Contributor: Stigma only makes drug use more dangerous

Until we stop viewing all drug use and overdose as issues of “addiction” and “substance use disorders,” we will continue to miss the mark when it comes to overdose prevention. Historically, overdose was considered a serious indicator of addiction – but that has never been the best way to understand it, given that someone who begins using is potentially at greater risk than someone who uses chronically and has built up a tolerance. The unpredictability of the drug supply has further weakened the link between overdose and chronic use, as anyone – a habitual user for decades or a first-time user – can overdose on drugs that are more potent than expected or contain substances such as fentanyl.

I used opioids, benzodiazepines and amphetamines for almost four years before my family found out. During this time, I earned 102 college credits and was elected to the local village council. Most of my drug use has been helpful; it made me work harder, helped me deal with depression, and made me a more social and less anxious person.

Most people who use drugs do not consider themselves “addicts” and do not meet the criteria for an addiction diagnosis. Most drug use does not lead to addiction, and many stop on their own without treatment. They are not all “suffering” and waiting to be saved. People use drugs for logical reasons: to relieve pain, to feel happy, to be less anxious, and to escape. If they were useless, most people wouldn’t start using them.

The next time you take a sip of wine or drink a beer, imagine if we considered everyone who drinks any amount to be “an alcoholic” or if we labeled all alcohol consumption an “alcohol use disorder.” The teenager who takes 10 shots in 10 minutes (that was me at 15) will most likely experience an overdose, even if that experience alone will be labeled a “bad night” rather than becoming the sole basis for diagnosing an alcohol use disorder.

The difference between views on alcohol and drugs reflects our prevailing laws, culture, and religious philosophies. In many Islamic countries, alcohol is restricted in the same way as heroin or cocaine. In some regions of South America, the coca plant (where cocaine comes from) is consumed daily along with caffeine. In Mormon communities, caffeine is considered taboo. If our definitions of “acceptable” drug use can change so drastically across borders or religions, then perhaps the real problem lies not with drugs at all, but rather with the conditions we have created for using them.

There are real dangers associated with drug use, but many of these dangers are not inherent in the drugs themselves. The supply of illicit drugs is completely unregulated and their potency varies greatly from batch to batch. It’s like you drink a cup of coffee one day and it’s normal, and the next day it has 200 times more caffeine, but you can’t tell the difference until it’s too late. Legal consumer products such as coffee or prescription drugs are regulated and consistent – ​​regardless of whether experts or the dominant culture consider their use healthy – but illegal substances do not benefit from our most fundamental principles of consumer protection.

For decades, the dominant approach has been to criminalize drugs and those who use them. This policy encourages people to use alone, and hiding one’s drug use is deadly. In Californiamore than 80% of overdose deaths that occurred in a private place occurred in the deceased’s home. People who die from overdoses are often shelters, employees, parents, caregivers, neighbors and friends. They die quietly in bedrooms and bathrooms because shame and fear make isolation safer than disclosing their use, even to the people who love them most. Half of all deaths occurred with a bystander nearby who did not react to the overdose, either because they were separated, such as in a different room (45.7% of the time), or because they were unaware the deceased was using drugs (25.9%).

The risk of disclosure during active use can be catastrophic. People are losing their jobs, their custody, their homes, their partners and their freedom. Courts and child welfare systems view all drug use as criminal behavior incompatible with parenting. Even within treatment systems, returning to use is often punished and not met with compassion.

The criminalization of drugs does not prevent people from using them, but it pushes their use underground and makes it more dangerous. According to a recent report from California Correctional Health Servicesnot only are overdoses the leading cause of death for incarcerated people, but they are also the leading cause of death for people leaving incarceration in California.

As an alternative to incarceration, there is a growing movement toward involuntary commitment where people are forced into locked treatment centers. When we remove a person’s autonomy under the pretext of “saving” them, we reproduce the same moral logic that leads to punishment: we cannot entrust our own lives to people who use drugs. In Massachusettswhere we have been involuntarily committed for decades, research has shown that in the first 30 days after release, they face a 41% higher risk of death from overdose than people who sought care on their own.

Overdose prevention has been seen as synonymous with drug treatment, as if the only way to save lives is to get people “into recovery.” But what if prevention also meant creating conditions in which people can be safe, even if they continue to use? What if that meant recognizing that drugs can have positive effects on people and that the real danger comes from unregulated supply, stigma and isolation?

The next phase of overdose prevention must go beyond punishment and the fantasy that everyone who uses drugs is broken and waiting to be cured. We can build something better. We can create systems and stories rooted in dignity, safety, and compassion for all people, whether they use drugs, stop using drugs, or use them again.

It starts with how we talk to the people we love. Instead of reacting with fear or judgment, start by being curious by asking yourself: What’s in it for you? How does it help? What would make it safer?

If someone in your life uses drugs, you don’t need to approve or excuse them to care about their safety. You can keep naloxone nearby and learn how to use it in case of an opioid overdose. You can register without giving a lesson. You can talk openly about safer drinking, such as not drinking alone, testing your supply when you can, and starting slowly with something new.

And if they trust you enough to use it in your presence, reject the narrative that your role is enabling. You choose love. You choose connection over concealment. Every overdose we prevent starts with one person’s decision to stay and not turn away.

This small but radical act of compassion can save a life. It can start with you.

Stephen P. Murray, an overdose survivor turned paramedic and public health advocate, is a clinical assistant professor at the Boston University School of Public Health. He runs the SafeSpot Overdose Hotline.