I remember the first time that I saw people injecting drugs. I had just arrived in Vancouver to lead a research project in HIV prevention in the infamous Downtown East Side. It was in the lobby of the Portland Hotel, a supportive housing project that gave rooms to the most marginalized people in the city, the so-called "difficult to house." I'll never forget the young woman standing on the stairs repeatedly jabbing herself with a needle, and screaming, "I can't find a vein," as blood splattered on the wall.
我還記得第一次看到 別人注射毒品的經驗 我才剛剛到溫哥華主導一個研究計畫 是一個愛滋病防治計畫 就在惡名昭彰的溫哥華城中東區 事情就發生在波特蘭旅館的大廳 那裡有個住房支持計畫提供住所 給城市中最邊緣化的一群人 所謂「很難收容的人」 我永遠無法忘記 那個站在樓梯上的年輕女子 一邊不斷地用注射針猛刺自己 一邊大喊「我找不到血管」 同時血飛濺到牆上
In response to the desperate state of affairs, the drug use, the poverty, the violence, the soaring rates of HIV, Vancouver declared a public health emergency in 1997. This opened the door to expanding harm reduction services, distributing more needles, increasing access to methadone, and, finally, opening a supervised injection site. Things that make injecting drugs less hazardous. But today, 20 years later, harm reduction is still viewed as some sort of radical concept. In some places, it's still illegal to carry a clean needle. Drug users are far more likely to be arrested than to be offered methadone therapy. Recent proposals for supervised injection sites in cities like Seattle, Baltimore and New York have been met with stiff opposition: opposition that goes against everything we know about addiction.
為了因應層出不窮的 毒品濫用 貧窮 暴力 和飆升的愛滋病罹患率 溫哥華市在 1997 年 宣佈進入公共衛生警戒狀態 此舉開啟了一扇門來擴展減害服務 分發更多注射針 讓美沙酮更容易取得 最後,還開設了一個 有人管理的安全注射站 這些都能讓毒品注射的危險降低 但 20 年後的今天 減害的概念仍然被視為 是某種極端的觀念 帶著乾淨的注射針 在某些地方仍然不合法 毒癮者被逮捕的機會 高過得到美沙酮治療的機會 有些近期提案建議把安全注射站 開設在像是西雅圖 巴爾的摩及紐約這類城市 卻被強力抵制 這種抵制和所有我們 對成癮的認知背道而馳
Why is that? Why are we still stuck on the idea that the only option is to stop using -- that any drug use will not be tolerated? Why do we ignore countless personal stories and overwhelming scientific evidence that harm reduction works? Critics say that harm reduction doesn't stop people from using illegal drugs. Well, actually, that is the whole point. After every criminal and societal sanction that we can come up with, people still use drugs, and far too many die. Critics also say that we are giving up on people by not focusing our attention on treatment and recovery. In fact, it is just the opposite. We are not giving up on people. We know that if recovery is ever going to happen we must keep people alive. Offering someone a clean needle or a safe place to inject is the first step to treatment and recovery. Critics also claim that harm reduction gives the wrong message to our children about drug users. The last time I looked, these drug users are our children. The message of harm reduction is that while drugs can hurt you, we still must reach out to people who are addicted. A needle exchange is not an advertisement for drug use. Neither is a methadone clinic or a supervised injection site. What you see there are people sick and hurting, hardly an endorsement for drug use.
