I work in homeless services and see the failures of our costly programs every day. Some participants are blessed with rental assistance (up to 110% FMR I might add), with the hope that they will progressively take over responsibility of their rent, and work with a case manager to overcome whatever the root of their housing crisis was. But this program has nearly a 0% success rate if the metric of success is the participant taking responsibility of their rental payments. It is a only providing a 2-year bandaid solution, and no one is talking about it. The metrics that are publicized only address “participants served”.
Thank you so much for sharing your actual experience. It is people like yourself and Kevin that are our only hope for educating the voters in a way that will hopefully lead them to vote for responsibility at every level of Government and in every NGO that we are funding.
NGOs (at all levels of government: local, county, state, federal) should be reigned in. They have taken over legislative, executive, and judicial functions within their own sphere of technical "expertise" from the government. They continue to exist regardless of who is voted into power. It is an erosion of democracy (representative or not).
At the county (or city) level, trying to figure out where the power lies and where the money goes with all the overlapping and sometimes invisible NGOs is an impossible job. Sharon Meieran spent a good part of her 8 years as a Multno County Councilor trying to understand it. With any luck, she'll be voted County Chair in November and can help disentangle the mess and help make our local and county governments leaner, more cost effective, more effective overall, and more answerable to those whom the people vote into power.
Even if she makes minimal progress, she will at least set us on the right track.
Thank you for pointing out all the good work Sharon Meieran tried to do on the County Board. The mystery that you have brought up is clearly at play with the last two County Chairpersons, who refused every request to even discuss Sharon’s information and potential solutions 😡. Why? Who received the nearly 2 billion dollars that has already been spent? Why did the 2 girls who were County Chair’s refuse to allow the data and facts she presented? Jealousy, inferiority complexes, or the outright greed in giving the public dollars to their families and friends without explanation?
Ironically, the leading cause of poverty and eventual homelessness or other addictions start with the Oregon Lottery. It is Ironic because the falsified revenue allowed the State to borrow $7.1+ Billion in Lottery Revenue Bonds where much of it went toward Homelessness.
Kevin - I know you are controversial, but you speak the truth. "At some point, we have to stop judging these policies by their intentions and start judging them by their results."
There are many questions that dare not be asked--but the profit motive is at the top 'o' the list. Housing First is a scam that spends $-millions on developers (here's lookin' at ya, Related Companies), union jobs (mandated by Oregon law), crap architecture, and the bureaucracies that funnel the dough to clients of the political machine.
It used to be that typical American machines (Chicago, NYC, Philly, etc) were conduits for insurance, public works, road-pavers...but now Homelessness Inc. has scooped all of this up into one easily-managed package.
The dispensers and receivers of this pork will fight like cornered rats to give up the dough (to mix metaphors). Nothing will change until the political matrix changes. A machine that controls the voting mode, that runs extortionate tax policies, that drives out any potential serious opponents to lower-tax states, that controls education/indoctrination, that runs super-majorities, that makes racial-payoffs, that engineers end-runs around elections with the resign-appoint gambit...well, think any of these institutions will disappear?
The homeless will be ever with us. Pay up and shut up.
James Burnham discusses how things used to work in his book "Suicide of the West: An Essay on the Meaning and Destiny of Liberalism" from 1964.
He says that every city has its skid row. That we will never completely rid society of the homeless or "bums" or alcoholics, etc. And that rather than have them spread out all over town in the "nice area" we should allow them to remain in a certain area of town (on the edge of town, or edge of downtown) where they are tolerated. I've recently noticed that Vancouver B.C. does this (Portland used to) and it seems to work quite well.
“Some years ago liberals concerned w/ social reform & urban renewal, as it has come to be called, turned their attention to Skid Row. In accord w/ the canons of ideological thinking, Skid Row was understood as a ʻproblemʼ; & [consequently]... liberals had a duty to ʻsolveʼ it.
"But what exactly is Skid Row? In reality it is not, other than incidentally, a spatial concept at all -- but a functional concept; and not so much a special ʻproblemʼ as merely a natural, indeed inevitable, condition of every articulated community of any size.
"Skid Row is the end of the line; there must be an end of the line somewhere. It is the state of those individuals who by destiny or choice drop out of normal society... Most of these individuals are alcoholics and some are drug addicts.”
“Where they are is Skid Row; and Skid Row exists in every city, and always has.” –
You are expectingto find the results looking at the homeless. The true results are in the hands of the bureaucrats and nonprofits, and that is money and power for them. If the homeless disappeared tomorrow, their jobs would end.
Great insight Kevin! How frustrating it all must be for you to witness and experience. I don't even live in your country but cannot believe what's going on😞
Keep speaking your truth and take care of yourself.
May I describe a cycle you referenced (you identified several cycles, most of which are downward spiraling descents) by using a very real cycle that a next door neighbor described to me 50 years ago.
Austin was raised in Luray, Virginia and he was around 40 when I was 17. We lived in Falls Church, Va and he was a top mechanic for the bus company; Metro Transit. Austin would help me fix my car and he would tell me boyhood stories. One evening in 1966, he told me his story of a bountiful cherry tree and the consumption pattern he developed. He would climb onto a limb that gave him an “umbrella” of large, hanging, cherries and he gorged himself until he could not eat anymore. But he wanted to continue eating those large, delicious, cherries. So he inserted his index finger down his throat and triggered the vomit reflex, projecting much of what he’d eaten to the ground, and he would “start over.” Perhaps the only risk his body experienced was the convulsion he produced in his throat/esophagus as he emptied his stomach. I cannot recall how Austin described his boyhood Cherry-gorging activity, but I have come to refer to it as “re-loading”.
When I started blogging on Substance Abuse in April, 2016, a few weeks after Prince OD’d on Fentanyl, I quickly caught-up on my knowledge of the synthetic opioids/Central Nervous System (CNS) depressants which slow respiration and heartrate, in some cases, all-the-way to flat-line…death.
Over the remainder of 2016 and throughout 2017, I posted miracle stories of revival of near-death Fentanyl users through the administration of Narcan, which sometimes required two or three nasal spraying. In some of the articles, the revived user would display anger at the EMT - sometimes assaulting them - and the reports described how the revived person ran-off to purchase some more Fentanyl so he/she could resume getting “low.” CNS Depressants do not make people “high,” Fentayl can bring one to Death’s gate quickly.
As I would read these near-death-Narcan-revival stories, I recalled Austin’s harmless reloading of cherry-gorging by forced vomiting and I have come to see Narcan as a two-edged sword. It revives near-death Fentanyl users. Narcan also lets Fentanyl users tempt death…and then start over again…reload.
Not to be critical, but how is this speaking "truth to power"? Wouldn't speaking truth to power be Kevin speaking before the Multno County Board of Councilors, or the Portland City Councilors, or whoever the new Homelessness Czar is, etc.?
If I understand the phrase correctly, I believe posting on Substack (however important) is not, technically speaking, speaking "truth to power," but rather speaking the truth (powerfully).
Let's hope Sharon Meieran gets elected to the County Chair. Have you spoken to her at all?
Is this some sort of tactic? Or intentional. You are joking right? The democratic party starting 1930 has been the most focused on helping low income individuals and families ever. From Roosevelt to Obama. The amount of poverty fighting initiatives have accomplished so much more than any other party. If you truly believe that than you do not understand politics at all.
What once was a cause had become a multi-billion-dollar industry. Sadly, Democrats turned homelessness into an ideological battle. How do I know this? Thirty years working in homeless non-profits and several years documenting the streets daily, seeing the reality. They had good intentions in the very beginning. The system, though, has failed the homeless.
I still respectfully reject your claim! Respectfully reject it! Kevin. Hear me out! This is important for my owm theory.To further this! I would even advocate for the advanced study of homelessness by sending you, Kevin to freaking Denmark, Norway 🇳🇴 Finland 🇫🇮!!! To social media documentary homelessness in those countries as a comparison study! A trip to Norway for Portland's homeless documentarist! For better understanding of homeless policies and handling in those countries!!!
My entite grounds, my entire, very new, outlook for understanding and looking at poverty (and homelessness) have changed dramatically! That resourcing is not the entire solution. That it is, in fact, a weakening rule of law - more civil and criminal injustices for the poor - weaker rules of law (Corruption in funds approprations perhaps as you pointed out) that is causing higher amounts of homelessness all together!! Across all boards.
