If substance abuse is a route to rock bottom, crack cocaine can be a devastatingly effective shortcut.
In her 14 years of work at the Meeting Place Adult Drop-In in Toronto, Leslie Saunders has come to know this particularly well in the past two or three years, as the cheap and highly addictive drug has proliferated on the sidewalks.
"That bottom is the same no matter what you're using," Ms. Saunders points out, "but the progression is so much faster with crack ... it shreds people's lives so much faster."
Stitching those shreds back together is especially difficult for the 49 per cent of Toronto's homeless people who described themselves as regular crack users in a recent health survey, according to those who are trying to help them.
A stigma that makes so-called crackheads the lowest of the low among street addicts, due to the erratic behaviour and desperation the drug can induce, means users are "very unwelcome in many places, including some services for the homeless," said Erika Khandor, a researcher who helped produce the survey for the Street Health agency. "There is a real lack of supports and services for them, and they do feel isolated even from existing services for homeless people."
Street Health launched one of the few crack-specific programs, called the Crack Users Project, at the Regent Park Community Health Centre in the downtown east end almost two years ago. The project, funded by Health Canada, includes a drop-in for crack users and an outreach program in which former users are trained as "crackologists" and sent out to help others still struggling with addiction.
The program "has actually led to phenomenal results" by linking users to workers who help them get health care, housing and addiction counselling, Ms. Khandor said. "With that support, people have decreased their use [of crack]and a lot of people have been able to stabilize their lives."
Still, with an estimated 5,000 homeless people sleeping in shelters and in public places on any given night, "there could definitely be more done" to get adequate help to those who use crack, she said.
Rules barring intoxication and substance use keep many addicts out of Toronto's 60-plus homeless shelters, where they might otherwise be able to get referrals to services to help them. The Street Health report calls for a more flexible shelter system to accept users.
Cocaine Anonymous, which operates on the same principle as Alcoholics Anonymous, offers a helpline to link crack users to support-group meetings attended by others trying to kick addictions.
Withdrawal treatment, however, has been more difficult for the homeless to obtain since the Ontario government began to shift money away from residential detoxification centres and into "daytox" programs, in which addicts are treated at home. Street Health pegged the number of detox beds in Toronto at 90 to 100 for men and 30 to 35 for women, the lowest per capita supply among Canadian cities.
Toronto's shelter, support and housing administration cited the lack of detox beds among 10 major gaps in services for homeless people in a 2005 report on its Streets to Homes initiative.
"Accessing detox has never been easy for people who are homeless or the people who provide them with outreach services ... the challenges of connecting clients to withdrawal management are intensifying," the report said.
Those who manage to obtain a detox bed often wind up using again when they are discharged back into the same street environment.
This helps to explain why Streets to Homes - a city program that moves homeless people into their own apartments, where they receive follow-up visits from support workers - can claim significant success in reducing drug use and associated health problems among the 1,200 people it has housed over the past two years.
In a recent survey of 88 of those people, 70 per cent said their health had improved and, among drug users, 74 per cent said their use had decreased and 33 per cent reported having quit entirely.
"Housing is medicine; housing is harm reduction," Phil Brown, the city's general manager of shelter, support and housing, said yesterday. "Just by getting them into housing, and the follow-up supports, you can see the effects of stability on the consumption of drugs and alcohol."
And simply having a home, away from other users on the street, helped to prevent relapses, the report said.
Crack-use kits are another tool, albeit a controversial one, that health workers have been using to make contact with crack users and offer help.
In December, 2005, the Toronto Public Health Department took over distribution of the kits from the Safer Crack Use Coalition, which formed in 2001 to push for improved health and social services.
While some citizens groups complained the kits would only encourage further drug abuse, advocates successfully made the case that clean pipes would help stem the spread of disease, and give outreach workers a chance to connect with the most marginalized drug users.
In fact, the two-year-old Crack Users Project conducted by Street Health sprang directly from a survey conducted by workers handing out the crack kits, said Paula Tookey, who oversees the CUP.
"The general sort of attitude from a lot of service agencies is that crack users are difficult - their behaviour is uncontrollable, they are distrustful," Ms. Tookey said. "So we figured ... what would happen if we opened our door and welcomed crack users in?"
The project has since trained 20 crack users as outreach workers, 10 of whom are still working and four of whom have landed paying jobs doing similar work, Ms. Tookey said.
Hundreds of users have attended the three-times-weekly drop-ins at the health centre, where they can get help.
Despite all of this, it still comes down to whether a drug user really wants to be helped, said Bonnie, a 38-year-old Toronto woman who has used crack, off and on, for the past 10 years.
"If you really want the help, the help is there for you," she said in an interview last week at the Meeting Place, at Queen and Bathurst Streets. "They're not going to hold your hand, though. You've got to want to do it.
"I don't blame anyone for where I am," Bonnie said. "I'm here because of my own problems, and when I'm ready to quit, I'm ready."