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West Virginia and Vancouver, B.C., could not be more different in their responses to the opioid crisis. In West Virginia, addiction treatment programs are in short supply, with waiting lists as long as a year, and many people can’t access existing programs because they lack health insurance and are too poor to pay out of pocket. The state’s most populous city, Charleston, has exactly one needle exchange program, after political opposition closed the other one. Meanwhile, city, state and federal law enforcement officials regularly make arrests designed to cut the supply of drugs in West Virginia. Vancouver, by contrast, is in a country that provides universal health insurance and has much less economic inequality than the United States. The city offers a range of addiction treatment services, needle exchange programs, supervised drug consumption rooms and a clinic that prescribes heroin.