Author: Canadian Drug Policy Coalition

Stigma is a mark or characteristic connected to negative attitudes or beliefs about people because of who they are, what they do, or their circumstances in life. Negative attitudes or beliefs could be about race, social class, and even behaviour. Many people who currently use drugs or have used drugs in the past may experience stigma on a frequent or daily basis. Because many of the activities around substance use—like possessing or dealing drugs—are criminalized, people who use substances are often stigmatized as both people who use substances and criminals.

Stigma is harmful because it creates real barriers to people accessing health care, legal support and important social services, creating a perpetual harmful cycle where those who would most benefit from help cannot access it and are further marginalized in society. People are less likely to seek help for substance use disorder because of the shame associated with stigma. They are more likely to use substances alone, greatly increasing their risk of death because there will be no one to intervene should they overdose.

Avoiding Stigmatizing Narratives

Perpetuating stigmatizing stereotypes by advancing inaccurate narratives can also have harmful consequences for people affected by substance use disorder. These narratives often don’t reflect the lived realities of the people involved. Here are a few to avoid:

• Harm reduction enables drug use. Harm reduction services do not exist in silos. At supervised consumption sites, people can access a whole range of supportive services, such as housing and counselling, that drastically increase their likelihood of improving their health and stability in life. Harm reduction does not enable people who use drugs; it provides a pathway to health and recovery while keeping people alive.
• Abstinence is the most effective (only) way to address substance use disorder. This has not been borne out in research. For some people, it is impossible to adhere to abstinence as a condition of treatment; therefore, these health interventions fail these individuals. Effective treatment involves accessibility and lower barriers to ensure those who want and are ready for treatment can access it.
• Fentanyl can lead to overdose through skin contact. This is false. Fentanyl is not absorbed through the skin well enough to pose a significant health risk from casual contact.
• Fentanyl over-prescription is fuelling overdose. The majority of overdoses in Canada are not caused by pharmaceutical-grade fentanyl produced by drug companies, which is often prescribed to patients in the form of take-home patches or administered in hospitals. Most overdose deaths are caused by illegally produced fentanyl created in clandestine labs and sold on the street, often as heroin. Focussing on the former diverts attention away from the latter and thus the true cause of the overdose crisis (prohibition and flawed drug policy) and affects access to pain medication for a population that requires it.
• The dichotomy between a person who uses drugs and a person who sells them (“drug dealer”). This “criminal versus victim” separation is based on an inaccurate understanding of substance use and has been popularized by its simplicity and the convenient way it vilifies members of society deemed “criminal.” In reality, people who use drugs often sell them to support their own substance use. These individuals—often highly marginalized and precariously housed—face a range of systemic barriers and stigma preventing them from fully integrating into society.
• Hitting rock bottom is necessary for someone to recover. Human connection and support is essential for people to successfully recover. Allowing a person to “hit rock bottom” is the opposite of these conditions and will often end in fatal overdose. As noted by the First Nations Health Authority, “hitting rock bottom can be more destructive than helpful.”
• Addiction is a choice and moral failing. Many reasons cause people to turn to drugs, but underpinning much of the substance use disorder we see in society is trauma. Substance use is often a response to traumatic life events wherein individuals seek relief from significant pain—physical/psychological—while navigating life to the best of their ability. People should not be vilified for the ways they choose to cope with this trauma. It is natural to seek respite through some external object or activity, and many individuals face barriers to accessing less harmful means of support, for example, healthy and supportive social networks and counselling services.

Considerations for More Accurate Storytelling

Avoid sensational photos. Sensationalized images—including extreme close-ups of jagged needles, broken glass, and large mounds of white powder—unnecessarily ratchet up fear. This fuels stigma towards people who use drugs, increasing social isolation and thereby also adversely affecting their health and safety. These images are also inaccurate and fail to reflect the realities of substance use for most people. This article by the New York Times is a good example of how non-stigmatizing images can both respect the requirements of journalism and the dignity of subjects involved. It features people with dignity and respect while not sanitizing the realities of substance use.

