Stick Doesn't Work, Let's Try The Carrot

Corey: 00:00:00

So Nathan, this is, this is an article that came out on New

Corey: 00:00:04

Year's Eve, so I've kind of had this one in my pocket, but I've

Corey: 00:00:08

been wanting to bounce this off you.

Corey: 00:00:09

So you have not heard this article to my knowledge.

Corey: 00:00:12

Maybe you have, but if you have not, I wanted to read it to you,

Corey: 00:00:16

see what you thought about it, and we can kind of go from there.

Corey: 00:00:19

This was put up by Global News.

Corey: 00:00:21

Uh, a former BC drug user turned harm reduction and recovery advocate

Corey: 00:00:25

and an Alberta addiction physician are proposing governments pay

Corey: 00:00:29

some people to enter treatment.

Corey: 00:00:32

Guy Ella and Dr.

Corey: 00:00:33

Monty gosh said that the idea of incentivized treatment would see those

Corey: 00:00:38

who cannot access treatment through other means, including the homeless

Corey: 00:00:42

and those living below the poverty.

Corey: 00:00:44

Could be eligible for a small stipend of $20 a day to enter a 90

Corey: 00:00:48

day treatment program or facility.

Corey: 00:00:52

Six.

Corey: 00:00:52

The $600 a month would go into people's pockets and not towards food or

Corey: 00:00:56

accommodation costs, giving, giving them something to work with when they

Corey: 00:01:00

leave treatment and attempt recovery.

Corey: 00:01:02

And then it goes on a, a little bit of, um, into some of the specifics.

Corey: 00:01:06

Contingency management, gosh, gosh said, is a rewards-based system

Corey: 00:01:10

with incentives to get people into certain treatment programs That has

Corey: 00:01:14

been very effective for drugs like methamphetamines, cannabis, and alcohol.

Corey: 00:01:18

One of the big things that substance use hijacks is the rewards system of the.

Corey: 00:01:24

Pella, who spent two decades fighting homelessness and

Corey: 00:01:27

heroin addiction in Vancouver's.

Corey: 00:01:28

Downtown East Side is well aware of how a powerful motivator drugs are.

Corey: 00:01:33

He said that he's overdosed six times.

Corey: 00:01:35

Once Fentanyl hit the streets before he found a recovery through a safety net of

Corey: 00:01:39

harm reduction, compassion and suboxone.

Corey: 00:01:41

Drugs need to be counteracted with another catalyst, Ella and gosh

Corey: 00:01:45

said, monetary incentives work citing $5 in cash that convince dozens of

Corey: 00:01:51

downtown Eastside residents to get their COVID 19 vaccines in 2021.

Corey: 00:01:54

This is giving people confidence back and a little bit of identity that they too

Corey: 00:01:59

are a part of something that's bigger.

Corey: 00:02:01

So I guess my first question is how does that sit with you?

Corey: 00:02:04

$20 a day for a 90 day treatment program.

Corey: 00:02:07

To your knowledge with your background, would this be something that would, would

Nathan: 00:02:11

work?

Nathan: 00:02:12

I'm aware of the, uh, the, the one of the guys you're talking about there.

Nathan: 00:02:17

Mm-hmm.

Nathan: 00:02:18

guy, guy, uh, whatever his last name is there.

Nathan: 00:02:21

Um, I see him on Twitter quite a bit and he's definitely an advocate for getting

Nathan: 00:02:28

people to recover from drugs and alcohol.

Nathan: 00:02:30

That does seem to be something that he's pretty interested in.

Nathan: 00:02:32

And, uh, he's right about the motivation.

Nathan: 00:02:36

Factor as far as you know, they've done lots of studies like the, what

Nathan: 00:02:41

they did with the covid there, with the, uh, getting people to get a

Nathan: 00:02:45

shot for $5, but that's not the same.

Nathan: 00:02:48

It's not, no.

