The harm reduction model of drug addiction treatment | Mark Tyndall

翻译人员: Wei Houjun 校对人员: Joey Chen

I remember the first time that I saw people injecting drugs.

我依然记得第一次看到 别人注射毒品的场景。

I had just arrived in Vancouver to lead a research project

当时，我刚到达温哥华，

in HIV prevention in the infamous Downtown East Side.

准备在臭名昭著的东城区 领导一个防治艾滋病的研究项目。

It was in the lobby of the Portland Hotel,

这是一个位于波特兰酒店的大厅，

a supportive housing project that gave rooms

旨在为这个城市中

to the most marginalized people in the city,

最边缘的人们提供房间的，

the so-called "difficult to house."

被称为“住房困难”的支持性住房项目。

I'll never forget the young woman standing on the stairs

我永远也不会忘记那个 站在楼梯上的年轻女性，

repeatedly jabbing herself with a needle, and screaming,

用针筒反复地刺着自己，并不停喊叫着，

"I can't find a vein,"

“我找不到血管，”

as blood splattered on the wall.

同时血液不断飞溅到墙上。

In response to the desperate state of affairs, the drug use,

为应对这些绝望的事态、毒品使用、

the poverty, the violence, the soaring rates of HIV,

贫穷、暴力以及飙升的艾滋病率，

Vancouver declared a public health emergency in 1997.

温哥华在 1997 年宣布了 一项公共健康紧急计划，

This opened the door to expanding harm reduction services,

这打开了扩大伤害减轻服务的大门——

distributing more needles,

分发更多的针筒，

increasing access to methadone,

提高获取美沙酮 （一种阿片类药物）的机会，

and, finally, opening a supervised injection site.

以及开放一个受监管的注射点，

Things that make injecting drugs less hazardous.

使注射毒品变成不那么危险的事。

But today, 20 years later,

但是，20 年后的今天，

harm reduction is still viewed as some sort of radical concept.

伤害减轻仍被认为是 某种激进概念。

In some places, it's still illegal to carry a clean needle.

在有的地方，携带一个 干净的针筒仍是违法的。

Drug users are far more likely to be arrested

毒品使用者更有可能被捕，

than to be offered methadone therapy.

而不是接受美沙酮治疗。

Recent proposals for supervised injection sites

最近对于在像西雅图、巴尔的摩

in cities like Seattle, Baltimore and New York

和纽约这类城市的 受监管注射点的提议

have been met with stiff opposition:

受到了强烈的反对：

opposition that goes against everything we know about addiction.

反对所有我们已知的 与毒瘾相关的事实。

Why is that?

为什么会这样呢？

Why are we still stuck on the idea

为什么我们仍然坚持认为，

that the only option is to stop using -- that any drug use will not be tolerated?

唯一的选择就是放弃使用—— 即任何的毒品使用都是无法容忍的？

Why do we ignore countless personal stories

为什么我们忽略无数能够证明

and overwhelming scientific evidence

伤害减轻的确有效的那些真实经历

that harm reduction works?

以及压倒性的科学证据呢？

Critics say that harm reduction doesn't stop people

批评者们说伤害减轻 并不会阻止人们

from using illegal drugs.

使用非法的毒品。

Well, actually, that is the whole point.

实际上，这就是问题的关键。

After every criminal and societal sanction

在采用了我们所能想到的

that we can come up with,

每项刑事和社会制裁后，

people still use drugs, and far too many die.

人们仍在使用毒品， 并且造成了很多很多的死亡。

Critics also say that we are giving up on people

批评者们还说， 我们放弃了这些人

by not focusing our attention on treatment and recovery.

因为我们没把注意力 放在他们的治疗恢复上。

In fact, it is just the opposite.

然而，事实正好相反。

We are not giving up on people.

我们没有放弃人们。

We know that if recovery is ever going to happen

我们知道如果有可能康复，

we must keep people alive.

我们必须挽救大家的生命。

Offering someone a clean needle or a safe place to inject

为某人提供一个干净的针筒 或是一个安全的地方去注射

is the first step to treatment and recovery.

是治疗与康复的第一步。

Critics also claim that harm reduction

批评者们还宣称，伤害减轻

gives the wrong message to our children about drug users.

给了我们的孩子关于 使用毒品的错误信号。

The last time I looked, these drug users are our children.

上次我观察时发现， 这些毒品使用者正是我们的孩子。

The message of harm reduction is that while drugs can hurt you,

伤害减轻传递的信息是， 即便毒品有害，

we still must reach out to people who are addicted.

我们仍然必须向 那些上瘾的人伸出援手。

A needle exchange is not an advertisement for drug use.

