Inconsistent potency makes doing fentanyl—already up to 50 times stronger than heroine—like playing a game of Russian roulette. Will you get the dose you can tolerate or will you take the hit that leads to overdose? For Esquire, Jack Holmes reports from Portland in Oregon, a state which decriminalized drug possession via Measure 110 in an attempt to treat drug abuse as a behavioural-health disorder.

This was black tar heroin’s last stand,” Morgan told me, referring to the I-5 corridor from Washington to California. These days, she sits on the Oversight and Accountability Council for Measure 110, but years ago she was deep into heroin herself. She was in and out of jail for a long time, including four years on a federal charge when she was held responsible for her friend’s overdose death, but going to prison over and over never did much to stop her using. She was shocked at what she found in Portland when she got out in 2018, as a longtime housing shortage gave way to an explosion of tent cities. Then the state saw a surge in heroin and prescription-opioid use in 2019 and 2020, the culmination of a shift in which Portland’s beaming openness to the world began to fade toward something darker. Then the fentanyl flooded in, and now everything is fentanyl. It has almost completely replaced heroin on the street. A serviceable amount costs three dollars.

The true harm reductionists know that the material aid is about establishing a connection, planting a seed that you have to go back to the garden and tend to week after week until someone starts to believe for the first time in however long that somebody cares what happens to them, that maybe they should care, that they can’t just keep saying none of this shit matters so why not keeping getting high.

Everybody in this field has their own ways to navigate the philosophical quandaries, and nobody getting money through Measure 110 is pretending they have all the answers. Is the solution “housing first,” even before somebody gets sober, or do you give people medication and the supplies to keep living on the streets, hoping they can get clean in a tent? And considering all the many years when patients—especially Black patients—were thrown out of traditional inpatient programs so hastily, how do you decide when and why to toss somebody for screwing up?