Nathan: 00:02:49

My first question would be, are they doing this for people who are already seeking

Nathan: 00:02:55

treatment or are they seeking to motivate people solely on a monetary basis?

Nathan: 00:03:00

Because I'll tell you right now, From what I understand about how motivation

Nathan: 00:03:06

works, when your brain is, uh, you know, if you're using a heavy drug,

Nathan: 00:03:10

chronically, we've talked about it before, you tend to be front loaded.

Nathan: 00:03:14

Mm-hmm.

Nathan: 00:03:14

. So what that means is you're.

Nathan: 00:03:16

Uh, executive function in your prefrontal cortex.

Nathan: 00:03:19

Uh, actually I just looked at a study the other day actually, that they've, they've

Nathan: 00:03:24

shown that dendrites start to retract in the prefrontal cortex and in a weird

Nathan: 00:03:30

twist dendrites extend in the amygdala.

Nathan: 00:03:34

in the nucleus accumbens and all the, uh, hip, uh, the, the areas that are

Nathan: 00:03:38

associated with, uh, memory and emotion.

Nathan: 00:03:41

So you can see how that's a double-edged sword.

Nathan: 00:03:45

Mm-hmm.

Nathan: 00:03:45

in front-loading the brain to a, we look at it as a now

Nathan: 00:03:48

versus, uh, future type mindset.

Nathan: 00:03:51

Right?

Nathan: 00:03:52

Yeah.

Nathan: 00:03:52

When you're doing drugs like that on a, on a regular basis, Normally the

Nathan: 00:03:57

human brain has a, a kind of level playing field where as an adult you

Nathan: 00:04:02

understand that delaying gratification is many times better in the long run.

Nathan: 00:04:07

Yeah.

Nathan: 00:04:08

We don't always do that, but that's, you know, that's, that's

Nathan: 00:04:11

kind of what a healthy brain does.

Nathan: 00:04:12

It's able to look at both options and make a, a judgment

Nathan: 00:04:15

call, and that's the part of.

Nathan: 00:04:19

Choice, I guess you could say that is affected by doing drugs on a

Nathan: 00:04:23

especially highly rewarding drugs on a consistent basis for sure.

Nathan: 00:04:27

It's not that you're unable to delay gratification, it

Nathan: 00:04:31

just becomes much harder.

Nathan: 00:04:33

So taking that as a kind of framework to work with and then.

Nathan: 00:04:38

using a small amount of money like that.

Nathan: 00:04:42

I mean, that's even a small amount of money to people

Nathan: 00:04:44

who are using drugs, right?

Nathan: 00:04:45

Yes.

Nathan: 00:04:46

Uh, it's not going to, $20 is like, that's a very mild, like you could get high

Nathan: 00:04:54

for $20 a day on, on meth and fentanyl.

Nathan: 00:04:57

It could be done, but you have to be a fairly new user, I think, to, to

Nathan: 00:05:01

be able to get by like that, right?

Nathan: 00:05:03

Mm-hmm.

Nathan: 00:05:03

, um, to my knowledge, Maybe, uh, you know, they, if they did studies and

Nathan: 00:05:11

uh, it would be interesting to see at what point, cuz you'd think there

Nathan: 00:05:15

would have to be a number, right?

Nathan: 00:05:18

, where if, if there was, you know, X amount of dollars presented to

Nathan: 00:05:22

get people to go to treatment, uh, they would probably say yes.

Nathan: 00:05:27

but it would, I think there'd be many people who would, uh, contrary

Nathan: 00:05:32

to what most doctors and a lot of advocates think that people would,

Nathan: 00:05:38

are able to delay gratification.

Nathan: 00:05:40

If they can see out the other side of that 90 days, and they're gonna get a

Nathan: 00:05:43

big chunk of ch change that they can use, they're gonna say, , okay, so

Nathan: 00:05:48

you're gonna feed me and you're gonna keep me off the streets for 90 days.

