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https://www.infirmiere-canadienne.com/blogs/ic-contenu/2022/01/17/le-leadership-infirmier-est-vital-au-faconnement-d

What individuals can do to counter the harmful effects of criminalization

Jan 17, 2022, By: Shanyn Simcoe

Nurses witness the harms of drug criminalization first-hand. These harms, spanning physical, mental, emotional and psychological injuries, have never been so evident as during the current drug-poisoning crisis. In 2020, accidental overdoses killed an average of 17 Canadians each day (Public Health Agency of Canada [PHAC], 2021). Although the majority occurred in British Columbia, Alberta and Ontario, preventable and fatal overdoses spiked across the country during the COVID-19 pandemic (PHAC, 2021).

In response, a growing cross-section of advocates and health, safety and political leaders have called for decriminalization of personal possession as an upstream measure to help address this crisis. In the midst of unprecedented rates of accidental and fatal overdoses, it is vital that nurses amplify their support for decriminalization and advocate for a model that will reduce stigma and harm and save lives. (See Appendix A: examples of how decriminalization works.)

Criminalization forces users to rely on drugs obtained from the black market and of unknown content and potency.

As a substance use nurse, I am keenly aware of the multiple and lasting impacts that drug criminalization has on people who use illicit drugs and its contribution to the risk of accidental overdose. Two years into B.C.’s opioid overdose crisis, it seemed that the primary focus on naloxone and overdose prevention sites was having a limited impact on reducing the rates of accidental overdoses and fatalities. Because I was unable to address the root causes of overdose risk in the context of my employment, I turned to policy advocacy. This led to the creation of an official petition to the House of Commons in 2018. The petition sparked numerous conversations with the public and my colleagues, officially documented public support, and served as a foundation to secure union endorsement of decriminalization.

In this article, I share what I have learned about decriminalization and policy advocacy to inspire other nurses to also take steps, in their personal or professional roles, to address the worsening overdose crisis. Fortunately, in the digital age, policy advocacy can be as simple or complex as one desires, and every effort, no matter what scale, brings us closer to reforming harmful drug policies and resolving the drug-poisoning crisis.

The impacts of criminalization

Even prior to the drug-poisoning crisis, drug criminalization was responsible for the increased health and social harms that nurses witness. For example, fear of criminal charges and incarceration leads to rushed drug preparation and ingestion, increasing the potential for injury, disease transmission and overdose (Canadian Nurses Association [CNA], 2017).

For some individuals, illicit drug use results in involvement with the correctional system, which can keep them trapped in a cycle of crime, violence, injury, trauma and addiction. Individual lives, family and community cohesion are (often irreversibly) dismantled by this cycle. Drug criminalization disproportionately affects Black and Indigenous people, people of colour, and poor and other marginalized populations (Ka Hon Chu, Elliot, Guta, Gagnon, & Strike, 2020).

Drug criminalization forces users to rely on drugs obtained from the black market and of unknown content and potency (Levy, 2018). Further adulteration of the unregulated drug supply with fentanyl, fentanyl analogues and benzodiazepines has resulted in unprecedented numbers of accidental overdoses across socio-demographic and socio-economic groups (PHAC, 2021). Drug criminalization is therefore directly responsible for the increased toxicity of the drug supply (Levy, 2018).

Fear of criminal prosecution and incarceration also prevents people from disclosing their drug use and seeking health and safety supports.

Influencing attitudes that impact health outcomes

Drug criminalization impacts social norms and creates negative stereotypes of illicit drug users. Nurses are not immune from having their attitudes and beliefs about illicit drug users negatively shaped by anti-drug propaganda. When these stereotypes are unchallenged, people who use illicit drugs experience stigma, discrimination and poorer health outcomes (CNA, 2017).

