Though the continued opioid (and now fentanyl) crisis may be a reason to despair, there are many individuals, social movements, and other organizations who are working to address problems associated with substance use. Social science, public health, biomedical, and legal scholars and researchers are diligently producing more evidence-based knowledge to guide societal efforts toward more humane and pragmatic responses to substance use. Reducing harmful drug use is social justice.

11.5.1 Harm-Reduction Movement

Figure 11.17. Transformation: The Alchemy of Harm Reduction [YouTube]. Please watch at least the first 5 minutes of this hour-long video. It describes an innovative harm reduction program in New York. As you watch, please consider how this approach changes the conversation around harmful drug use. Also, how can syringe exchange be a starting place for creating social transformation? Transcript

Harm reduction offers a lens through which we can understand and address issues associated with substance use. The first minute of the video in Figure 11.17 provides a list of the ways that harm reduction creates a safer environment for everyone. Harm reduction can be understood as a set of practices. It can also be understood as a social justice movement. The philosophy behind harm reduction revolutionizes the way we respond to human problems, namely addiction, drug overdose, and HIV.

Harm reduction uses a grassroots approach based on advocacy from and for people who use drugs and accept alternatives to abstinence that reduce harm (Marlatt 1996). According to the Harm Reduction Coalition, the central harm reduction organization in the US, a core principle of harm reduction philosophy “accepts for better or worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them.”

Syringe exchange programs, or their more current name—syringe service programs—were one of the early harm reduction efforts made to address the AIDS crisis of the 1980s and ’90s. The Harm Reduction Coalition states that “Syringe service programs (SSPs) distribute sterile syringes, safer drug use supplies, and education to people who inject drugs.” The current opioid crisis in the United States is causing a dramatic increase in infectious diseases associated with injection drug use, such as HIV or hepatitis C. Syringe service programs are known to reduce HIV and hepatitis C infection rates by an estimated 50 percent (Platt et al. 2017). When paired with medication-assisted treatment to treat opioid dependence, syringe service programs can reduce HIV and hepatitis C transmission by over two-thirds (Platt et al. 2017; Fernandes et al. 2017).

Sometimes people oppose syringe service programs because they think it might enable drug use. Research shows the opposite. According to the US Centers for Disease Control and Prevention (2019), new users of syringe service programs are “five times more likely to enter drug treatment and three times more likely to stop using drugs than those who don’t use the programs.”

Syringe service programs can also prevent opioid overdoses by educating people who use drugs about ways to prevent overdose. Syringe service programs provide training on how to recognize an overdose and how to use naloxone or Narcan, a harmless medication that reverses opioid overdoses. Often syringe service programs will distribute overdose prevention kits that include naloxone (CDC 2019).

11.5.2 Decriminalize Low-Level Drug Offenses

National social justice advocates recommend decriminalizing low-level drug offenses as a way to decrease oppression in our criminal justice system. Decriminalization is the act of reducing penalties for possession/use of small amounts from criminal sanctions to fines or civil penalties (Galvin 2014). For example, in order to address the racial and ethnic disparities in criminal justice systems, Ashley Nellis from the Sentencing Project recommends that we:

discontinue arrest and prosecutions for low-level drug offenses which often lead to the accumulation of prior convictions which accumulate disproportionately in communities of color. These convictions generally drive further and deeper involvement in the criminal legal system. (Nellis 2021)

Decreasing criminal involvement in the first place related to harmful drug use is a step in treating harmful drug use like a medical condition that needs treatment rather than a criminal condition that needs punishment.

Legalization of Cannabis

Social movements, as well as individuals who sought to decriminalize and legalize cannabis, were often motivated by the United States’s long history of systemic racism and the war on drugs. Legalization means to make the possession and use of a drug legal (Galvin 2014a). Since 2012, 24 states and Washington, D.C., have legalized cannabis for adults over the age of 21. Legalizing cannabis has meant fewer arrests and jail time. In Oregon, the number of cannabis arrests decreased by 96 percent from 2013–2016, the year cannabis was legalized for adult recreational use Drug Policy Alliance 2022).

The Drug Policy Alliance, a nonprofit organization that advocates for the decriminalization of drugs, examined rates of youth cannabis use. They found that since the legalization of cannabis use in some states, youth use rates have remained stable and, in some cases, gone down. They have also found that legalization has not made roadways less safe due to driving under the influence of cannabis. Finally, they show that states are using the money generated through taxes on legal cannabis for social good (The Drug Policy Alliance 2022). In Oregon, 40 percent of the cannabis tax revenue goes to the state school fund, and 20 percent goes to alcohol and drug treatment.

However, health researchers remain concerned about the impacts of cannabis legalization on adolescent cannabis use. Increasing amounts of research reveal correlations between adolescent cannabis use and short and potentially long-term impairments on cognition, worse academic/vocational outcomes, and increased prevalence of psychotic, mood, and addictive disorders (Hammond et al. 2020). Though cannabis use rates among adolescents are higher in states that have legalized the substance, those rates were higher even before legalization (Choo et al. 2014; Wall et al. 2011; Ammerman et al. 2015). Legalization itself did not cause higher usage rates.

