DRIVERS OF DRUG-RELATED HARMS

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Social and structural factors explain the majority of variance in substance use–related outcomes,⁹ yet the majority of US policy and funding investments to address the overdose crisis continues to center drug law enforcement, abstinence-based recovery, and biomedicalized-based approaches that focus only on opioid use disorder medications and addiction medicine dissemination. For example, analyses of US federal drug policy of the past decade have shown a dearth of funding for health and social service systems, an emphasis on drug law enforcement, and the development and delivery of medications¹⁰; there has been little focus on harm reduction and structural interventions that respond to the underlying conditions that drive harm among populations marginalized on the basis of race/ethnicity, social class, ability, gender, and sexual orientation.¹¹ This omission may be owing, in part, to an effort among clinician advocates to redefine substance use disorder as a chronic brain disease in an attempt to destigmatize it. In the process, however, they omit the social– and political–structural contexts of drug use, including severe marginalization and drug law enforcement, particularly in Black, Latinx, and Indigenous communities. This omission may also be attributable to the individualist, clinical treatment focus of US health policies, which often fail to consider social and political drivers of substance-related harms.

Never has there been a more urgent time to reverse this trend. Overdose deaths have accelerated during the COVID-19 pandemic, and the rise of fentanyl, fentanyl-related analogues, and other adulterants in the street-based drug supply has created a systemic crisis. Overdose is an indicator of deepening inequalities in the United States, including racially stratified policing and drug policy; mass incarceration; and segregation in health care systems, housing, and employment; as well as the illegal status of harm reduction measures in many US states and the lack of sufficient public funding for addiction and harm reduction programs.¹² At the same time, the new US federal administration is facing rising pressure from harm reduction activists, politicians, and scientists to address social inequalities as a national priority. This presents a window of opportunity for social science and population health research to highlight the failures of drug policies based on prohibition and to inform public policy with a broader international perspective that includes the voices of people who use drugs.

The situation outside the United States has unfolded differently, and insights from global research are critical to informing the US response to these overlapping public health crises. In many countries, COVID-19 has not been accompanied by a rise in overdose deaths, especially where the street-based drug supply has not yet been transformed by fentanyl, fentanyl-related analogues, and other adulterants. Countries that had robust social safety nets, universal health care, commitments to housing first approaches, evidence-based harm reduction practices, and decriminalization policies before COVID-19 have been better able to protect people who use drugs during the pandemic.

Some countries in Europe faced difficulties in addressing the needs of people who use drugs during the first wave of COVID-19, but they also used the pandemic crisis as an opportunity to improve the conditions of people who use substances as a part of their COVID-19 containment measures by developing drug consumption rooms or access to housing.¹³ In addition, lower-income countries of the Global South that have adopted public health–oriented drug policies, including Vietnam¹⁴ and Iran,¹⁵ have been able to limit the impact of COVID-19 containment on drug-related deaths.

Meanwhile, Canada, whose overdose crisis has worsened and similarly been driven by the intersection of inequality and the transformation of the street-based drug supply, has begun to implement novel harm reduction interventions, including providing greater access to safer alternatives to illicit drugs, with significant potential to address drivers of the crisis. Comparative analysis that accounts for the social, political, and economic contexts of each country, as well as opportunities to examine novel interventions, can instrumentally inform the reform of US health and drug policies.

This special supplement engages with social science and population health research inside and outside the United States as well as commentary from organizations engaged in drug policy reform and led by people who use drugs to (1) highlight innovative, evidence-based, and grassroots approaches (e.g., peer-led harm reduction) that have been marginalized in the United States because of previous policy barriers; (2) spotlight social–scientific, ethnographic, and community-based research that is not usually featured in mainstream clinical and health policy journals; (3) foreground the present as a historical moment when US drug and health policies are reexamined; and (4) apply an intersectional lens in considering structural inequalities and effective upstream interventions.

