How many of you reading this have tried a drug in your lifetime? Don’t forget, alcohol is considered a drug. I will thus use the word substance as there are many different classifications and types of substances used worldwide by millions of people for as many reasons. Canada is no different. In fact the majority of us use substances on a recreational and/or regular basis, usually with little to no negative consequences. Yet we focus all of our attention, disgust and disdain towards those 10-20% of people who use substances who do develop issues for many different reasons.
Historically we have treated such people with moralistic judgement, and at times, brutally punished them. Some countries still do treat such people with capital and even summary death sentences. Yet more and more we are talking about “addiction” as a disease, as a disorder, as a health issue. The evidence we have discovered over the last century certainly has supported these concepts. And we continue to learn more about how “addiction” is even more than just about using a substance. We’ve learned that it can become a coping mechanism for triggers and stressors such as trauma. Addiction can include many different behaviours other than substance use.
So why in hell are we so bent on hurting, punishing, and banishing people for developing what we now have come to believe is a health issue, that isn’t even experienced by all who use substances, but yet for who the punishments and stigma still apply? There was a time in most of our lives where we would have been incarcerated with a permanent criminal record if we had been caught even being curious. I watched it happen in my youth.
We have learned that psychologically, punishment tends to drive behaviour underground. Behaviour appears changed but it is typically hidden. Thus internal behaviours including lying, manipulation, theft all become a part of the “addicted” personality. This is because there is no safety in punishment. Any well educated and experienced counsellor will agree that a person is far more willing to look at behaviours when in a safe and compassionate environment. We also know that a healthy connected support system is crucial for anyone with any type of illness or disorder to heal and function.
Yet we continue to isolate people who use substances in cages. Literally and metaphorically. And we view them as objects through criminalization. We sickly believe that it is far easier to banish and punish a criminal than to offer a compassionate firm hand when issues around substance use develop. They are objects. This is stigma.
If there is any doubt about the impact of stigma caused by criminalization of substance use, and whether or not proper decriminalization will be effective for all substances, all anyone needs to do is compare the overdose death rate between Portugal, Canada, and the US
In 2021:
USA – 32 deaths per 100,000 people
Canada – 19 deaths per 100,000
Portugal – 0.7 deaths per 100,000
Portugal has exercised a degree of decriminalization of all drugs since 2001. It also put an infrastructure of social supports other than just treatment into place as options for people. Portugal provides opiate agonist treatments as well as harm reduction throughout their system. Unfortunately the number above is a 45% increase in deaths in 2021. I would attribute that to the global increase that occurred due to the decrease in access to services during the pandemic.
Canada has implemented a harm reduction infrastructure across the country including increased availability and access to narcan kits, safe consumption and overdose prevention sites (there is a difference), expanded existing opiate agonist programs, increased low barrier housing with OPS. The first Safe Infection Site was officially sanctioned in 2003 in BC. Canada. Law enforcement has been instructed across Canada to ease up on possession charges and in Jan of 2023 BC implemented formal yet very limited decriminalization of select substances. In 2019 the death rate fell significantly as public workers, health care, outreach workers, shelter workers, and law enforcement all carried narcan. However, overdose deaths increased to record levels with the decrease in access to services due to the pandemic from 2020 to 2022. Various Provinces increased treatment beds but that had little if any impact on the number of deaths. Overall, Canada has begun to view the overdose crisis as a health and social issue rather than criminal.
The USA has the highest number of deaths per 100,000. They are only now beginning to approve and increase access to methadone and suboxone across the country, under much resistance and continued misinformation. Narcan is not universally carried by public, health and law enforcement as it is in Canada. It is only now being considered by some law enforcement departments. There is restrictions and shortages with opiate agonist supplies as the DEA continues its choke hold on drug policy. There is also an unfounded panic amongst law enforcement around the myth of touching fentanyl as a cause of overdose. This myth creates panic amongst people, not in the know, when it comes to assisting someone in an overdose. The US is looking at supervised consumption with sites again under much resistance. (There is still considerable resistance in some parts of Canada to this as well). The first site did open in New York in November of 2021. (note about 18 years after Canada’s first site). Overall though the go to drug policy in the US is still attempting to arrest their way out of any substance use issues.
It is easy to see the impact of criminalization. The numbers don’t lie. Portugal has pretty much established a long term decriminalization policy in that country. It is not perfect and still does not address certain issues but again, the numbers don’t lie.
Canada has established a fairly robust harm reduction infrastructure and is moving closer to a decriminalized approach to drug policy. Imagine if we retained the “tough on crime” policies that the USA seems to embrace. Our numbers, though still unacceptable would have been a lot higher.
Is there any question that criminalization affects how we see people who use substances. The harm that criminalization of substances has caused far surpasses any harm that the drugs themselves do.
It would seem that there are still too many of us who consider people who struggle with substances as somehow expendable. There is an answer just as there was with alcohol back almost a century ago. Repeal prohibition and regulate all substances.
We need to separate the concept of substance use from the concept of substance use as a disease or a disorder. Afterall, more than three quarters of Canadians use substances for various reasons and do not suffer from the issues that can develop with some.
We can still provide a diverse system of much needed regulated official evidence based treatment programs to meet the myriad needs for those who request it.
We need to take this health and social issue out of the hands of law enforcement completely and put it into the hands of health and social programming. This is the only way to change the way we see people who struggle with substance use issues and truly reduce and maybe even eliminate overdose death due to the toxic poisoning of an illegal supply of substances.
People who use substances are not criminals. They are not objects. They are people with names and stories and basic rights. They do not deserve to live in cages nor do they deserve to die.
A safe supply saves lives. Stigma kills.
Resources:
https://www.portugalresident.com/overdose-deaths-leap-45/
https://www.statista.com/statistics/812260/number-of-deaths-from-opioid-overdose-canada-province/
https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm
https://www.pbs.org/newshour/health/a-look-inside-the-1st-official-safe-injection-sites-in-u-s
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2942917/
Alexander, Bruce K: “The Globalization of Addiction: A Study in Poverty of Spirit”, Oxford University Press (2008)
Canada Drug Rehab: “The Evolution of Addiction Models: How Drug Rehab and Alcohol Treatment Program Thinking in Canada Has Evolved”, Canadadrugrehab.ca/blog
Fisher, Carl Erik “The Urge: Our History of Addiction” Allen Lane – Penguin Random House 2022
Franzwa, Gregg: “Degrees of Culpability Aristotle and the Language of Addiction” Humanitas Volume XI, No. 1, 1998
Hari Johann: “Chasing the Scream: The First and Last Days of the War on Drugs” New York, Bloomsbury 2015
Lewis, Marc: “The Biology of Desire: Why Addiction Is Not A Disease” Philadelphia, Public Affairs, 2015
Mate, Gabor: “In the Realm of Hungry Ghosts: Close Encounters with Addiction” Vintage Books Canada 2009
Sandhu, Mandy: “History of Addiction Treatment and Rehab Facilities: A Timeline” Freedom From Addiction.ca/blog 2022
Talwar V, Lee K. A punitive environment fosters children’s dishonesty: a natural experiment. Child Dev. 2011 Nov-Dec;82(6):1751-8. doi: 10.1111/j.1467-8624.2011.01663.x. Epub 2011 Oct 24. PMID: 22023095; PMCID: PMC3218233.