Other negative impacts of cannabis use have risen in states where cannabis is legalized. Motor vehicle accidents and deaths where cannabis was involved have increased. Young children and pets accidentally overdose more often. Finally, emergency rooms see more patients and hospitalize them more often due to potent cannabis causing psychosis, depression, and anxiety (Committee on Substance Abuse & Committee on Substance Abuse Committee 2015, as cited in Hammond et al. 2020).

When considering whether cannabis should be legal, Hammond et al. (2020) point out that we must balance the negative impacts (discussed above) with the positive effect of decriminalization, reducing youth juvenile justice involvement. Youth involvement in the juvenile justice system can have long-lasting negative impacts on the life outcomes of youth. For example, involvement in the juvenile justice system may disrupt education or cause long-lasting mental health problems. We must consider the reduction of these types of issues alongside the known negative impacts of youth cannabis use.

Another equity issue arises with the legalization of cannabis and the rise of a money-making industry. A drug-related felony on an individual’s record may be a barrier to gaining a license to sell cannabis through a dispensary. As we’ve discussed in this chapter, due to systemic racism within drug policy enforcement, those with drug-related felonies on their record are disproportionately Black. This means that Black entrepreneurs may be disproportionately blocked from entering the cannabis industry. Several states and cities have implemented equity programs to address this issue. In California, a prior drug felony cannot be the sole basis for denying a cannabis license. In Portland, Oregon a portion of cannabis sales tax revenue is spent on funding women-owned and minority-owned cannabis businesses (DPA).

Decriminalizing Personal Possession of Illegal Drugs in Oregon

On November 3, 2020, Oregon became the first state in the United States to decriminalize the personal possession of illegal drugs. By approving Measure 110, Oregon voters significantly changed the way drug possession violations are addressed. People found with smaller amounts of controlled substances (such as heroin, cocaine, or methamphetamine) are issued a Class E violation, which is punishable by a $100 fine. Alternatively, people in violation can have the fine waived if they complete a health assessment at an addiction recovery center.

Measure 110 also created a new drug addiction treatment and recovery grant program funded by the anticipated savings due to reduced enforcement of criminal drug possession penalties, as well as cannabis sales tax revenues (Lantz and Neiubuurt 2020). Advocates for Measure 110 saw it as a way to eliminate drug policies that were having a disproportionately negative impact on Black and Indigenous People of Color. This law also shifted the societal response to drug use from a punitive, moralistic approach to one that involved treatment and compassion.

Figure 11.18. Store for Magic Mushrooms in the Netherlands. How do we use social construction at work in the conversation around the decriminalization of psilocybin?

During the same election vote in 2020, Oregonians also approved Measure 109, which directs the Oregon Health Authority to license and regulate the manufacturing, transportation, delivery, sale, and purchase of psilocybin products and the provision of psilocybin services (Oregon Health Authority N.d.). Psilocybin is the main psychoactive component of magic mushrooms (Figure 11.18). This substance has been utilized for thousands of years in spiritual ceremonies in Indigenous cultures (Lowe et al. 2021). Psilocybin is considered a psychedelic hallucinogenic drug that produces both mind-altering and reality-distorting effects.

Following negative stigmatization of the substance due to its use within the hippie counterculture movement, in 1970, the federal government changed the classification of psychedelics (including psilocybin) to Schedule 1 drugs, which ended all scientific research on psychedelics. Research interest in the therapeutic uses of psychedelics resumed in a 2004 pilot study from the University of California, Los Angeles, which investigated the use of psilocybin treatment in patients with advanced-stage cancer (Grob et al 2010).

Since then, significant amounts of research into the use of psilocybin to treat an array of health concerns, from anxiety to cluster headaches, have taken place. Measure 109 in Oregon required a comprehensive review of the scientific literature on psilocybin’s therapeutic uses. This review found research that suggests that psilocybin can reduce depression and anxiety. The FDA has designated psilocybin as a “breakthrough therapy” for the treatment of depression, which means that psilocybin treatment may be a significant improvement over existing therapies to treat depression Psilocybin therapy involves the administration of the substance in the context of counseling support in the weeks before and after dosing (Abbas et al. 2021). Though Oregon’s regulated psilocybin treatment programs will not be up and running until 2023, they offer hope to those suffering from mental health disorders for whom other treatments do not work.

Oregon’s decriminalization of low-level drug offenses is revolutionary, but it follows the advice of national social justice advocates, who recommend this action to address systemic inequalities related to harmful drug use.

11.5.3 Community Collaboration for Drug Treatment

A final way to address the social problem of harmful drug use is to expand access to effective drug treatment. Expanding options takes collaboration by federal, state, and community partners to make a difference.