Nathan: 00:05:51

You're gonna pay me to listen to your, your program, or whatever.

Nathan: 00:05:55

and then I'm gonna get a bunch, bunch of money when I leave this place.

Nathan: 00:05:59

My concern would be, are we actually going to kill more people?

Nathan: 00:06:03

Mm-hmm.

Nathan: 00:06:04

. Um, because now you, you're giving them a, a bunch of money and they've been.

Nathan: 00:06:09

, you know, you've basically perfectly reset their brain for use.

Nathan: 00:06:13

Yeah.

Nathan: 00:06:13

That would be, 90 days would arguably be the most dangerous

Nathan: 00:06:17

time to give somebody money and send them on their way like that.

Nathan: 00:06:21

Unless the key thing would be what the initial motivation is.

Nathan: 00:06:25

Yeah.

Nathan: 00:06:26

You know, if they were motivated to do it themselves, and you are doing

Nathan: 00:06:30

that to give them a way of having a leg up when they get outta treat.

Nathan: 00:06:34

Then by all means, I think that's an excellent idea.

Nathan: 00:06:37

But it would all come down to what is the, what is the individual's motivation for

Nathan: 00:06:44

going to treatment in the first place?

Nathan: 00:06:45

And if you're trying to lure people into treatment with money, You better

Nathan: 00:06:50

have like a safety net set up on the other side to monitor for overdoses.

Nathan: 00:06:55

That would be my primary concern.

Nathan: 00:06:57

And then, uh, if you are gonna do that, uh, it, it's an excellent opportunity

Nathan: 00:07:02

for data collection, which is sorely missing from a lot of these things.

Nathan: 00:07:06

So, , that would be the, the two points I would make.

Nathan: 00:07:09

I mean, the guy's trying to do this in Alberta, that's

Nathan: 00:07:11

a, that's an uphill battle.

Nathan: 00:07:13

I can't see, I can't see, uh, any el like as far as getting money for

Nathan: 00:07:19

something like that, I would be shocked.

Nathan: 00:07:21

But we'll see.

Nathan: 00:07:22

I mean, I, I, is it something that's just been kind of proposed

Nathan: 00:07:26

or is it something that's gonna go forward, or what's the, to my

Corey: 00:07:30

knowledge, just proposed.

Corey: 00:07:32

I agree with you, Nathan, first, about the risk of actually setting

Corey: 00:07:36

people up for overdose on the other side when they come out.

Corey: 00:07:39

I think $600 a month is not, if we're looking at housing as being

Corey: 00:07:45

one of the primary issues, this is not gonna do anything for housing.

Corey: 00:07:48

$600 doesn't touch anyone's housing needs.

Corey: 00:07:53

In our province, we have, there are a lot of nonprofit organizations.

Corey: 00:07:58

There are underpaid social workers.

Corey: 00:08:01

And support staff of nonprofits and of government organizations.

Corey: 00:08:06

It's a fact that social workers are are hard, hard to find because

Corey: 00:08:10

they're not simply not paid enough.

Corey: 00:08:12

There's very little incentive for people to go in and stay in that industry.

Corey: 00:08:17

So we've now put people through this mandatory treatment and, and then what?

Corey: 00:08:22

You know, to me it's, when I think about the allocation of resources, allocation

Corey: 00:08:26

of money, I think I would rather see that go to ensuring that there are

Corey: 00:08:31

better support services and, and more social workers who are well paid for

Corey: 00:08:35

their many, many hours of hard work.

Corey: 00:08:38

Cuz I don't, I I think if we're gonna create a lasting change,

Corey: 00:08:41

that's what is, that's what is needed there among other, other

Nathan: 00:08:44

things.

Nathan: 00:08:45

Yeah, I'm not entirely sure what the angle is there.

Nathan: 00:08:48

Like what if, what $1,800 is meant to do, if it was coupled with like a

Nathan: 00:08:54

halfway house situation or something where there was some ability to

Nathan: 00:08:58

have access to enough housing to.