During health-care encounters, a prior experience of stigma and discrimination may prevent individuals from fully disclosing the extent of their drug use (CNA, 2017). This omission can result in inadequate withdrawal or pain management and can lead to interrupted or incomplete medical treatment when individuals elect to leave a facility to self-medicate or discharge themselves against medical advice (Rachlis, Kerr, Montaner, & Wood, 2009). In the context of the toxic drug poisoning crisis, non-disclosure or the minimization of illicit drug use is particularly dangerous as overdose risk may be overlooked or exacerbated.

Nurses’ increased proximity to illicit drugs

In some practice settings, nurses have increased physical proximity to illicit drugs. As an outreach nurse, I often transported people who regularly used illicit drugs, which raised unique concerns for my colleagues and me. Could illicit drugs or drug residue remain in our cars and be detected during a border crossing? What are the legalities and logistics of handling a drug sample to facilitate sending it for drug-checking? What are the legal implications of volunteering at unsanctioned overdose prevention sites? Although these concerns could be easily mitigated and our questions answered, they illustrate the fear that is generated by the criminalization of some drugs but not others; this interferes with the delivery of harm reduction and potentially life-saving care.

By comparison, such fears were absent in relation to our increased proximity to alcohol, tobacco, cannabis and regulated and controlled prescription drugs. Decriminalization, which falls between criminalization and legalization (see Appendix B), would reduce the double standard that exists between regulated and unregulated substances that are commonly used for enjoyment and to manage physical, mental, emotional and spiritual pain.

Nursing input is essential to drug policy

Influencing policy is both a professional responsibility and an expectation of nurses held by the general public (Villeneuve, 2017). Although nurses have been directly involved in developing policies and programs in response to the current drug-poisoning crisis, preventive measures, such as decriminalization, are also urgently required. Challenging and changing the drug policies responsible for the loss of lives to preventable drug poisonings is within the purview of nurses’ ethical and professional responsibilities.

Creating and circulating a petition provided a vehicle for professional engagement, public education and policy advocacy and served as a platform to appeal for union endorsement of decriminalization. After documenting support from the members of my region, I could confidently appeal to the union executive for further endorsement. Consequently, in July 2018, the BC Nurses’ Union issued a press release in support of decriminalization (O’Hara, 2018). This example demonstrates how leadership by individuals and nursing organizations is critical to “bring nursing knowledge, science, and experience to bear on selected areas of policy with targeted outcomes that are amenable to nursing input” (Villeneuve, 2017, p. 24).

Drug policy reform: what can nurses do?

As decriminalization policy begins to take shape, it is vital that nurses are knowledgeable about the various models of decriminalization and their strengths and limitations. Knowledgeable nurses can influence their peers, the public and their leaders to promote evidence-informed drug policy reform, and many nurses and some nursing organizations are already doing this. With this in mind, here are some actions that nurses can take to build momentum toward drug policy reform:

• Learn about the various models of decriminalization.
• Have evidence-informed conversations and share information with peers, the public, unions, and professional organizations.
• Post on social media and other digital platforms.
• Create or sign a petition.
• Contact elected officials.
• Appeal to your union(s) and professional organization(s) to endorse full rather than partial decriminalization. Public statements, press releases and position statements issued by these groups in support of full decriminalization amplify nurses’ input, elevate patient voices, influence the public and ultimately influence policy.

To date, only a handful of nursing organizations have publicly endorsed decriminalization, and even fewer have endorsed a specific model. At this point in the drug-poisoning crisis, and given the multiple harms of drug criminalization on individual, family and community health, the absence of additional nursing positions and input on this issue is curious.

Across Canada, municipal support for decriminalization has noticeably increased, and early policy development is occurring in the City of Vancouver (see Appendix A). In fact, Vancouver recently submitted its proposed decriminalization policy to the federal government for approval. Their model reflects full decriminalization but has received criticism for not going far enough to balance various stakeholder input and acknowledge individual self-determination. Although this policy would only apply to Vancouver, it could set a precedent for future federal drug policy.