READ MORE: Evidence around harm reduction and progressive, public health-based drug policies

READ MORE: Photographing beyond ‘Needle-in-Puddle’ (The Tyee)

Use credible subject-matter experts and sources. Hearing from both sides of the story on a matter of public health is important when both sides represent honest, credible viewpoints informed by evidence. Members of the scientific and drug policy communities who rely on rigorous studies and evidence are best positioned to comment on matters of substance use. The scientific consensus strongly supports harm reduction and a move away from a criminal justice approach in a similar way to how the vast majority of science supports the reality of human-caused climate change. Based on expertise and experience, numerous senior public health officials have also openly supported legal regulation and a safe supply of drugs for people experiencing substance use disorder. Giving police, business associations, and other individuals lacking expertise in public health wide latitude to comment on this issue in a way that puts their comments on an equal footing to credible sources distorts the debate away from scientific consensus and can help amplify misinformation. These groups are able to comment on their own personal, isolated experiences (and those of their members and community), but it is also important to put these comments into a wider public health context where the evidence has borne out more societal benefits than harm.

Note: Some of the information in this guide was adapted from “Changing the Narrative.” For more information, visit https://www.changingthenarrative.news/

Compassion Clubs

Compassion—or buyers’—clubs are “autonomous association[s] of persons united voluntarily to meet their common economic, social and cultural needs and aspirations through a jointly-owned and democratically-controlled enterprise.”¹ They first emerged in the 1980s and 90s in response to the AIDS epidemic when people living with HIV/AIDS used them to procure then-illegal cannabis for pain management. Today, they still provide a safe space for members to acquire one or more substances, most notably heroin, while connecting to like-minded peers. Compassion club models vary, with some functioning as small, underground initiatives and others operating more openly. Regardless, they appear when government inaction to crises—be that HIV/AIDS or drug poisoning—limits access to life-saving measures.²

Compassion clubs differ from market distribution models and maintain the following principles: voluntary and open membership; democratic member control; member economic participation; autonomy and independence; education, training, and information; cooperation among cooperatives; and concern for community.¹ By aggregating purchasing orders, members can access volume discounts, price protection, shared storage and distribution facilities, and other economies of scale to reduce their overall purchasing costs.²  This happens regularly through the healthcare supply chain (e.g., health insurance) and across sectors (e.g., with housing and grocery supplies.)

An example of a prospective compassion club model has been outlined by the Vancouver-based Drug User Liberation Front (DULF). On August 31, 2021, members submitted a 56(1)-exemption request to the federal government for the DULF Fulfillment Centre and Compassion Club Model. If approved, this exemption would enable members to legally purchase pharmaceutical-grade cocaine, heroin, and methamphetamine from a properly licensed and regulated producer, securely store the substances, implement quality control measures, reliably package the substances, and distribute them to a screened members list.³ 

Controlled Drugs and Substances Act (CDSA)

The Controlled Drugs and Substances Act (CDSA) is Canada’s federal drug control statute. Originally passed in 1996 to replace the Narcotics Controlled Act and parts of the Food and Drug Act, it also serves as the implementing legislation for several international anti-drug treaties. The CDSA established eight “schedules” of substances, which are categories of drugs and devices related to creating drugs based on their perceived personal and public safety dangers, and two classes of “precursors” (compounds used to produce controlled substances). “Schedule 1” controlled substances have been deemed the most dangerous. Offences under the CDSA include possession, “double doctoring,” trafficking, importing and exporting, and production of substances included in the schedules. While the punishment for these offences depends on which schedule applies to the drug in question, there are mandatory prison terms under the CDSA and the most serious drug offences have a maximum penalty of life imprisonment.⁴

Notably, the Act also asserts that “The Governor in Council may, by order, amend any of Schedules I to VIII by adding to them or deleting from them any item or portion of an item, where the Governor in Council deems the amendment to be necessary in the public interest.” Several amendments have been made to the Act over time, all of which have also required amending adjacent legislation. For example, in 2018, Bill C-45: An Act Respecting Cannabis and to Amend the Controlled Drugs and Substances Act, the Criminal Code and other Acts was passed in parliament. This entailed repealing multiple sections of the CDSA as well as altering sections of the Criminal Code, Narcotic Control Regulations, Industrial Hemp Regulations, the Non-Smokers’ Health Act, the Criminal Records Act, and the Identification of Criminals Act, among others.⁵ 