A way out of the equation systematic leveraging point that we, all Americans, need to tend to!
And to prove it! I think we need to collect some world data. I am there for calling for dumbing up the funds somehow to send Kevin to a country with very little homeless, to document the homeless and homeless policies and have him report back!!!
Maybe put together somesort of champaign or go fund me to up the game. Instead of just filming and documenting homelessness in Portland. Portland needs send our homeless documentor expert to one of those countries! Who with me? Just a thought.
I have put ALOT of time into just thinking about poverty. Just into that piece alone. The origins of poverty. Poverty creation compared to wealth creation. Social engineering of oppression. First instances of poverty in Mesopotamia. The age old questions of poverty. Why are some people poorer than others. Even thought on how to use AI to solve poverty to frame it as a solvable problem with many possible solutions. Even attempting to make an app using base44 for poverty in Oregon.
I am deep into understanding poverty.
And the latest layer I have peeled off this metaphorical onion called poverty is injustice. Simple as that. Injustice causes poverty. Injustice causes corruption. Weak rules of law indirectly cause poverty. Not having legal representatives or lawyers for free for the poor in civil litigations causes poverty for those being victimized. Injustices in employment disputes lead to situational poverty. In a very broad framing poverty is driven (created in expansive ways) by injustice primarily.
The broad fix: fair and more legal justice systems. And the more honed in fix. Housing First. Instead of Shelter First.
To back up this claim. One strong reasoning or main reason:
"Countries with strong rule of law and low injustice—like Denmark, Norway, and Finland—maintain exceptionally low homeless populations (often under 20 per 100,000 people) through "Housing First" and robust welfare systems. In contrast, countries with higher injustice and weaker social safety nets, such as the US and UK, experience vastly higher homeless rates (300+ per 100,000)."
So it's a two part fix. Strong rules of law for everyone not just the established or rich. Actual justice for the poor who often cannot afford it. And end up allowing injustice to become their norm. And a Housing First approach instead of a Shelter First approach. I think we do a shelter first approach with some advocacy workers.
I believe in this so much! So much so that I would be willing to put in the time to volunteer or fund raise to send you to Denmark, Norway 🇳🇴 Finland 🇫🇮 on a social media documentary trip to filmed the homelessness in those countries and work with their governments or whatever to better understand how they handle poverty and homelessness in comparison to here!!
I have made my claims known. I rest my case.
I have in no way the level of experience in talking to the homeless than yourself. It's not something I enjoy. Because there is no fix for it cirrently in the US that is longterm. Other than to find places outside of Portland that are less expensive to live. Hotels and motels that rent by the week. To build back up the resources to not be in perpetual poverty. Poverty is also taxed in an abstract way of thinking about it - poor tax. Once you have fallen so far below the federal poverty line the expense of getting back up over that line is double sometimes tripled. Temporary house is twice as expensive as long term housing. Bad credit is twice as expensive to burden than good credit. Etc. However rural Oregon does help with that through places like Capeco. Which will pay for hotels for homeless during the coldest 🥶 times of the year.
I was homeless technically for a few weeks or so once. Crashing at my folks place or on a friend's couch. Or sleeping in my car to get to work. Sometimes you have to do what you have to to survive.
Involuntary civil commitment was basically abolished in the 70s. Coupling it with treatment will be expensive but the cost pales beside the cost of inaction or continuing our failed policies. I guess there must be change and recovery before independent housing. Many if not most of the homeless are a danger to themselves and the public.
Sadly Megan, the rabid politics and resistance of accepting factual data have prevented the few good Democrats from actually helping those in need. A hard look at the inner city black community shows just how much harm the good intentions of those wielding the power have inflicted upon the people they proposed to help 😢
I believe it. Injustice and corruption tends to take over and influence politics. And then politics just go crazy. Im still holding the hard line that poverty is created primarily through a lack of justices for the poor. I hold on that. Because wasn't it Nelson Mandela who also pointed that out. As well as how many other countries have successfully used stronger rules of law and housing first approaches (not shelter first) to greatly reduce homelessness. If you look at hunter Biden's addiction recovery and art theory page he has a post on how the poor cannot fight unfair eviction due to a lack of legal funding to do so. I wouldn't call hunter Biden a saint or even a saint among democrats. However he made a good point about how the civil system is contributing very directly to homelessness through evictions. What if access to legal counsel for the poor was the hardline that everyone held. That landlords couldn't just throw people out for not having money to pay rent. That they had to be more flexible and understanding of specifically what situational poverty is and how it unfold. and how situational poverty creates these homeless sceneros. Charity isnt the most important solution for Homelessness in Portland. Maybe a more just system would prevent more evictions. And inturn help that.
Anyway I'm thinking about and writing about my long term discovery goal. Dark energy. I have ransacked NASA's website for any morsels of information regarding Dark Matter and am tearing into the meat of it. There's Dark Matter in the human body. That's very studiable from Earth. That means!!!! There maybe dark energy in the human body!!! Mindblowingly awesome never territory for discovery.
Beautifully written, Kevin. As always. Thank you for describing what is happening in Portland.
The only point I can add is that what you are asking for costs a lot of money. And the people who currently get the huge sums of money would like to hold onto it for themselves, thank you very much.
They don't wish to actually spend it on helping the addicts.
I am hoping for more conservative governance focusing on short term civil commitment for up to six weeks along with substituted decision consent for those committed to local general hospital psychiatric units. This gives us a mechanism for people who are severely mentally ill and disabled by their illness and poor choices. We badly need to toss out the guilty but mentally ill verdict, empty the long-term hospitals, and instead hold people accountable, no matter their mental state, for violating laws. This gives us a practical way to address community safety, civility and beauty and balance it with the liberty interests of the severely mentally ill and also acts to destigmatize the severely mentally ill by having enforceable expectations of personal and social responsibility. It isn't enough to critique the left which has failed. Real policy and law changes are required to move forward. A good way to start a more conservative movement would be to mandate abstinence in secure facilities for six weeks following near death overdoses requiring naloxone. Who would want their father, mother, or child to overdose and almost die, and yet be left with no significant intervention that allows them the opportunity for mental clarity to make better future decisions.
Why not study that first? What if your idea were horribly ineffective in that people forced to lose tolerance over 6 weeks then go out and use again and die (just like we already know tends to occur)? We already know that cravings decrease way way after tolerance decreases. This creates a high risk mismatch. Incarcerated folks being released (in this window) account for a disproportionate # of opioid deaths.
I suppose there is Turkey, where there are apparently some forced 6-12 month programs for alcohol that can work, but this would be quite expensive in the US.
Regarding the severely mentally ill population that you want to “hold accountable,” I am not sure if you have experience with this population, but most people who are acutely ill have impaired insight (not a great time to teach them a lesson). Okay, let’s say we “fix” this by forcibly institutionalizing them and forcing medications. A) not great evidence for invol hospitalization in helping long term B) now you have often caused distrust and avoidance of all treatment (if I were constantly assessed about needing to be locked up and injected with stuff by a clinician, I would not want to visit them very often) C) they often experience amnesia to their period of illness (hard to learn your lesson when you have little context for the offense… particularly when you are being coerced into all sorts of stuff against your will!) D) if they’re in jail or prison instead, we tried that with the war on drugs and it didn’t do so well.
Really, I don’t see how most of what you’re suggesting is just a more broad war on drugs. Can you name any meaningful differences about your interventions?
You are referring to insight regarding their illness, not insight into whether they are being punished for violating the law. I have also written on long term hospital care which I oppose. Brief, six weeks max, hospital stays, with a substituted judgement consent by the judge(a big argument that psychiatry lost to the legal minds years ago) to get them detoxed, medicated if appropriate, and counseled. For those who are so impaired after six weeks, we can establish a guardianship if necessary, give them an apartment, and hire 24/7 caregivers at a fraction of the cost of state hospital care(over 400,000 dollars per year per patient) Their distrust and avoidance isn’t related to our actions. Personal and social responsibilities are worth insisting upon. This would turn some people around and also give society a procedure to follow to lighten the load on law enforcement which is spending much of its time dealing with them on the street. You can’t make people learn their lesson. But you can set standards for criminality in community that are punishable if violated. It may not work well, but it will work better than newer approaches which are obviously failing here on the West Coast. The severe mentally ill homeless populations are on the rise because of them and failures to get drug availability down. Needle distribution, much like legalizing narcotics, incentivizes drug use.