Conclusion

The COVID-19 pandemic public health measures contributed to increased rates of toxic drug poisonings and led to escalated calls for decriminalization. The City of Vancouver responded by initiating municipal drug policy reform. The Vancouver model is significant in setting precedent in Canada. Although a sign of progress, the current Vancouver model does not go far enough to reduce stigma, reduce harm, and honour human-rights, according to those who are most affected by it. It is at this juncture that nurses, as patient advocates, and the largest group of health professionals in the country, play a vital role to influence the direction of drug policy reform. Federal approval of decriminalization is within reach. With sustained and strategic advocacy, nurses and nursing organizations can influence the path forward to develop a federal model of full decriminalization with the potential to effectively reduce stigma that is based on the most current evidence and that acknowledges individual self-determination. To not do this risks drug policy reform in name alone.

Appendix A: examples of how decriminalization works

Decriminalization is not new or straightforward as a range of models exist. Most legislated models reflect partial decriminalization, replacing criminal with administrative fines. Here are three examples of how this can be done.

Vancouver

The Vancouver model was developed with diverse stakeholder input and reflects full decriminalization, with the removal of criminal sanctions, evidenced-based personal use threshold amounts and voluntary rather than mandatory referrals to health services (City of Vancouver, 2021a). The proposed model applies to the four main drugs found to contribute to high rates of fatal overdoses: opioids, cocaine, crack cocaine and amphetamines (City of Vancouver, 2021b). Vancouver’s proposal for decriminalization includes recommendations for ongoing evaluation to assess and review the risks and impacts (City of Vancouver, 2021a) and represents a vital step in advancing drug policy reform in the Canadian context. It reflects elements of a well-designed model of full decriminalization by including measures for evaluation and ongoing education of police and the public and acknowledging the need for additional harm reduction, health and social supports without being contingent upon their prior implementation (Madden, Tanguay, & Chang, 2021; Nurses and Nurse Practitioners of British Columbia & Harm Reduction Nurses Association, 2019).

Nevertheless, the Vancouver model has received criticism from drug user groups for tokenizing their consultation and having personal use threshold amounts based on outdated data (Kerr & Mullins, 2021). Drug users have consistently asserted that their authentic consultation is essential to develop a model of decriminalization that is intended to achieve its objectives, is based on current evidence and reduces rather than exacerbates harm (Kerr & Mullins, 2021; Madden et al., 2021). Voluntary rather than mandatory health service referrals are an improvement; however, including a referral component undermines individual self-determination to access health and social service supports. As well, for marginalized populations, there is an inherent coercion associated with a police-issued referral, even if deemed voluntary (Elliot, McPherson, & Shane, 2021). For these reasons, the Vancouver model reflects paternalism and risks the undue pathologization of drug use, mirroring the experiences described by Portuguese drug users.

Portugal

Portugal has been extensively studied for its model of partial decriminalization and therefore offers evidence to inform our choices in Canada. In 2001, Portugal implemented partial decriminalization as part of comprehensive drug policy reform. Subsequently, Portugal has seen decreases in stigma, social harms, overdoses, public drug use, HIV transmission, lost productivity and the demand on criminal justice resources (Laqueur, 2015). However, Levy (2018) reported that Portuguese drug users are still subjected to confiscations, fines, monitoring and surveillance, and stigma and discrimination remain with the added pathologization of drug use. Instead of criminals, drug users are now seen as people with an illness requiring treatment. Partial decriminalization reflects a public health approach but fails to centre drug users as autonomous, self-determining individuals.

Germany

Germany offers the only model of full decriminalization of personal possession of drugs beyond cannabis. Germany reports lower rates of drug use, HIV infection and drug-related overdose than many other European countries. Although it is impossible to attribute this only to its progressive drug laws, Germany “has seen increased treatment access through stigma reduction” (Hughes & Hulme, 2019, p. 13). According to Hughes and Hulme (2019), the key disadvantage of this model is the lack of legal interventions to address problematic drug use.

Appendix B: degree of criminal justice involvement graphic

This graphic is reproduced with permission from the Canadian Centre on Substance Use and Addiction.

