The harm reduction model of drug addiction treatment | Mark Tyndall

譯者: Lilian Chiu 審譯者: Helen Chang

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

我還記得第一次看到 別人注射毒品的經驗

I had just arrived in Vancouver to lead a research project

我才剛剛到溫哥華主導一個研究計畫

in HIV prevention in the infamous Downtown East Side.

是一個愛滋病防治計畫

就在惡名昭彰的溫哥華城中東區

It was in the lobby of the Portland Hotel,

事情就發生在波特蘭旅館的大廳

a supportive housing project that gave rooms

那裡有個住房支持計畫提供住所

to the most marginalized people in the city,

給城市中最邊緣化的一群人

the so-called "difficult to house."

所謂「很難收容的人」

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

我永遠無法忘記 那個站在樓梯上的年輕女子

repeatedly jabbing herself with a needle, and screaming,

一邊不斷地用注射針猛刺自己

一邊大喊「我找不到血管」

"I can't find a vein,"

as blood splattered on the wall.

同時血飛濺到牆上

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

為了因應層出不窮的

毒品濫用 貧窮 暴力

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

和飆升的愛滋病罹患率

Vancouver declared a public health emergency in 1997.

溫哥華市在 1997 年 宣佈進入公共衛生警戒狀態

This opened the door to expanding harm reduction services,

此舉開啟了一扇門來擴展減害服務

distributing more needles,

分發更多注射針

increasing access to methadone,

讓美沙酮更容易取得

and, finally, opening a supervised injection site.

最後，還開設了一個 有人管理的安全注射站

Things that make injecting drugs less hazardous.

這些都能讓毒品注射的危險降低

But today, 20 years later,

但 20 年後的今天

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

減害的概念仍然被視為 是某種極端的觀念

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

帶著乾淨的注射針 在某些地方仍然不合法

Drug users are far more likely to be arrested

毒癮者被逮捕的機會

than to be offered methadone therapy.

高過得到美沙酮治療的機會

Recent proposals for supervised injection sites

有些近期提案建議把安全注射站

in cities like Seattle, Baltimore and New York

開設在像是西雅圖 巴爾的摩及紐約這類城市

have been met with stiff opposition:

卻被強力抵制

opposition that goes against everything we know about addiction.

這種抵制和所有我們 對成癮的認知背道而馳

Why is that?

怎麼說呢?

Why are we still stuck on the idea

為什麼很多人仍然堅持

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

阻止濫用毒品的唯一的選擇 是全面禁止施打毒品？

Why do we ignore countless personal stories

為什麼我們還是不願意正眼看待

數不清的成功案例 和壓倒性的科學證據

and overwhelming scientific evidence

that harm reduction works?

證明減害計畫是有效的？

Critics say that harm reduction doesn't stop people

有評論說，減害方案沒有辦法遏止

from using illegal drugs.

大眾吸食毒品

Well, actually, that is the whole point.

其實這才是重點

After every criminal and societal sanction

就算加諸所有我們想到的 刑法和社會制裁

that we can come up with,

people still use drugs, and far too many die.

毒品濫用還是存在且太多人因此喪命

Critics also say that we are giving up on people

很多批評說我們是在放棄毒癮者

by not focusing our attention on treatment and recovery.

因為我們沒有著重在治療和康復上

In fact, it is just the opposite.

事實上恰恰相反

We are not giving up on people.

我們沒有放棄毒癮者

We know that if recovery is ever going to happen

我們很清楚如果要讓他們恢復

we must keep people alive.

我們得先讓他們能活下來

Offering someone a clean needle or a safe place to inject

提供他們一支乾淨的注射針 或一個安全的注射地點

is the first step to treatment and recovery.

就是治療和康復的第一步

Critics also claim that harm reduction

也有人批評說 減害計畫

gives the wrong message to our children about drug users.

讓我們的孩子對毒癮者有錯誤的印象

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

我最後一次看 這些毒癮者就是我們的孩子

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

減少傷害所傳遞的訊息 是雖然毒品會傷害你

we still must reach out to people who are addicted.

我們還是得要向成癮的人伸出手

A needle exchange is not an advertisement for drug use.

換新注射針並不是幫施打毒品打廣告

Neither is a methadone clinic or a supervised injection site.

安全注射站或美沙酮診所也不是

What you see there are people sick and hurting,

在這些地方你只會看見生病受苦的人

hardly an endorsement for drug use.

根本不是在為吸食毒品做背書

Let's take supervised injection sites, for example.

以安全注射站為例

Probably the most misunderstood health intervention ever.