People without illness insight typically are not in the best place to understand the deterrence/punishment for actions ideas. It is not zero, but if I think the dude on the street I attacked was part of a cabal that is after me... I am going to feel pretty justified about fighting back even in jail. That's not to say I don't believe that people deserve to be let out... it just isn't accomplishing that much to prevent future behavior (recidivism is a huge issue).
I need to reiterate that if you are detoxing people from opioids over six weeks, we have good data that tradition/judgement really ought not ignore that they go out and die more often once released. It is a deadly policy to advocate for. Just because that idea sounds nice does not mean it is helpful. For schizophrenia and bipolar disease, Six weeks generally corresponds to 1 proper med trial. That might have an effect, but forcing all that treatment will certainly have some unintended consequences and harms. Declining to measure or study it and calling it "judgement" makes it difficult to know if it is really better than the extant standard of care. But hey, maybe it could help. The more common problem with severe mental illness in jail and inpatient psych units is that we discharge people to very little. So if there were a home, support staff, and low-barrier treatment, that could help some people for sure. We already have a model like this called ACT, but it can be both under used and under resourced. Your model would probably be quite expensive even if not rising to institutionalization costs, and society has trouble wanting to pay for these things.
The distrust and avoidance is often absolutely related to actions of forced treatment. The rate of substantial PTSD symptoms after even one episode of agitation treatment (forced intramuscular medication, restraints) hovers around 50%. Forced med protocols in psychiatry e require a second opinion for a reason - they have harms.
I certainly agree with your wrap around service approach for the severely mentally ill, to some extent. But we need to recognize this would increase government cost of treating this population. That can be a hard sell. This stuff has also been tried, and we know it doesn't help a meaningful proportion of folks. That is why I advocate for what I spelled out a little more in another post, which is a lot more prevention (which is highly cost effective) and stronger, more competent, more centralized, and available services like FQHCs (but with appropriate staffing and resourcing), housing, social work, efforts to increase social cohesion, and a strong rule of law that isn't just reverting to the tough on crime stuff that did not work.
Your interpretation of needle distribution's effects is inaccurate. Users who access safe use supply sites are 5 times more likely to initiate medication treatment and are 3 times more likely to stop using drugs. Whether it increases their use has been studied with RCTs and consistently shows it does not increase their use.
I have written about the tolerance issue in a previous post and believe it is best managed by continual education directed at those who have been detoxed. I have also written about scientism, the over valuing of science in psychiatry, also applicable to things like economics. I am not against science, just believe in our world it has taken to be fact, rather than what it usually is, tendencies and significances. We just have way too many variables to try to control and studies often need to defer to what I think of as tradition and judgement.
In the context of Portland, Oregon where I live, I can’t believe that the average person, if they had a son, daughter, parent or close friend overdosing on the sidewalk, would think that what we are doing is sufficient for them. Another way of looking at it is that societal rights for safety, civility, and beauty in the public square, can take precedence over individual rights at times. It is foolish to entirely believe that forcibly hospitalizing people is “for their good” and I believe it safer to presume that societal needs are what are being insisted upon in such cases. Anyway, it isn’t a good thing when a teenager walks to school and discovers a dead body on a sidewalk. Or when you see people folded over from fentanyl or shooting up on the sidewalk. Businesses are relocating and commercial property values have plummeted. Imagine living in an apartment across from where needles are distributed. People can’t count on selling their properties in those areas.
The science of needle distribution is weak. Alot of it is based on survey results. Here in Portland, people aren’t required to get a simple blood test to check for Hep C or HIV. And how many of the needles dispensed end up with people who are not in the cohort that picks up needles. Would individual physicians pass out needles to people that are injecting unknown quantities of illicit substances?
The problem is that the consequence of focusing on the public good to lock addicted people up is that they tend to die after you release them. This both adheres to common sense that follows from how these drugs act, and is seen in very clear data. We can say “that’s your choice” and let them die, but I would not want that particular intervention for my friends and family suffering from addiction. For opioid use in particular, I don’t know if I could think of a less safe intervention.
I don’t know what the purpose of the economic/property cost stuff is. I think we are all aware that is wrapped up in the human cost of all this. What I’m saying is heck yeah society matters, but the realistic consequence of your ideas that we know happens (both via common sense and data) is a lot more death and disease as consequence for poor choices, compared to what is available currently.
Deference to tradition and judgement is a lot less objective than a preponderance of RCT data, as is the case for much harm reduction, like contingency management.
But again, your thoughts seem to echo the tough on crime/personal responsibility/societal cost points seen in the war on drugs. Maybe I’m wrong. Can you identify meaningful differences? What is your perception of the war on drugs? Have you seen the data on this or is it generally illegitimate for some reason or other ? If you are concerned about poor science, how do you intend to identify if tradition based measures work or are harmful?
How about just giving them a needle so they can shoot up and die? You have been brainwashed and believe you can predict the future through social experiments like needle distribution which are not science, but a type of social investigation at best. Preponderance of the evidence is a very low standard, and common sense outweighs it when the two conflict.
Of course we are at war with drugs. Heroin, cocaine, fentanyl epidemics have decimated standards of living in many neighborhoods and contributed to many deaths. It has incapacitated many people, damaged their brains in cases irrevocably, and here we are giving them needles. People don't think this makes sense. They are right. Perhaps we might compare it to the Tuskegee studies or to the deliberate inoculation of yellow fever into patients in mental hospital. Those experiments were also conducted by well-meaning people and funded by the government. Needle distribution doesn't pass the "do no harm" standard.
If I had a son, daughter, relative, parent, or friend who had a near death overdose requiring naloxone, I would want someone to take them someplace for 45 days so that they could get realistically mentally competent. And I certainly would not want people giving needles to them. Additionally, their behavior is harming communities who see cities deteriorating affecting them negatively both financially and mentally.
I think that we can both agree that 45 days of abstinence will change a few minds and they will seek a more personally and socially responsible life. Modern psychiatry has lots of tools short of needle distribution that they could choose to partake in such as methadone maintenance or suboxone. And also, communities will have some avenue to deal with individuals who are literally dying across the streets from their houses. We can also both agree it is a fool's errand to predict the future with individual human beings, much less communities of people, who are far from static objects but always changing. Whatever interventions we make, shown to be of limited help today, may be of no help tomorrow.
Human behavior is not always predictable. When you tell people to stop doing something you think is deleterious to their health, what's your success rate on that? Mine is very low. When I force someone to take a long-acting injectable antipsychotic to stabilize them, I tend to see them again in the hospital in the future (despite their short-term, partial convalescence). Many possible explanations here but we definitely need to consider that more effective interventions need to foster internal locus of control. Forcing stuff generally reduces the likelihood that occurs. But yeah, sometimes involuntary treatment is necessary or helpful (I do it all the time). PNW is awfully inadequately resourced in this manner.
Why does giving someone clean needles actually improve their outcomes and they don't die? I don't know. But the data on that in particular is surprisingly robust, even if you don't want it to be. I would not be advocating for this if your assertion were remotely the case (you seem to just have made it up or maybe have heard some stories about this occurring). The 45 days of forced abstinence against someone's will being a harmful endeavor is also demonstrably harmful AND common sense, at least with opioids. Do you understand how tolerance versus cravings work?
I ask about the war with drugs because the collective effort to get tough on crime and heavier criminalization of substance use achieved very little in its goals of decreasing drug availability/pricing, decreasing overdoses/deaths, crime serving as an effective deterrent. It rhymes with what the author is saying in the article we are commenting on, and it is really expensive and is both inhumane and poorly effective.
