Five Examples of What “Public Health” Can Mean for Drugs — and for drug users
How we conceive of public health in relation to drugs is crucial for the policies we adopt and invest in and the success of their outcomes.
Drug policy reformers often describe their project as being the removal of drug use from the criminal justice system and placing it instead in the domain of public health. But, actually, what that means is open to a wide range of interpretation. Indeed, at its extreme poles it means opposite things.
Here are five interpretations of “public health” with regard to drugs.
Treat drug use as a disease. The most extreme form of the so-called public health model is “defelonization,” in which drug use is not directly subjected to criminal penalties, but it is still illegal and demonized. In this framework anyone arrested with drugs is offered the option of treatment. Only if they refuse are they then sentenced directly to criminal penalties. (This is the approach in drug courts.)
The underlying model of drug use in this defelonization approach is the same as the criminalization model — that all drug use is bad, wrong, and/or unhealthy and must be stamped out. It is, like the criminalization approach, a coercive model.
Treating unhealthy/addictive drug users only. A crucial modification of the defelonization model is that anyone found in possession of nonprescribed or recreational drugs is assessed for the nature of their use. Only if a person is found via this process (say by a clinical review board) to have a substance use disorder (SUD) are they then mandated into treatment.
The “treat-SUDs” model is likewise coercive in that the individual’s subjective view of their drug use is overridden by outside observers. But key models for treating addictions (i.e., motivational interviewing, life process model) have discarded clinical “objective” assessments as useless in comparison with the person’s self-assessment of their drug use, which is the ultimate motivation for hard-wrought change.
Provide individuals with tools and support to facilitate and improve their drug use health. Labeled harm reduction, this is the ideal public health model for drug use. It includes guaranteeing people’s housing and health care, offering ready means for testing for drug purity and accessing pure drugs, and providing low-barrier, nonjudgmental, non-coercive, self-directed coaching and treatment options for people who are concerned about the impact of their substance use.
In fact, this life enhancement option characterizes American differences in social status of those receiving drug treatment at the individual level. It also underlies the Life Process Program model. In LPP individuals are encouraged and assisted in developing their personal life resources so as to minimize negative, addictive outcomes over the entire range of their health and consumption behaviors.
Assisting people to use substances in the most healthy ways possible, however, runs afoul of moralistic views of substances. This is most especially true of America’s staunch temperance tradition that pervades even progressive and drug policy reform thinking.
Address high-risk communities. Virtually every public health and medical concern — COVID, childbirth, heart disease/cancer/diabetes, drug death — confronts the same template: less well-off people face significantly worse outcomes than better-educated more prosperous individuals and communities. The point of attack is thus to remediate and support depleted and deprived communities, families and individuals.
This is a political goal with an underlying economic philosophy — one on which the US scores poorly. That is, as the wealthiest country, it has near-to-the bottom health outcomes in virtually every area — from birthing to drug use to mental health to heart disease — as measured by death and disability rates. America in many ways continues to be predicated on a survival-of-the-fittest, Malthusian (helping the worst-off backfires) model.
Public health writ large. The broadest definition of the public health model is to make the entire population as healthy as possible. A rather large task, this approach begins with global measures to address climate deterioration and inequality. Smaller bites at this apple take community-based approaches.
Of course, increasing a nation’s and the world’s health at large is a gargantuan task that we have only intermittently addressed and, even then, which has yielded at best spotty results.
On the other hand, is there any alternative for guaranteeing the public’s health — make that the survival of humanity — against global assaults on its well-being?
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