By Hakique N. Virani, MD and Rebecca J. Haines-Saah, PhD
Since 2016, more than 10,300 Canadians have died of an apparent opioid-related overdose, with the majority involving fentanyl or fentanyl analogs. This unprecedented public health crisis has decreased life expectancy at birth in the country’s most affected provinces of Alberta and British Columbia. Concerned by this epidemic of overdoses, Canadian advocates for drug policy reform have welcomed the recent recommendation from British Columbia’s Provincial Health Officer that drug possession for personal use be decriminalised. Canada’s national newspaper, the Globe and Mail, published an editorial endorsement of this recommendation stating that “addiction, the compulsion to use drugs, is largely a health problem—not a criminal-law problem.” Indeed, the topic of decriminalization was also front and center at this Spring’s Harm Reduction International conference held in Portugal, a country often cited for leadership in implementing effective, health-driven policies on illicit drug use that included decriminalizing drug possession. The growing chorus of voices now calling for drug policy change is encouraging. However, the underlying reasons for a new policy direction are critically important and, on that, many well-intentioned newcomers to the chorus are somewhat offkey. The central cause for drug law reform is not its relevance to health or the present public health catastrophe. It is a matter of correcting a social injustice. Failing to articulate this in public discourse risks perpetuating harms on the people decriminalization advocates wish to help.
Public health dialogue must highlight the history, evolution, and manipulation of drug policies and should compel reformation of laws rooted in racism and subjugation as a matter of correcting injustice and inequity, not only promoting better health. In Canada, the Opium Act of 1908 was used to portray Chinese Canadians as an outside threat, despite that it was Canada’s colonizer, Britain, who drove opium use in China, smuggling enough product from British Bengal to reverse a trade deficit and create immense demand. In the U.S., Presiddent Nixon’s War on Drugs declaration of 1971 vilified those who opposed him and the Vietnam War by disproportionately criminalizing drugs popular among black Americans, student demonstrators, and anti-war pacifists. Drug policies in North America and beyond continue to achieve their original discriminatory and oppressive intents. In Canada, Indigenous people in some regions are almost nine times more likely to be arrested for drug possession, and black Canadians are more than five times as likely to be arrested despite similarities in illegal substance use across racial groups. In the U.S., between 2001 and 2010, black Americans were more than 3.73 times more likely to be arrested for cannabis possession than white Americans despite a roughly equal prevalence of use. With more than seven million arrests for cannabis possession during that period, the disparity is no small matter.
Describing substance use as a health issue suggests that solutions lie in the health domain, but this is often inconsistent with the lived experiences of people using drugs. Medical approaches that do not account for social and structural factors potentially entrench stigma and further disempower people who already experience diminished agency over their life circumstances. Especially for those experiencing social injustices that increase their risk of isolation and harm, healthcare systems that typically view illicit substance use as a hedonistic personal health behavior (without other functions or benefits) can be disengaging. Regarding healthcare professionals, one of the most concerning health outcomes of drug use is addiction, and because medicine characterizes addiction in part as using drugs despite associated problems, many quickly conclude that people who use illicit substances at all are addicted and irrational. Under this incorrect assumption, ideas like involuntary treatment and forced abstinence naturally gather momentum even though they are inconsistent with scientific evidence and the paramount medical ethic of respect for autonomy. When their presenting concerns are frequently dismissed as only drug-related, people who use drugs therefore often experience healthcare settings as stigmatizing or dictatorial. Likewise, when people using drugs encounter the view held by some medical professionals that their illicit substance use is necessarily problematic (i.e.,“disordered”) or antisocial, it should not come as a surprise that many leave health care feeling more dejected, debased, and desperate than before they sought care.
How the rationale for decriminalization is framed and the terms that are used to describe the need for drug policy reform extend beyond semantic concerns. Framing has important implications for policy responses and the allocation of resources. Just as media and governments inaccurately interchange the phrases “overdose crisis” and “addiction crisis,” health professionals commonly see“health issue”and“health problem”as the same. Yet, population studies have shown that most people who use substances do not have an associated health problem, such as addiction, and that most people with addiction eventually stop having drug problems without any medical intervention. Commonly, people describe substances as a temporary solution to problems and not as a health behavior that results in them. If the substance they choose is criminalized, however, they may only have access to more toxic illicit drug analogs that are easier to traffic, and their risk of death from accidental overdose is heightened whether they use them occasionally or compulsively.
A rising body count does present an opportunity in a callous political world to advance progressive drug policy, and portraying drug use as a health issue might evoke sympathy from voters rather than derision. But this narrative skirts necessary uncomfortable conversations about inequity and injustices, and those should be the lede. Drug law reform is a small part of addressing indefensible wrongs such as poverty, homelessness, xenophobia, gender discrimination, and the inexcusable conditions facing Indigenous peoples. These inequities are not distinct from the public health crisis of deaths from overdose, and they need to be foremost in the dialogue on policy imperatives. It should not take an epidemic of fatalities for structural injustices to be corrected, and it should not take biomedical explanations of behavioral differences to accept people as they are. If it does, just like with drug laws, by the time people get around to fixing things, unforgiveable damage will be done.