Carlyn Zwarenstein is the author of Opium Eater: The New Confessions.
The opioid crisis is a public-health emergency: At least 3,987 people in Canada died from overdoses in 2017 – a jump of more than 1,000 deaths compared to the previous year. Due to an increasingly dangerous illicit-drug market, along with decreasing access to “safe” prescription opioids, the fatality rate dramatically overshadows the E. coli outbreak in Walkerton, Ont., in 2000 (which killed seven people) and the SARS outbreak in 2003 (which resulted in 44 deaths). These crises spurred relatively quick and serious public-policy changes. Not so with the opioid crisis, which is a steam roller accelerating across the country. There’s a sickening feeling among drug users that nobody cares if they are picked off, one by one. Among several possible parallels is that of the early years of the HIV crisis, when gay men suffered a similar sense of the end of the world while life went on for everybody else. This has led to frustrated calls from drug users, as well as allies (including family members who’ve lost loved ones) for a commensurate policy shift.
Last week, I attended the Opioid Symposium, a conference hosted in Toronto by Health Canada and The Globe and Mail. There, we heard clearly from front-line workers, government officials, law enforcement and drug users alike that addiction and drug use are, indeed, public-health issues, not moral or criminal ones. Users and advocates were repeatedly and explicitly lauded by policy-makers for their activism, for pushing government to do the right thing by implementing decriminalization and radical harm reduction policies – even while, smiling, they continued to refuse to do the right thing.
I felt helpless sorrow as person after person stated clearly and directly what they need to be safe and was met with feel-good evasions. I can only imagine what it felt like for them. If you are physically dependent on opioids, you may need to inject several times a day. Each time, you know that this time it may kill you, and that if it were not illegal – better yet, if it were legal and regulated – you’d be fine.
And yet decriminalization (to which, as André Picard pointed out in a recent column, the Liberals do not seem “philosophically opposed”) was off the table.
This is not a little rift; it’s a tectonic one – based on the difference between who gets to decide policy and who suffers its consequences.
“Our presence there,” says Garth Mullins, a Vancouver broadcaster, harm-reduction activist and union organizer, “did not influence things.” Mr. Mullins told me that, in advance of the conference, he and his PWUD (people who use drugs) colleagues feared their presence might be tokenistic. On the bright side: “At least any false sense of consensus was broken up."
I’m a pain patient and dependent – in all the senses of that word – upon opioids. I take these powerful drugs as (appropriately) prescribed. They’ve been life-saving, while all other treatments have been intolerable or inadequate in restoring the function and quality of life needed to work, raise my children and stay sane in the face of daily pain from an unpleasant spine disease. Suppose, because drug makers cease to see profit in making them or because physicians are scared to prescribe them, I lose access to this sort of medication. This is occurring right now in Oregon, where doctors have been told to taper all chronic-pain patients off their opioids. For a few, a slow and supportive taper will improve things or leave them with equivalent pain, and fewer side effects. For most who were appropriately prescribed their medications in the first place, even such a careful taper will be devastating. I’d have to choose between mindfully meditating on my lost quality of life and income – and the illicit market.
Despite us both requiring safer access to powerful drugs, #patientsnotaddicts has been a social-media rallying cry among pain patients. Our strategy has been to argue, indignantly, our drugs don’t get us high. It’s a reaction to being increasingly scrutinized in a way illicit drug users find very familiar, and to the untested assertion that any pain relief we think we feel is just relief of withdrawal symptoms.
The patients-not-addicts argument has a deeply classist, often racist, very hateful subtext. In the Philippines, hatred of “drug addicts” and “junkies” has allowed a gradual massacre of poor people and political opponents (around 12,000 extrajudicial killings) to proceed unchecked – because the people disappearing are considered human rubbish. In the United States, we frequently hear comments such as, “Well, that’s another addict off the streets,” when someone dies of an inadvertent fentanyl overdose. This week, in fact, The New York Post reported an NYC police officer telling methadone clinic patients to “shoot your fucking heroin and die." In 2016, another officer was photographed giving the thumbs-up beside the body of a man who’d fatally overdosed in Missouri. I wish these were rare examples, but an inability to see drug users as human beings is pervasive and deeply linked to other hatreds: of Indigenous people, homeless people, sex workers, convicts – in other words, those with the least power and greatest hardship.
In Opium Eater: The New Confessions, my account of, in part, my subjective experience of taking opioids and living with pain, I share my previously secret fascination with addiction and the lives and experiences of people who use drugs. Since my book was published in 2016, I’ve had the privilege of speaking with many. It should surprise no one that illicit-drug users are not a different species. The only difference is not that they use psychoactive substances for various reasons – those who enjoy coffee or wine do, too – but that criminalization exacerbates existing economic inequalities, forces new poverty and further illegal activities upon them, results in new traumas, and dramatically increases dangers intrinsic to the substance itself. It’s important to recall that Prohibition made alcohol a far riskier substance than it is now under a regulated, legal system. And to understand that there are actually relatively few health risks in properly dosed, cleanly injected diacetylmorphine – pharmaceutical-grade heroin – which is why it can be used for surgery or labour, as well as long term for patients who can’t or won’t stick with addiction medications such as methadone or buprenorphine, which can be life-saving but don’t work for all users owing to their side effects or punitively rigid dosing regimen.
Various approaches to a safe, legal supply plus necessary, ultimately cost-saving supports (affordable housing, counselling, adequate income) have been successful in Switzerland, Portugal, Britain (through an early prescription heroin initiative), British Columbia and elsewhere. But Health Minister Ginette Petitpas Taylor told us “there is no silver bullet.” Apparently no variation on the basic tenet of the “Portugal model” – no longer making drug use a criminal act – could possibly work here in Canada.
The nod-and-smile approach to policy consultation is a real problem, not just because it’s patronizing and ineffective. The way people who use drugs are treated is a public health issue but also a rights one, to do with a distinct group of people being treated as less than human. I learned, as the child of white South Africans, that bad, wrong laws must be fought. The fact that my drug use is lawful (though stigmatized) means I have access to pain relief, and a fuller life. I’ve become friendly with other people with pain who, unlike me, also have a substance use disorder diagnosis and a history of street life – they don’t get pain relief. And yet their suffering and need for effective treatment of both physical and emotional pain – and minimization of harms – are as great as, or greater than, mine.
Mark Tyndall, executive director of the BC Centre for Disease Control, pointed out at the symposium that our efforts to de-stigmatize addiction, treat drug use as a health rather than criminal issue and save lives are actively undermined by a continued legal regime that criminalizes drug use. Afterward, he told me, “Let’s say you wanted to come up with the worst possible system for people who use drugs and are traumatized: you’d put them in jail. We’ve created a system where recovery is impossible.” I ask him why, if the Liberals are committed to evidence-based policy, they are so resistant to considering robust evidence favouring decriminalization. “In Canada, we have been bombarded with messages that certain drugs are so terrible that the general public can’t possibly see how decriminalization could help,” he said. “I understand how the Liberal government would see this as a no-win issue.”
Sheila Jennings is a lawyer and member of Moms Stop the Harm, a group of parents whose children have overdosed, often fatally, and who now advocate for harm reduction and decriminalization. “Some of the federal minister’s comments seemed to lack the necessary gravitas," she says, "so that was a sort of emotional dissonance that made folks distressed.”
But if anyone on the decision-maker side felt distressed, it was a passing qualm. Those whose health issues (and poverty) are criminalized don’t have that luxury. It was certainly a lot of political theatre: not for nothing did advocates hold up banners stating “They talk, we die.”