When Portugal decriminalized all drugs in 2001, they saw infection rates of HIV go from being the highest in the EU – 104.2 new cases per million, down to 4.2 cases per million by 2015.
by Trevor Lapointe
Now more than ever, as COVID-19 disproportionately impacts low-income, marginalized, and disadvantaged communities across Canada, people who use drugs and who are directly impacted by the opioid crisis, are also at greater risk. Opioid overdose deaths typically occur from acute levels of respiratory depression. With COVID-19 being a respiratory illness, this exacerbates the risk for opioid users, many of whom are unable to shelter in place or socially distance – often relegated to the streets to acquire the drugs they need.
A human rights response to the opioid crisis has long been thought of by progressives as a logically obvious framework. This policy proposal aims to legitimize progressive public health measures related to substance use, combatting public and political stigma by acknowledging this as the public health crisis that it is, as opposed to a criminal issue, or a moral deficiency in people who use drugs. To varying degrees, the federal government, and various provincial, territorial and municipal governments, have paid lip service to these ideas, but where is the real response? Where is the action? In the context of a pandemic, we are justifiably steadfast in condemning the lack of appropriate care for marginalized Canadians, provided they are recently unemployed, have pre-existing medical conditions, or reside in long-term-care facilities. So, why do we turn a blind eye to a community that is in many ways amongst the most marginalized? A lack of care for those dealing with substance use disorders, and so often concurrent mental health challenges, is an infringement on their Charter Rights, particularly – Section 15. (1)
Equality before and under law and equal protection and benefit of law. Every individual is equal before and under the law and has the right to the equal protection and equal benefit of the law without discrimination… sex, age or [mental or physical disability]. (Canadian Charter of Rights and Freedoms)
The Charter, as it relates to the criminal component of the opioid crisis, is useful in demanding that the human life and dignity of people who use drugs be maintained. Further, that people living in active addiction are not persecuted and criminalized but dealt with instead with the compassionate care required to address their complex health needs. Decriminalization as a measure of harm reduction, to some extent, is already protected under this charter right. I am referring to drug exemptions federally legislated for safe consumption sites in Canada – Bill C-2: (An act to amend the controlled drugs and substances act, respect for communities’ act. 2015.) In other words, government has already conceded we can no longer afford to punish and criminalize people who use drugs, and through these exemptions, are taking steps to re-establish their fundamental human rights. Once full-scale decriminalization is implemented it legitimizes the nature of the response and makes drug overdose deaths equal to all public health crises, be it opioids or Coronavirus. Establishing legislated drug use exemptions demonstrates a willingness by government to address the opioid crisis as a public health and human rights issue, so why not go all the way?
People who use drugs are people
Equal benefit of the law without discrimination is not possible for marginalized people, largely abandoned under the current system – especially those plagued by addiction. Addiction and substance use disorders are symptomatic of unequal access to resources, supports and an overall inability to avoid many of the risks associated with drug use. Bill C-2’s drug exemptions have made some progress, and show clear economic motives related to costs associated with new transmissions of HIV and Hepatitis C, but they don’t go far enough.
When Portugal decriminalized all drugs in 2001, they saw infection rates of HIV go from being the highest in the EU – 104.2 new cases per million, down to 4.2 cases per million by 2015. Therefore, policies bolstering harm reduction models should not be partisan. They are pragmatically beneficial in addressing myriad societal concerns, including but not limited to; crime, recidivism, mental and physical health, and the endless financial burden on our health care system. The bottom line is that when you remove stigma and any sort of moral argument – we all benefit. The cost of treating someone with a concurrent mental health and substance use disorder far under-weighs the cost of emergency room visits, legal fees, incarceration, and community and police resourcing designed to punish people for their affliction. While needle exchange programs, access to clean supplies, drug testing kits, and educating people on the risks of opioid use only puts a dent in the problem, the most legitimate policy response to date is, that of drug exemptions inside of legally sanctioned safe consumption sites. This legislation treats drug use and addiction as a complex bio, psycho, socio-political and economic problem, desperately in need of robust, seemingly unconventional responses.
Drug addiction is a complex medical and mental health problem
Bill C-2 makes a great case for decriminalizing all drugs in order to better assist those suffering from concurrent disorders. The irrefutable intersectionality of drug use and mental health only strengthens an argument for a public health and human rights response. When someone suffers from PTSD for instance, we treat them for their illness. If they are affluent, or even gainfully employed, there are safety nets in place to catch them. We offer solutions and resources to establish a care plan toward recovery and wellness. At the very least, we help them manage the illness. When someone who is already marginalized and living in poverty suffers from PTSD, they are immediately disadvantaged in terms of accessing resources. They are in many ways rejected by the care system, their only recourse often being to self-medicate with legal and illegal substances.
Herein lies the often-inevitable manifestation of concurrent disorders. An ‘equal care for all’ mandate takes legislative gains like Bill C-2 and expands the framework even further, addressing many of the intentional and unintentional negative effects of criminalizing a public health issue. The mandate of safe consumption sites is to reduce harm, but also to offer access to drug counselling, in and out-patient treatment programs, family support and other invaluable resources for wellness and recovery. The constant threat of criminalization thwarts the efforts of community interventions from the start. It stifles all attempts by health care professionals, social workers, and community health agencies to foster trust and get people the care they need.