Nathan: 00:09:01

uh, you know, have a shower every day, and okay, here's some money to

Nathan: 00:09:05

keep yourself fed while you look for a job, or something like that, you know?

Nathan: 00:09:08

Mm-hmm.

Nathan: 00:09:09

, but just $600 per month on the other end.

Nathan: 00:09:11

That doesn't make any sense to me.

Nathan: 00:09:13

So maybe something's, you know, maybe they tend to do something like that.

Nathan: 00:09:16

And that's not, uh, mentioned in the story.

Nathan: 00:09:19

I mean, everybody's trying to do the best with, uh, with their perspective, I think.

Nathan: 00:09:23

And, and, and he, he seems like the type of guy whose heart is definitely

Nathan: 00:09:27

in the right place, but, It's, uh, it's a real tough one when you're trying

Nathan: 00:09:33

to incentivize people in that way.

Nathan: 00:09:38

I guess if you wanted to run a trial like that, I guess the, the easiest

Nathan: 00:09:42

way to do it would be, uh, make it scalable and start very small and you

Nathan: 00:09:47

must different differentiate between.

Nathan: 00:09:50

The people who want treatment and are actively seeking it

Nathan: 00:09:53

versus the people who aren't.

Nathan: 00:09:55

Yeah.

Nathan: 00:09:55

Otherwise you'll get no data.

Nathan: 00:09:57

That's useful.

Nathan: 00:09:58

And, uh, I think that if you did a cost benefit analysis based on, uh, even

Nathan: 00:10:05

a few of those, like a few trials of that type of program, you would find

Nathan: 00:10:11

that, like you said, the, in the end, the $600, because it's not just $600,

Nathan: 00:10:15

it's also 90 days worth of treatment.

Nathan: 00:10:18

which is gonna be, even if it's in Alberta, you're looking at, I don't

Nathan: 00:10:22

know, 40,000, something like that.

Nathan: 00:10:24

Mm-hmm.

Nathan: 00:10:25

. Mm-hmm.

Nathan: 00:10:25

. So that is gonna be an, yeah, I, I think that's gonna be a real tough sell as far

Nathan: 00:10:31

as the Alberta government's concerned.

Nathan: 00:10:32

I don't know if they'd even go for that here.

Nathan: 00:10:34

Yeah.

Nathan: 00:10:35

Because we can't even show results from people who are motivated to go to treat.

Nathan: 00:10:41

can do a 90 day treatment in a facility that's, you know, supposed to be high

Nathan: 00:10:46

end and they spend a lot of money for, and it's still , it still can be not

Nathan: 00:10:52

a, not a great success rate, right.

Nathan: 00:10:53

So mm-hmm.

Nathan: 00:10:55

, um, yeah.

Nathan: 00:10:56

Yeah, it's interesting.

Nathan: 00:10:57

I mean, I've never heard anybody trying to do that before.

Corey: 00:11:01

I also worry, you know, in reading, briefly reading through the

Corey: 00:11:04

responses that that article got like the.

Corey: 00:11:08

Comment section of Twitter below that article, it.

Corey: 00:11:12

And this doesn't make it a bad idea, but that very proposal is ripe for someone

Corey: 00:11:19

who is very critical of, of either social services or, um, money towards drug.

Corey: 00:11:24

Those who use drugs or harm reduction advocates.

Corey: 00:11:28

It, it's like dangling a , dangling a, the bait out there for, for that conflict.

Corey: 00:11:35

And I wonder if it.

Corey: 00:11:37

It feeds.

Corey: 00:11:38

An idea like that.

Corey: 00:11:39

And I'm all, I'm all for risk taking ideas or radical ideas that are

Corey: 00:11:44

gonna save lives and make a change.

Corey: 00:11:46

So it's not that, but like mm-hmm.