SUPPLEMENT THEMES

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This supplement is divided into four themes. Articles addressing the first theme, operationalizing harm reduction in response to drug-related harms in different global contexts, illustrate that the definition of harm reduction varies from country to country, reflecting political and social movements to legitimize the right to survival of people who use drugs. Davidson et al. (p. S166), Houborg and Jauffret-Roustide (p. S159), and Jauffret-Roustide et al. (p. S99) analyze the process of establishing supervised consumption sites in the United States, two European countries (i.e., Denmark and France), and the United Kingdom, highlighting how the legal status and social and political entities organize risk environments of people who use drugs as well as how welfare states, activism, and the process collectivizing risks influence supervised consumption site strategies and user outcomes.

Nguyen et al. (p. S182) discuss the limitations of the methadone maintenance political strategy in Vietnam; this strategy is embedded in repressive drug policies that impede the development of a strong harm reduction approach. McNeil et al. (p. S151) explore experiences with a novel harm reduction intervention in a Canadian province. The intervention facilitates access to pharmaceutical alternatives to the street-based drug supply, and the authors underline the urgent need to consider tectonic shifts in drug policy approaches. Boyd et al. (p. S191) explore how systems of surveillance and control of mothers who use drugs can undermine harm reduction and produce overdose risk. Lie et al. (p. S104), through a historical comparison of drug policy across Norway, the United Kingdom, and France, critically reflect on the globalization of a US National Institutes of Health–sponsored concept of addiction as a “chronic relapsing brain disease.” The authors note that a biological concept of addiction is at odds with both harm reduction activism and social and economic support for marginalized people who use drugs.

In the second theme, decriminalization in global perspective—formal and informal, Carroll et al. (p. S123) and Friedman et al. (p. S199) provide lessons learned from COVID-19–related changes in drug law enforcement in Russia and at the Mexico–US border that signify the promise of decriminalization as a long-term public health measure. They also discuss the shifting, time-limited nature of COVID-19–related changes in drug law enforcement and the urgency of solidifying public health gains through durable changes in policy and practice.

The third theme of this supplement, convergence of harm reduction, recovery, and treatment, examines the potential to integrate multiple strategies to improve health outcomes—from harm reduction and peer support to opioid maintenance treatment and comprehensive social services. Suen et al. (p. S112) and Hansen et al. (p. S109) focus on the lessons learned from COVID-19 containment, substance use, and treatment in the United States for future integration of clinical care with social interventions. Farhoudian and Radfar (p. S133) and Nguemeni Tiako et al. (p. S128) expand the lens to Iran and France, countries that have had significant successes in protecting the health of people who use drugs during COVID-19 through national support for integrated services. Blanco et al. (p. 147) demonstrate how overdose deaths are multidetermined, which directs us to develop research programs that address structural and environmental factors, including social inequities.

The fourth and last theme of the supplement, racial justice and grassroots leadership in drug policy and harm reduction, foregrounds the need to support leaders who are themselves from marginalized groups or have lived experience with substance use to promote racial justice in drug policy and services. Hughes et al. (p. S136) present the thoughts of US–Mexico border–based leaders of color in harm reduction and community substance use disorder treatment as they reflect on their specific strategies for community engagement and maximizing the impact of their work on policy and practice. Lopez et al. (p. S173) provide a case study of racial inequalities in harm reduction services in Maryland to outline the policy and institutional changes that are required to redress those inequalities. Simon et al. (p. S117) describe the research and policy advocacy work of the Urban Survivors Union, the largest US national union of people who use drugs, as embodied in their “methadone manifesto.” They urge changes in methadone regulation and dissemination to address systemic barriers to access, quality, and comprehensiveness of methadone treatment especially for low-income people marginalized by race, gender, parenting status, and disability. Finally, Tay Wee Teck and Baldacchino (p. 140) point to the need for enhancing the participation of grassroots social movements of people who use drugs in designing and conducting drug research.