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Discrimination against drug addicts

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Discrimination against people with substance use disorders is a form of discrimination against people with this disease. In the United States, people with substance use disorders are often blamed for their disease, which is often seen as a moral failing, due to a lack of public understanding about substance use disorders being diseases of the brain with 40-60% heritability. People with substance use disorders are likely to be stigmatized, whether in society or healthcare.

In the process of stigmatization, people with substance use disorders are stereotyped as having a particular set of undesirable traits, in turn causing other individuals to act in a fearful or prejudicial manner toward them.[1][2][3]

Background

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Global Marijuana March, Paris.
See also: Responsible drug use

Drug use discrimination is the unequal treatment people experience because of the drugs they use.[4] People who use or have used illicit drugs may face discrimination in employment, welfare, housing, child custody, and travel,[5][6][7][8] in addition to imprisonment, asset forfeiture, and in some cases forced labor, torture, and execution.[9][10] Though often prejudicially stereotyped as deviants and misfits, most drug users are well-adjusted and productive members of society.[11][12] Drug prohibitions may have been partly motivated by racism and other prejudice against minorities,[13][14][15] and racial disparities have been found to exist in the enforcement and prosecution of drug laws.[16][17][18] Discrimination due to illicit drug use was the most commonly reported type of discrimination among Blacks and Latinos in a 2003 study of minority drug users in New York City, double to triple that due to race.[19] People who use legal drugs such as tobacco and prescription medications may also face discrimination.[20][21][22]

Individual factors

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Clinicians use DSM-V-TR criteria to establish whether a person has a Substance Use Disorder, which may be classified as mild, moderate, or severe. It may also be ruled out, as some people may use substances or may be prescribed controlled substances that have the potential for addiction, but never go on to develop a substance use disorder. Addictive substances include stimulants, (caffeine, cocaine, amphetamine, methamphetamine, ephedra, etc.), sedatives/anxiolytics (benzodiazepines, barbiturates, quaaludes, etc.), opioids (oxycodone, fentanyl, etc.), alcohol, nicotine/tobacco, cannabis, dissociatives (ketamine, nitrous oxide, etc.), certain hallucinogens (especially MDMA), hormones (testosterone), GHB, Kratom, gabenergic agents (such as gabapentin), and more. The term addiction usually correlates with a severe substance use disorder. Addiction is characterized by behavior that is originally voluntary and reward-seeking that over time, becomes compulsive, with a desire to avoid dysphoria or withdrawal rather than to experience the original positive effects associated. A person may become physiologically dependent, experience withdrawal, and experience significant cravings. It does not degrade their personality, but people may engage in illicit behaviors such as buying drugs that are controlled substances, or engaging in prostitution to fund their addiction. Since these behaviors are illegal and they may face legal issues as a result, people who use drugs may not be forthcoming about these practices and may also delay seeking medical treatment for sequelae related to substance use out of fear of stigma or legal consequences.

Institutional basis

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Stigma by health care professionals has many contributing factors. The first is a well-documented, decades-long lack of education on substance use disorders in many healthcare professions, such as medicine, nursing, and pharmacy. Due to this gap in educational curricula, and competency, healthcare professionals may be unaware of how much of what they assume to be true about treatment and people with substance use disorders is neither evidence-based nor factual. Very few providers are certified in addiction treatment; addiction is often thought of as a subspecialty with providers having an initial certification in another specialty area, such as psychiatry. Healthcare professionals may hold biases similar to those of the general US population, who often see substance use disorders as a moral failure rather than a chronic brain disease that has significant contributory racial and psychosocial factors, with 40-60% heritability. Unfortunately, healthcare providers may perpetuate stigma when they use language that is stigmatizing/non-factual or refuse to provide care that is evidence-based or person-centered as a result of their lack of competency or biases which may be subconscious. Unfortunately, they may also believe stereotypes about people with substance use disorders or drugs, that the general population holds. These include people with SUDs not being able to get better when they have similar relapse rates to people with diabetes or hypertension, and most people with SUDs recovering without treatment. What is more, medications for opioid use disorder are highly effective at preventing relapse; methadone and buprenorphine specifically also prevent all-cause mortality by more than 70% in patients with OUD. However, medical providers may hold the false belief that in being prescribed these, patients are "substituting one drug for another". Medications for Opioid Use Disorder (MOUD), Medications for Alcohol Use Disorder (MAUD), and medications for Tobacco Use Disorder, are widely used in the United States Healthcare System. However, regulatory and legal barriers to methadone and buprenorphine prescription have inhibited their utility. Under current law, people on methadone have to go to SAMHSA-approved OTPs (special facilities) to receive this medication, on a nearly daily basis. Although now removed, until recently providers who wanted to prescribe buprenorphine had to be x-waivered, receiving addition education to prescribe, and were limited in the number of patients they could prescribe for. SAMHSA and ASAM have clinical guidelines for things such as medications for addiction treatment, withdrawal management, and non-pharmacological therapeutic interventions as well.