Criminalization

Refers to the direct and indirect criminal penalties for any prohibited, drug-related activity in the CDSA. Although some forms of criminalization are obvious (e.g., criminal convictions for simple possession or drug trafficking), others are less so. For example, many of the circumstances associated with poverty are implicitly criminalized or make people more vulnerable to criminalization irrespective of whether they’ve broken the law. We see this dynamic manifest in “street sweeps” wherein police routinely confiscate and discard unhoused people’s belongings, which then exposes this population to being searched for illegal drugs. Even if they aren’t formally penalized for possession, their drugs may be taken and they may then be encouraged to commit acquisitive crime (e.g., theft) or engage in other illegal behaviours to obtain more drugs. Criminalization in this context, then, denotes the cyclical, mutually reinforcing nature of poverty, surveillance, and drug-related offences, as well as the impact this has on one’s psyche.

Decriminalization

Decriminalization refers to a range of policies and practices that replace criminal penalties with non-criminal ones for designated activities. There is not a single regulatory framework for decriminalization, and interpretations of what constitutes decriminalization; how formerly criminalized activities should be treated by police, medicine, and the state; and the extent to which these new treatments should be applied on a discretionary basis versus codified in law vary widely. When it comes to controlled substances, decriminalization exists on a continuum of legislative categories from criminalization (most restrictive) to decriminalization to legalization and regulation (most liberal.)

“De facto” decriminalization implies that criminal penalties for activities related to controlled substances are informally implemented. Put differently, the possession and distribution of controlled substances remains illegal, but police may be instructed not to enforce these laws. In British Columbia, there are discrepancies between reports by police and from people who use drugs on the extent to which simple possession has actually been decriminalized. Specifically, a 2020 analysis of provincial drug arrests dating back to 2014 found that drug possession charges are inconsistent inter-jurisdictionally.⁶ Furthermore, even if a person is not arrested or charged for drug possession, visible drug users (e.g., unhoused people, particularly if they are racialized and/or sex workers) may still have their drugs confiscated by police. This speaks to the benefits of “de jure” decriminalization, which is reflected in policy and legislation to limit discretionary powers of police. 

There are many possible pathways to decriminalization. Municipally, any city council member, municipal board of health member, or local medical health officer can request a section 56(1) exemption under the CDSA to apply to a specific class of people or geographic region.⁷ Provincially, one option in British Columbia is to amend the provincial Police Act to allow the Minister of Public Safety and Solicitor General to set broad provincial priorities with respect to people who use drugs. This could include declaring a public health and harm reduction approach as a provincial mandate and providing mechanisms for police to link people to health and social services. The possession of a small amount of drugs for personal use would be changed from a criminal offence (with a potential jail sentence) to an administrative one. The second, more formal option is to develop a new regulation under the Police Act to include a provision that prevents any member of a police force in BC from expending resources on the enforcement of simple possession offences under Section 4(1) of the CDSA. BC’s provincial health officer, Dr. Bonnie Henry, recommended the province urgently pursue one of these two options in 2019.⁸ Finally, as with municipalities, government actors including the chief provincial health officer, premier, provincial ministers (of health, mental health and addictions, public safety, justice and attorney general, or the solicitor general) can also request a section 56(1) exemption under the CDSA to apply to a specific class of people or geographic region if deemed in the public interest.

READ MORE: [Platform] Decriminalization Done Right: A Rights-Based Path to Drug Policy

Federally, the minister of health has broad power to exempt people or jurisdictions from provisions in the CDSA (e.g., the criminal prohibition on simple possession) without needing to consult parliament. We have seen this occur in the case of specific safe consumption sites (SCS) and for research purposes. Notably, provinces and municipalities can also request exemptions in their jurisdiction from the federal government.⁷