Corey: 00:11:48

that idea, particularly without the support, without flushing the idea

Corey: 00:11:52

out enough so that it has, so you have some of those safeguards and have.

Corey: 00:11:57

Have it as a, a trial with, with really carefully collected data and

Corey: 00:12:02

really carefully selected users to come into the trial and just like

Corey: 00:12:06

show that you're really putting all these pieces together to make it work.

Corey: 00:12:10

It just seems like it's ripe for, for criticism and more division and more

Corey: 00:12:15

mud slinging towards the drug using

Nathan: 00:12:18

community, I think.

Nathan: 00:12:19

Yes.

Nathan: 00:12:19

Yes.

Nathan: 00:12:20

You, you.

Nathan: 00:12:21

It's, it's so . It's so.

Nathan: 00:12:27

I don't know.

Nathan: 00:12:28

Like it definitely you could look for sources of income and, uh, you

Nathan: 00:12:32

could almost check for like, uh, you know, government involvement

Nathan: 00:12:35

to see if there wasn't some right wing , , Albertan, uh, premier or

Nathan: 00:12:41

rich person who is actively trying to, to make it the, the situation worse.

Nathan: 00:12:46

Yeah.

Nathan: 00:12:46

That, that is how that idea looks.

Nathan: 00:12:48

Yeah.

Nathan: 00:12:50

Because , it doesn't have, there's not a lot of chances for it to succeed versus

Nathan: 00:12:57

many disastrous problems that could occur.

Nathan: 00:13:00

That, again, I, I don't know.

Nathan: 00:13:03

You never know how a story is presented, especially coming outta Alberta.

Nathan: 00:13:07

It could be that they had the best of intentions, they did have safeguards in

Nathan: 00:13:10

place and they were thinking of that.

Nathan: 00:13:12

But, um, if you're not at least aware of, uh, of the dangers associated

Nathan: 00:13:17

with something like that, then I don't think you should probably be involved

Nathan: 00:13:21

in putting those ideas forward.

Corey: 00:13:23

Yeah, and you know, so the obvious comparison to me is like,

Corey: 00:13:27

Someone listening could say, well, how is that different than the idea

Corey: 00:13:30

of giving drug users free clean drugs?

Corey: 00:13:34

It's very different.

Corey: 00:13:36

It's very different.

Corey: 00:13:37

I mean, Well, one, you can directly measure the lives saved

Corey: 00:13:42

by someone who suddenly has access to a clean drug supply.

Nathan: 00:13:46

Yeah.

Nathan: 00:13:47

It's uh, com I mean, I don't see a more pragmatic common sense approach.

Nathan: 00:13:52

And the only argument against it, uh, other than the obvious political nonsense

Nathan: 00:13:57

would be, uh, is it cost effective?

Nathan: 00:14:00

Mm-hmm.

Nathan: 00:14:00

, and I would argue that yes, it is.

Nathan: 00:14:03

Because if you do the math on, you know, somebody who's already say they've

Nathan: 00:14:10

overdosed once, twice, whatever it may be, every overdose is very, very expensive.

Nathan: 00:14:14

Every hospital visit, every ambulance ride to stay a night in a hospital to recover.

Nathan: 00:14:19

Even if you get out that day.

Nathan: 00:14:22

there's a hefy, uh, price tag involved with that.

Nathan: 00:14:25

And that's just the overdoses.

Nathan: 00:14:27

That's not the physical injury that aren't, that doesn't turn out

Nathan: 00:14:31

to be registered as an overdose.

Nathan: 00:14:32

It's just a person is hurting badly and needs to go mm-hmm.

Nathan: 00:14:35

now they need to go see somebody at a walk-in clinic or, you know, there's

Nathan: 00:14:39

all these extra things that add up.

Nathan: 00:14:41

And if you eliminate those by providing drugs that are very, very, very cheap

Nathan: 00:14:47

to manufacture, then I think you.

