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Is stigma something the province should be fighting when it comes to battling the drug crisis? While current efforts are geared towards destigmatization, some experts believe stigma still has a role to play in addressing the crisis and others explain why it doesn't.

The word 'stigma' is thrown around a lot in the narrative on BC's drug crisis and policies surrounding it. Part of the Province's efforts seeks to destigmatize, but what are they destigmatizing and why is it an effective strategy? PhD candidate at UBC's School of Population and Public Health, Sarinn Blawatt, explains.

"Stigma is a method of social exclusion. It's often driven by a lack of understanding and fear, including misleading representations whether that's through the media or through folks and community that are talking about their opinions. Largely, one of the things that we see when talking about stigma is the aspect of how it can create that isolation and alienation for a group of people that are experiencing it," she says.

"We want to make sure that services that are available to individuals who live with addiction are offering a non-judgemental space. Oftentimes, folks who are trying to access forms of care have received challenges in the way that they have been treated when they go to engage other health-care services leading to that lack of trust that can exist between a person who is seeking to engage in whatever service is being given and the person that is offering it."

Blawatt explains that stigma not only alienates certain individuals from certain spaces in society but is a hurdle on the road to recovery for people who live with addictions. The goal of destigmatization is to create a space, especially in healthcare, where people who need help feel like they can seek it freely.

"We know that, overwhelmingly, that aversion or that fear of receiving the stigma, when they're talking about accessing the means of care that are available to them, are going to be really prohibitive," she says.

"They need to feel like they can come to talk freely whether that's about their substance use or relating to other needs they have, as well, which include things like housing, a lack of access to community support and social support. We want to be able to cross that gap and act as a bridge so we can bring people into and welcome them into care in a very person-centred kind of way."

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In this case, destigmatization efforts are geared toward reducing the exclusion of drug users in society and ensuring their needs are met in spaces free of judgment. This is something, a majority of experts believe to be efficient in addressing the drug crisis.

Where experts seem to disagree is on the topic of destigmatizing the substances that are fuelling the drug crisis such as fentanyl, opioids, heroin and others.

"Given the way that stigma operates at the level of the individual, having destigmatizing efforts (of substances themselves) certainly would assist in early intervention strategies, because no matter who you're engaging with and at any point in their lives, the ability for education and a comfort level to discuss with somebody that feels safe for those people is going to be the most critical piece to opening that conversation and opening that dialogue and making sure that there are the appropriate supports that are put in place depending on their needs," Blawatt says.

Dr. Jonathan Caulkins, Professor of Operations Research and Public Policy at Carnegie Mellon University, views the stigmatization of drugs as potentially useful, especially when it comes to preventing more individuals from becoming addicted to dangerous substances.

"Call it maybe a taboo: if people thought 'nope, I just don't use pills that are sold on the street,' or 'I'm not that person, I don't want to do that thing,' then that would be protective," he says.

"We want to create a barrier of either 'I'm never going to use it once,' or 'I'm going to recognize this thing is too dangerous to use often and I'm going to get myself in a situation,' because the vast majority of people who are dependent weren't planning on it."

The disagreement in whether or not destigmatization will be an efficient approach seems to come from what is considered the most problematic aspect of the drug crisis.

For some, the belief is that the drugs themselves are the problem and portraying drugs as 'bad' would obviously be helpful.

"We would like for people to recognize how powerful and dangerous these things are and it's the thing itself that is that dangerous, it's the opioid itself that is that dangerous, it's not the fact that they are stigmatized that makes them problematic for people," Caulkins says.

"In the late 19th century, both cocaine and heroin had periods of widespread use and dependence and society learned from it and the rates of use dropped. Laws and policies were put in place, but as David Musto studied the historical record, he thinks a lot of change came with people coming to recognize how dangerous these substances are and staying away from them; if you have a bulk of people deciding to stay away from these substances than it's a much better situation than having a bulk of people actually trying these dangerous substances. We don't want to sugarcoat it, we don't want to hide that reality of just how dangerous these substances are because that would be doing a disservice to the next generation."