I also disagree with a lot of what the left has done. Take cannabis, for example. That should definitely not be so widely MEDICALLY legal because it in actuality has 2-3 evidence based uses (yet states have legalized it for >100 indications) and is profoundly harmful. Permissiveness with crime and public disorder has been taken too far too. There is some truth to the homeless industrial complex this guy hates. But the answer is not to go back to war on drugs era strategies. There is a combination of highly effective interventions we have discovered since then, with some medicolegal moves away from the over-reliance on autonomy towards a more societal focus, like you allude to. But this needs to be done really carefully to NOT recreate the war on drugs (because it doesn't work) and you can't just ignore stuff like needle exchanges or other harm reduction policies like MOUD because they work so well (even if it makes you feel uncomfortable and wouldn't want it for your family). I think we also need to actually listen to public health colleagues and get more serious about ACEs, the environments we design, etc. for prevention, as well as anti-poverty efforts for everyone as these generally speak to how this population has proliferated so drastically.
The study relies on survey data from people who have an interest in getting the needles. Surveys generally have about 70 percent reliability, but how do you know? What people report can be vastly different from what they do. This is not proof and the authors don’t claim it is. It is weak evidence and studies like this are driving policy and law. Very unfortunate.
I not telling people to stop doing something. I am for not facilitating what they do. I am opposed to forcing people to take long-acting antipsychotic drugs. It is a bridge too far for me.
My experience is that people often don’t do what you say they should do. And they do it repeatedly. It doesn’t mean, though, that you shouldn’t say it. If you say the same things enough times, eventually some people do change. And of course there are those that will follow advice from the start. It is better to say and act in a way that doesn’t reinforce bad behavior.
I don’t agree that forcing people causes people to be less compliant in most cases. They just don’t comply. It has no effect. And compulsory action occurs in life for all of us. We are compelled to do certain things and do them in part because of the fear of punishment. Forcing people to drive the speed limit works for most of us.
It would be helpful if you know how many needles are being dispensed in Multnomah County by the county and by PPOP. Perhaps you would be interested in limiting needle distribution to only exchange programs rather than PPOP which doesn’t require exchange. I certainly would like to know how many needles we are dispensing in Multnomah County and think it would likely surprise people. When you flood the market with needles you can expect that some of them lead to fatalities. It may be a numbers game, but is this what we have come to?
The public has an interest here in clean, safe, and civil communities. The balance for me lies in getting people off the streets and off drugs for a period. It will be much better for the community to have a functional process to deal with individuals who are personally and often socially unresponsible. If there are significant questions about their judgement after explaining the heightened overdose risk post discharge, then they could be put on methadone or better Suboxone on discharge.
If you were asked to prescribe needles for a patient and they overdosed and died, would that make you partially liable for their death? I think the public health department is on tenuous grounds by passing out needles especially in light of Packham’s article from 2022 showing increased death in counties with needle distribution versus those without. She is an economist out of Vanderbilt. In communicating with her she had difficult following up because of the backlash against her study. She can’t get graduate students to take a look and do future studies. Doleac out of Minnesota also published on naloxone distribution and found increased death associated with it.
I believe the war on drugs is worth fighting in much the same way that we fight to help people that are often resistant and difficult. They are also our difficult patients but what else are you going to do? If you ignore or avoid severely mentally ill people, they will tear themselves apart and much of the community as well. I know someone who was a narcotic addict and ended up in prison. He quit after that and became a contributing member of society. I do believe that we fail when we think that people that are addicted like many of the streets, shooting up fentanyl 10 times per day, that they can stop that habit without a significant period of abstinence.
The history of needle distribution has a lot to do with the AIDS epidemic but now, we have treatments for HIV. The public health failure to allow drug addicted people to donate blood with non A non B hepatitis(undiagnosable at that time by blood test) led to 300,000 people getting transfusions to get Hep C. Interestingly, the health department continues to allow people with intravenous addiction histories to donate blood. I witnessed and knew people who live close to where PPOP used to distribute needles and they were not fans. Would you want to live across the street from where the needles were distributed? How would you sell your house if you wanted to move?
This is the best commentary I've seen on the homeless. First, we need to get all of them off the street. Into treatment centers, hospitals, or jail. That's for them, but moreover for the rest of us. We need to give them the treatment they need. Then a good haircut, clothing, and send them out to get a job. Sober houses come in there somewhere. This will cost bucks, but we don't need addicts on the streets anymore. Last night at 5:00 I saw four guys smoking off of tin foil on SW Jefferson.
I think that Vegas Pederson particularly (the sooner she's gone the better) and the Multnomah County Councilors as a whole have done a terrible injustice to the city, the middle American tax payers and citizens, and the needy (homeless, drug addicts, mentally ill).
I have hope that Sharon Meieran can get elected to county chair, inject a strong dose of common sense, and financial accountability, into the government, and help turn things around politically, socially and economically.
I have to believe you’re responding to a real phenomenon precipitated by some unholy alliance of politicians, non profit leaders, and very liberal clinicians, but both that group and your own (probably more conservative) assertions swing from one extreme to another. There’s a wide open space in the middle. You know, where the evidence is at.
Should we ignore the multiple RCTs showing housing first + ACT or additional services reduce homelessness, ED visits, and are cost effective? Totally agree with your more comprehensive, person centered list of measures that could help, too.
Harm reduction, as you rightfully identify, is generally a “risk-risk” endeavor. Might some people internalize that the aid work giving them safe use supplies is normalizing their substance use? I guess. But there is also the fact that people visiting safe use sites are in the range of 50% as likely to contract HIV or hepatitis (expensive and deadly conditions), live longer, and are in fact several times more likely to enter into substance use treatment than those not visiting such a service. I get the temptation of wanting to add strings to obtaining safe use supplies… but instead of getting the “right message” from aid workers, I’d guess users would just go back to sharing (and dying) when they hit their limit.
Also your assertion seems to generally be that there needs to be more accountability and/or deterrence and/or punishment in the mix. I agree that this could be helpful to some extent. The European poster advocating for better rule of law for all seems to have a good approach… but how do you propose we avoid the mass incarceration and cycle of poverty such a change produces on its own (see: war on drugs)? You rightly identify many of the proximal causes of this type of visible despair and disorder but focus on a way downstream (and demonstrably less effective) “solution:” accountability (read: punishment).
As above, I agree there should be some better enforcement of laws, but orienting focus on punishment doesn’t change behavior particularly well in this realm. The kernel of truth in your assertion is that people have to internalize their locus of control to see durable improvement, and if they decline to do that, society eventually needs to step in more than it does currently, particularly for the illegal stuff. But evidence for forced treatments you advocate for (as a result of making enough bad choices) is really thin and very expensive. Some AOT is helpful for a minority of this vast group (maybe we can find better models!), maybe some degree of institutionalization for another, (re: substance use - good luck achieving anything meaningful or cost effective with forced rehab), but that’s never going to move the needle and is profoundly expensive (see “asylums”).
Where does this leave us? Probably in the realm of something you suggest: heavily personalized treatment recommendations (like what it seems your work entails!) with a more effective incentive structure; stronger institutions involving comprehensive and accessible services that may be accessed by all to both prevent poverty (way way more helpful and cost effective than coercion) and to treat people who are currently homeless and ill. As a leading schizophrenia researcher responded after a talk I attended about the biological underpinnings of schizophrenia, when asked how do we prevent it? “Reduce childhood poverty.”
Lastly, it sounds like your experiences align with mine in that implementation of many attempted interventions often lacks fidelity to whatever is actually being attempted. That’s a real problem and I imagine progress in implementation of interventions could be very meaningful.
Ok im done posting in complete and utter astonishment at this incredibly incorrect/offbased conclusion about people and homelessness that has an overly partisan outlook. For what should really be a bipartisan issue. Or the coming together together politics aside improve justice outcomes in civil justice and criminal justice for the poor. The one of two real cruxes of poverty. Injustice and corruption.
Megan-reread Kevin’s article. It’s a clear and compassionate view of the current state of the homeless problem. You are spinning yourself out of earths orbit.
I work in homeless services and see the failures of our costly programs every day. Some participants are blessed with rental assistance (up to 110% FMR I might add), with the hope that they will progressively take over responsibility of their rent, and work with a case manager to overcome whatever the root of their housing crisis was. But this program has nearly a 0% success rate if the metric of success is the participant taking responsibility of their rental payments. It is a only providing a 2-year bandaid solution, and no one is talking about it. The metrics that are publicized only address “participants served”.
I agree that is a BS metric.
Have you thought of running for a city or county position of responsibility to help turn things around?