它可能是史上最被誤解的醫療介入了

All we are saying is that allowing people

我們要說的是 讓毒品成癮者

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

能在一個衛生乾淨的空間中 用新的注射針來施打藥物

surrounded by people who care

身邊圍繞的是在乎他們的人

is a lot better than injecting in a dingy alley,

這樣的做法遠遠勝過讓他們 在骯髒巷子裡注射

sharing contaminated needles and hiding out from police.

共用針頭 躲著警察

It's better for everybody.

這樣對大家都好

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

溫哥華的第一個安全注射站 位在卡羅街 327 號

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

一個小小的房間 水泥地板 幾張椅子 和一盒乾淨的針頭

The police would often lock it down,

警方常常把它鎖起來

but somehow it always mysteriously reopened,

可是它總是很神奇地又重新開張

often with the aid of a crowbar.

通常是有鐵橇的幫忙

I would go down there some evenings

我有時候會晚上到那裡去

to provide medical care for people who were injecting drugs.

提供醫療照護給在注射毒品的人

I was always struck with the commitment and compassion

我總是被營運和使用該站點的人

of the people who operated and used the site.

展現的投入和同理心深深感動

No judgment, no hassles, no fear,

沒有評斷 沒有口角 沒有恐懼

lots of profound conversation.

有的是很多深刻的對談

I learned that despite unimaginable trauma,

我了解到儘管有無法想像的傷痛

physical pain and mental illness,

身體痛苦和精神疾病

that everyone there thought that things would get better.

但那裡的每個人相信 一切都會好轉

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

大部分人深信 有一天他們會完全脫離毒品

That room was the forerunner to North America's

那間房間可說是引領北美的先驅

first government-sanctioned supervised injection site, called INSITE.

第一個政府批准的安全注射站點

稱為 INSITE

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

它在 2003 年 9 月開張 是一項 3 年研究計畫

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

保守黨政府一直試圖 在研究結束之後關閉它

After eight years, the battle to close INSITE

8 年後 關閉 INSITE 的官司

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

一路打到加拿大的最高法庭

It pitted the government of Canada

和加拿大政府分庭抗禮的是

against two people with a long history of drug use

兩個有多年毒癮

who knew the benefits of INSITE firsthand:

親身體驗過 INSITE 益處的人

Dean Wilson and Shelley Tomic.

狄恩威爾森和雪莉托米克

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

法庭的判決同意讓 INSITE 從早上 9 點營運到午夜

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

法官在回應檢方時嚴厲痛斥

And I quote:

我引述一段話：

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

「否認 INSITE 提供服務給受惠大眾產生的效應

and the correlative increase in the risk of death and disease

和毒品注射者相對增加的 死亡和生病的風險

to injection drug users is grossly disproportionate to any benefit

和加拿大對持有致幻毒品的一致態度

that Canada might derive

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

以及從中獲得的利益

大相逕庭」

This was a hopeful moment for harm reduction.

對減害方案來說 這是個充滿希望的時刻

Yet, despite this strong message from the Supreme Court,

然而 儘管最高法庭強烈表態

it was, until very recently,

直到近期仍無法

impossible to open up any new sites in Canada.

在加拿大設立任何新站點

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

在 2016 年 12 月 發生了一件有趣的事

when due to the overdose crisis,

當時因為用藥過量的危機

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

卑詩省政府允許開設用藥過量預防站

Essentially ignoring the federal approval process,

完全不理會聯邦審核流程

community groups opened up about 22 of these de facto illegal

社區團體在全省開設了 大約 22 個事實上

supervised injection sites across the province.

非法營運的安全注射站

Virtually overnight,

差不多就是一夜之間

thousands of people could use drugs under supervision.

數千人得以在安全監督下施打毒品

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

靠著納洛酮救回數百個用藥過量的人 沒有人因此喪命

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

事實上 過去 14 年間 在 INSITE 也是這樣子

75,000 different individuals have injected illegal drugs

7 萬 5 千名注射非法毒品的人

more than three and a half million times,

注射次數超過 350 萬次

and not one person has died.

沒有任何人死亡

Nobody has ever died at INSITE.

沒有任何人在 INSITE 身亡

So there you have it.

這些就是

We have scientific evidence and successes from needle exchanges

替換針頭 美沙酮 和安全注射站的

methadone and supervised injection sites.

相關科學證據和成功案例

These are common-sense, compassionate approaches to drug use

這些常識性且充滿關懷的 處理毒癮方法

that improve health, bring connection

能夠改善健康 增進人與人的連結

and greatly reduce suffering and death.

並大大減少痛苦以及死亡

So why haven't harm reduction programs taken off?

可是減害方案為什麼沒有大受歡迎？

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

為什麼我們還認為 施打毒品是執法議題？

Our disdain for drugs and drug users goes very deep.

我們對於毒品和毒癮者有很深的誤解

We are bombarded with images and media stories

我們受到大量影視媒體的誤導

about the horrible impacts of drugs.

