A Call for Substance Use Justice

I decided to go to medical school after working for years with homeless folks, most of whom were active drug users. Our work included everything from HIV testing and talking to people about how to use drugs more safely, to organizing against police brutality in our neighborhood, or visiting our dying patients in the hospitals, stairwells, or doorways where they spent their last moments.

The years I spent doing this work on the ground taught me more than anything about how connected things really are. How lack of economic opportunity, or discrimination in more "respectable" fields, can force someone into sex work, causing him or her to start using crystal meth as a way to stay awake and keep working. How poverty, for example, might cause someone to shoot up with a dirty needle, thereby increasing their risk for HIV or hepatitis C. How the War on Drugs disproportionately targets low-income people of color, funneling more people from these communities into the criminal justice system instead of health-based solutions for drug problems.

These things matter to us. They matter because as long as there is inequality in the way our society deals with substances and substance users, there will be inequality in our own treatment of substance use as health professionals. When I took on this position, I felt that it would be disingenuous for me to approach substance use from anything less than a comprehensive social justice perspective.

As health professionals advocating around issues of substance use, it makes sense for us to have a complete understanding of substances themselves and the effects of substance use upon individuals and communities. But if we are to approach this issue from a social justice perspective, we can't stop there.

As a beginning, substance use justice requires us, as healthcare providers, to take a look at our own biases when it comes to substance use and examine the effects of those biases on the care we do, or will, deliver. Say, for example, one of my patients is a middle-class white male alcoholic. Another patient is a low-income African-American female crack smoker. To which of these patients am I likely to be able to offer more detailed, non-judgmental information about the consequences of their use? In which area do I have more extensive knowledge about safer use strategies, ways to cut down or quit safely and effectively, documented health effects (both short-and long-term), or potential harms? What are my own values about licit and illicit drugs? What are my thoughts or ideas about people who use drugs? How do my values or judgments about drugs help (or hinder) my patients' healthcare?

Substance use justice requires us to seek out information we may not have so that our patients can be as educated as possible about their use, regardless of which drugs they are using. Currently, the overwhelming message drug users receive from well-meaning health professionals tends to be: "stop using." Many times, this message is informed by the alarming lack of treatment or other substance use programs that are not strictly abstinence-based. While this approach may have a positive impact on many users, it leaves out the large numbers of users who may not be ready, willing, or able to quit. It leaves out the users who may not know how to quit on their own. It doesn't offer concrete tools for users who are interested in quitting but don't know what they need to do, and it doesn't acknowledge that there may be ways to stay healthy before a user is at the point where they are ready to quit. Most importantly, this message shuts down dialogue between patient and provider.

Substance use justice demands that we address not only substance use itself, but the contexts in which use occurs. How is substance use influenced by poverty, lack of healthcare access, or racism? Substance use justice requires us to understand the health impacts of our society's responses to drug use. The United States has one of the harshest systems of drug laws in the world; yet at the same time we have very few resources available for people who wish to enter treatment. The health impacts of the War on Drugs, particularly on communities of color, are enormous.

We owe it to our patients to be able to give them concrete tools, useful information, and workable strategies that will improve their health, regardless of our attitudes or beliefs about their drug use. We owe it to our communities to advocate for comprehensive substance use services that are health-based, rather than punitive, and that address all stages of use. And finally, we owe it to our society to advocate for real solutions to substance use problems, which are based not in sending people to jail, but upon creating concrete improvements in people's lives: improving the quality and quantity of information available about drug use; improving access to healthcare, jobs, housing and education; fighting against racism and economic injustice; and working toward justice and self-determination for all people.

I hope you will join us.