There are benefits and drawbacks to decriminalization. Evidence demonstrates that it is an effective framework for encouraging uptake of health and social services by people who use drugs and reducing crime and social disorder, drug-related littering, public drug use, and overall drug-related charges.⁹ However, this data obscures the limitations of decriminalization. First, decriminalization does not fundamentally alter the volatility of the drug market. This means that people who use drugs are no less likely to consume contaminated substances and are no more protected from accidental overdose and/or death than they are when drug use is criminalized. Next, discretionary enforcement disproportionately impacts poor and racialized people. Those who are stably housed and can use discreetly are not under surveillance and thus their drugs are rarely confiscated. Beyond this, “diversion” mechanisms introduced in lieu of criminal sanctions are not always appropriate. Portugal’s model of decriminalization, which was introduced in 2000 and is often cited as an example of successful reform, does not meaningfully address the violence, stigmatization, displacement, and discrimination that drug users experience. And, because police are still mandated to search and detain people suspected of possessing drugs, many people caught with drugs are still abused, this time “off-the-record,” and/or obliged to engage with the medical system, including attending addiction treatment despite not wanting to, instead of being incarcerated.¹⁰

Drug

Any chemical substance that, when consumed, alters psychological and/or physiological (bodily) processes. A drug may be legal to consume, illegal to consume, or legal to consume only for specific people in specific circumstances. 

Examples of drugs that are usually or always legal to consume include alcohol, caffeine, nicotine, and drugs like antidepressants and antipsychotics. Examples of drugs that are usually or always illegal to consume include cocaine, crack cocaine, heroin, and methamphetamine. These latter drugs are more often referred to as “drugs of abuse” because they are considered more likely to cause mental or physical dependence in the user.

The legality or illegality of a drug is more complex than some realize. For instance, fentanyl is illegal to purchase on the street but physicians can legally prescribe it to patients in hospital for pain management. Similarly, it is legal for adults to purchase alcohol from licensed establishments, but they cannot consume it in most public places. Children can never purchase or consume alcohol legally. Next, cannabis, once illegal for everyone, is now legal for adults to purchase from licensed dispensaries. Finally, drugs such as Ritalin, which is legally prescribed to children and adults to treat the symptoms of attention deficit hyperactive disorder (ADHD), a clinically diagnosed neurodevelopmental difference, is almost chemically identical to methamphetamine, which is illegal for all people to manufacture, distribute, or purchase. 

A drug’s level of risk or dangerousness is linked to how the public views it. Laws and policies that govern access to the drug also inform how safe it is to consume. Important to remember is that access to a drug (as well as punishment for using drugs illegally) depends on several factors, most of which are unrelated to the actual chemical structure of the drug. 

Drug Consumption

Introducing any chemical substance that alters one’s mental and/or physical state to the body. The most common forms of drug consumption include swallowing, snorting, inhaling, smoking, and injecting. 

Drug Dependence 

The state of being mentally and/or physically reliant on one or more drugs. Typically, dependence develops over time and is preceded by increased physical tolerance to the drug(s). Absence of the drug may induce physical withdrawal symptoms that range from mild to very severe and may also be accompanied by mental and/or emotional discomfort. Drug consumption patterns, including duration and frequency of use, may predict dependence but this is not always the case. Finally, dependence does not just occur in illegal drugs: Caffeine, alcohol, tobacco, and prescription medications are also dependence-inducing.

Drug Poisoning Crisis 

A more appropriate way to refer to what is sometimes called the “opioid epidemic” or “overdose crisis.” In Canada it is no longer accurate to attribute rates of accidental overdose and death to opioids because it is virtually impossible to procure unadulterated versions of these drugs outside of medically regulated contexts. Further, people who use stimulants and other non-opioids are now impacted by the toxic drug supply. This shift in terminology appropriately acknowledges that accidental overdose is predominantly caused by drug policy, not the drugs themselves. Specifically, prohibition destabilizes the drug market and people who use (and sell) drugs do not know what they are getting and may thus consume more of a substance, a different substance(s), or a dangerous combination of substances. The Canadian AIDS Treatment Information Exchange (CATIE) explains, 

“Prohibition creates incentives to make and sell drugs that are smaller and stronger so that production and transportation volumes can be reduced and profits can be increased. ⁶ Prohibition is why fentanyl and fentanyl analogues, drugs that are many times stronger than heroin in much smaller doses, have severely contaminated the illicit drug supply and have been linked to the increases in overdose deaths.”¹¹

(Interactive Graph)

Drug Selling

Commonly referred to as drug dealing, drug selling refers to distributing small quantities of illegal drugs (or legal drugs that are being distributed in an illegal way). Drug dealing is a common income generation strategy among many people who use drugs, particularly those who report daily use.¹² And, although popular conceptions of drug selling are that it is a predatory or immoral activity, research demonstrates that: a) drug users and drug sellers are often the same people; b) drug sellers tend to have positive relationships with those they sell to; and c) drug sellers regularly participate in care practices that minimize the harms of a toxic drug supply (e.g., carrying naloxone, responding to overdose, developing rapport with buyers).