There are several terms related to addiction that are not stages of addiction per se. Tolerance means the need to take more of a substance to achieve the desired effect when compared to before--it does not matter what the desired effect is (pain control/focus/euphoria/etc.). Tolerance to opioids can develop rapidly. Tolerance may occur in addiction but also occurs in those who are prescribed certain medications who may not meet DSM-V-TR criteria for a Substance Use Disorder. Tolerance quickly develops to the effects of hallucinogens after a few administrations, which is part of the reason why addiction to this class of substances is rare. When people describe dependence in addiction treatment, they often mean physiological rather than psychological dependence. If someone is physiologically dependent, they are likely to experience withdrawal once the substance is removed, as their body has become accustomed to the substance's presence and its presence has affected their body's homeostasis. Withdrawal symptoms are often unpleasant and are typically the opposite of those experienced during intoxication. Rarely, withdrawal can be life-threatening; this may occur in patients with benzodiazepine, alcohol, or barbiturate dependence for example. Withdrawal is not a stage of addiction but is often a symptom, although a few drugs do not have withdrawal as part of their DSM-V-TR criteria (hallucinogens and cannabis).


People with substance use disorders may have co-occurring mental health disorders, substance-induced mental disorders, both, or not have mental health disorders. Substance-use disorders are not thought of as mental health disorders, but can induce acute symptoms such as mood alterations or psychosis, depending on the drug and whether a person is intoxicated, experiencing withdrawal. In some cases, a person can be in active recovery (methamphetamine-induced psychosis specifically can last up to 2 years following discontinuation of methamphetamine, and hallucinogen persistent perception disorder can last several months following discontinuation). Generally, however, substance induced mental health symptoms are time-limited, clearing up within one month or less based on DSM-V-TR criteria. If symptoms persist for longer following discontinuation, providers may consider a mental health disorder as primary, or as stemming from a different etiology, rather than as substance-induced. Thus the person's diagnosis may change based on the timeframe and symptoms following discontinuation. People with substance use disorders still have agency, but it may be very difficult to control cravings and urges in early recovery. Therefore, people who use drugs win early recovery may avoid people, places, or things, that serve as triggers for these. If unavoidable, they may urge surf, call a friend or sponsor, or use other coping mechanisms to distract themselves or ride the cravings and urges out. While much substance use is initially voluntary, this is not always the case. People may be exposed to substances in utero, or involuntarily initially in childhood (especially if parents use or manufacture drugs) or in adulthood (e.g. GHB, rophynol, etc.). Some people who use may use substances that do not know are contaminated (laced) with other substances, such as fentanyl, nitrazine, or xylazine. This is a significant problem, with the DEA reporting fentanyl-related overdoses are the #1 cause of death in people 18-45.

Although 1 in 10 people in the United States will meet criteria for a substance use disorder in their lifetime, few will receive treatment.


With the increasing number of adults that suffer from an addiction, only a few will receive treatment due to the complexity of health care systems.[23] Most health care systems do not have insurance coverage for addiction recovery and many health care providers have little to no training in treating addiction.[24] Some doctors do not feel comfortable treating addictions, due to their lack of knowledge and training of the topic.[25] The American Society of Addiction Medicine reports that there are only 3,000 board-certified addiction specialist physicians in the United States while there are nearly 2 million people experiencing opioid addiction.[26] The limited presence and access to comprehensive care for addiction poses a barrier for recovery for many, particularly those hailing from lower socioeconomic backgrounds.[27]