一个针筒交易并不是 号召大家使用毒品，

Neither is a methadone clinic or a supervised injection site.

美沙酮诊所，或者一个 受监管的注射点也不是。

What you see there are people sick and hurting,

你们所看到的人们生病和受伤害，

hardly an endorsement for drug use.

并不是对使用毒品的认可。

Let's take supervised injection sites, for example.

以受监管的注射点为例，

Probably the most misunderstood health intervention ever.

这很可能是有史以来 被误解最深的医疗干预。

All we are saying is that allowing people

我们想要传达的信息是，允许人们

to inject in a clean, dry space with fresh needles,

在一个干净、干燥的， 有关心他们的人陪伴的地方

surrounded by people who care

用新的针筒进行注射，

is a lot better than injecting in a dingy alley,

比在一个昏暗的、远离警察的胡同，

sharing contaminated needles and hiding out from police.

共用受污染的针筒进行注射要好得多。

It's better for everybody.

这对所有人都好。

The first supervised injection site in Vancouver was at 327 Carol Street,

温哥华的第一个受监管的 注射点位于卡罗尔街 327 号，

a narrow room with a concrete floor, a few chairs and a box of clean needles.

这是一个有水泥地板，一些椅子 和一盒干净针筒的小房间。

The police would often lock it down,

警察通常会将其封锁起来，

but somehow it always mysteriously reopened,

但是它往往总会被人用撬棍

often with the aid of a crowbar.

悄悄地重新打开。

I would go down there some evenings

有时候，我会在晚上前往那里，

to provide medical care for people who were injecting drugs.

给那些注射毒品的人提供医疗服务。

I was always struck with the commitment and compassion

注射点的经营和使用者身上的

of the people who operated and used the site.

专注和热情深深触动了我。

No judgment, no hassles, no fear,

这里没有批评， 没有分歧，没有恐惧，

lots of profound conversation.

有的只是很多深切的交谈。

I learned that despite unimaginable trauma,

我体会到，不管人们经历了 多么难以想象的创伤，

physical pain and mental illness,

生理上的痛苦以及精神折磨，

that everyone there thought that things would get better.

那里的所有人都希望事情会好起来。

Most were convinced that, someday, they'd stop using drugs altogether.

大多数人都相信，有一天， 他们会一起摆脱毒品。

That room was the forerunner to North America's

那个房间是北美第一个政府批准的

first government-sanctioned supervised injection site, called INSITE.

受监管注射点 INSITE 的前身。

It opened in September of 2003 as a three-year research project.

该注射点在 2003 年 9 月开放， 是一个为期三年的研究项目。

The conservative government was intent on closing it down at the end of the study.

保守党政府打算 在研究结束时关闭它。

After eight years, the battle to close INSITE

八年后，关于是否 关闭 INSITE 的抗争

went all the way up to Canada's Supreme Court.

一路进行到了加拿大的最高法院。

It pitted the government of Canada

它突出了加拿大政府与

against two people with a long history of drug use

两个拥有长期吸毒史，

who knew the benefits of INSITE firsthand:

深知 INSITE 好处的人，

Dean Wilson and Shelley Tomic.

迪恩 · 威尔逊和 雪莱 · 托米奇之间的矛盾。

The court ruled in favor of keeping INSITE open by nine to zero.

法院以 9:0 的投票结果 判决维持 INSITE 开放，

The justices were scathing in their response to the government's case.

并在回应中严厉地 批评了政府的这个案子。

And I quote:

我引用如下：

"The effect of denying the services of INSITE to the population that it serves

“拒绝 INSITE 为它所服务的 人群提供服务的后果，

and the correlative increase in the risk of death and disease

以及由此造成的毒品注射者的

to injection drug users is grossly disproportionate to any benefit

死亡与患病风险的上升，

that Canada might derive

与加拿大对待毒品的一致立场

所产生的任何好处完全不相称。”

from presenting a uniform stance on the possession of narcotics."

This was a hopeful moment for harm reduction.

这一判决为伤害减轻 提供了一线生机。

Yet, despite this strong message from the Supreme Court,

然而，即使有这个来自 最高法院的强烈信息，

it was, until very recently,

直到最近，

impossible to open up any new sites in Canada.

在加拿大开设新的注射点 才真正成为了可能。

There was one interesting thing that happened in December of 2016,

在 2016 年 12 月发生了一件有趣的事，

when due to the overdose crisis,

面对过量注射危机，

the government of British Columbia allowed the opening of overdose prevention sites.