The Intersectionality of Drug Treatment

Socioeconomic status and race impact access to drug treatment. Most elective drug treatment programs require some form of payment for services. Those without insurance and without the financial means to pay will be unable to receive treatment. Researchers have also found that racial discrimination has prevented entry for Black and Indigenous People of Color into more desirable forms of drug treatment (Hansen 2015).

While some may actively seek drug treatment, others may be forcefully mandated to attend strong-arm or faith-based rehabilitation programs. Sociologist Teresa Gowan asserts that these types of mandated rehab programs are used by the state to manage the poor. Poor individuals with a drug violation may be mandated to undertake forms of treatment that are designed to “transform basic behavioral dispositions and instill a new moral compass” (Gowan 2012).

At strong-arm rehab centers, all DWI (driving while intoxicated) and many low-level drug offenders are encouraged to define themselves as addicts, even if they may not actually have a substance use disorder. They are also punished for relapse and rewarded for a “cure.” Gowan found that cultural styles and tastes that were not middle class were brought into the so-called therapeutic habilitation process and considered to be in need of reform. Bringing up the role of poverty or racism in one’s life is thought to be immature and evidence of the addict’s ego (Gowan 2012).

Race and class also play a role in determining which type of opioid use disorder treatment one will receive. Hansen (2015) found that BIPOC was often only offered the option of the less desirable methadone treatment, which requires near-daily visits to a clinic and a demeaning and constricting practice of surveillance (Bourgois 2000). In contrast, White middle-class individuals were more likely to be given the opportunity to receive buprenorphine treatment for their opioid use disorder. This type of treatment is more private and requires significantly fewer medical interactions. Hansen (2015) sees this systemic discrimination as working to maintain the race and class privilege of White middle-class individuals.

Increasing Drug Treatment Options in Local Communities

Drug treatment in Oregon is particularly lacking. Oregon ranks 47th among the 50 US states in access to treatment for substance use disorders. Treatment needs are significantly unmet In fact, only 8.5 percent of teens and adults in Oregon who needed treatment actually received it (Substance Abuse and Mental Health Administration 2020). How might increasing treatment options impact the social problem of harmful drug use?

Higher levels of social capital within a community might protect it from higher overdose rates. Social capital is defined as the social networks or connections that an individual has available to them due to group membership. These researchers measured social capital by looking at voting rates, the number of non-profit and civic organizations in a community, and response rates to the census (Zoorob and Salemi 2017). These are all indicative of one’s engagement with their community, as well as increased social linkages between people through community organizations.

Community connections can also decrease drug use. Research documents the relationship between experiences with racism and illicit drug use among Black women (Ehrmin 2002). This research shows that while socioeconomic class was a factor, it was not the sole determinant of drug use (Stevens-Watkins et al.2012). Instead, Black women used drugs less if they had a strong ethnic identity and were connected to their communities (Maclin-Akinyemi et al. 2019).

Figure 11.19. A Small-Town Plague: A New Approach to Opioid Addiction [YouTube]. This 9.52-minute video describes community partnerships that support reducing harmful drug use in communities. Please watch the first 5 minutes. How do these approaches leverage existing interdependence, individual agency, and collective action to reduce harm? Transcript

Increasing funding for drug treatment, including drug treatment facilities, harm reduction programs, and community-based drug treatment programs can expand social justice for drug users. Community-based drug treatment programs serve over 53% of people in recovery (Bowser 1998). They include Twelve Step programs and other peer-led recovery groups. These community-based organizations may serve people with specific social identities, such as recovery groups for firefighters, queer people, or women, as examples. In addition, a recent study found that even when harm reduction or drug treatment services were available, they couldn’t offer enough wrap-around services to their clients. For example, even though many clients were unhoused, most programs didn’t offer housing. Even when clients were parenting, the programs had no funding for childcare services (Krawczyk et al 2022).

One way to increase funding for drug treatment is through local ballot measures. Measure 110, which decriminalizes possession of small amounts of illicit drugs, was passed in the 2020 election in Oregon. This law increases state funding for drug treatment services.

11.5.4 Licenses and Attributions for Recovery is Social Justice

Open Content, Original

“Recovery is Social Justice” by Kelly Szott and Kimberly Puttman is licensed under CC BY 4.0.

Open Content, Shared Previously

“Social capital” definition from the Open Education Sociological Dictionary edited by Kenton Bell is licensed under CC BY-SA 4.0.

Figure 11.18. “Photo” by Marcus Loke is licensed under the Unsplash License.

All Rights Reserved Content

Figure 11.17. “Transformation: The Alchemy of Harm Reduction” by Lower East Side Harm Reduction Center is licensed under the Standard YouTube License.

Figure 11.19. “A Small-Town Plague: A New Approach to Opioid Addiction” by The Atlantic is licensed under the Standard YouTube License.