Thank you so much for sharing your actual experience. It is people like yourself and Kevin that are our only hope for educating the voters in a way that will hopefully lead them to vote for responsibility at every level of Government and in every NGO that we are funding.
NGOs (at all levels of government: local, county, state, federal) should be reigned in. They have taken over legislative, executive, and judicial functions within their own sphere of technical "expertise" from the government. They continue to exist regardless of who is voted into power. It is an erosion of democracy (representative or not).
At the county (or city) level, trying to figure out where the power lies and where the money goes with all the overlapping and sometimes invisible NGOs is an impossible job. Sharon Meieran spent a good part of her 8 years as a Multno County Councilor trying to understand it. With any luck, she'll be voted County Chair in November and can help disentangle the mess and help make our local and county governments leaner, more cost effective, more effective overall, and more answerable to those whom the people vote into power.
Even if she makes minimal progress, she will at least set us on the right track.
Thank you for pointing out all the good work Sharon Meieran tried to do on the County Board. The mystery that you have brought up is clearly at play with the last two County Chairpersons, who refused every request to even discuss Sharon’s information and potential solutions 😡. Why? Who received the nearly 2 billion dollars that has already been spent? Why did the 2 girls who were County Chair’s refuse to allow the data and facts she presented? Jealousy, inferiority complexes, or the outright greed in giving the public dollars to their families and friends without explanation?
Ironically, the leading cause of poverty and eventual homelessness or other addictions start with the Oregon Lottery. It is Ironic because the falsified revenue allowed the State to borrow $7.1+ Billion in Lottery Revenue Bonds where much of it went toward Homelessness.
Kevin - I know you are controversial, but you speak the truth. "At some point, we have to stop judging these policies by their intentions and start judging them by their results."
Always appreciate you!
There are many questions that dare not be asked--but the profit motive is at the top 'o' the list. Housing First is a scam that spends $-millions on developers (here's lookin' at ya, Related Companies), union jobs (mandated by Oregon law), crap architecture, and the bureaucracies that funnel the dough to clients of the political machine.
It used to be that typical American machines (Chicago, NYC, Philly, etc) were conduits for insurance, public works, road-pavers...but now Homelessness Inc. has scooped all of this up into one easily-managed package.
The dispensers and receivers of this pork will fight like cornered rats to give up the dough (to mix metaphors). Nothing will change until the political matrix changes. A machine that controls the voting mode, that runs extortionate tax policies, that drives out any potential serious opponents to lower-tax states, that controls education/indoctrination, that runs super-majorities, that makes racial-payoffs, that engineers end-runs around elections with the resign-appoint gambit...well, think any of these institutions will disappear?
The homeless will be ever with us. Pay up and shut up.
Well said brother
NGO's and non-profits are the graft of the left.
James Burnham discusses how things used to work in his book "Suicide of the West: An Essay on the Meaning and Destiny of Liberalism" from 1964.
He says that every city has its skid row. That we will never completely rid society of the homeless or "bums" or alcoholics, etc. And that rather than have them spread out all over town in the "nice area" we should allow them to remain in a certain area of town (on the edge of town, or edge of downtown) where they are tolerated. I've recently noticed that Vancouver B.C. does this (Portland used to) and it seems to work quite well.
“Some years ago liberals concerned w/ social reform & urban renewal, as it has come to be called, turned their attention to Skid Row. In accord w/ the canons of ideological thinking, Skid Row was understood as a ʻproblemʼ; & [consequently]... liberals had a duty to ʻsolveʼ it.
"But what exactly is Skid Row? In reality it is not, other than incidentally, a spatial concept at all -- but a functional concept; and not so much a special ʻproblemʼ as merely a natural, indeed inevitable, condition of every articulated community of any size.
"Skid Row is the end of the line; there must be an end of the line somewhere. It is the state of those individuals who by destiny or choice drop out of normal society... Most of these individuals are alcoholics and some are drug addicts.”
“Where they are is Skid Row; and Skid Row exists in every city, and always has.” –
Suicide of the West, James Burnham
You are expectingto find the results looking at the homeless. The true results are in the hands of the bureaucrats and nonprofits, and that is money and power for them. If the homeless disappeared tomorrow, their jobs would end.
Exactly!
Great insight Kevin! How frustrating it all must be for you to witness and experience. I don't even live in your country but cannot believe what's going on😞
Keep speaking your truth and take care of yourself.
One day eyes and ears will be open.
Loved your last paragraph/conclusion.
May I describe a cycle you referenced (you identified several cycles, most of which are downward spiraling descents) by using a very real cycle that a next door neighbor described to me 50 years ago.
Austin was raised in Luray, Virginia and he was around 40 when I was 17. We lived in Falls Church, Va and he was a top mechanic for the bus company; Metro Transit. Austin would help me fix my car and he would tell me boyhood stories. One evening in 1966, he told me his story of a bountiful cherry tree and the consumption pattern he developed. He would climb onto a limb that gave him an “umbrella” of large, hanging, cherries and he gorged himself until he could not eat anymore. But he wanted to continue eating those large, delicious, cherries. So he inserted his index finger down his throat and triggered the vomit reflex, projecting much of what he’d eaten to the ground, and he would “start over.” Perhaps the only risk his body experienced was the convulsion he produced in his throat/esophagus as he emptied his stomach. I cannot recall how Austin described his boyhood Cherry-gorging activity, but I have come to refer to it as “re-loading”.
When I started blogging on Substance Abuse in April, 2016, a few weeks after Prince OD’d on Fentanyl, I quickly caught-up on my knowledge of the synthetic opioids/Central Nervous System (CNS) depressants which slow respiration and heartrate, in some cases, all-the-way to flat-line…death.
Over the remainder of 2016 and throughout 2017, I posted miracle stories of revival of near-death Fentanyl users through the administration of Narcan, which sometimes required two or three nasal spraying. In some of the articles, the revived user would display anger at the EMT - sometimes assaulting them - and the reports described how the revived person ran-off to purchase some more Fentanyl so he/she could resume getting “low.” CNS Depressants do not make people “high,” Fentayl can bring one to Death’s gate quickly.
As I would read these near-death-Narcan-revival stories, I recalled Austin’s harmless reloading of cherry-gorging by forced vomiting and I have come to see Narcan as a two-edged sword. It revives near-death Fentanyl users. Narcan also lets Fentanyl users tempt death…and then start over again…reload.
Thank you for this post. I'm a resident of Austin, TX. Need I say more?
Thank you for speaking truth to power.
Not to be critical, but how is this speaking "truth to power"? Wouldn't speaking truth to power be Kevin speaking before the Multno County Board of Councilors, or the Portland City Councilors, or whoever the new Homelessness Czar is, etc.?
I have testified at all those boards. They never listen. Also, I highly doubt this new Czar will ever let me talk to him.
I was mostly commenting on the phrase "truth to power" after having recently read George Orwell's "Politics and the English Language" essay.
https://www.orwellfoundation.com/the-orwell-foundation/orwell/essays-and-other-works/politics-and-the-english-language/
If I understand the phrase correctly, I believe posting on Substack (however important) is not, technically speaking, speaking "truth to power," but rather speaking the truth (powerfully).
Let's hope Sharon Meieran gets elected to the County Chair. Have you spoken to her at all?
So well reasoned and insightful. I pray they'll finally start to listen to people like you.
Is this some sort of tactic? Or intentional. You are joking right? The democratic party starting 1930 has been the most focused on helping low income individuals and families ever. From Roosevelt to Obama. The amount of poverty fighting initiatives have accomplished so much more than any other party. If you truly believe that than you do not understand politics at all.
What once was a cause had become a multi-billion-dollar industry. Sadly, Democrats turned homelessness into an ideological battle. How do I know this? Thirty years working in homeless non-profits and several years documenting the streets daily, seeing the reality. They had good intentions in the very beginning. The system, though, has failed the homeless.
I still respectfully reject your claim! Respectfully reject it! Kevin. Hear me out! This is important for my owm theory.To further this! I would even advocate for the advanced study of homelessness by sending you, Kevin to freaking Denmark, Norway 🇳🇴 Finland 🇫🇮!!! To social media documentary homelessness in those countries as a comparison study! A trip to Norway for Portland's homeless documentarist! For better understanding of homeless policies and handling in those countries!!!