The Drug Policy Alliance also notes that anti-drug laws in the US are written so broadly that people who get caught possessing drugs for personal use are often charged with drug selling, even if they do not distribute.¹³ In Canada, though the legal system has evolved to focus on “high-level” dealers (also known as traffickers) in theory, low-level sellers remain targeted by police.

Drug Trafficking

In section 2 of the CDSA, “trafficking” is defined to include any act of selling, administering, giving, transferring, transporting, sending, or delivering of a controlled substance—or offering to do any of these things—unless authorized by a regulation, whether for a profit or for free. Section 6(1) of the CDSA also prohibits importing controlled substances into Canada, while section 7(1) prohibits their production.

Under Section 5(1) of the CDSA, “traffic” means, in respect of a substance included in any of Schedules I to V,

• (a) to sell, administer, give, transfer, transport, send or deliver the substance
• (b) to sell an authorization to obtain the substance⁴

The criminal punishments for trafficking vary based on factors such as where the offence was committed, whether the accused is connected to a criminal organization, if the accused used violence when committing the offence, if they had previously been convicted of a designated substance offence, if minors were involved, and whether the prosecution treats the offence as an indictable one (more serious) or a summary conviction (less serious). In other words, there is significant diversity among those accused of trafficking and the penalties they receive. The maximum penalty upon conviction for trafficking or possession for the purpose of trafficking is life in prison (for a Schedule I or II substance), ten years (for a Schedule III or V substance), and three years (for a Schedule IV substance). There are also minimum penalties for some offences. 

It is crucial to recognize that drug trafficking in Canada is tied to the global illegal drug trade. A demand for drugs exists, and prohibition has established the conditions through which transnational criminal organizations completely control the supply chain. For example, overcrowded prison systems in Latin America and the Caribbean have been described as “near-perfect recruiting centers and incubators for crime, as organized crime groups have come to control drug economies within prisons and use the facilities as bases by which to control trafficking operations outside.”¹⁴ An internationalist perspective is thus vital when considering how Canada influences and is influenced by trafficking. Regions that are affected by western imperialist expansion are fertile ground for volatile “turf wars” and, aided by government corruption and militarized responses that exacerbate local violence, there are strong incentives for maintaining control of transit routes.¹⁵ In Canada, prohibitionist approaches to drug importing similarly ensure that it is done through illicit means such as money laundering. Advocates of legal regulation thus emphasize that justice-oriented regulatory frameworks must consider the impact this would have on communities who are not directly impacted by Canadian federal law while paying heed to western destabilization of the global south as both a cause and effect of trafficking. 

Harm Reduction

Harm reduction is a social justice movement built on a belief in the inalienable human rights of people who use drugs.¹⁶ Early proponents drew inspiration from LGBTQIA+ activists to implement care practices that protected the life, liberty, and freedoms of those suffering due to prohibition. This included distributing supplies (e.g., unused syringes, condoms), opening safe consumption sites, offering myriad forms of community support, practicing mutual aid, and engaging in civil disobedience. Harm reduction has thus traditionally existed in opposition to the state. However, its meaning has evolved, and some people now express concern over the co-option of harm reduction by medical, non-profit, and social service professionals whose values are not liberation from the drug war and its antecedents.¹⁷ For instance, it is common for access to medical care to be contingent upon one’s willingness to provide identification and have their movements tracked by employees. In our current context, then, harm reduction may denote state-sponsored programs that reduce the physical consequences of illegal drug use or grassroots care practices. 

