Outside of youth and cannabis policy I also have a project that is a research partnership with parents whose children have died from opioid overdose/poisoning, leading them to become advocates for harm reduction and drug policy reform. Because of this and my expertise on youth prevention and public health I was asked to speak on the panel, “Examining the Factors that Lead to Problematic Substance Use” at the 2018 Opioid Symposium that took place in Toronto September 5-6. Below is the text of my remarks (with slight variations as ad-libbed it a bit on the day). You can view the archived webcast of the panel here: https://www.pscp.tv/w/1MYGNqyjaAQKw
I also want to acknowledge the helpful advice of Dr. Hakique Virani in helping me frame this talk.
I am a sociologist and I work at O’Brien Institute for Public Health where my research focuses on youth substance use and families’ experiences of a young person’s death from opioid overdose.
What a sociologist contributes to public health discussions about preventing problematic substance use are the theoretical and methodological tools for understanding how drug use is tied to social context. A critical public health approach studies how drug use is shaped not just by the social conditions of our daily lives but also by the structural determinants that shape our experiences, our access to resources, and the range of upstream factors that influence our health and well-being. Social determinants are key to prevention, because we know from research at the population level that trajectories into problematic substance use reflect societal inequities – meaning they are shaped by the intersections of broad social forces including socioeconomic positioning, racism, homophobia, trauma and exclusion.
Put more simply, substance use is a part of many people’s lives – but we know that pathways into problematic use are not randomly distributed – populations already made vulnerable experience the most problems and the worst outcomes.
In this sense, we desperately need prevention that is oriented to equity, and we must anticipate unintended consequences of our interventions for those across the social spectrum, but especially for those groups on the margins. To be sure, this is complicated and even messy at times, requiring solutions that are complex and much more difficult to measure and to implement – that don’t fit neatly into the contained package of an RCTs experimental design – and that often require prolonged community engagement.
But before we throw up our hands and say that inequities are just too complicated to address, one important take away that we can orient ourselves to is that the work of drug prevention in public health should be the work of human rights and social justice.
What I like to say is that the best prevention is really not specific to drugs alone, or even about drugs at all, but rather, encompasses interventions that address the structural contexts that keep people marginalized and excluded. As we move through the next two days and hear from a variety of perspectives, let’s try not lose sight of that. WE CANNOT SAY THAT WE HAVE THOROUGHLY CONTEMPLATED ANY POPULATION LEVEL HEALTH OR POLICY INITIATIVE UNTIL WE’VE CONSIDERED ITS BENEFITS AND HARMS TO EXCLUDED GROUPS.
The other thing that a critical public health approach orients us to – and Dr. Tam has already alluded to this in her opening remarks – is a reminder of this tension between individual “choices” and the structuring of life chances. So through this lens blaming people for their so-called failures around drug use (or any other health problem, for that matter) without understanding the context that produced those choices is decidedly wrong-headed.
Writing in the American Journal of Public Health recently, Beletsky and colleagues argue that the stark numbers of deaths from addiction and suicide in America are best described as “diseases of despair,” as population-level outcomes resulting from the profound social, economic, and political divisions we are witnessing in the United States – and that also exist here in Canada. Nowhere such ideological division more evident than in our criminalization of people who use drugs, which entrenches the stigma of substance use and serves as a very real barrier to health and social inclusion.
This tension between individual and social contexts of drug use is also evident in how we do prevention work with young people. We often focus on delivering education and facts, we preach abstinence, or even worse use scare tactics. An yet none of this really resonates with youth, precisely because we do not take into account the social and peer contexts that shape young people’s decisions about substance use – nor do we consider the connection between drug outcomes and their broader social and economic opportunities. What we know from prevention science is that school-based programs or mass media campaigns specific to drugs do not lead to sustainable changes in behaviors or show weak evidence for impact on population-level harms.
Therefore, in addition to advancing social justice and equity goals in our interventions for young people, we really need to focus on providing comprehensive mental health and social supports for youth and their families in their communities so that more of our young people have a sense opportunities to succeed and hope for their futures. That is part of what upstream prevention looks like.
Yet when it comes to our current cultural climate around harm reduction we see a great deal of push back based on the premise that legalization and harm reduction in our communities will supposedly normalize substance use for youth. But to paraphrase a recent insight from Dr. Aaron Fox, when we have policy solutions and effective treatments that can save lives but we fail to implement them, what we are actually teaching our young people that some lives are valued more than others, that excluding people is okay, and that speaking up and asking for the help can just lead to more stigma and shame so you’d better think twice.
Finally, I’ve been asked to speak about my project partnering with parents whose children have died from overdose and who advocate for harm reduction and drug policy reform. This is the first qualitative research project of it’s kind in Canada – and in addition to mumsDu and Moms Stop the Harm, my academic partners are Dr. Elaine Hyshka from the University of Alberta and Dr. Emily Jenkins from UBC. Last year we interviewed 43 mothers across Canada about their experiences of advocacy after the death of a child. I am glad to see that mumsDU and Moms Stop the Harm are being featured in their own sessions and I urge you to attend these talks to hear these insights firsthand. For me, it was a great privilege to hold this space with people who have lost a child – and yet are working tirelessly, mainly in unpaid and unsupported roles – with the goal of preventing other families from experiencing a similar loss and similar pain.
Very relevant to my points about prevention I want to end with a key message that is linked to what we have learned from this work – and that is this:
In the absence of access to any formal, coordinated system of supports what was so remarkable is how the participants in our study had come to fulfill the roles of grief counselors, system navigators and treatment referral sources – supporting other families who are dealing with substance use and also those who are newly bereaved. Their unpaid work not just in providing these supports but as policy advisers and advocates fills a critical gap in the health and social service systems – and yet because they are women and “just mothers” this is often dismissed or under-valued – and this is also true of the work of peers, People Who Use Drugs and other front-line people who are providing response to the opioid crisis in their communities.
More than anything else, our work in this project hinges on the key principle that people with lived experience of drug use – and those who love and care for them – are THE most important voices and the most important experts in this field – they can do more than just share their story. They have the intimate knowledge – the evidence – of exactly how and where the systems have failed them, their families, and their loved ones who are struggling or who are no longer with us.
To do prevention in a different and more meaningful way, we need to make sure that we continue to center these voices.