum­baya fac­tor is high. But there re­mains one ma­jor, lin­ger­ing dis­con­nect: the God thing.

ANOTHERPATH TOTRANSCENDENCE

the psy­cho­an­a­lyst Carl Jung ad­vised Bill W. that with­out a spir­i­tual di­men­sion to AA, it would never work—the roots of ad­dic­tion run too deep. Many in the re­cov­ery move­ment hold fast to that the­ory, but the re­quired be­lief in a higher power also pre­vents many seek­ing re­cov­ery from buy­ing into the pro­gram.

Wood be­lieves there may be a way to square the cir­cle here—to bring God into the pic­ture with­out los­ing one’s ev­i­dence-based bona fides.

The last five or so years have seen aresur­gence of

clin­i­cal in­ter­est in psychedelics—the old hip­pie drugs that can open what Johns Hop­kins psy­chol­o­gist Roland Grif­fiths calls a“spir­i­tual win­dow” through which deep in­sight might flow.

“The neu­roimag­ing work that’s be­ing done around this, par­tic­u­larly in the U.K., is re­ally fas­ci­nat­ing,” Wood says. One way to look at ad­dic­tion is as a com­mu­ni­ca­tion fail­ure on a neu­ral level. The most prim­i­tive part of the brain—the in­stinc­tive, rep­til­ian part that drives com­pul­sive be­hav­iour—“doesn’t typ­i­cally talk to the frontal lobe that’s re­ally want­ing to make changes,” Wood says. “But on psilo­cy­bin, those two brain re­gions are talk­ing like crazy.” In pre­lim­i­nary ex­per­i­men­tal tri­als, the deep emo­tions that hal­lu­cino­genic trips un­lock seem to help users reach a pro­found level of in­sight into their self and their predica­ment—which can prove apow­er­ful weapon against hard-to-re­sist crav­ings.

In­deed, Bill W. him­self ex­per­i­mented with LSD after he be­came sober, and found it to be such an ef­fec­tive spir­i­tual as­sist he con­sid­ered mak­ing it as­tan­dard part of AA meet­ings. “So the sci­ence is show­ing that we can prob­a­bly bring about a spir­i­tual awak­en­ing for peo­ple at a much higher rate this way than our tra­di­tional mo­ti­va­tional tech­niques can,” Wood says.

This spring, the BCCSU an­nounced plans to fast­track hal­lu­cino­genic ex­per­i­ments. Drugs such as psilo­cy­bin, the ac­tive in­gre­di­ent in “magic mush­rooms,” LSD and/or MDMA (ec­stasy) will be ad­min­is­tered in a con­trolled set­ting—a ded­i­cated, sound­proof room in the BCCSU’s head­quar­ters on Pow­ell Street. (Right now the room is bare and clin­i­cal; it’s def­i­nitely go­ing to need some groovy-ing up—and abath­room.)

“It’s just a ques­tion now of the clin­i­cal pro­to­cols and then get­ting them through ethics,” Wood says. “And then get­ting th­ese med­i­ca­tions made by phar­ma­ceu­ti­cal labs, stor­ing them and then do­ing the tri­als” with trained psy­chother­a­pists. “But we hope to be do­ing them in the next year.”

This isn’t some­thing the BCCSU is try­ing to sneak past the pub­lic. The ini­tia­tive is openly dis­played on the web­site, along with other re­search such as “In­ten­tional cannabis use to re­duce crack co­caine use in aCana­dian set­ting: a lon­gi­tu­di­nal anal­y­sis.”

The mes­sage? The road from “sick” to “well” is not a straight shot. For many, the endgame is to­tal so­bri­ety, but for some it will never be. While work­ing at the heroin pre­scrip­tion clinic on the Down­town East­side, Wood al­ways asked his clients about their long-term goals. In some cases it was as straight­for­ward as “Hey, if you want to see your kids again, this co­caine thing is go­ing to be an is­sue.” But for oth­ers, say, an al­co­holic who just wants to be able to drink so­cially, “re­cov­ery” has a dif­fer­ent mean­ing and re­quires another pro­to­col al­to­gether. A sys­tem that can han­dle both has yet to be de­vel­oped.

The endgame, which Wood sees as in­evitable, is the de­crim­i­nal­iza­tion of all drugs along the lines of what Por­tu­gal has un­der­taken. The fen­tanyl cri­sis may even­tu­ally seal the fate of the dis­as­trous, larce­nously ex­pen­sive cen­tury-old War on Drugs, Wood be­lieves, but we’re not there yet.

“If you look at the sit­u­a­tion in the States, the opi­oid cri­sis is the big­gest is­sue that’s be­ing de­bated around health-care re­form. The Repub­li­can base of mid­dle-class white con­ser­va­tive Amer­i­cans, they’re be­ing hit hard. And this thing hasn’t peaked yet.

“I think fen­tanyl is go­ing to lead to pretty dra­matic changes in Canada, for sure. I think we’re go­ing to see pre­scrip­tion heroin. In­vest­ments in things like ther­a­peu­tic com­mu­ni­ties”—long-term, pro­fes­sion­ally staffed re­hab fa­cil­i­ties—“on the other end.

“Un­for­tu­nately, be­fore that hap­pens, there are go­ing to be thou­sands more dead­peo­ple than there shouldbe.”

Newspapers in English

Newspapers from Canada

© PressReader. All rights reserved.