My entite grounds, my entire, very new, outlook for understanding and looking at poverty (and homelessness) have changed dramatically! That resourcing is not the entire solution. That it is, in fact, a weakening rule of law - more civil and criminal injustices for the poor - weaker rules of law (Corruption in funds approprations perhaps as you pointed out) that is causing higher amounts of homelessness all together!! Across all boards.
A way out of the equation systematic leveraging point that we, all Americans, need to tend to!
And to prove it! I think we need to collect some world data. I am there for calling for dumbing up the funds somehow to send Kevin to a country with very little homeless, to document the homeless and homeless policies and have him report back!!!
Maybe put together somesort of champaign or go fund me to up the game. Instead of just filming and documenting homelessness in Portland. Portland needs send our homeless documentor expert to one of those countries! Who with me? Just a thought.
I have put ALOT of time into just thinking about poverty. Just into that piece alone. The origins of poverty. Poverty creation compared to wealth creation. Social engineering of oppression. First instances of poverty in Mesopotamia. The age old questions of poverty. Why are some people poorer than others. Even thought on how to use AI to solve poverty to frame it as a solvable problem with many possible solutions. Even attempting to make an app using base44 for poverty in Oregon.
I am deep into understanding poverty.
And the latest layer I have peeled off this metaphorical onion called poverty is injustice. Simple as that. Injustice causes poverty. Injustice causes corruption. Weak rules of law indirectly cause poverty. Not having legal representatives or lawyers for free for the poor in civil litigations causes poverty for those being victimized. Injustices in employment disputes lead to situational poverty. In a very broad framing poverty is driven (created in expansive ways) by injustice primarily.
The broad fix: fair and more legal justice systems. And the more honed in fix. Housing First. Instead of Shelter First.
To back up this claim. One strong reasoning or main reason:
"Countries with strong rule of law and low injustice—like Denmark, Norway, and Finland—maintain exceptionally low homeless populations (often under 20 per 100,000 people) through "Housing First" and robust welfare systems. In contrast, countries with higher injustice and weaker social safety nets, such as the US and UK, experience vastly higher homeless rates (300+ per 100,000)."
So it's a two part fix. Strong rules of law for everyone not just the established or rich. Actual justice for the poor who often cannot afford it. And end up allowing injustice to become their norm. And a Housing First approach instead of a Shelter First approach. I think we do a shelter first approach with some advocacy workers.
I believe in this so much! So much so that I would be willing to put in the time to volunteer or fund raise to send you to Denmark, Norway 🇳🇴 Finland 🇫🇮 on a social media documentary trip to filmed the homelessness in those countries and work with their governments or whatever to better understand how they handle poverty and homelessness in comparison to here!!
I have made my claims known. I rest my case.
I have in no way the level of experience in talking to the homeless than yourself. It's not something I enjoy. Because there is no fix for it cirrently in the US that is longterm. Other than to find places outside of Portland that are less expensive to live. Hotels and motels that rent by the week. To build back up the resources to not be in perpetual poverty. Poverty is also taxed in an abstract way of thinking about it - poor tax. Once you have fallen so far below the federal poverty line the expense of getting back up over that line is double sometimes tripled. Temporary house is twice as expensive as long term housing. Bad credit is twice as expensive to burden than good credit. Etc. However rural Oregon does help with that through places like Capeco. Which will pay for hotels for homeless during the coldest 🥶 times of the year.
I was homeless technically for a few weeks or so once. Crashing at my folks place or on a friend's couch. Or sleeping in my car to get to work. Sometimes you have to do what you have to to survive.
Involuntary civil commitment was basically abolished in the 70s. Coupling it with treatment will be expensive but the cost pales beside the cost of inaction or continuing our failed policies. I guess there must be change and recovery before independent housing. Many if not most of the homeless are a danger to themselves and the public.
Sadly Megan, the rabid politics and resistance of accepting factual data have prevented the few good Democrats from actually helping those in need. A hard look at the inner city black community shows just how much harm the good intentions of those wielding the power have inflicted upon the people they proposed to help 😢
I believe it. Injustice and corruption tends to take over and influence politics. And then politics just go crazy. Im still holding the hard line that poverty is created primarily through a lack of justices for the poor. I hold on that. Because wasn't it Nelson Mandela who also pointed that out. As well as how many other countries have successfully used stronger rules of law and housing first approaches (not shelter first) to greatly reduce homelessness. If you look at hunter Biden's addiction recovery and art theory page he has a post on how the poor cannot fight unfair eviction due to a lack of legal funding to do so. I wouldn't call hunter Biden a saint or even a saint among democrats. However he made a good point about how the civil system is contributing very directly to homelessness through evictions. What if access to legal counsel for the poor was the hardline that everyone held. That landlords couldn't just throw people out for not having money to pay rent. That they had to be more flexible and understanding of specifically what situational poverty is and how it unfold. and how situational poverty creates these homeless sceneros. Charity isnt the most important solution for Homelessness in Portland. Maybe a more just system would prevent more evictions. And inturn help that.
Anyway I'm thinking about and writing about my long term discovery goal. Dark energy. I have ransacked NASA's website for any morsels of information regarding Dark Matter and am tearing into the meat of it. There's Dark Matter in the human body. That's very studiable from Earth. That means!!!! There maybe dark energy in the human body!!! Mindblowingly awesome never territory for discovery.
To paraphrase the old radio show The SHADOW, “There’s dark matter in the hearts of men “
Beautifully written, Kevin. As always. Thank you for describing what is happening in Portland.
The only point I can add is that what you are asking for costs a lot of money. And the people who currently get the huge sums of money would like to hold onto it for themselves, thank you very much.
They don't wish to actually spend it on helping the addicts.
I am hoping for more conservative governance focusing on short term civil commitment for up to six weeks along with substituted decision consent for those committed to local general hospital psychiatric units. This gives us a mechanism for people who are severely mentally ill and disabled by their illness and poor choices. We badly need to toss out the guilty but mentally ill verdict, empty the long-term hospitals, and instead hold people accountable, no matter their mental state, for violating laws. This gives us a practical way to address community safety, civility and beauty and balance it with the liberty interests of the severely mentally ill and also acts to destigmatize the severely mentally ill by having enforceable expectations of personal and social responsibility. It isn't enough to critique the left which has failed. Real policy and law changes are required to move forward. A good way to start a more conservative movement would be to mandate abstinence in secure facilities for six weeks following near death overdoses requiring naloxone. Who would want their father, mother, or child to overdose and almost die, and yet be left with no significant intervention that allows them the opportunity for mental clarity to make better future decisions.
Why not study that first? What if your idea were horribly ineffective in that people forced to lose tolerance over 6 weeks then go out and use again and die (just like we already know tends to occur)? We already know that cravings decrease way way after tolerance decreases. This creates a high risk mismatch. Incarcerated folks being released (in this window) account for a disproportionate # of opioid deaths.
I suppose there is Turkey, where there are apparently some forced 6-12 month programs for alcohol that can work, but this would be quite expensive in the US.
Regarding the severely mentally ill population that you want to “hold accountable,” I am not sure if you have experience with this population, but most people who are acutely ill have impaired insight (not a great time to teach them a lesson). Okay, let’s say we “fix” this by forcibly institutionalizing them and forcing medications. A) not great evidence for invol hospitalization in helping long term B) now you have often caused distrust and avoidance of all treatment (if I were constantly assessed about needing to be locked up and injected with stuff by a clinician, I would not want to visit them very often) C) they often experience amnesia to their period of illness (hard to learn your lesson when you have little context for the offense… particularly when you are being coerced into all sorts of stuff against your will!) D) if they’re in jail or prison instead, we tried that with the war on drugs and it didn’t do so well.
Really, I don’t see how most of what you’re suggesting is just a more broad war on drugs. Can you name any meaningful differences about your interventions?