不列颠哥伦比亚省政府 允许开设过量注射防治点。

而社区组织基本上 忽略了联邦的审批流程，

Essentially ignoring the federal approval process,

community groups opened up about 22 of these de facto illegal

在全省开设了大约 22 个

supervised injection sites across the province.

类似但非法的受监管注射点。

Virtually overnight,

一夜之间，

thousands of people could use drugs under supervision.

上千人能够在监督下使用毒品。

Hundreds of overdoses were reversed by Naloxone, and nobody died.

几百个过量注射的生命因钠洛酮 被挽救了回来，没有人死亡。

In fact, this is what's happened at INSITE over the last 14 years:

实际上，这也是过去 14 年 在 INSITE 所发生的：

75,000 different individuals have injected illegal drugs

75000 个不同的个体注射

非法的毒品超过 350 万次，

more than three and a half million times,

and not one person has died.

并且没有一例死亡。

Nobody has ever died at INSITE.

没有人死在 INSITE。

So there you have it.

所以大家应该明白了。

We have scientific evidence and successes from needle exchanges

我们有科学证据， 以及针头交换，美沙酮

methadone and supervised injection sites.

以及受监管的注射地点的成功案例。

These are common-sense, compassionate approaches to drug use

这些常识和对毒品使用的同情

that improve health, bring connection

能够改善健康， 带来人与人之间的联系，

and greatly reduce suffering and death.

并极大地减少痛苦与死亡。

So why haven't harm reduction programs taken off?

那么为什么伤害减轻项目 没有大规模普及呢？

Why do we still think that drug use is law enforcement issue?

为什么我们仍然认为 毒品使用是执法问题？

Our disdain for drugs and drug users goes very deep.

我们对毒品以及 毒品使用者的蔑视程度极深。

We are bombarded with images and media stories

关于毒品的可怕影响的

about the horrible impacts of drugs.

图片和媒体故事不计其数。

We have stigmatized entire communities.

我们污名化了整个团体。

We applaud military-inspired operations that bring down drug dealers.

我们甚至鼓励采用军事手段 来打击毒品贩子。

And we appear unfazed by building more jails

并且，我们无所顾忌地 建设更多监狱，

to incarcerate people whose only crime is using drugs.

来监禁那些罪刑只是使用毒品的人。

Virtually millions of people are caught up

数百万的人陷入了漫漫无期的监禁、

in a hopeless cycle of incarceration, violence and poverty

暴力与贫穷的循环中，

that has been created by our drug laws and not the drugs themselves.

而这个循环恰恰是由我们的毒品法律， 而非毒品本身制造出来的。

How do I explain to people that drug users deserve care and support

当我们所能看到的总是 枪支、手铐和牢房的照片时，

and the freedom to live their lives

我如何向人们解释，

when all we see are images of guns and handcuffs and jail cells?

毒品使用者也应当得到照顾、支持， 并拥有自由的生活？

Let's be clear:

我们要清楚的一点是：

criminalization is just a way to institutionalize stigma.

犯罪化只是将耻辱制度化的一种方式。

Making drugs illegal does nothing to stop people from using them.

使毒品非法并不会 让人们停止使用它们。

Our paralysis to see things differently

我们无法从不同的角度看待事物

is also based on an entirely false narrative about drug use.

也是源于对使用毒品 完全错误的叙述。

We have been led to believe that drug users

我们听信了宣传，认为毒品使用者

are irresponsible people who just want to get high,

是不负责任的人，他们只想找点乐子，

and then through their own personal failings

由于个人的失败，导致自己的生活

spiral down into a life of crime and poverty,

逐渐陷入了犯罪和贫困——

losing their jobs, their families and, ultimately, their lives.

丢掉了工作、家庭，甚至是生命。

In reality, most drug users have a story,

然而事实上，大多数毒品使用者 之所以走到今天都有着特殊的原因，

whether it's childhood trauma, sexual abuse, mental illness

比如童年创伤，性虐待，精神疾病

or a personal tragedy.

以及遭遇的不幸。

The drugs are used to numb the pain.

毒品只是用来麻痹痛苦的。

We must understand that as we approach people with so much trauma.

当我们接触遭受过很多创伤的人时， 应该理解这一点。

At its core, our drug policies are really a social justice issue.

我们的毒品政策本质上 其实是社会公平的问题。

While the media may focus on overdose deaths like Prince and Michael Jackson,

当媒体聚焦在类似 Prince 和 Michael Jackson 因吸毒过量而导致的死亡时，

the majority of the suffering

遭受痛苦的大多数

happens to people who are living on the margins,

是那些生活在社会边缘的、

the poor and the dispossessed.

贫穷的、无依无靠的人。

They don't vote; they are often alone.

