Stigma By Emily Ager, Street Outreach Supporters It is sometimes said that Santa Cruz has a permissive attitude toward drugs, and drug users. In the case of marijuana use, medical or recreational, to some extent this is true. However, as in the rest of the country, users of drugs like heroin and other opiates, methamphetamine, crack, and cocaine, and especially those who inject these drugs, have consistently been characterized by negative stereotypes. The stigma attached to injection drug use is extremely harsh, and deeply entrenched in our culture. The very real mortal dangers of overdose and AIDS are intrinsically linked to injection drug use, and the notion that anyone would voluntarily subject oneself to such risks suggests a deteriorated morality, something that could be dangerous not only to the individual drug user, but to the community at large. The shadow of contagious damage permeates the cultural understanding of and feelings about injection drug users (IDUs), which leads to responses of fear and revulsion. IDUs do not need additional reminders that they are largely a reviled group of people, whose presence in our community is unwelcome. In fact, the role of social stigma as it fuels the cycle of addiction, is profound, and is something we as community health outreach workers endeavor to counter with compassion, patience, and a pragmatic approach to troubleshooting the myriad harms associated with injection drug use. The unremitting negative pressure of the Junkie stereotype is present in our medical culture, legal system, and popular media. It is a stereotype that is remarkably pervasive, in spite of the fairly well-accepted idea that addiction is at least in part a disease. Common assumptions about IDUs include the notion that all Junkies are selfish, amoral, aggressive, unstable, crazy liars, thieves, and criminals. This drives a cycle of fear that perpetuates many of the already problematic features of addictive behavior, such as isolation, reluctance to access support (treatment, medical care, the emotional support of loved ones), and a persistent erosion of positive self-image. When a person lacks confidence, and sees themselves as worthless, their behavior tends to reflect this. And to an unfortunate extent, when a person "knows" that they are dangerous, worthless, disgusting, unwelcome, etc, they will tend to treat themselves as such, often exhibiting "evidence" of the stereotype. As a culture we seem to agree that positive reinforcement is a highly useful tool in shaping negative behavior into positive behavior, but in the case of injection drug use, the idea that there is a core evil at work prevents many otherwise compassionate people from extending any degree of acceptance, patience, or willingness to help, IDUs in their communities. This is true among people who have IDUs in their families, as well as those who only recognize their presence in terms of a generalized criminal element. The experience of injection drug use is at once intensely, though temporarily, healing, while concurrently being a profound form of self destruction. For chronic injection drug users, there is a strange balance struck between two warring internal pressures. The instinct to survive manifests in the physical response to drug withdrawal, thus the impulse to heal, or self-medicate. This is counterbalanced by the emotional impulse to punish oneself for being weak, flawed, evil, damaged, rotten to the core. Feelings of self- loathing, hopelessness, and deep pain were likely already factors that influenced an individual's drug use. Coupled with stigma, the sense of rejection by one's own community can easily extinguish initial surges of motivation to improve one's life. The experience of physical and emotional degradation must be recognized as distinct from a desire to "get high," which typically is present at the earliest stage of addiction. Differentiating between emotional triggers that motivate an individual to start using in the first place, and to continue using in spite of the profound negative impact of addiction, and the response to cease the intolerable experience of withdrawal, is important when working with an individual to unravel their particular patterns of drug use. It is also central to developing a general understanding of addiction in terms of being able to parse the various impediments to change. One's sense of self-worth is the greatest element in the foundation for all positive changes in one's life. As harm reduction counselors and community health outreach workers, it is our job to connect with IDUs, and to find ways to encourage and instill self-worth. Delivering health education, distributing safer injecting supplies and exchanging syringes in an atmosphere of mutual respect and trust allows those basic activities to become tools for effectively undoing the barriers built by stigma. We endeavor to offer our participants genuine compassion and respect, we believe that they are inherently valuable as human beings, and deserve the support required to make difficult changes to improve their health and their lives. The more a person believes they are worthy and deserving of kindness and respect, the more likely they are to offer that to themselves, which is prerequisite to any significant and lasting behavioral change. It is a cornerstone of the Harm Reduction movement to acknowledge that injection drug users are human beings, innately deserving of compassion, support, respect, and care. However, the broader cultural perceptions about injection drug use involve so much horror, that most people do not find it emotionally comfortable to consider the IDUs in their own communities as fellow human beings, individuals with families and other people who they love and who love them, people with whole complex lives that often include the experience and the potential to be contributing members of society. It is easy to demonize IDUs and allow those negative stereotypes to justify the wish to simply remove them from one's community, either through long-term incarceration, forceful return to their original home (so long as that home is out-of-town), or the harsh belief that it is inevitable they suffer one of the fatal dangers of their risky behavior, such as overdose or AIDS. However, this is unrealistic in terms of actual, pragmatic problem- solving, on either an individual or community level. As a Harm Reduction-based organization, we are strongly committed to working closely with the IDUs of Santa Cruz county, offering a space to be honest about the struggles, challenges, and needs they face. It is the core of our work to offer compassionate support to find practical solutions to the plethora of troubles common in the lives of chronic drug users. As with any therapeutic counseling efforts, we work to assist in the rebuilding of individuals' sense of self-worth. Feeding off the intrinsic impulse to heal and survive, we recognize the opportunity to support the improvement of self-esteem. This happens slowly, and in small advances, but progress is possible, and we absolutely see people who are able to make extraordinary changes in their lives. But every step of the way we are battling the impact of anti-Junkie stigma, which does not serve to educate, heal, or in fact to eliminate drug use, drug users, or any of the public health and public safety issues associated with them.