Role of language

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Stigma founded in societal preconceptions about substance dependence often perpetuates discrimination against those with Substance use disorder (SUD).[28] How language regarding SUD is framed plays an important role in mediating stigma experienced by those with the condition, which can consequently shape critical outcomes for this population such as treatment contact, social isolation, and attitudes towards healthcare providers.[28] Shifting towards person-first language has been emphasized in healthcare provider circles to mitigate such stigma. For instance, as opposed to saying "former addict" or "reformed addict", the National Institute on Drug Abuse (NIDA) recommends language such as "person in recovery" or "person who previously used drugs" to separate the problem from the individual.[29][30][31] The NIDA additionally applies a similar framework to terminology such as "clean" or "dirty" to denote whether or not someone is actively using as they cite the former vocabulary holds punitive connotations.[31][32] Moreover, SUD policy reform advocates report language adjacent to SUD can misconstrue associated medical treatment practices which in turn poses barriers to expanded harm reduction efforts from being adopted.[32] An example of this provided in a 2017 executive memorandum from The National Prevention Council was a recommendation to wean usage of "opioid substitution replacement therapy" which many believe falsely alludes that an individual is substituting their addiction for another (i.e. from heroin to methadone) to "opioid agonist therapy".[29][32] Another term that is losing favor is "abuse", due to its negative connotations and its impact on patient care. Instead, the terms "misuse" for prescribed medications or "use" for illicit substances are used. Similarly, "user" is not used in favor of person-first language, such as "person with a substance use disorder", or "person who uses intraveneously"

Drugs and HIV infection

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Among people who use drugs intravenously, the incidence of HIV and Hepatitis C infection is higher than among those who administer drugs through other routes. However punitive and discriminatory measures against people who use drugs are not able to eliminate either the spread of drug addiction or HIV. Researchers say that around 90% of people who choose to inject drugs have missed prior opportunities for HIV testing that were provided.[33] This is why annual screening for Hep C and HIV is recommended for patients who use drugs. Also, in states where it is legal, people may use syringe service programs, or use at safe consumption sites. Also, patients may employ other harm reduction measures, such as employing aseptic technique, to reduce their risk of exposure to infectious disease. The website NextDistro has harm reduction resources for people who use drugs to minimize the risk associated with intravenous use.

Regional patterns

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Africa

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In Africa, approximately 28 million people use substances.[34] This number is impacted by the rising availability of drugs that can be administered intraveneously such as heroin, cocaine, and methamphetamine.[34] Socio-demographic factors are often primary determinants of the health status of people who use drugs.[34] These factors contribute to an individual's drug use behaviors such as the sharing of needles and the solicitation of sex in exchange for police protection or more drugs.[34] Nutritional status, family support, stigma/discrimination, adherence to medication, and recovery from addiction are also impacted by these socio-demographic factors.[34] Research shows that the majority of people who use drugs transition from the use of non-soluble substances s to substances that can be used intravenously or end up using both simultaneously.[34]

Kenya

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In Kenya there is a link between injection-related discrimination, mental health, physical health, and the quality of life for those who inject drugs.[35] The rates of discrimination are linked to higher levels of psychological distress and risky behaviors.[35] Women in Kenya account for 10% of people who use drugs.[35] These women tend to experience typical discrimination faced by people who use drugs in addition to gender-related discrimination.[35] Levels of discrimination are often higher for those that are also HIV positive.[35]

Tanzania

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The Tanzanian government initiated support for substance-dependence treatment rehabilitation in the latter 20th century, with the Ministry of Health administering the Treatment II center network to oversee this care.[36] Treatment centers and harm reduction efforts in Tanzania have come into conflict with recent discourse from politicians, such as President John Magufuli, who established the nation's war on drugs in early 2017.[37] Calling for the arrest of anyone involved in narcotics, Magufuli's stance is distinct from growing harm reduction pathways established in sub-Saharan Africa in the early decades of 2000.[37] This wave of criminalization policy aims to redress the issue of those who use being primarily being targeted by law enforcement, rather than other individuals involved in the trafficking schema.[38] Tanzania's policing of injection drug use has encouraged both consumers and traffickers to further ingratiate themselves in the nation's black market, with injection drug users consequently being more likely to be involved in sex work and other illicit trafficking, rather than engage in traditional employment opportunities which risk greater exposure.[39] Populations that exist at this intersection, for instance, Tanzanian women sex workers who engage in injection drug use, are alienated from utilizing risk reduction interventions due to fear of arrest.[40]