他们不投票，通常是独居的。

They are society's disposable people.

他们很容易被社会抛弃。

即使在医疗领域， 毒品使用也遭受了严重的非议。

Even within health care, drug use is highly stigmatized.

People using drugs avoid the health care system.

使用毒品的人会主动避免 进入医疗保健系统。

They know that once engaged in clinical care

他们知道一旦踏入诊所，

or admitted to hospital, they will be treated poorly.

或被医院接收， 他们就会遭受不公的对待。

And their supply line, be it heroin, cocaine or crystal meth

他们的补给线—— 海洛因、可卡因或冰毒，

will be interrupted.

将会被中断。

On top of that, they will be asked a barrage of questions

最重要的是， 他们会被问一连串的问题，

that only serve to expose their losses and shame.

而那些问题只会让他们 暴露他们的失败和耻辱。

"What drugs do you use?"

“你使用哪些毒品？”

"How long have you been living on the street?"

“你在那条街生活了多久？”

"Where are your children?"

“你们的孩子在哪里？”

"When were you last in jail?"

“你上次入狱是什么时候？”

Essentially: "Why the hell don't you stop using drugs?"

以及最根本的： “为什么你不停止使用该死的毒品？”

In fact, our entire medical approach to drug use is upside down.

事实上，针对毒品使用的 整个医疗方法是由上而下的。

For some reason,

因为某些原因，

we have decided that abstinence is the best way to treat this.

我们最终认为， 戒除毒瘾是最好的治疗方法。

If you're lucky enough, you may get into a detox program.

如果你足够幸运， 有可能进入一个戒除毒瘾的项目。

If you live in a community with Suboxone or methadone,

如果你生活在一个运用 盐酸丁丙诺啡或美沙酮的社区，

you may get on a substitution program.

有可能进入一个替代治疗的项目。

Hardly ever would we offer people what they desperately need to survive:

我们几乎不向人们提供 他们为了活命而迫切需要的东西：

a safe prescription for opioids.

阿片类药物的安全处方。

Starting with abstinence is like asking a new diabetic to quit sugar

一开始就进行戒除，就好像 要求一个刚患糖尿病的患者戒掉糖，

or a severe asthmatic to start running marathons

或者让一个严重的 哮喘病人开始跑马拉松，

or a depressed person to just be happy.

或者让一个抑郁的人 立刻变得快乐一样。

For any other medical condition,

对于其他任何医疗状况，

we would never start with the most extreme option.

我们决不会一开始就做出 这个极端的选择。

What makes us think that strategy

是什么让我们认为那个策略

would work for something as complex as addiction?

会对像毒瘾这么复杂的事情起作用呢?

While unintentional overdoses are not new,

尽管意外的毒品使用过量 已经不是什么新鲜事，

the scale of the current crisis is unprecedented.

当前的危机规模却是前所未有的。

The Center for Disease Control estimated

疾病控制中心估计，

that 64,000 Americans died of a drug overdose in 2016,

在 2016 年，有 64000 名美国人 死于毒品使用过量，

far exceeding car crashes or homicides.

远超车祸或谋杀的死亡人数。

Drug-related mortality is now the leading cause of death

如今在北美 20 岁 到 50 岁之间的人群中，

among men and women between 20 and 50 years old in North America

与毒品相关的死亡 是最主要的死亡原因。

Think about that.

想想吧。

How did we get to this point, and why now?

我们怎样，又是为什么 落到了今天这种境遇？

There is a kind of perfect storm around opioids.

针对阿片类药物存在着巨大的争议。

Drugs like Oxycontin, Percocet and Dilaudid

在过去的几十年中，像奥施康定、 扑热息痛和盐酸二氢吗啡酮这样的药物

have been liberally distributed for decades for all kinds of pain.

已经被广泛地用于缓解各种疼痛。

It is estimated that two million Americans are daily opioid users,

据估计，有两百万美国人是 阿片类药物的日常使用者，

and over 60 million people

并且仅仅在去年，就有超过 6000 万人

received at least one prescription for opioids last year.

获得了至少一个阿片类药物的处方。

This massive dump of prescription drugs into communities

这种大量地向社区倾售处方药的行为

has provided a steady source for people wanting to self-medicate.

为那些想要自行治疗的人 提供了稳定的药物来源。

In response to this prescription epidemic,

为应对处方药的泛滥，

people have been cut off, and this has greatly reduced the street supply

人们的药物供应渠道被切断， 这大大地减少了街道层面的药物供应。

The unintended but predictable consequence

这一做法无意间产生了 一个可预料的后果，

is an overdose epidemic.