References

Canadian Nurses Association. (2017). Harm reduction & illicit substance use: Implications for nursing. Ottawa: Author.

City of Vancouver. (2021a, March 1). Preliminary submission to Health Canada: Exemption request. Retrieved from https://vancouver.ca/files/cov/cdsa-preliminary-exemption-request.pdf

City of Vancouver. (2021b, April 8). Submission on thresholds. Retrieved from https://vancouver.ca/files/cov/vancouver-proposed-threshold-submission.pdf

Elliot, R., McPherson, D., & Shane, C. (2021, March 25). Rights organizations advocate for unconditional drug decriminalization in Vancouver. [Letter]. Retrieved from https://www.pivotlegal.org/rights_organizations_advocate_unconditional_drug_decriminalization_vancouver

Hughes, C., & Hulme, S. (2019). Models for the decriminalisation, depenalization and diversion of illicit drug possession: An international realist review. [Conference Paper]. Retrieved from https://harmreductioneurasia.org/wp-content/uploads/2019/07/Hughes-et-al-ISSDP-2019-Models-for-the-decriminalisation-depenalisation-and-diversion-of-illicit-drug-possession-FINAL.pdf

Ka Hon Chu, S., Elliot, R., Guta, A., Gagnon, M., & Strike, C. (2020). Decriminalizing people who use drugs: Managing the ask, minimizing the harm. HIV Legal Network. Retrieved from http://www.hivlegalnetwork.ca/site/decriminalizing-people-who-use-drugs-a-primer-for-municipal-and-provincial-governments/?lang=en

Kerr, T., & Mullins, G. (2021, May 27). The Vancouver model of decriminalization leaves out those who need it most. The Vancouver Sun. Retrieved from https://vancouversun.com/opinion/thomas-kerr-and-garth-mullins-the-vancouver-model-of-decriminalization-leaves-out-those-who-need-it-most?fbclid=IwAR1XNdiNxVb73W78b1GvdENjOQLZPWobkcwMuTUEmgQSm39_ec_-BW-4YAs

Laqueur, H. (2015). Uses and abuses of drug decriminalization in Portugal. Law & Social Inquiry, 40(3), 746-781. doi:10.1111/lsi.12104

Levy, J. (2018). Is decriminalization enough? Drug user community voices from Portugal. London, GB: INPUD Secretariat.

Madden, A., Tanguay, P., & Chang, J. (2021). Drug decriminalisation: Progress or political red herring? London, GB: INPUD Secretariat.

Nurses and Nurse Practitioners of British Columbia & Harm Reduction Nurses Association (2019, August 9). Nurses and Nurse Practitioners of British Columbia (NNPBC) and the Harm Reduction Nurses Association (HRNA) call for the decriminalization of people who use drugs in B.C. [Press Release]. Retrieved from https://www.nnpbc.com/pdfs/media/press-releases/PR-HRNA-NNPBC-Statement.pdf

O’Hara, B. (2018, July 18). BC Nurses’ Union president calls for decriminalization and national public health emergency to combat opioid crisis. CHEK News. Retrieved from https://www.cheknews.ca/bc-nurses-union-president-calls-for-decriminalization-and-national-public-health-emergency-to-combat-opioid-crisis-471007/

Public Health Agency of Canada. (2021, March). Opioid- and stimulant-related harms in Canada. Retrieved from https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants

Rachlis, B. S., Kerr, T., Montaner, J. S. G., & Wood, E. (2009). Harm reduction in hospitals: Is it time? Harm Reduction Journal, 6, 19. doi:10.1186/1477-7517-6-19

Villeneuve, M. J. (2017). Public policy and Canadian nursing: Lessons from the field. Toronto: Canadian Scholars.

Shanyn Simcoe, BSN, RN, is a student in the University of Victoria master of nursing program. Her nursing practice is grounded in mental health and substance use, harm reduction and primary care. Her interests include personal, social and professional decolonizing practices and policy advocacy to address the structural determinants of health.