Low-income, urban, young men which are the most likely populace to be recruited to illicit substance trafficking due to lack of economic opportunity otherwise, have been highly scrutinized under recent waves of drug criminalization.[41] Substance use ranging from marijuana to heroin is prohibited and a record denoting arrest for such use highly influences subsequent employment outcomes after time served for these individuals, which can ultimately be deleterious to expanding economic mobility within the communities they hail from.[42]

A study published in the Review of African Political Economy notes that commerce and political corruption in Tanzania have promulgated crack cocaine consumption and flash-blood practices, or blood sharing between substance users after recent injections, specifically among poor youth in urban centers.[43]

Asia

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India

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Narcotic substance consumption is prohibited in India by the Narcotic Drugs and Psychotropic Substances Bill inducted in 1985, which also levies punitive measures on adjacent activities such as production or vending of such substances.[44] Possession of a controlled substance can result in punishment ranging from a $136.21 USD fine and half a year imprisonment to $121,261 USD and twenty years imprisonment, depending on whether the amount identified is considered small or commercial. Certain crimes outlined by the Narcotic Drugs and Psychotropic Substances Bill are also eligible for the death penalty, and while cases involving marijuana have been charged with capital punishment in the past, they tend to be successfully appealed in higher courts.[45] This legislation is heavily influenced by a coordinated United Nations effort throughout the latter twentieth century to stymie international drug trafficking.[46]

According to the International Drug Policy Consortium, India's Narcotics Control Bureau, which executes the various facets of the Narcotic Drugs and Psychotropic Substances Bill, has encountered criticism for the legislation's stringent measures which have limited access to pain-relief medication, specifically the prescription of opiates for post-operative patients.[47] Bill revisions in response have expanded access to such substances, like methadone, to be distributed through recognized care providers, and members of parliaments have subsequently pushed for expanded bill protections for marijuana use, which has not gained traction.[48] Language cited as demeaning within the 2012 National Policy on Drugs and Psychotropic Substances regarding harm reduction pipelines such as clean needle programs, referring to such as "shooting galleries," have posed barriers to preventing comorbidities such as HIV which are prevalent among people who inject drugs in India.[49] This poses an issue in states such as Punjab where over 20% of people who inject drugs are also infected with HIV.[50]

Philippines

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See also: Extrajudicial killings and forced disappearances in the Philippines

In the Philippines, the government's war on drugs has led to allegations of killings and other human rights violations by the Philippine National Police against drug suspects.[51]

This has led the United Nations Human Rights Council to adopt a resolution urging the Philippine government to set up an investigation into mass killings during the war on drugs.[52]

Vietnam

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Drug control strategy in modern Vietnam was first formally introduced in 1990 around the cause of eradicating "social evils," in reference to substance use.[53] Such policies were inspired by the UN, and specifically, its International Drug Conventions which took placed from the latter 1960s to 1997.[54] Ordinances and violation measures were propositioned by the Vietnamese National Assembly in this legislation to mandate compulsory treatment for substance users, rather than subject them to prison.[55] High input in mandatory treatment centers has resulted in a tendency for there to be more patients at treatment centers than can be handled, thus limiting access to rehabilitation for these individuals.[56] Harm reduction measures such as clean needles and condom access have been introduced throughout the 2000s at a national level to address the prevalence of HIV and HCV among drug users.[56] Inconsistencies between the Ordinance on HIVAIDS which outlines such harm reduction practices, and the Drug Law of 2000, which prohibits the distribution of materials like needles, has made provincial adoption of harm reduction institutions, like syringe exchanges, challenging.[57]

While Vietnamese policy leaders generally veer towards addressing substance use as a medical issue, rather than criminal activity, having decriminalized many substances since 2009, the Ordinance of Administrative Violation continues to classify illicit substance consumption as a crime.[55] Consequently, at a local level, substance users remain eligible to be charged by law enforcement and subjected to forced labor treatment centers that are comparable to detention.[58] Thus, many substance users do not access harm reduction institutions out of fear of being identified by law enforcement and placed in these conditions.[58]

