Visions Journal

Dan Reist

Reprinted from "Opioids" issue of Visions Journal, 2018, 13 (3), p. 5

Overdose deaths in British Columbia have been increasing since 2012. This fact led the Provincial Health Officer to declare a public health emergency in April 2016. Since then, much has been done to address the problem. But we still have a long way to go.

We know far more than we used to about the drugs being used. Many overdoses are caused by a set of drugs called opioids. These include traditional opiates, like heroin, which are derived from the opium poppy, as well as a range of similar, chemically derived drugs, such as fentanyl. We also now have much better up-to-date data to track what’s happening on the street, and we have increased the number and type of services available to people who use opioids.

Yet the number of overdose deaths continues to increase. Why is this? What more can we do?

When I read the reports and look at the numbers, it is very difficult for me to see the human beings that the data represent. It’s time to change how we think about drug use and problems like overdose: it’s time to humanize our approach.

By humanizing our approach, I don’t mean talking more about client-centred services or running more anti-stigma campaigns.

Humanizing the system means that we must stop focusing on drugs as the problem. We must stop making artificial distinctions between bad drugs, less bad drugs and good drugs. We have to get over our hang-ups about drug use in general. The fact is that human beings have been using psychoactive substances for thousands of years—for both recreational and medicinal purposes. Our ancestors didn’t distinguish between a drug that made them feel good and a drug that made them healthy and well.

Humanizing the system also requires that we take an honest and critical look at how drugs have played a role in human power relationships throughout modern history. Some (but not all) Indigenous cultures were destroyed when European explorers and settlers introduced them to alcohol. Prohibition—the government-sponsored, widescale ban of alcohol and other drugs in the early 20^th century—and the promotion and sale of drugs in the modern world have been shaped by racial tensions, economic interests and patterns of social control in our communities.

For example, Canadian prohibitions against opium were introduced as a way to control the Chinese immigrants in cities like Vancouver in the context of racially motivated labour unrest. Similarly, the promotion of amphetamines to women after World War II was largely designed to find a market for the over-supply of a drug that had been used by the troops and to pacify women displaced from the workforce by the returning soldiers.

The control of drugs (by government and non-government figures) has supported long-term power imbalances and has contributed to cultural disintegration. Consider, for example, the impact of the intentional over-production of gin in 18th-century London, England, on the urban poor, or the introduction of whisky into Indigenous communities whose land and way of life was being systematically stripped from them.

Minority groups and disempowered populations paid the greatest price in overdoses and other drug-related problems in the past. It is hardly surprising that they continue to pay the greatest price today.

With some historical understanding and insight, we should be able to admit that the problem is not the drugs. But are we prepared for the alternative—that the problem lies in how we view drugs and the individuals who use them, and that our treatment systems often perpetuate the power imbalances already in place?

In our modern social services and health care systems, treatment and care plans are often based on a power and control model. We have “experts” (doctors, nurses, counsellors and other staff) who prescribe solutions to the “non-experts” (patients or individuals seeking help). Our treatment systems rely on medical “evidence” derived from carefully controlled studies that tell us what the “problem” is and what our best “fix” is likely to be. In this power structure, the expert gives the orders, and the non-expert follows them.

Even our prevention programs use this power and control model. We are constantly looking for new and better programs that will successfully prevent people from adopting behaviours that are harmful to their health. We focus on getting the “right” message to people so they can make the “right” choices. We use a range of social marketing techniques to persuade people to view drugs in the “right” way and to adopt the “right” behaviours when it comes to drug use. And it is always the authority figure who knows what is “right.”

There is no doubt that almost all drugs can be dangerous, especially if they are used too often, in a concentrated form or without careful thought and intention. While there has been a lot of talk about legalizing drugs as a first step towards solving the “problem” of substance use in our communities, legalization alone is not going to solve all the problems we have created. Legalizing alcohol after the experiment with prohibition was an important step, but we still have significant problems with its use in our communities. We need to rebuild a healthier culture of substance use.

But how?

Oddly enough, we can find the beginnings of an answer to this contemporary question by looking at how the ancient Greek philosopher Aristotle and later thinkers in the humanist tradition have thought about knowledge.^1-4 Aristotle talked about two kinds of knowledge. The careful study of patterns of cause and effect leads to a very useful kind of knowledge—the kind of knowledge that allows us to expand our control of the world around us. Today, we might call this scientific knowledge. But Aristotle also spoke of another kind of knowledge—the knowledge of practical reason. This knowledge comes to us from our interactions with other human beings and our environment as we explore ideas of what it means to live a good life.

Within the humanist tradition, which emphasizes self-knowledge over external authority, such exploration requires that we view others as having agency and the freedom and ability to make decisions about their own well-being. In this framework, practical reason involves a give-and-take process in which we seek to understand one another while at the same time finding a way to live together in society. While scientific knowledge is focused on achieving certain goals, practical reason is focused on the relationships between separate autonomous beings. It is about building bridges between individuals and within communities.

We’ve done a pretty good job of expanding our scientific knowledge about drugs and their potential benefits and harms. But has that expansion taken the place of, or come at the cost of, a more humanist approach? Scientific knowledge is expressed as fixed realities and exact measurements. It provides us with a means of control. Human emotions and social interactions, however, are not fully captured by scientific laws and numbers. Increased social understanding is possible only when we stop viewing and treating human beings as mere scientific objects. We need to see them as individuals whose subjective experiences are as important as the objective events that happen to them.

In order to solve the problems that we have created with our use and perception of drugs, we need to resolve the complex power dynamics in our society. This might mean easing our commitment to controlling drugs, controlling messages and controlling people. It might also mean investing more in building understanding, building connections and building capacities for self-care and self-healing within individuals and among our communities.

As more voices are heard and more perspectives understood through genuine, respectful dialogue, we are more likely to find real, long-term solutions to substance use issues in our communities. The social norms and rules we craft together will be less reflective of the desires of special-interest groups and be more responsive to the needs of everyone.

But engaging in this dialogue is far from simple. We are each limited by our own perspectives, and we are all influenced by special interests. We must constantly ask ourselves, Whose voice has not been heard? How might our cultural assumptions and social rules impact different individuals and groups? How do we create equitable, inclusive, engaged communities