內容都是關於毒品的可怕影響

We have stigmatized entire communities.

我們把整個族群污名化了

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

我們對鏟除毒販的軍事行動喝采

And we appear unfazed by building more jails

毫不懷疑地建立更多監獄來監禁

to incarcerate people whose only crime is using drugs.

只是因為吸毒而入獄的人

Virtually millions of people are caught up

有數百萬人被困在一個毫無希望的

in a hopeless cycle of incarceration, violence and poverty

充滿監禁 暴力 以及貧窮的循環

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

造成這個循環的並非毒品本身 而是我們的法律

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

我該怎麼解釋 毒癮者也值得被關心和支持

and the freedom to live their lives

值得擁有生活自主權

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

而不是跟槍枝 手銬 牢房 這些印象綁在一起？

Let's be clear:

簡單來說

criminalization is just a way to institutionalize stigma.

加諸罪名是一種 把汙名化合理納入體制的做法

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

將毒品非法化 並不能阻止大眾施打毒品

Our paralysis to see things differently

我們僵化的觀點

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

是來自對施打毒品全然錯誤的描述

We have been led to believe that drug users

我們被誤導去相信

are irresponsible people who just want to get high,

吸毒者是不負責任只追求快感的人

and then through their own personal failings

他們是被自己個人的失敗

spiral down into a life of crime and poverty,

捲入一個充滿犯罪和貧窮的人生

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

失去工作 家人 最終也失去了性命

In reality, most drug users have a story,

事實上大部分用毒者有自己的故事

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

不論是兒時的創傷 性侵害 精神疾病

or a personal tragedy.

或是個人的不幸

The drugs are used to numb the pain.

毒品是用來麻痺痛苦的

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

當面對有著深沉創傷的人 我們必須要有這樣的理解

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

毒品政策的核心 其實是個社會正義議題

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

雖然媒體聚焦在用藥過量致死的例子 像王子和麥可傑克森

the majority of the suffering

但是大部分的苦難

happens to people who are living on the margins,

發生在處於社會邊緣的人身上

the poor and the dispossessed.

貧窮和無依無靠的人

They don't vote; they are often alone.

他們不投票 他們通常獨自一人

They are society's disposable people.

他們是隨時會被社會拋棄的人

Even within health care, drug use is highly stigmatized.

即使在醫療衛生領域中 吸毒也被嚴重污名化

People using drugs avoid the health care system.

施用毒品的人 通常會避開醫療衛生系統

They know that once engaged in clinical care

他們知道一旦有 醫療照護介入或是住院

or admitted to hospital, they will be treated poorly.

他們就會受到很差的待遇

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

而他們的供應線 不論是海洛因 古柯鹼或冰毒

will be interrupted.

都會被切斷

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

此外 他們會被一大堆問題轟炸

that only serve to expose their losses and shame.

逼他們揭露自己的失敗和恥辱

"What drugs do you use?"

「你吸食哪一種毒品？」

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

「你流落街頭多久了？」

"Where are your children?"

「你的孩子在哪裡？」

"When were you last in jail?"

「你上次坐牢是甚麼時候？」

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

基本上就是在問： 「你為什麼不停止吸毒？」

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

事實上整個醫療系統 處理毒癮的方法弄反了

For some reason,

基於某種原因

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

我們自顧自地認定 最好的治療方式就是全面戒除

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

如果你夠幸運 或可參加戒癮計畫

If you live in a community with Suboxone or methadone,

如果你住在一個提供舒倍生 或美沙酮療法的社區

you may get on a substitution program.

你或許可以參與替代品計畫

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

我們幾乎從來沒有提供毒癮者 他們生存最迫切需要的東西：

a safe prescription for opioids.

一個安全的類鴉片藥物處方

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

直接從完全戒除開始治療 就像是要糖尿病患者一下子戒掉糖

or a severe asthmatic to start running marathons

或是要嚴重氣喘患者去跑馬拉松

or a depressed person to just be happy.

或是要憂鬱症患者開心點

For any other medical condition,

既然對任何其他醫療疾病

we would never start with the most extreme option.

我們從來不會從最極端的療法開始

What makes us think that strategy

那麼我們為什麼會認為這種方法

would work for something as complex as addiction?

對於成癮這麼複雜的狀況會有用？

While unintentional overdoses are not new,

意外用藥過量不足為奇

the scale of the current crisis is unprecedented.

但是當前危機的規模是前所未見的

The Center for Disease Control estimated

疾病管制局估計

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

2016 年就有 6 萬 4 千名 美國人死於用藥過量

far exceeding car crashes or homicides.

遠遠超過車禍或自殺的死亡人數

Drug-related mortality is now the leading cause of death

毒品相關造成的死亡

如今是 20 到 50 歲 北美男性與女性的主要死因

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

Think about that.