Europe

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Sweden

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Narcotic substance use is criminalized in Sweden, with drug offenses holding punishments ranging from fines to six months imprisonment.[59] To apprehend people who use, law enforcement is permitted to conduct urine testing based on suspicion, rather than wholly requiring a public disturbance.[60] Such protocol is justified by lawmakers as a way to expand early intervention for people who use substances to be referred to rehabilitation channels, but legal advocates have challenged such practices for infringing upon personal freedoms.[60][61] Diversion to court-ordered treatment programs rather than criminalization has been expanded in response during the early 21st century. However, there are disparities in representation in such programs.[61] For example, people who use drugs found in violation who belong to the top third Swedish wealth bracket are twice as likely to be admitted into a treatment program rather than imprisoned compared to people who committed a similar offense but belong to the bottom two-thirds of the wealth bracket.[61] Moreover, while those who use drugs can apply to their local welfare administrator for rehabilitative services, this process is selective despite being less costly than long-term imprisonment for an associated drug-related crime.[62]

Sweden has faced criticism for having harsher drug policies and less accessible rehabilitative programs for people who use drugs than peer Nordic nations which are moving towards drug liberalization.[61] Many cite this for why Sweden has rising substance-related mortality in the 21st century, for instance, having 157 overdose deaths in 2006 compared to the Netherlands which had a little over a hundred despite having a population close to double the size.[63] Zero-tolerance policies are also in place for those who drive under the influence of an illicit substance.[64]

North America

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Canada

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In Vancouver, Canada, there have been efforts to reduce opioid-related deaths. An article published by the Canadian Medical Association Journal discusses new efforts to create safe injection sites for people struggling with opioid addiction. Vancouver politicians created these sites for people to safely use drugs that they are addicted to without the risk of infection or prosecution by the police. These safe injection sites provide sterilized needles to limit the reuse of needles that lead to the spread of AIDS and other diseases.[65] Drug addicts in Vancouver have been discriminated against on numerous occasions. Mothers who are said to be drug addicts have had their children taken away, as they are thought to be unfit mothers. These women have a hard time getting jobs because employers might not want to hire someone who they believe are drug addicts. Women have started a union for drug users in Vancouver to aid them with housing and education to help them get back on their feet.

United States

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The Prison Policy Initiative cites that the criminalization of drug use in the United States can limit personal daily activities for those who may use substances, even if it is done in a safe, recreational manner.[66]

The War on Drugs, which formalized in the 1970s with the Nixon administration, has disparately affected communities of color in the United States.[67] Substantial punitive measures exist for illicit possession, whether that be in the context of use, trafficking, or selling, with length of incarceration scaling up with repeat offenses.[68][69] Charges can go up to life without parole for third-time offenses related to opioids such as fentanyl.[69] Three-quarters of those imprisoned for fentanyl today are people of color, which directly corresponds to Black and Latin populations being disproportionately policed for drug-related crimes.[70] This additionally infringes upon voting eligibility among people who use drugs, as more extreme drug charges hold felony status which revokes voting rights in a majority of states.[71] Drug criminalization moreover operates within the deportation pipeline in the US, with drug charges making all individuals without citizenship eligible for deportation.[72] This includes marijuana-related charges which have constituted over ten thousand deportations from 2012 to 2013, often severing families and communities.[72] While statewide measures to legalize marijuana have gained traction throughout 2010, individuals of color have been less likely to receive post-carceral clemency for these charges due to barriers to legal advocacy.[73]

Human rights advocates have criticized the use of demeaning language regarding the condition in criminal litigation to leverage character assault against defendants or victims who have or are presumed to have the condition.[74] A prominent example of this is the trial of Derek Chauvin, the former Minneapolis police officer convicted of murdering George Floyd, whose legal defense asserted substance use as a potential cause of death, rather than the asphyxiation which incurred from Chauvin.[75]

In the US, employers and educational institutions may legally discriminate against people who are currently using based on the results of their drug screens. Otherwise, the ADA protects people with a prior history of substance use or who are receiving treatment. Employers may elect to administer drug screens at random, upon suspicion, on a routine basis, and before employment as a prerequisite as part of a zero-tolerance policy.[76] However, according to the Rehabilitation Act of 1973, employers are supposed to ensure that people with alcohol use disorder and substance use disorders receive needed treatment and accommodations. The lack of job opportunities and treatment for people with substance use disorders may result in relapses or jail time .[77] Nathan Kim and his associates once conducted a study on the HIV status of people who inject drugs and found that the HIV rate in those individuals in San Francisco increased by 16.1% from the year 2009 when the HIV rate was 64.4%, to 80.5% in 2015.[78]

See also

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References

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