Notably, one of the biggest barriers for people in active addiction is access to treatment, largely cost prohibitive when offered by private facilities and underfunded in the public system. Decriminalization could eventually lead to wide-spread legalization of many illicit substances, subsequently allowing for governments to adequately tax these market drugs, expanding public coffers and creating more accessible options for treatment. Streamlining drug treatment into a universal program like Medicare would be an ideal outcome. Politically speaking, it’s highly unlikely at the onset of such a paradigm shift. To that end, while the private, for-profit rehabilitation system is problematic for patients and workers alike, we don’t necessarily need to do away with it entirely in the interim. The pre-existing infrastructure for drug treatment facilities would quickly be improved through collaborative efforts between elected officials and private ownership, holding everyone accountable and to a higher standard. Create federal laws requiring public and private treatment facilities in all provinces to maintain equal operational standards of care, ubiquitous internal policies and protocols, and contingencies ensuring equal quality of care for people who cannot afford the cost of private care.
Lessons from COVID-19
COVID-19 has revealed many stark inequities, but perhaps none quite as blatant as in long-term-care. With 82% of Canada’s COVID-19 deaths coming from long-term-care, it’s becoming harder and harder to look away. In the province of Ontario, the abysmal failure has been felt worse than almost anywhere else in the country – Quebec having comparable numbers and recently calling in the military and Red Cross. In Ontario, 82.5% of deaths have been in for-profit care facilities. When considering these numbers, it’s important to note how many Ontarians are in the for-profit system versus public and non-profit. The Ontario Ministry of Long-Term Care reports that the bed count in each respective segment (for-profit / non-profit and municipal) is about the same – 5669 operated by for-profit facilities and 5733 in non-profit and municipal. To offer context on a national level, for-profit care represents 44% of long-term-care providers, non-profit entities 29% and public 27%. Almonte Country Haven (which happens to be in the town where I live) was hit harder than anywhere else, with 37% of its residents having died from Covid-19. Think about that number for a second. That is almost half of the home’s residents, gone. The way the system failed these people has brought palpable sadness and confusion to the entire community.
The long-term-care problem has even garnered international attention. Particularly from the U.S, which has little to be proud of in its own response. The Wall Street Journal referred to what’s happened in our nursing homes as “a huge black eye”. The Washington Post recently called it, “Canada’s Nursing Home Crisis”. It’s no secret that our neighbours to the South have a government pathologically in denial of the toll this virus is taking on its citizens, and let’s face it, we love hiding in their big, bad shadow. That said, as it relates to long-term-care, this unfortunately seems to be a uniquely Canadian problem. All of this to say, the private sector, left entirely to its own devices, has revealed itself to be dysfunctional, disorganized, and ill-prepared for a viral pandemic. The same can be said for the drug treatment business – hence the need for private-public partnerships to maintain checks and balances.
Notwithstanding, government has been quick to acknowledge these gaps and failures in long-term-care. There has also been, rightfully so, a decent amount of public outcry for seniors. So why not the same advocacy for people who use drugs – many of whom are extremely vulnerable due to co-morbidities such as pre-existing substance use and mental health disorders? In May, British Columbia reported its highest number of opioid related deaths to date – a 93% spike from just one year ago, and a 44% increase from April 2020. That equates to roughly 5.5 deaths per day, which is contextually staggering when compared to the 53 COVID-19 deaths (roughly 1.7 per day) on record in B.C in the same month. These sorts of reports and headlines don’t seem to gain the same traction. Are the lives of people who use drugs worth less than people in long-term-care? Again, reframe the opioid crisis as a public health emergency in need of a human rights response, and we change that purview.
Let the experts get to work
Public health officials, and the medical community at large, have less ability to understand and effectively treat addiction without decriminalizing illicit drugs and humanizing those who use them. We see this now in the recent legalization of cannabis: the beginning stages offering legalization for medicinal users, and now, legalization for recreational users. This inhibits the exploitive nature of black-market operatives, controls quality and safety, and benefits all Canadians through the taxation of a legal market product. Moreover, it allows for proper research to be done on the substance and on the effects experienced by the people using it. Of course, opponents will argue, it brings with it issues on the supply side, but these kinks will be ironed out over time. If governments can’t keep up with demand and offer product at an accessible price point, the black market will gladly step in to fill those gaps. One of many incentives for big government to get it right.
When championing drug policy proposals that vie for anti-discriminatory, health-based responses, it is imperative we understand that harm reduction exists on a continuum. In order to have mainstream society understand these nuances, we need to paint the picture through a human rights lens. This will legitimize the harm reduction model and begin to diminish stigma around drug use in general. It will also show the complexities of drug use and addiction are much better handled by public health branches of governments instead of law enforcement and the courts. Maintaining a condemnatory position toward people who use drugs results in drug use and addiction becoming overly simplified. If you want simple, if you want cost-effective, humanize the problem, and much like the rapid response to address the failures in protecting vulnerable seniors in long-term-care from COVID-19, offer the same urgency for people dying preventable deaths from opioid poisonings.
Trevor J. Lapointe works in community development and social welfare. He is also a musician, visual artist and freelance Writer.