Medicalization

Broadly speaking, medicalization refers to the social, economic, and political processes through which human behaviour becomes defined and treated through a medical lens. Historically, the institution of medicine has had a narrow reach and scope: Only very specific phenomena were in its purview, and medical professionals had limited influence over the social world. Over time, however, and particularly in the last century, what were previously seen as “normal” human issues have been increasingly labeled as problems for medicine to diagnose and solve.¹⁸

Medicalization occurs on three levels: conceptual, whereby medical vocabulary is used to “order” or define a problem at hand; institutional, which entails medical organizations becoming involved in defining and treating problems as well as medical professionals functioning as “gatekeepers” or “institutionally legitimized claims-makers” with exclusive access to treatment through specialized institutions (i.e., hospitals, detox centers, addiction treatment centers); and interactional, by which medical understandings of phenomena shape our interpersonal relations.²³ Practically, emphasizing the socially constructed nature of “sickness” enables us to interrogate taken-for-granted assumptions about the origins and effects of drugs, drug use, and drug policy. It also prompts us to consider which actors and institutions have authority to determine the meanings we attach to “abnormal” or “deviant” behaviour and what their nascent motivations are. Bluntly, we should ask who benefits from calling people “ill” and to what ends.

A specific example of medicalization occurring with drug use is the emergence of “substance use disorder” diagnoses. These labels are recent additions to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and their inclusion required significant lobbying by psychiatrists and other medical actors. Making substance use medical has benefits and drawbacks (see “substance use disorder”), but most crucially, it makes obvious that politics are as—if not more—important than science in creating diagnoses. Whether the expansion of disease and disorder categories leads to more equitable outcomes for people who use drugs is contested. Regardless, that drug use is a “disorder” is not politically neutral nor is it objectively “true”—this is being negotiated. 

Safe Supply

The Canadian Association of People Who Use Drugs (CAPUD) defines safe supply as “a legal and regulated supply of drugs with mind/body altering properties that traditionally have been accessible only through the illicit drug market.”¹⁹ It denotes distributing regulated (pharmaceutical-grade) drugs through legal channels and enabling a person to know precisely what they are consuming and in what quantities. Like harm reduction, safe supply as a concept is rooted in the principles of human rights for all people, irrespective of how or why they choose to change their cognitive-affective-physiological processes. Safe supply is not the same as opioid agonist treatment (OAT) or other substitution therapies that may be prescribed in lieu of actual drug use.

In Canada, accessing safe supply is difficult. Presently, the federal government stipulates that healthcare practitioners (e.g., medical doctors, nurse practitioners, pharmacists) may prescribe opioids, stimulants, and benzodiazepines based on their professional judgement.²⁰ However, it is common for someone who wishes to procure safe supply to first require a diagnosis of “substance use disorder” (SUD), which erroneously conflates drug use with addiction and ignores those for whom use is recreational. Additionally, not all drugs are available via current models (e.g., acquiring heroin requires enrolment in a highly specialized program) nor are all drugs dispensed in the form that some users prefer (e.g., injection drugs are excluded), nor are most people able to take home or “carry” more than a limited dose of their prescription. Unpredictable decisions by policy without the consultation of consumers are also points of tension,²¹ and the disparities between supply and demand are particularly pronounced in remote and rural areas. Though minor shifts during the COVID-19 pandemic have marginally enhanced the availability of prescriptions, the logistics of obtaining one remain extremely convoluted.

Social Control

The way that society regulates human action to maintain the status quo. Mechanisms such as rules, norms, laws, and policies are exercised interpersonally and through institutions to prohibit change. In terms of discouraging illegal drug use, social control is both formal (e.g., criminal punishments, ) and informal (e.g., shaming). Similarly, positive controls exist to reward those who do not use drugs or who reduce or stop their use. These include mechanisms such as having criminal penalties softened after periods of abstinence, being permitted to return to work once one has tested negative for drugs, and being congratulated by friends and family for “recovering” or “getting sober.” Social control is everywhere, and it is important to recognize that it primarily benefits those whose societal power requires wide-spread conformity.

