Vincent Lam is an addiction medicine physician. His recent novel, On The Ravine, explores Canada’s opioid crisis.
Recently, one of my patients was arrested. She asked to see me, her addiction doctor, before going to the police station, and was brought to my office. I asked the officers to wait outside the clinic room. My patient wanted to restart addiction treatment, which I was glad to provide.
She said she had one point of “down,” the street term for fentanyl, in her bag. I offered her a biohazard disposal box, to avoid adding drug possession to her other charges. Instead, she began to prepare the drug for injection. I reminded her that my office was not intended for injecting drugs. She agreed, apologized and injected it. We arranged for the first dose of her treatment, and she went with the police.
As British Columbia tries to humanely rebalance its stand on drug decriminalization, preserving decriminalization in private spaces while not allowing open public use of drugs, Premier David Eby observes, “There are important lessons to be learned, about where we are to date.” Some of these lessons are core concepts in the practice of addiction medicine.
Firstly, recovery requires healthy engagement – with addiction treatment, with loved ones and with broader society. I ask my patients, “Why do you want to recover?” They often answer – for their partner, their children, their job. They want to be engaged with people and activities they care about. The goal of decriminalization is for people who use drugs to be able to engage with essential public services. When 911 is called, multiple types of responders often arrive. People who use drugs need to be able to call for help if someone has overdosed, without fear that police will arrive alongside medical responders and jail them for possessing a small quantity of hard drugs. If someone with drugs in their apartment is afraid of calling 911 during a fire, everyone in the building is at greater risk.
What’s next for B.C.’s decriminalization experiment
Meanwhile, B.C. is articulating what healthy engagement looks like: We want all citizens, including people who use drugs, to engage with public spaces such as parks and restaurants in keeping with community norms. My patients who are trying to avoid using drugs tell me it is challenging if they encounter drugs in public because it triggers them. The use of hard drugs in those shared public spaces is not engagement – it violates community norms, and creates risks including injury from drug-use equipment and the risks that come from unpredictable behaviour. A societal commitment to engagement also means that if we don’t want people who use drugs to simply disengage into more isolated and dangerous spaces, we need more safe consumption sites and overdose-prevention sites, where they can also be offered access to addiction care.
A second core lesson in addiction medicine, which B.C. is learning, is that good boundaries are crucial to sustaining collaboration. With the police standing outside my clinic room, I watched as my patient did her shot of down. However, I always insist upon the boundary that patients not use drugs in my waiting area because other patients there could be triggered.
For families of patients, I emphasize that their loved one absolutely needs them in their lives, and that they need to articulate their boundaries. Whether around the use of space, or finances, or other issues – these allow families to stay engaged for the long term. My patients in recovery also tell me that boundaries and expectations – at home, in treatment, for legal reasons, or at work – can form part of the structure that supports their recovery. The public has the right to set a boundary that it is not exposed to illicit drug use in shared public spaces, and only if the public feels it can set acceptable boundaries will it continue to support people who use drugs to access harm reduction and treatment.
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A third lesson well known to practitioners of addiction medicine is that addressing substance-use disorders requires sustained commitment both to a compassionate approach and to working through challenges. This means learning and adjusting one’s own practices, while also believing that others can achieve their own best expectations if given a chance to do so. Staying the course can be tough work.
That is what Mr. Eby is doing in seeking an acceptable version of decriminalization that is “caring and compassionate for those struggling with addiction.” Neither Conservative Leader Pierre Poilievre pointing fingers while exclaiming about “drugs, disorder, death and destruction,” nor Ontario Premier Doug Ford vowing, “I will fight this tooth and nail,” is going to find the right balance on decriminalization. Mr. Eby has done something rare and admirable in politics: admitting to missteps and hoping that insight will help others.
The patient who injected in my clinic room continued her addiction treatment in jail, and later returned to my clinic for care. Many medical treatments get adjusted, and we should expect social and legal initiatives around substance use such as decriminalization to also be adjusted.
An effective response to the opioid crisis is not just about decriminalization. It is also about providing excellent addiction medicine care, psychosocial care that incorporates the knowledge of people with lived experience, and workable housing and employment options. In all of these areas, the principles we need to use are engagement, boundary setting, and long-term commitment to supporting the recoveries of people who use drugs.