怎麼說呢? 為什麼很多人仍然堅持 阻止濫用毒品的唯一的選擇 是全面禁止施打毒品? 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 證明減害計畫是有效的? 有評論說,減害方案沒有辦法遏止 大眾吸食毒品 其實這才是重點 就算加諸所有我們想到的 刑法和社會制裁 毒品濫用還是存在且太多人因此喪命 很多批評說我們是在放棄毒癮者 因為我們沒有著重在治療和康復上 事實上恰恰相反 我們沒有放棄毒癮者 我們很清楚如果要讓他們恢復 我們得先讓他們能活下來 提供他們一支乾淨的注射針 或一個安全的注射地點 就是治療和康復的第一步 也有人批評說 減害計畫 讓我們的孩子對毒癮者有錯誤的印象 我最後一次看 這些毒癮者就是我們的孩子 減少傷害所傳遞的訊息 是雖然毒品會傷害你 我們還是得要向成癮的人伸出手 換新注射針並不是幫施打毒品打廣告 安全注射站或美沙酮診所也不是 在這些地方你只會看見生病受苦的人 根本不是在為吸食毒品做背書
Let's take supervised injection sites, for example. Probably the most misunderstood health intervention ever. All we are saying is that allowing people to inject in a clean, dry space with fresh needles, surrounded by people who care is a lot better than injecting in a dingy alley, sharing contaminated needles and hiding out from police. It's better for everybody. The first supervised injection site in Vancouver was at 327 Carol Street, a narrow room with a concrete floor, a few chairs and a box of clean needles. The police would often lock it down, but somehow it always mysteriously reopened, often with the aid of a crowbar. I would go down there some evenings to provide medical care for people who were injecting drugs. I was always struck with the commitment and compassion of the people who operated and used the site. No judgment, no hassles, no fear, lots of profound conversation. I learned that despite unimaginable trauma, physical pain and mental illness, that everyone there thought that things would get better. Most were convinced that, someday, they'd stop using drugs altogether. That room was the forerunner to North America's first government-sanctioned supervised injection site, called INSITE. It opened in September of 2003 as a three-year research project. The conservative government was intent on closing it down at the end of the study. After eight years, the battle to close INSITE went all the way up to Canada's Supreme Court. It pitted the government of Canada against two people with a long history of drug use who knew the benefits of INSITE firsthand: Dean Wilson and Shelley Tomic. The court ruled in favor of keeping INSITE open by nine to zero. The justices were scathing in their response to the government's case. And I quote: "The effect of denying the services of INSITE to the population that it serves and the correlative increase in the risk of death and disease to injection drug users is grossly disproportionate to any benefit that Canada might derive from presenting a uniform stance on the possession of narcotics."
以安全注射站為例 它可能是史上最被誤解的醫療介入了 我們要說的是 讓毒品成癮者 能在一個衛生乾淨的空間中 用新的注射針來施打藥物 身邊圍繞的是在乎他們的人 這樣的做法遠遠勝過讓他們 在骯髒巷子裡注射 共用針頭 躲著警察 這樣對大家都好 溫哥華的第一個安全注射站 位在卡羅街 327 號 一個小小的房間 水泥地板 幾張椅子 和一盒乾淨的針頭 警方常常把它鎖起來 可是它總是很神奇地又重新開張 通常是有鐵橇的幫忙 我有時候會晚上到那裡去 提供醫療照護給在注射毒品的人 我總是被營運和使用該站點的人 展現的投入和同理心深深感動 沒有評斷 沒有口角 沒有恐懼 有的是很多深刻的對談 我了解到儘管有無法想像的傷痛 身體痛苦和精神疾病 但那裡的每個人相信 一切都會好轉 大部分人深信 有一天他們會完全脫離毒品 那間房間可說是引領北美的先驅 第一個政府批准的安全注射站點 稱為 INSITE 它在 2003 年 9 月開張 是一項 3 年研究計畫 保守黨政府一直試圖 在研究結束之後關閉它 8 年後 關閉 INSITE 的官司 一路打到加拿大的最高法庭 和加拿大政府分庭抗禮的是 兩個有多年毒癮 親身體驗過 INSITE 益處的人 狄恩威爾森和雪莉托米克 法庭的判決同意讓 INSITE 從早上 9 點營運到午夜 法官在回應檢方時嚴厲痛斥 我引述一段話: 「否認 INSITE 提供服務給受惠大眾產生的效應 和毒品注射者相對增加的 死亡和生病的風險 和加拿大對持有致幻毒品的一致態度 以及從中獲得的利益 大相逕庭」
This was a hopeful moment for harm reduction. Yet, despite this strong message from the Supreme Court, it was, until very recently, impossible to open up any new sites in Canada. There was one interesting thing that happened in December of 2016, when due to the overdose crisis, the government of British Columbia allowed the opening of overdose prevention sites. Essentially ignoring the federal approval process, community groups opened up about 22 of these de facto illegal supervised injection sites across the province. Virtually overnight, thousands of people could use drugs under supervision. Hundreds of overdoses were reversed by Naloxone, and nobody died. In fact, this is what's happened at INSITE over the last 14 years: 75,000 different individuals have injected illegal drugs more than three and a half million times, and not one person has died. Nobody has ever died at INSITE.