You are referring to insight regarding their illness, not insight into whether they are being punished for violating the law. I have also written on long term hospital care which I oppose. Brief, six weeks max, hospital stays, with a substituted judgement consent by the judge(a big argument that psychiatry lost to the legal minds years ago) to get them detoxed, medicated if appropriate, and counseled. For those who are so impaired after six weeks, we can establish a guardianship if necessary, give them an apartment, and hire 24/7 caregivers at a fraction of the cost of state hospital care(over 400,000 dollars per year per patient) Their distrust and avoidance isn’t related to our actions. Personal and social responsibilities are worth insisting upon. This would turn some people around and also give society a procedure to follow to lighten the load on law enforcement which is spending much of its time dealing with them on the street. You can’t make people learn their lesson. But you can set standards for criminality in community that are punishable if violated. It may not work well, but it will work better than newer approaches which are obviously failing here on the West Coast. The severe mentally ill homeless populations are on the rise because of them and failures to get drug availability down. Needle distribution, much like legalizing narcotics, incentivizes drug use.
People without illness insight typically are not in the best place to understand the deterrence/punishment for actions ideas. It is not zero, but if I think the dude on the street I attacked was part of a cabal that is after me... I am going to feel pretty justified about fighting back even in jail. That's not to say I don't believe that people deserve to be let out... it just isn't accomplishing that much to prevent future behavior (recidivism is a huge issue).
I need to reiterate that if you are detoxing people from opioids over six weeks, we have good data that tradition/judgement really ought not ignore that they go out and die more often once released. It is a deadly policy to advocate for. Just because that idea sounds nice does not mean it is helpful. For schizophrenia and bipolar disease, Six weeks generally corresponds to 1 proper med trial. That might have an effect, but forcing all that treatment will certainly have some unintended consequences and harms. Declining to measure or study it and calling it "judgement" makes it difficult to know if it is really better than the extant standard of care. But hey, maybe it could help. The more common problem with severe mental illness in jail and inpatient psych units is that we discharge people to very little. So if there were a home, support staff, and low-barrier treatment, that could help some people for sure. We already have a model like this called ACT, but it can be both under used and under resourced. Your model would probably be quite expensive even if not rising to institutionalization costs, and society has trouble wanting to pay for these things.
The distrust and avoidance is often absolutely related to actions of forced treatment. The rate of substantial PTSD symptoms after even one episode of agitation treatment (forced intramuscular medication, restraints) hovers around 50%. Forced med protocols in psychiatry e require a second opinion for a reason - they have harms.
I certainly agree with your wrap around service approach for the severely mentally ill, to some extent. But we need to recognize this would increase government cost of treating this population. That can be a hard sell. This stuff has also been tried, and we know it doesn't help a meaningful proportion of folks. That is why I advocate for what I spelled out a little more in another post, which is a lot more prevention (which is highly cost effective) and stronger, more competent, more centralized, and available services like FQHCs (but with appropriate staffing and resourcing), housing, social work, efforts to increase social cohesion, and a strong rule of law that isn't just reverting to the tough on crime stuff that did not work.
Your interpretation of needle distribution's effects is inaccurate. Users who access safe use supply sites are 5 times more likely to initiate medication treatment and are 3 times more likely to stop using drugs. Whether it increases their use has been studied with RCTs and consistently shows it does not increase their use.
I have written about the tolerance issue in a previous post and believe it is best managed by continual education directed at those who have been detoxed. I have also written about scientism, the over valuing of science in psychiatry, also applicable to things like economics. I am not against science, just believe in our world it has taken to be fact, rather than what it usually is, tendencies and significances. We just have way too many variables to try to control and studies often need to defer to what I think of as tradition and judgement.
In the context of Portland, Oregon where I live, I can’t believe that the average person, if they had a son, daughter, parent or close friend overdosing on the sidewalk, would think that what we are doing is sufficient for them. Another way of looking at it is that societal rights for safety, civility, and beauty in the public square, can take precedence over individual rights at times. It is foolish to entirely believe that forcibly hospitalizing people is “for their good” and I believe it safer to presume that societal needs are what are being insisted upon in such cases. Anyway, it isn’t a good thing when a teenager walks to school and discovers a dead body on a sidewalk. Or when you see people folded over from fentanyl or shooting up on the sidewalk. Businesses are relocating and commercial property values have plummeted. Imagine living in an apartment across from where needles are distributed. People can’t count on selling their properties in those areas.
The science of needle distribution is weak. Alot of it is based on survey results. Here in Portland, people aren’t required to get a simple blood test to check for Hep C or HIV. And how many of the needles dispensed end up with people who are not in the cohort that picks up needles. Would individual physicians pass out needles to people that are injecting unknown quantities of illicit substances?
The problem is that the consequence of focusing on the public good to lock addicted people up is that they tend to die after you release them. This both adheres to common sense that follows from how these drugs act, and is seen in very clear data. We can say “that’s your choice” and let them die, but I would not want that particular intervention for my friends and family suffering from addiction. For opioid use in particular, I don’t know if I could think of a less safe intervention.
I don’t know what the purpose of the economic/property cost stuff is. I think we are all aware that is wrapped up in the human cost of all this. What I’m saying is heck yeah society matters, but the realistic consequence of your ideas that we know happens (both via common sense and data) is a lot more death and disease as consequence for poor choices, compared to what is available currently.
Deference to tradition and judgement is a lot less objective than a preponderance of RCT data, as is the case for much harm reduction, like contingency management.
But again, your thoughts seem to echo the tough on crime/personal responsibility/societal cost points seen in the war on drugs. Maybe I’m wrong. Can you identify meaningful differences? What is your perception of the war on drugs? Have you seen the data on this or is it generally illegitimate for some reason or other ? If you are concerned about poor science, how do you intend to identify if tradition based measures work or are harmful?
How about just giving them a needle so they can shoot up and die? You have been brainwashed and believe you can predict the future through social experiments like needle distribution which are not science, but a type of social investigation at best. Preponderance of the evidence is a very low standard, and common sense outweighs it when the two conflict.
Of course we are at war with drugs. Heroin, cocaine, fentanyl epidemics have decimated standards of living in many neighborhoods and contributed to many deaths. It has incapacitated many people, damaged their brains in cases irrevocably, and here we are giving them needles. People don't think this makes sense. They are right. Perhaps we might compare it to the Tuskegee studies or to the deliberate inoculation of yellow fever into patients in mental hospital. Those experiments were also conducted by well-meaning people and funded by the government. Needle distribution doesn't pass the "do no harm" standard.
If I had a son, daughter, relative, parent, or friend who had a near death overdose requiring naloxone, I would want someone to take them someplace for 45 days so that they could get realistically mentally competent. And I certainly would not want people giving needles to them. Additionally, their behavior is harming communities who see cities deteriorating affecting them negatively both financially and mentally.
I think that we can both agree that 45 days of abstinence will change a few minds and they will seek a more personally and socially responsible life. Modern psychiatry has lots of tools short of needle distribution that they could choose to partake in such as methadone maintenance or suboxone. And also, communities will have some avenue to deal with individuals who are literally dying across the streets from their houses. We can also both agree it is a fool's errand to predict the future with individual human beings, much less communities of people, who are far from static objects but always changing. Whatever interventions we make, shown to be of limited help today, may be of no help tomorrow.
So you just get to decide when your understanding of common sense outweighs randomized control trial data?
Here's an RCT that disagrees with your opinion:https://pubmed.ncbi.nlm.nih.gov/12794555/
Human behavior is not always predictable. When you tell people to stop doing something you think is deleterious to their health, what's your success rate on that? Mine is very low. When I force someone to take a long-acting injectable antipsychotic to stabilize them, I tend to see them again in the hospital in the future (despite their short-term, partial convalescence). Many possible explanations here but we definitely need to consider that more effective interventions need to foster internal locus of control. Forcing stuff generally reduces the likelihood that occurs. But yeah, sometimes involuntary treatment is necessary or helpful (I do it all the time). PNW is awfully inadequately resourced in this manner.
Why does giving someone clean needles actually improve their outcomes and they don't die? I don't know. But the data on that in particular is surprisingly robust, even if you don't want it to be. I would not be advocating for this if your assertion were remotely the case (you seem to just have made it up or maybe have heard some stories about this occurring). The 45 days of forced abstinence against someone's will being a harmful endeavor is also demonstrably harmful AND common sense, at least with opioids. Do you understand how tolerance versus cravings work?
I ask about the war with drugs because the collective effort to get tough on crime and heavier criminalization of substance use achieved very little in its goals of decreasing drug availability/pricing, decreasing overdoses/deaths, crime serving as an effective deterrent. It rhymes with what the author is saying in the article we are commenting on, and it is really expensive and is both inhumane and poorly effective.