When it comes to drug use, a crucial mechanism of social control is medicine. The origins of medical social control can be traced to the 18th century, at which time the west experienced a series of economic crises. Cities were increasingly concerned with productivity under capitalism, and “normalcy” and “morality” became defined almost exclusively by one’s ability to generate surplus wealth for large producers. Simultaneously, science replaced religion as the dominant institution of social regulation. With the introduction of secularism and democracy, the state needed new ways to regulate its citizens. It did this through the “science” of psychiatry, which hadn’t previously existed. By labeling the unemployed as “mentally ill” or “diseased,” it justified confining them in forced labour institutions, the legacy of which is felt today.²² Although “patients” are no longer obligated to work when confined, the notion that an inability to do so indicates a “brain disease” or “mental disorder” is the premise of much psychiatric and addiction-related care.

In practice, formal medical social control for drug use manifests as involuntary admission to hospital; extensive medical documentation being a requirement for accessing safe supply or substitution therapies; policing strategies that “divert” people caught using drugs to drug treatment courts; and mandatory urine screenings as a condition for maintaining housing and employment. Informal social control for drug use manifests as being told by doctors and medical professionals that drug-related illness is one’s own fault; being encouraged to see oneself as “sick” for using drugs, including in 12-step programs that promote quasi-religious self-surveillance; being called “junkie” or “addict” by strangers; and the common myth that doctor-prescribed medications such as those given to people diagnosed with ADHD or other disorders are more respectable than street-based medication, despite their similar effects.⁵

Stigma

The most common description of stigma comes from sociologist Erving Goffman, who defined it as, “an attribute that is deeply discrediting that causes one’s identity to be ‘spoiled’ compared to the dominant group.” He divided stigma into three types: those linked to “abomination of the body” (e.g., physical disability); those that incite “tribal” responses (e.g., race, religion); and those derived from “character traits” (e.g., drug use, mental illness, HIV status).²⁴ Published in 1963, Goffman’s theory is dated but remains influential. For instance, the Government of Canada defines stigma as “negative attitudes, beliefs or behaviours about or towards a group of people because of their situation in life.” This is a limited depiction of how and why stigma emerges, who benefits from enacting it, and the different ways it is sustained. 

Specifically, stigma is not stable. Whether a certain characteristic is stigmatized is constantly negotiated and re-negotiated, and this changes over time.²⁵ Consider that homosexuality was once criminalized, and it later appeared as a mental disorder in psychiatric texts. Although queerness is still “non-normal” in some contexts, general responses to it have shifted dramatically alongside legislation, policy, and evolving trends in medicine. Drug use is no different. Before anti-drug laws were implemented, and long before “substance use disorders” existed as official diagnoses, drug use was deemed neutral. It became stigmatized as the “war on drugs” escalated and, with it, so too did racial, ethnical, religious, and class-based inequalities. Important to remember is that in both the cases of sexuality and drug use, alterations in public perception have been due to grassroots activism and civil disobedience. 

Next, stigma is not just interpersonal. It is more trenchant than individual attitudes and behaviours, and stigma becomes institutionalized and systemic when official policies (in housing, employment, education, the child welfare system, and so on) prohibit entrance based on identification with a particular class. For example, compulsory attendance at 12-step meetings as a condition of not being re-incarcerated reflects this latter type of stigma. So too do requirements placed on healthcare professionals who have been to addiction treatment who must complete regular drug tests to remain employed. 

Finally, stigma becomes internalized. Research on this phenomena repeatedly concludes that viewing oneself as “bad,” “Mad,” and/or “diseased,” which is an outcome of institutionalized and systemic stigma, leads to negative outcomes.²⁶ People who are stigmatized begin to anticipate rejection, they may alter behaviour based on these expectations, and their material conditions deteriorate. This is especially true of people who are stigmatized on multiple axes, which highlights that drug use alone is not a sufficient condition for being stigmatized. Those who use drugs but are otherwise stably housed, employed, and part of dominant racial and cultural groups can consume with near-impunity. Anti-stigma campaigns, then, which address drug use and drug use alone, may not be effective because this is just one facet of one’s identity. 

Substance Use Disorder (SUD)

A category of disorders that reflect the medical label for addiction. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the official text on which diagnoses are based in North America, lists 11 criteria for SUD that include “hazardous use” (using a substance in ways that are dangerous to oneself and/or others), “social or interpersonal problems related to use,” “much time spent using,” and “spending a good deal of time getting the drug, using the drug or recovering from the effects of the drug.” In order to be diagnosed with a SUD, a person must demonstrate at least two of these symptoms within a 12-month period. A taken-for-granted assumption associated with this category of diagnoses is that drug use takes place “against one’s will” in ways that are aberrant, chaotic, and compulsive.