Nathan: 00:14:50

, like again, it wouldn't be hard to do a small study to, to see what,

Nathan: 00:14:56

you know, you take, take a hundred chronic users, uh, who've had at least

Nathan: 00:15:01

one overdose, you could start there.

Nathan: 00:15:03

Mm-hmm.

Nathan: 00:15:03

, provide them with something cheap like, uh, diacetylmorphine,

Nathan: 00:15:08

heroine, or Hydromorph mm-hmm.

Nathan: 00:15:10

and see what happens.

Nathan: 00:15:12

Do it for a month.

Nathan: 00:15:13

Yeah.

Nathan: 00:15:13

You know, see how expensive it is to do that for a month versus how much of a, a

Nathan: 00:15:18

burden it takes off the healthcare system.

Nathan: 00:15:20

, and this is not, again, counting the police that are Yeah.

Nathan: 00:15:24

You know, we're trying to alleviate that, but, and on top of that, you have to, if

Nathan: 00:15:29

you're somebody who's in a situation where you're using a lot of illicit drugs, you

Nathan: 00:15:34

have to find that money somewhere and you need to account for the crime, so, mm-hmm.

Nathan: 00:15:39

you gotta take that amount of money that's being taken outta the economy.

Nathan: 00:15:43

You know, it's not just a, people need to understand that

Nathan: 00:15:46

it's, it's not just that you.

Nathan: 00:15:49

You're being altruistic and giving people money.

Nathan: 00:15:52

In a lot of these cases, I believe that it would actually

Nathan: 00:15:55

save us money in the long term.

Nathan: 00:15:58

Mm-hmm.

Nathan: 00:15:58

and people can't, they, it seems to be difficult for people to understand

Nathan: 00:16:01

that, but, and I could be wrong.

Nathan: 00:16:04

I could certainly be wrong, but to me it, it doesn't look even close.

Nathan: 00:16:07

I mean, no,

Corey: 00:16:08

I, and without, without fixing, The safe supply issue without fixing

Corey: 00:16:13

the toxic drug supply that is still on the streets like it has been

Corey: 00:16:17

for years now without fixing sort of our very clunky, dysfunctional

Corey: 00:16:23

mental health and healthcare system.

Corey: 00:16:26

Understaffed, overserved, putting someone through a treatment program for

Corey: 00:16:31

90 days to let their tolerance plummet.

Corey: 00:16:35

Yeah, I think it's a recipe for tragedy.

Nathan: 00:16:38

Mm-hmm.

Nathan: 00:16:40

. . I would take that deal if, I mean, if I was really in a bad place and I

Nathan: 00:16:45

was on the street, I'd take that deal just for the, the shelter and the

Nathan: 00:16:49

food and then I would say, fuck it.

Nathan: 00:16:52

Yeah, I'll use INS in at the facility too.

Nathan: 00:16:56

And you know, if they catch me, they catch me.

Nathan: 00:16:59

I, what are they gonna do?

Nathan: 00:16:59

Boot me outta the program.

Nathan: 00:17:00

I don't get my money.

Nathan: 00:17:01

Who cares?

Nathan: 00:17:02

I still, you know, like people are not idiots.

Nathan: 00:17:05

No, no.

Nathan: 00:17:06

So, I dunno.

Nathan: 00:17:07

Yeah, that's a , that's a pretty cool story to, uh, to bring up.

Nathan: 00:17:11

Interesting.

Nathan: 00:17:12

We'll keep our eye on that one.

Nathan: 00:17:13

Yeah.

Nathan: 00:17:13

Yeah, yeah.

Nathan: 00:17:14

Yeah.

Nathan: 00:17:16

, I'd love to hear a response from the, uh, from guy.

Nathan: 00:17:20

Well, from, from Guy i'd I, I'd be more interested in a response from

Nathan: 00:17:24

the Alberta government because, uh, I think that would be pretty funny.