‘Where there is love’: Reflections on caring in Vancouver’s Downtown Eastside

The first time I went to Providence Health Care’s Crosstown Clinic on Vancouver’s notorious Downtown Eastside (DTES) was a surreal experience. Walking down Abbott Street, one encounters a true menagerie of urban living: fashionable business people; students; tourists; street people; drug dealers; and many people with walkers, wheelchairs or scooters.

The DTES is one of Canada’s poorest neighbourhoods and is ground zero for British Columbia’s opioid crisis. The Crosstown Clinic has been helping to address this crisis since 2011 by providing medically prescribed injectable heroin (diacetylmorphine) and hydromorphone for people with chronic and severe opioid use disorder who don’t benefit from other conventional treatments. Clients come into the clinic up to three times a day to self-inject medicine. There they are supported by nurses, care aides, doctors, social workers and myself—a spiritual care practitioner.

The first time I witnessed the clinic at work I found myself thinking, What on earth are we doing here? Are we really providing free drugs to heroin users? The clinic is firmly rooted in the philosophies of patient-centered care and harm reduction, so there is no expectation that clients will work towards abstinence or attempt to control or reduce their substance use.

Is this not enabling self-destructive behaviour? Should we really be doing this?

It didn’t take me long to hear the stories and learn about the impact that trauma, abuse and attempted genocide have on people, which sadly is very real and ultimately leads to tremendous pain and suffering. Bodies, minds and spirits get broken. While we have the ability to heal, deep scars can remain and treatment can turn into desperate need and addiction.

Some are here because of the over-prescription of opioids like oxycodone after an accident or other physical trauma. Some were born into families where addiction was prevalent and learned about substance use from the adults around them. Some suffer from physical, sexual and emotional violence and abuse. Many are Indigenous and live with the legacy of the Indian Act, residential schools and the Sixties Scoop. Mental health challenges, such as debilitating and uncontrolled depression, anxiety and schizophrenia, are prevalent—and this just scratches the surface of the challenges facing those on the DTES.

It also didn’t take me long to learn that the thoughts which ran through my head that first day were informed by stigma—the perception that people who live with a particular characteristic that is considered undesirable are undesirable themselves.

Stigma occurs on three levels: social, self and professional. Social stigma is “a belief held by a large faction of society in which persons with the stigmatized condition are part of an inferior group”¹ (like being from Nazareth—John 1:46).

Self-stigma occurs when stigmatized beliefs held by society are internalized by the individual who is identified to be part of the stigmatized group, resulting in the individual feeling guilt or inadequacy in terms of their core identity and belief about themselves (as when the Samaritan woman asks Jesus, “How can you ask me for a drink?”—John 4:9). Professional stigma occurs when these beliefs are internalized by health-care professionals and impact the caregiving provided to people in this population—just as I held the belief that those with addictions issues need help getting “clean and sober,” and we should not be providing access to a clean and safe supply of the drug their bodies and minds need.

My belief has changed as I have learned that the pain these people live with is very real and present on physical, mental and spiritual levels. Substances, particularly opioids, are very effective at relieving this pain, if only temporarily. As anyone knows who has taken a pain reliever like ibuprofen (e.g. “Advil”) to relieve a headache, a stimulant like caffeine (in coffee or tea) to get going in the morning, or a depressant like alcohol (wine, beer, scotch, etc.) to relax at a social gathering or after a hard day at work—substances effectively shift our experience of life. And when life is full of pain and suffering, any shift is welcome.

The difficulty with opioids is that while the relief is very effective in the moment, the pain ultimately returns, and we end up feeling horrible as the drug leaves our system. Having another dose makes everything good again, but it doesn’t quite provide as much relief as before, and the withdrawal is worse. This leads to a vicious cycle: pain, use, relief, withdrawal, more pain, more use, some relief, more withdrawal, even more pain, and on and on, as our body gets used to the drug being in our system. Over time the amount needed for relief increases. Soon our entire life can be focused on getting that next dose, no matter what—which inevitably can lead to criminal behaviour, broken homes and broken lives.

For those at the Crosstown Clinic, everything changes. I have begun to see our clients for who they are: beloved children of God who need help and support to cope with the significant challenges they face in life. We respond with love and compassion, providing access to a safe and clean supply of the medicine they need and surrounding them with medical, social and spiritual support. When this happens, the cycle of stigma, shame and anxiety about having to steal or sell possessions or bodies in order to get that next fix is broken. And sometimes, they begin to see themselves as beloved children of God facing significant challenges in life.

Some end up making decisions to reduce their dependence on substances, and others decide to pursue education and work opportunities. Some seek reconciliation with estranged families. For others, the struggle continues. But everyone is impacted by the love and compassion present at the Crosstown Clinic. And where there is love, there is God.

Ubi caritas et amor, ubi caritas deus ibi est.

¹Ahmedani B. K. (2011). “Mental Health Stigma: Society, Individuals, and the Profession.” Journal of social work values and ethics, 8(2), 4-1–4-16.

Philip Murray, MDiv, is a certified spiritual care practitioner with Providence Health Care in Vancouver.