對減害方案來說 這是個充滿希望的時刻 然而 儘管最高法庭強烈表態 直到近期仍無法 在加拿大設立任何新站點 在 2016 年 12 月 發生了一件有趣的事 當時因為用藥過量的危機 卑詩省政府允許開設用藥過量預防站 完全不理會聯邦審核流程 社區團體在全省開設了 大約 22 個事實上 非法營運的安全注射站 差不多就是一夜之間 數千人得以在安全監督下施打毒品 靠著納洛酮救回數百個用藥過量的人 沒有人因此喪命 事實上 過去 14 年間 在 INSITE 也是這樣子 7 萬 5 千名注射非法毒品的人 注射次數超過 350 萬次 沒有任何人死亡 沒有任何人在 INSITE 身亡
So there you have it. We have scientific evidence and successes from needle exchanges methadone and supervised injection sites. These are common-sense, compassionate approaches to drug use that improve health, bring connection and greatly reduce suffering and death. So why haven't harm reduction programs taken off? Why do we still think that drug use is law enforcement issue? Our disdain for drugs and drug users goes very deep. We are bombarded with images and media stories about the horrible impacts of drugs. We have stigmatized entire communities. We applaud military-inspired operations that bring down drug dealers. And we appear unfazed by building more jails to incarcerate people whose only crime is using drugs.
這些就是 替換針頭 美沙酮 和安全注射站的 相關科學證據和成功案例 這些常識性且充滿關懷的 處理毒癮方法 能夠改善健康 增進人與人的連結 並大大減少痛苦以及死亡 可是減害方案為什麼沒有大受歡迎? 為什麼我們還認為 施打毒品是執法議題? 我們對於毒品和毒癮者有很深的誤解 我們受到大量影視媒體的誤導 內容都是關於毒品的可怕影響 我們把整個族群污名化了 我們對鏟除毒販的軍事行動喝采 毫不懷疑地建立更多監獄來監禁 只是因為吸毒而入獄的人
Virtually millions of people are caught up in a hopeless cycle of incarceration, violence and poverty that has been created by our drug laws and not the drugs themselves. How do I explain to people that drug users deserve care and support and the freedom to live their lives when all we see are images of guns and handcuffs and jail cells? Let's be clear: criminalization is just a way to institutionalize stigma. Making drugs illegal does nothing to stop people from using them. Our paralysis to see things differently is also based on an entirely false narrative about drug use. We have been led to believe that drug users are irresponsible people who just want to get high, and then through their own personal failings spiral down into a life of crime and poverty, losing their jobs, their families and, ultimately, their lives. In reality, most drug users have a story, whether it's childhood trauma, sexual abuse, mental illness or a personal tragedy. The drugs are used to numb the pain. We must understand that as we approach people with so much trauma.
有數百萬人被困在一個毫無希望的 充滿監禁 暴力 以及貧窮的循環 造成這個循環的並非毒品本身 而是我們的法律 我該怎麼解釋 毒癮者也值得被關心和支持 值得擁有生活自主權 而不是跟槍枝 手銬 牢房 這些印象綁在一起? 簡單來說 加諸罪名是一種 把汙名化合理納入體制的做法 將毒品非法化 並不能阻止大眾施打毒品 我們僵化的觀點 是來自對施打毒品全然錯誤的描述 我們被誤導去相信 吸毒者是不負責任只追求快感的人 他們是被自己個人的失敗 捲入一個充滿犯罪和貧窮的人生 失去工作 家人 最終也失去了性命 事實上大部分用毒者有自己的故事 不論是兒時的創傷 性侵害 精神疾病 或是個人的不幸 毒品是用來麻痺痛苦的 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. While the media may focus on overdose deaths like Prince and Michael Jackson, the majority of the suffering happens to people who are living on the margins, the poor and the dispossessed. They don't vote; they are often alone. They are society's disposable people. Even within health care, drug use is highly stigmatized. People using drugs avoid the health care system. They know that once engaged in clinical care or admitted to hospital, they will be treated poorly. And their supply line, be it heroin, cocaine or crystal meth will be interrupted. On top of that, they will be asked a barrage of questions that only serve to expose their losses and shame. "What drugs do you use?" "How long have you been living on the street?" "Where are your children?" "When were you last in jail?" Essentially: "Why the hell don't you stop using drugs?"