I also disagree with a lot of what the left has done. Take cannabis, for example. That should definitely not be so widely MEDICALLY legal because it in actuality has 2-3 evidence based uses (yet states have legalized it for >100 indications) and is profoundly harmful. Permissiveness with crime and public disorder has been taken too far too. There is some truth to the homeless industrial complex this guy hates. But the answer is not to go back to war on drugs era strategies. There is a combination of highly effective interventions we have discovered since then, with some medicolegal moves away from the over-reliance on autonomy towards a more societal focus, like you allude to. But this needs to be done really carefully to NOT recreate the war on drugs (because it doesn't work) and you can't just ignore stuff like needle exchanges or other harm reduction policies like MOUD because they work so well (even if it makes you feel uncomfortable and wouldn't want it for your family). I think we also need to actually listen to public health colleagues and get more serious about ACEs, the environments we design, etc. for prevention, as well as anti-poverty efforts for everyone as these generally speak to how this population has proliferated so drastically.
The study relies on survey data from people who have an interest in getting the needles. Surveys generally have about 70 percent reliability, but how do you know? What people report can be vastly different from what they do. This is not proof and the authors don’t claim it is. It is weak evidence and studies like this are driving policy and law. Very unfortunate.
I not telling people to stop doing something. I am for not facilitating what they do. I am opposed to forcing people to take long-acting antipsychotic drugs. It is a bridge too far for me.
My experience is that people often don’t do what you say they should do. And they do it repeatedly. It doesn’t mean, though, that you shouldn’t say it. If you say the same things enough times, eventually some people do change. And of course there are those that will follow advice from the start. It is better to say and act in a way that doesn’t reinforce bad behavior.
I don’t agree that forcing people causes people to be less compliant in most cases. They just don’t comply. It has no effect. And compulsory action occurs in life for all of us. We are compelled to do certain things and do them in part because of the fear of punishment. Forcing people to drive the speed limit works for most of us.
It would be helpful if you know how many needles are being dispensed in Multnomah County by the county and by PPOP. Perhaps you would be interested in limiting needle distribution to only exchange programs rather than PPOP which doesn’t require exchange. I certainly would like to know how many needles we are dispensing in Multnomah County and think it would likely surprise people. When you flood the market with needles you can expect that some of them lead to fatalities. It may be a numbers game, but is this what we have come to?
The public has an interest here in clean, safe, and civil communities. The balance for me lies in getting people off the streets and off drugs for a period. It will be much better for the community to have a functional process to deal with individuals who are personally and often socially unresponsible. If there are significant questions about their judgement after explaining the heightened overdose risk post discharge, then they could be put on methadone or better Suboxone on discharge.
If you were asked to prescribe needles for a patient and they overdosed and died, would that make you partially liable for their death? I think the public health department is on tenuous grounds by passing out needles especially in light of Packham’s article from 2022 showing increased death in counties with needle distribution versus those without. She is an economist out of Vanderbilt. In communicating with her she had difficult following up because of the backlash against her study. She can’t get graduate students to take a look and do future studies. Doleac out of Minnesota also published on naloxone distribution and found increased death associated with it.
I believe the war on drugs is worth fighting in much the same way that we fight to help people that are often resistant and difficult. They are also our difficult patients but what else are you going to do? If you ignore or avoid severely mentally ill people, they will tear themselves apart and much of the community as well. I know someone who was a narcotic addict and ended up in prison. He quit after that and became a contributing member of society. I do believe that we fail when we think that people that are addicted like many of the streets, shooting up fentanyl 10 times per day, that they can stop that habit without a significant period of abstinence.
The history of needle distribution has a lot to do with the AIDS epidemic but now, we have treatments for HIV. The public health failure to allow drug addicted people to donate blood with non A non B hepatitis(undiagnosable at that time by blood test) led to 300,000 people getting transfusions to get Hep C. Interestingly, the health department continues to allow people with intravenous addiction histories to donate blood. I witnessed and knew people who live close to where PPOP used to distribute needles and they were not fans. Would you want to live across the street from where the needles were distributed? How would you sell your house if you wanted to move?
This is the best commentary I've seen on the homeless. First, we need to get all of them off the street. Into treatment centers, hospitals, or jail. That's for them, but moreover for the rest of us. We need to give them the treatment they need. Then a good haircut, clothing, and send them out to get a job. Sober houses come in there somewhere. This will cost bucks, but we don't need addicts on the streets anymore. Last night at 5:00 I saw four guys smoking off of tin foil on SW Jefferson.
I think that Vegas Pederson particularly (the sooner she's gone the better) and the Multnomah County Councilors as a whole have done a terrible injustice to the city, the middle American tax payers and citizens, and the needy (homeless, drug addicts, mentally ill).
I have hope that Sharon Meieran can get elected to county chair, inject a strong dose of common sense, and financial accountability, into the government, and help turn things around politically, socially and economically.
This is devastatingly spot on. Thank you for your great advocacy Kevin. This essay should be required reading for citizenship.
I have to believe you’re responding to a real phenomenon precipitated by some unholy alliance of politicians, non profit leaders, and very liberal clinicians, but both that group and your own (probably more conservative) assertions swing from one extreme to another. There’s a wide open space in the middle. You know, where the evidence is at.
Should we ignore the multiple RCTs showing housing first + ACT or additional services reduce homelessness, ED visits, and are cost effective? Totally agree with your more comprehensive, person centered list of measures that could help, too.
Harm reduction, as you rightfully identify, is generally a “risk-risk” endeavor. Might some people internalize that the aid work giving them safe use supplies is normalizing their substance use? I guess. But there is also the fact that people visiting safe use sites are in the range of 50% as likely to contract HIV or hepatitis (expensive and deadly conditions), live longer, and are in fact several times more likely to enter into substance use treatment than those not visiting such a service. I get the temptation of wanting to add strings to obtaining safe use supplies… but instead of getting the “right message” from aid workers, I’d guess users would just go back to sharing (and dying) when they hit their limit.
Also your assertion seems to generally be that there needs to be more accountability and/or deterrence and/or punishment in the mix. I agree that this could be helpful to some extent. The European poster advocating for better rule of law for all seems to have a good approach… but how do you propose we avoid the mass incarceration and cycle of poverty such a change produces on its own (see: war on drugs)? You rightly identify many of the proximal causes of this type of visible despair and disorder but focus on a way downstream (and demonstrably less effective) “solution:” accountability (read: punishment).
As above, I agree there should be some better enforcement of laws, but orienting focus on punishment doesn’t change behavior particularly well in this realm. The kernel of truth in your assertion is that people have to internalize their locus of control to see durable improvement, and if they decline to do that, society eventually needs to step in more than it does currently, particularly for the illegal stuff. But evidence for forced treatments you advocate for (as a result of making enough bad choices) is really thin and very expensive. Some AOT is helpful for a minority of this vast group (maybe we can find better models!), maybe some degree of institutionalization for another, (re: substance use - good luck achieving anything meaningful or cost effective with forced rehab), but that’s never going to move the needle and is profoundly expensive (see “asylums”).
Where does this leave us? Probably in the realm of something you suggest: heavily personalized treatment recommendations (like what it seems your work entails!) with a more effective incentive structure; stronger institutions involving comprehensive and accessible services that may be accessed by all to both prevent poverty (way way more helpful and cost effective than coercion) and to treat people who are currently homeless and ill. As a leading schizophrenia researcher responded after a talk I attended about the biological underpinnings of schizophrenia, when asked how do we prevent it? “Reduce childhood poverty.”
Lastly, it sounds like your experiences align with mine in that implementation of many attempted interventions often lacks fidelity to whatever is actually being attempted. That’s a real problem and I imagine progress in implementation of interventions could be very meaningful.
-A psychiatrist
Ok im done posting in complete and utter astonishment at this incredibly incorrect/offbased conclusion about people and homelessness that has an overly partisan outlook. For what should really be a bipartisan issue. Or the coming together together politics aside improve justice outcomes in civil justice and criminal justice for the poor. The one of two real cruxes of poverty. Injustice and corruption.
Megan-reread Kevin’s article. It’s a clear and compassionate view of the current state of the homeless problem. You are spinning yourself out of earths orbit.