For others, the problem stems from a failure in social systems leading individuals to fall into addiction for several different reasons. In this case, viewing drugs as 'bad,' is not necessarily efficient and wouldn't solve the root cause of the crisis.

"It is so steeped in the War on the Poor and, of course, talking about how folks are coming into contact with the social determinants of health: what income do they have available to them? What other resources do they have available to them? How are their social support systems? How are they set up where they are? And are they having all of their basic needs met?" Blawatt says.

"Before we really look at talking about how something like demonizing or creating fear around a substance itself is going to be the thing that somehow magically cures people, we need to understand that people come to substance use for all kinds of reasons including things like previous injuries, pain management, history of mental health and how our system has failed to support some people. What we need to be spending most of our time focusing on is less about demonizing the drug itself and looking at other ways that we can be educating people and another way we can be supporting people before we even see how they've been engaging with those illicit substances, to begin with."

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Blawatt argues that stigma is one part of the problem that, if resolved, will help individuals with addictions seek the necessary help. In so doing, it will also allow for a better understanding of what leads people to addictions and what more can be done in a holistic, human-based approach.

"The destigmatization itself is certainly not everything, whether you're looking at the decriminalization efforts in BC, for example, of course always wanting to make sure that there is meaningful engagement with people who are using drugs themselves and what that looks like and how much they're able to contribute to those kinds of policies, is a really critical piece of that," she says.

"The way to approach people who are using substances is always going to be with compassion and taking a human-based approach and being able to identify the complex factors that address the root causes of where that aspect of substance use has come into that person's life."

Caulkins believes that the anti-stigma approach simply isn't doing enough to reduce the number of people who continue to use addictive substances and who will become addicted. To reduce those numbers, individuals must seek treatment.

"I think it's more the addiction itself, the denial that it involves and the ambivalence that is the problem. If you think that ambivalence is part of the problem, then you think there might be room to push people into treatment because there's often a shove that pushes people into treatment: it can come from a partner, an employer and it can, also, in some jurisdictions, from law enforcement such as we see in Portugal and the United States. This shove from the criminal justice system isn't to try and hurt people, you're trying to get people to do something that is actually in their own best interest that they might be reluctant to do themselves," he says.

"A lot of the anti-stigma agenda doesn't agree with this, they think it's unethical or a violation of human rights, a lot of those folks are really opposed to the idea that there's such a way to push people into treatment in a way that will actually benefit them in the long run. And, when people have been coerced into treatment in some form, the outcomes are comparably good to when they volunteer and you get more people into treatment that way."

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The argument is still made that destigmatization is one part of a wider, more holistic solution that involves people with lived experiences relating to drug use. To include those people, they must first feel comfortable to speak about their experiences.

Jennifer Rae Lybbert is one of those individuals; she lives with a drug addiction and she says stigma is something she's had a lot of experience with.

"I've absolutely been stigmatized for my addiction," she says. "I absolutely find that things like decriminalization and safe supply and all those things, make us feel more normal and more comfortable getting help."

Similarly to Blawatt's statement, she says that other solutions relating to housing would also be helpful.

"Having more shelters and things like that would also be more helpful because they can help homeless people and allow for those who have an addiction to focus on getting clean."

She also echoes one of Caulkins' points saying that a little more of a push from the current system might also be helpful.

"I think we need more resources and sometimes I feel like the current system works to keep us at where we're at instead of helping us push forward, but that's not fair to say for all places, because I have found some places to be very helpful, but a lot of people are still struggling right now and need a push."

The current drug crisis is responsible for taking the lives of more than 2,500 individuals in British Columbia just last year.

To read more about BC's current approach to the crisis and to view resources available, visit the government's website here. 

To find out more about Dr. Jonathan Caulkins' take on the role destigmatization is playing in the drug crisis read the article he co-authored with Dr. Keith Humphreys here.

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