Brian Wagner was 13 years old when he began using methamphetamines.

“It was a survival tactic,” he says. “It would help me stay awake until my abusive stepdad went to sleep.”

More than a decade later, Wagner’s on-and-off addiction to meth led to him living in a tent in Portland. There, he’d use meth to stay awake and warm during winter nights. It also suppressed his appetite, meaning he wouldn’t have to buy food.

“It can numb the experience you’re going through,” Wagner says. “It helps when you don’t want to live with reality.”

After three years living outdoors, Wagner entered a residential drug treatment program, and left meth—and homelessness—behind. Not all are so lucky.

Since 2011, Multnomah County has released an annual report on the number of people who died while homeless in the past year. The county includes data on where each person died, how old they were, their race, gender, and, perhaps most importantly, what caused their death. While the latest report, released in late October, shows little change in the number of homeless fatalities between 2016 and 2017 (79 died in 2017; 80 in 2016), one piece of data stands out: For the first time in the seven years the county’s collected this information, methamphetamine has surpassed opioids as the top cause of death among homeless people who died from a substance-related cause.

In 2014, 22 percent of all homeless people whose death was caused by a substance died from meth use. Sixty-one percent died from opioid use—either heroin, prescription painkillers, or other illicit concoctions like fentanyl. In 2017, homeless deaths linked to meth rose to 46 percent, with opioid deaths dropping to 41 percent.

There’s potentially some good news tucked into this sobering data: Medical experts and lawmakers say the drop in opioid deaths are probably caused by improved access to naloxone, the drug that reverses an opioid overdose. But that still doesn’t explain an uneasy rise in deaths linked to meth.

While meth has plagued Oregon communities for decades, its resurgence has alarmed the local detox clinics, advocacy groups, and police teams that have struggled to keep the insidious drug at bay. Oregon’s homeless population is particularly vulnerable to the drug, and like meth’s tangled history in Oregon, the solution to the crisis is complicated.

Oregon grabbed national headlines in 2004 with Multnomah County Sheriff’s Department’s “Faces of Meth” project, which used county mug shots to illustrate how methamphetamine use changed a person’s appearance. Two years later, Oregon became the first state in the country to pass a law requiring a prescription to purchase medicine containing pseudoephedrine, a drug commonly used to produce meth. The 2006 law was instantly effective at shuttering Oregon’s homegrown meth labs—but it didn’t kill the demand. Mexican cartels stepped in, filling the void with extremely potent meth shuttled over the border. Not only was this meth extra-powerful, the flood of shipments into Oregon kept its street price remarkably low, especially compared to other stimulants like cocaine. And it’s only become more accessible since.

“It can numb the experience you’re going through. It helps when you don’t want to live with reality.”

According to Portland Police Bureau (PPB) Officer Carlos Pagan, an investigator in the police bureau’s Drugs and Vice Division, the bureau has already seized 300 percent more meth this year than it did in 2017.

“Meth has never left the Northwest,” says Pagan. “The model has just changed.”

The PPB estimates that in 2000, a pound of meth produced in Oregon would be 50 percent pure and cost around $15,000. Today, PPB says a pound of meth imported from Mexico is at least 90 percent pure—and costs just $3,000.

Andrew Mendenhall, the medical director for Substance Use Disorder Services at Central City Concern, says he can see this shift in his detox centers.

“Patients are reporting worse psychosis and longer periods of psychosis,” Mendenhall says. “Which makes sense if the drug is more potent.”

Mendenhall also oversees Hooper Detox Stabilization Center, the largest free-standing withdrawal management center in the country, which sees nearly 1,900 clients a year.

“Recovery outcomes are always better when people have access to housing. There’s no question.”

Mendenhall says that 15 percent of the clients served at Hooper enter for meth use. Treating meth abuse, he says, is particularly challenging for clinicians: Unlike other addictive drugs like opiates or alcohol, there is no medicinal treatment for meth withdrawal. All that staff can do is provide a “safe place for people to sleep” and ride out the detox process, Mendenhall says.

The most effective treatment he’s seen is permanent supportive housing—a model that pairs affordable housing with on-site substance abuse, health care, or other programs that will help keep residents stable. It’s a system that requires some coordination—and a lot of funding. But in 2017 Multnomah County and the City of Portland announced a plan to create 2,000 units of supportive housing each year for the next decade. Mendenhall says those kinds of commitments keep him optimistic.

“Recovery outcomes are always better when people have access to housing,” Mendenhall says. “The more the region can create those resources, the more we’re able to offer solutions. There’s no question.”

Before he entered a residential detox facility, Brian Wagner said he tried an outpatient recovery program. But despite treatment, the fact that he had to return to the same environment and community where he used meth every night made recovery nearly impossible.

“It’s simple,” Wagner says. “If you do outpatient and you don’t have a place to live, it’s not going to work.”

Despite the long-term promises of housing, Multnomah County is still facing a deep deficit in affordable—let alone supportive—housing. In the meantime, many without a home will follow Wagner’s path: using meth to help survive and ease the sometimes insurmountable challenges of homelessness.

Mendenhall recalls a past homeless client who explained to him that she mostly relied on meth to protect herself.

“She said staying awake would lower the chances of her being victimized while she was asleep,” Mendenhall says. “I had never considered that. It’s humbling to realize that’s sometimes the best option.”