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By Gabriela Novotna
and Tom McIntosh
Thirteen Canadians a day were hospitalized for an opioid overdose in 2014-2015, according to the Canadian Institute of Health Information (CIHI), and the rate of opioid poisoning hospitalizations has been steadily rising.
What began with the over-prescription of opioids such as OxyContin, a painkiller once thought to have a low potential for addiction, led to the diversion of legal drugs to the illegal market, and later to the dramatic expansion of the illegal production of fentanyl.
As the horror stories of addiction and death multiply, it is clear that what was once a medical issue is now a population health crisis.
We have had little success in dealing with this crisis because we focus on it in terms that fail to understand it as something other than a problem with illegal drugs. Seizing fentanyl shipments as they arrive in Canada has done little to interrupt the supply on the street. Harm reduction methods, while moderately effective, still operate within a framework that places the illegality of the drug at the centre of our understanding of the issue.
We supply police and other first responders with the opioid antidote naloxone and ask it be used to keep the addict/offender alive so that they can, in all likelihood, be processed into the criminal justice system. Supervised consumption sites rely on the police to turn a blind-eye to those entering or leaving the facility likely in possession of illegal drugs. The success of both Ottawa and Toronto’s pop-up safe-use sites in city parks came entirely from the willingness of the police to pretend they are not not there.
As a first step, this is fine. But it is not a long-term solution.
Situating our harm reduction activities within a criminal justice framework puts the focus on those populations already more likely to interact with the criminal justice system – the poor and racialized groups (especially Indigenous peoples).
Harm reduction’s success requires police to let criminal activity, such as possession of narcotics, slide in certain areas and at certain times so people won’t die.
We need to see addiction as, first, a health issue, not a criminal issue, and, second, as an issue that primarily preys on populations that are economically or socially marginalized.
Decades of a war on drugs has done nothing to reduce the supply or the demand for substances that are, to some extent, arbitrarily deemed illegal. We learned this lesson with the failed prohibitions of alcohol and, increasingly, we seem to be coming to terms with it with marijuana. We also know we can de-normalize harmful substances because we have done it with tobacco.
In 2001, Portugal decriminalized possession of all drugs in amounts deemed for personal use. Drug use and addiction (not the same thing) are public health issues, it asserted, not criminal matters. This freed up resources on the criminal justice side and allowed harm reduction methods to be integrated with preventative messaging more effectively.
Portugal now averages three overdose deaths per million people every year. The European Union average is 17.3 and the U.K. average is 44.6. Canada had 2,458 opioid related deaths in the past year, for a rate of 14.8 per million people.
However much we want to cling to the notion that drugs are bad, it is time to try something new. The criminal justice system is not the place to deal with addiction. It is a social and economic problem that requires more than a patchwork of public health interventions and treatment services based on local advocacy efforts.
With the scale of the opioid crisis reaching the middle class and young recreational drug users, many are being missed. Naloxone peer distribution programs aimed at street-entrenched chronic drug users are unlikely to reach suburban neighbourhoods. Strategies to reduce harms of drug use without criminalizing it first need to be embedded within a wider health and social policy reform.
This would mean a major policy shift in how we discuss addiction. But as the fentanyl deaths claim more and more lives, we cannot continue to pretend that we are on the path to solving this problem. The evidence is strong. It is our mindset that needs changing.
Gabriela Novotna and Tom McIntosh are expert advisers with EvidenceNetwork.ca and researchers with the Saskatchewan Population Health and Evaluation Research Unit at the University of Regina.
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