The medical profession considers SUD to be an incurable brain disease or mental disorder, which has consequences for users. As stated, stigma research has shown that being labeled as “mentally ill” triggers distrust among professionals and lay people. People with a “SUD” are seen as being less likely to maintain employment or be fiscally responsible, even if these biases are unconscious, and even to themselves.²⁶ At the same time, the notion of SUD as illness may elicit sympathy from outsiders; it is preferable to being criminalized; and accessing safe supply and other healthcare may require having this label on one’s medical records. 

Ultimately, there is no agreed upon definition for SUD. Critical researchers, as well as drug users and advocates, point out that many of the criteria for SUD are environmentally specific. For instance, whether or not a person has “social or interpersonal problems related to use” will depend on the norms in their peer network, their housing status, whether they have prior drug convictions, whether they have to complete drug screenings to maintain employment, and how often they use drug(s) in public. Similarly, the time one spends acquiring drug(s) will be influenced by their wealth and drug use scene. Finally, when two people exhibit identical behaviour, only one may be told they have a SUD while the other may go straight to jail based on race and class. For our purposes, “substance use disorder” will be used to confer official medical diagnoses. 

War on Drugs

Broadly, the war on drugs refers to a series of policies, practices, and laws introduced throughout the 20th century to criminalize drug consumption and activities associated with it. By now, it is well documented that the so-called drug war has been a proxy war whose true “enemies” are racialized, immigrant, and poor communities. Over the last 110 years, anti-drug laws have been an effective tactic for preventing the economic, political, and social advancement of those whose ways of life differ from those deemed ideal by the settler-colonial state.

In Canada, the war on drugs officially coincided with the anti-asiatic riots. Prior to this, tensions had escalated between Chinese men who lived on the West Coast after building the Canadian Pacific Railway (CPR) and white settlers: white settlers were threatened by a perceived lack of employment opportunities as well as the racist assumptions they held about non-white, non-Christian immigrants. On Sept. 07, 1907, fueled by fears of “moral decline” linked to “racial mixing,” 9000 people, including political and labour leaders, marched to Vancouver city hall to protest immigration. Some proceeded to vandalize and destroy Chinese and Japanese businesses. Deputy Minister of Labour Mackenzie King was then sent from Ottawa to investigate, and rather than focus on reparations, he concluded that opium, which was used for festive and economic purposes by the Chinese, should be banned. King stated,

“The Chinese with whom I converse on the subject assured me that almost as much opium was sold to white people as Chinese, and the habit of opium smoking was making headway, not only among white men and boys, but also among women and girls…to be indifferent to the growth of such an evil in Canada would be inconsistent with those principles of morality which ought to govern the conduct of a Christian nation.”²⁷

The recreational use of other drugs was outlawed in subsequent years, and by the time US President Richard Nixon officially declared a “war on drugs” in 1971, anti-drug propaganda had solidified in the public imagination. Penalties for drug possession and distribution intensified in the ‘70s, as did racial disparities in arrests, criminal convictions for possession, and sentencing severity. Throughout, the war on drugs was driven by white, Christian values and economic goals, so much so that a top Nixon aide later admitted, 

“You want to know what this was really all about. The Nixon campaign in 1968, and the Nixon White House after that, had two enemies: the antiwar left and Black people. You understand what I’m saying. We knew we couldn’t make it illegal to be either against the war or black, but by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night on the evening news. Did we know we were lying about the drugs? Of course we did.”²⁸

Since then, despite—or because of—its race and class-based motives, the war on drugs continues. Its influence is felt not just in the criminal justice system but in education, employment, housing, media, medicine, and families. Its impacts have been devastating. The drug war has destabilized entire nations, cost trillions of dollars in enforcement, ended countless lives, fueled organized crime; and still, the illegal drug trade remains the world’s most profitable illicit business.¹⁵ It is not uncommon to hear that “drugs have won the war on drugs,” but the drug wars’ losers, who are also society’s most marginalized, bear the brunt of this. 

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