即毒品使用过量问题的蔓延。

Many people who were reliant on a steady supply of prescription drugs

很多依赖稳定的处方药供应的人

turned to heroin.

开始转向了海洛因。

And now the illegal drug market has tragically switched

不幸的是，如今的非法毒品市场已经

to synthetic drugs, mainly fentanyl.

转而开始销售合成毒品，主要是芬太尼。

These new drugs are cheap, potent and extremely hard to dose.

那些新的毒品价格低廉、 药效强，并且极其难以服用。

People are literally being poisoned.

确切地说，人们正在被毒害。

Can you imagine if this was any other kind of poisoning epidemic?

你们能够想象出其他 类似的中毒蔓延事件吗？

What if thousands of people started dying

如果数千人因为有毒的肉，

from poisoned meat or baby formula or coffee?

或婴儿配方奶粉， 或咖啡开始死亡会如何？

We would be treating this as a true emergency.

我们应当把这件事 当成真正的紧急事件对待。

We would immediately be supplying safer alternatives.

我们应当立即提供更安全的替代品，

There would be changes in legislation,

应当修改法律，

and we would be supporting the victims and their families.

还应该支持 那些受害者及他们的家庭。

But for the drug overdose epidemic,

但是对于毒品使用过量问题的蔓延，

we have done none of that.

我们还没有采取任何行动。

We continue to demonize the drugs and the people who use them

我们继续妖魔化毒品和它们的使用者，

and blindly pour even more resources into law enforcement.

并且盲目地倾注更多的资源到执法中。

So where should we go from here?

那么，下一步应该怎么办呢？

First, we should fully embrace, fund and scale up

首先，我们应当全面地接受、资助，

harm reduction programs across North America.

并且在整个北美扩展伤害减轻项目。

I know that in places like Vancouver,

我知道在温哥华这样的地方，

harm reduction has been a lifeline to care and treatment.

伤害减轻一直是护理和治疗的生命线。

I know that the number of overdose deaths

我知道，如果没有伤害减轻项目，

would be far higher without harm reduction.

死于毒品使用过量的人数将会高得多。

And I personally know hundreds of people who are alive today

我个人就知道几百个 因伤害减轻项目

而得以存活下来的人。

because of harm reduction.

But harm reduction is just the start.

但是伤害减轻仅仅是一个开始。

If we truly want to make an impact on this drug crisis,

如果我们真正想要削弱毒品危机，

we need to have a serious conversation about prohibition

就必须开展一场关于禁毒

and criminal punishment.

和刑事处罚的严肃对话。

We need to recognize that drug use is first and foremost a public health issue

我们必须意识到，毒品使用 首先是一个公共健康问题，

and turn to comprehensive social and health solutions.

需要全面的社会医疗解决方案。

We already have a model for how this can work.

我们已经有了 一个关于这项措施的模型。

In 2001, Portugal was having its own drug crisis.

在 2001 年，葡萄牙 国内发生了毒品危机——

Lots of people using drugs, high crime rates

很多人使用毒品，高犯罪率

and an overdose epidemic.

以及毒品使用过量问题的泛滥。

They defied global conventions and decriminalized all drug possession.

他们拒绝了全球惯例， 并且将拥有毒品无罪化。

Money that was spent on drug enforcement

用于毒品执法的资金

was redirected to health and rehabilitation programs.

转而被用于资助医疗与康复项目。

The results are in.

这一举措的结果则是：

Overall drug use is down dramatically.

毒品使用的现象急剧减少。

Overdoses are uncommon.

毒品使用过量的情况越来越罕见。

Many more people are in treatment.

更多的人得到了及时的治疗。

And people have been given their lives back.

人们的生活回到了正轨。

We have come so far down the road of prohibition, punishment and prejudice

我们在禁止、惩罚 和偏见的道路上已经走得太远，

that we have become indifferent to the suffering

以致于我们对社会上 那些最脆弱的人们

that we have inflicted on the most vulnerable people in our society.

所遭受的痛苦已经变得漠不关心。

This year even more people will get caught up

今年，甚至会有更多的人

in the illegal drug trade.

因非法毒品交易被逮捕。

Thousands of children will learn that their mother or father

数千的孩子将会意识到 他们的妈妈或爸爸

has been sent to jail for using drugs.

因为使用毒品而被送进监狱。

And far too many parents will be notified

还有更多的父母会收到 他们的儿子或女儿

that their son or daughter has died of a drug overdose.

因为毒品使用过量而死去的噩耗。

It doesn't have to be this way.

事情本可以不必这样。

Thank you.

谢谢。

(Applause)

(掌声）