The Politics of Addiction: Evidence Needs to Inform Addiction Policy and Practice

As the political landscape heats up for elections, so too does the political rhetoric around addiction. Some political leaders seeking to respond to the overdose crisis and social disorder have recently focused on closing safer consumption services (SCSs) and proposed plans for legislating mandated treatment for addiction. These proposed responses, unfortunately, seem to have a disconnect from evidence, attempting to apply quick fixes to complex problems that only seem to further stigmatize those suffering from addiction. Despite the recognition that a comprehensive approach is needed for addiction,1–3 which address the 4 pillars of prevention, harm reduction, treatment, and enforcement, political expediency leads to reductionistic approaches that focus predominantly on enforcement or very limited aspects of treatment to the exclusion of evidence-based prevention, harm reduction, and more comprehensive treatment approaches. SCSs have known efficacy for preventing and reversing overdoses and engaging marginalized individuals in medical and social support.4–6 They are also efficacious in reducing drug use–related infection and disease transmission, as well as enhancing access to addiction and other health services. In contrast to how SCSs can sometimes be portrayed, they are not associated with significant increases in drug use.4 They can also promote a sense of community for people who use drugs (PWUD).4 Reducing the availability of SCS will cause harm. However, SCSs also need to be responsive to the concerns of the communities they exist in to maintain public support and safety. They also need to use available opportunities with PWUD to encourage behavior change, potentially connecting individuals with evidence-based treatment options. Mandated or involuntary addiction treatment has a dearth of supportive evidence7 with more negative than positive outcomes reported to date.8,9 Treatment gains are often rapidly lost upon leaving mandated treatment8; overdose risk increases after leaving mandated treatment;10,11 and forcing treatment, despite histories of trauma being frequent in people with addiction, may cause further institutional trauma and future avoidance of care provision.8,12 While some people benefit from short-term involuntary treatment to ensure safety, competence to make treatment decisions, and to develop a coherent treatment plan,13 or potentially longer if there is a comorbid severe and persistent mental illness or persistent lack of competence, creating legislation that adequately maintains individual rights would be challenging.8 In addition, facilities and practitioners capable of providing the complex care that would be required for people mandated into treatment are generally lacking.8 Rather than focusing on mandated treatment, it is an expansion of services from harm reduction to treatment and increasing the number of qualified health care practitioners that are needed for people suffering from addiction. For treatments to be most effective, approaches to addiction need to best meet the person’s individual needs and their stage of change.3 Interventions need to be integrated across health care settings but also include justice and social service systems.2,3 People with addiction need to be able to readily access psychiatric, medical, and social services that address their complex care needs that are culturally appropriate and ideally in one place.2,3 Harm reduction and treatment services need to function on a continuum of care, helping to facilitate and maintain substance use change and reduce fragmentation of care. Policies need to expand the addiction treatment workforce and address the social determinants of health that disproportionately influence health and well-being among people with addiction.3 And finally, the structural and individual stigma towards addiction needs to be addressed in policy and practice.1,14,15 In the end, evidence needs to guide policy and clinical practice for addiction. Although it does not make for good political sound bites, the approach to addiction needs to address all 4 pillars of care: prevention, harm reduction, treatment, and enforcement. In particular, there needs to be an expansion of harm reduction and treatment resources readily available for all people at risk for or suffering from addiction that address their often multiple and diverse care needs. David Crockford, MD, FRCPC Incoming Editor-in-Chief, CJA

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