毒品政策的核心 其實是個社會正義議題 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 但是大部分的苦難 發生在處於社會邊緣的人身上 貧窮和無依無靠的人 他們不投票 他們通常獨自一人 他們是隨時會被社會拋棄的人 即使在醫療衛生領域中 吸毒也被嚴重污名化 施用毒品的人 通常會避開醫療衛生系統 他們知道一旦有 醫療照護介入或是住院 他們就會受到很差的待遇 而他們的供應線 不論是海洛因 古柯鹼或冰毒 都會被切斷 此外 他們會被一大堆問題轟炸 逼他們揭露自己的失敗和恥辱 「你吸食哪一種毒品?」 「你流落街頭多久了?」 「你的孩子在哪裡?」 「你上次坐牢是甚麼時候?」 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. For some reason, we have decided that abstinence is the best way to treat this. If you're lucky enough, you may get into a detox program. If you live in a community with Suboxone or methadone, you may get on a substitution program. Hardly ever would we offer people what they desperately need to survive: a safe prescription for opioids. Starting with abstinence is like asking a new diabetic to quit sugar or a severe asthmatic to start running marathons or a depressed person to just be happy. For any other medical condition, we would never start with the most extreme option. What makes us think that strategy would work for something as complex as addiction?
事實上整個醫療系統 處理毒癮的方法弄反了 基於某種原因 我們自顧自地認定 最好的治療方式就是全面戒除 如果你夠幸運 或可參加戒癮計畫 如果你住在一個提供舒倍生 或美沙酮療法的社區 你或許可以參與替代品計畫 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: 一個安全的類鴉片藥物處方 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 或是要嚴重氣喘患者去跑馬拉松 或是要憂鬱症患者開心點 既然對任何其他醫療疾病 我們從來不會從最極端的療法開始 那麼我們為什麼會認為這種方法 對於成癮這麼複雜的狀況會有用?
While unintentional overdoses are not new, the scale of the current crisis is unprecedented. The Center for Disease Control estimated that 64,000 Americans died of a drug overdose in 2016, far exceeding car crashes or homicides. Drug-related mortality is now the leading cause of death among men and women between 20 and 50 years old in North America Think about that. How did we get to this point, and why now? There is a kind of perfect storm around opioids. Drugs like Oxycontin, Percocet and Dilaudid have been liberally distributed for decades for all kinds of pain. It is estimated that two million Americans are daily opioid users, and over 60 million people received at least one prescription for opioids last year. This massive dump of prescription drugs into communities has provided a steady source for people wanting to self-medicate. In response to this prescription epidemic, people have been cut off, and this has greatly reduced the street supply
意外用藥過量不足為奇 但是當前危機的規模是前所未見的 疾病管制局估計 2016 年就有 6 萬 4 千名 美國人死於用藥過量 遠遠超過車禍或自殺的死亡人數 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 想一想 我們是怎麼落入這個境況? 為什麼是現在? 類鴉片藥物帶來著一連串的災難 像奧施康定(土海洛因) 醅鈳塞 第勞第拖這類毒品 數十年來都被大量開立配藥 做各種止痛用途 據估計 有兩百萬美國人 每天服用類鴉片藥物 超過六千萬人 去年至少拿過一次 類鴉片藥物的處方 大量開立給民眾的處方藥 讓想要自行用藥的人 有穩定的藥品來源 為了因應這種處方疫情 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 is an overdose epidemic. Many people who were reliant on a steady supply of prescription drugs turned to heroin. And now the illegal drug market has tragically switched to synthetic drugs, mainly fentanyl. These new drugs are cheap, potent and extremely hard to dose. People are literally being poisoned. Can you imagine if this was any other kind of poisoning epidemic? What if thousands of people started dying from poisoned meat or baby formula or coffee? We would be treating this as a true emergency. We would immediately be supplying safer alternatives. There would be changes in legislation, and we would be supporting the victims and their families. But for the drug overdose epidemic, we have done none of that. We continue to demonize the drugs and the people who use them and blindly pour even more resources into law enforcement.