想一想

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

我們是怎麼落入這個境況？ 為什麼是現在？

There is a kind of perfect storm around opioids.

類鴉片藥物帶來著一連串的災難

Drugs like Oxycontin, Percocet and Dilaudid

像奧施康定（土海洛因） 醅鈳塞 第勞第拖這類毒品

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

數十年來都被大量開立配藥 做各種止痛用途

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

據估計 有兩百萬美國人 每天服用類鴉片藥物

and over 60 million people

超過六千萬人

received at least one prescription for opioids last year.

去年至少拿過一次 類鴉片藥物的處方

This massive dump of prescription drugs into communities

大量開立給民眾的處方藥

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

讓想要自行用藥的人 有穩定的藥品來源

In response to this prescription epidemic,

為了因應這種處方疫情

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

很多人的處方被取消了 這做法大幅降低了街頭的供應量

The unintended but predictable consequence

結果就是非刻意製造但可以預期的

is an overdose epidemic.

藥物濫用大流行

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

許多原本依賴處方藥穩定供應的人

turned to heroin.

轉向海洛因

And now the illegal drug market has tragically switched

很不幸地現在的非法藥品市場需求

to synthetic drugs, mainly fentanyl.

轉向合成藥品 主要是芬太奴

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

這些新藥很便宜 強效 但是極難控制劑量

People are literally being poisoned.

使用者基本上是被毒害的

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

各位能想像如果這是 另一種的中毒大流行嗎？

What if thousands of people started dying

如果有數以千計的人開始死於

from poisoned meat or baby formula or coffee?

被下毒的肉品 嬰兒配方奶粉或咖啡

We would be treating this as a true emergency.

我們會把它視為真正的緊急狀況

We would immediately be supplying safer alternatives.

我們會馬上供應比較安全的替代品

There would be changes in legislation,

立法也會因應改變

and we would be supporting the victims and their families.

我們會支持受害者和他們的家人

But for the drug overdose epidemic,

但對於藥物濫用的流行病

we have done none of that.

我們卻完全沒有那麼做

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

我們持續把藥品和用藥的人給妖魔化

and blindly pour even more resources into law enforcement.

甚至盲目地把更多資源投入執法單位

So where should we go from here?

我們接下來該怎麼做？

First, we should fully embrace, fund and scale up

首先 我們應該全面接受資助

harm reduction programs across North America.

和擴展北美各地的減害計畫

I know that in places like Vancouver,

我知道像溫哥華這樣的地方

harm reduction has been a lifeline to care and treatment.

減害方案一直都是 照護和治療的生命線

I know that the number of overdose deaths

我知道如果沒有減害方案

would be far higher without harm reduction.

用藥過量致死的人數會高出很多

And I personally know hundreds of people who are alive today

我自己本身就認識數百個

多虧減害方案才活到今天的人

because of harm reduction.

But harm reduction is just the start.

但減害方案只是個開始

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

如果我們真的想處理毒品危機

we need to have a serious conversation about prohibition

我們得要認真嚴肅地探討

and criminal punishment.

禁藥令和刑事懲處

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

我們得要承認 吸毒是最優先的公共健康議題

and turn to comprehensive social and health solutions.

並尋求全面的社會與健康解決方案

We already have a model for how this can work.

我們已經有一個可依循的模式

In 2001, Portugal was having its own drug crisis.

在 2001 年 葡萄牙發生毒品危機

Lots of people using drugs, high crime rates

高用藥率 高犯罪率

and an overdose epidemic.

用藥過量也很普遍

They defied global conventions and decriminalized all drug possession.

他們不採用全球普遍的習慣做法 反而將毒品持有除罪化

Money that was spent on drug enforcement

本來花在毒品執法的錢

was redirected to health and rehabilitation programs.

轉用到健康和康復計畫上

The results are in.

出來的結果是

Overall drug use is down dramatically.

整體的吸毒比例大幅下降

Overdoses are uncommon.

用藥過量案例變少了

Many more people are in treatment.

更多人接受治療

And people have been given their lives back.

而且很多人被救回一條命

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

我們長年以來一直使用 禁令 懲罰和偏見

that we have become indifferent to the suffering

使我們漠視人們的痛苦

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

我們竟然去打擊社會上 最脆弱的那群人

This year even more people will get caught up

今年還會有更多人陷於

in the illegal drug trade.

非法毒品交易

Thousands of children will learn that their mother or father

數以千計孩童的父母親

has been sent to jail for using drugs.

會因為吸毒而入獄

And far too many parents will be notified

更多父母親會接到通知

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

得知他們的兒女因為用藥過量而死

It doesn't have to be this way.

這一切大可不必發生

Thank you.

謝謝

(Applause)

（掌聲）