結果就是非刻意製造但可以預期的 藥物濫用大流行 許多原本依賴處方藥穩定供應的人 轉向海洛因 很不幸地現在的非法藥品市場需求 轉向合成藥品 主要是芬太奴 這些新藥很便宜 強效 但是極難控制劑量 使用者基本上是被毒害的 各位能想像如果這是 另一種的中毒大流行嗎? 如果有數以千計的人開始死於 被下毒的肉品 嬰兒配方奶粉或咖啡 我們會把它視為真正的緊急狀況 我們會馬上供應比較安全的替代品 立法也會因應改變 我們會支持受害者和他們的家人 但對於藥物濫用的流行病 我們卻完全沒有那麼做 我們持續把藥品和用藥的人給妖魔化 甚至盲目地把更多資源投入執法單位
So where should we go from here? First, we should fully embrace, fund and scale up harm reduction programs across North America. I know that in places like Vancouver, harm reduction has been a lifeline to care and treatment. I know that the number of overdose deaths would be far higher without harm reduction. And I personally know hundreds of people who are alive today because of harm reduction. But harm reduction is just the start. If we truly want to make an impact on this drug crisis, we need to have a serious conversation about prohibition and criminal punishment. We need to recognize that drug use is first and foremost a public health issue and turn to comprehensive social and health solutions.
我們接下來該怎麼做? 首先 我們應該全面接受資助 和擴展北美各地的減害計畫 我知道像溫哥華這樣的地方 減害方案一直都是 照護和治療的生命線 我知道如果沒有減害方案 用藥過量致死的人數會高出很多 我自己本身就認識數百個 多虧減害方案才活到今天的人 但減害方案只是個開始 如果我們真的想處理毒品危機 我們得要認真嚴肅地探討 禁藥令和刑事懲處 我們得要承認 吸毒是最優先的公共健康議題 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. In 2001, Portugal was having its own drug crisis. Lots of people using drugs, high crime rates and an overdose epidemic. They defied global conventions and decriminalized all drug possession. Money that was spent on drug enforcement was redirected to health and rehabilitation programs. The results are in. Overall drug use is down dramatically. Overdoses are uncommon. Many more people are in treatment. And people have been given their lives back. We have come so far down the road of prohibition, punishment and prejudice that we have become indifferent to the suffering that we have inflicted on the most vulnerable people in our society.
我們已經有一個可依循的模式 在 2001 年 葡萄牙發生毒品危機 高用藥率 高犯罪率 用藥過量也很普遍 他們不採用全球普遍的習慣做法 反而將毒品持有除罪化 本來花在毒品執法的錢 轉用到健康和康復計畫上 出來的結果是 整體的吸毒比例大幅下降 用藥過量案例變少了 更多人接受治療 而且很多人被救回一條命 我們長年以來一直使用 禁令 懲罰和偏見 使我們漠視人們的痛苦 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 in the illegal drug trade. Thousands of children will learn that their mother or father has been sent to jail for using drugs. And far too many parents will be notified that their son or daughter has died of a drug overdose. It doesn't have to be this way.
今年還會有更多人陷於 非法毒品交易 數以千計孩童的父母親 會因為吸毒而入獄 更多父母親會接到通知 得知他們的兒女因為用藥過量而死 這一切大可不必發生
Thank you.
謝謝
(Applause)
(掌聲)