People who are dependent on drugs need support, not punishment

We don’t have a drug problem. The problem lies in the way we think about drugs. Unless we stop demonising drugs, criminalising or pathologising the people that use them and abandon the goal of a drug-free society, we will continue to be distracted from the real problems that cause many of our youth to find solutions in the dependent use of drugs.

The 1961 United Nations Single Convention on Narcotic Drugs committed countries “to prevent and combat the evil of drug addiction”. In 2019 the heads of 31 UN agencies expressed unanimous support for the decriminalisation of possession and the use of drugs.

The shift in UN thinking enables us to move forward. We have relied on the criminal justice system to address drug use for far too long. In a 2020 article, Justice Edwin Cameron described the catastrophic effect of the “war on drugs”. We need a fresh, bold response to the use of drugs. People who are dependent on drugs need support, not punishment.

South Africa is beginning to see changes. The new National Drug Master Plan (2019-2024) promises a shift in policy. It “recognises that the punitive approach has not been successful in tackling drug-related problems”. Instead, it emphasises “evidence-based public health and social justice principles that focus on individuals, families, communities, society as a whole”. These must “underscore social protection and health care instead of conviction and punishment”.

Recent reports have shown programmes that help people dependent on drugs to resolve their problems using community-based teams: These include medication-assisted treatment, needle and syringe services, screening and treatment for psychiatric issues, psychosocial services, trauma counselling, vocational training and sport and recreational activities.

Examples are the University of Pretoria’s Community Oriented Substance Use Programme (Cosup) in Tshwane, the Belhaven Centre in eThekwini, the TBHIV Care Step Up Project and SAHARA in George.

With new approaches, the harms disproportionally suffered by specific communities will diminish. But to truly reform drug services and policy, three widely accepted beliefs must be challenged. Left unchallenged, we will soon find that the war on drugs is not over but has become an insidious cold war that continues to oppress and control certain groups.

Firstly, we must avoid over-pathologising drug use. A common refrain urging us to dismantle the criminal justice response is “patients not prisoners”. But this replaces crime with a disease.

Is addiction a disease? This is highly contested. What is certain is that most people who use drugs do not become “addicted”. The people most likely to develop a drug dependence often face limited choices due to marginalisation and economic deprivation, have a history of trauma and feel disconnected from their community.

Improvements in their circumstances, support, and hope for a future often reduce their drug use. Studies show that most people who develop an addiction will resolve it without treatment before turning 30-years-old.

Diseased or not, people who use drugs need access to health and psychosocial support services. Prescribing regulated drugs to prevent withdrawal from and cravings for street drugs and the supply and collection of sterile injecting equipment are essential harm reduction interventions. Many dependent drug users have pre-existing trauma, attention deficit hyperactivity disorder, depression, and post-traumatic stress disorder. When these are treated, the addiction is often resolved.

Voluntary psychosocial services that emphasise the therapeutic relationship, support and non-confrontational approaches have shown positive outcomes. Contrast this with the confrontational, directive, and prescriptive non-collaborative approaches that emphasise powerlessness, denial, and having an incurable disease, which evidence shows are ineffective and may prolong an addiction.

To be sure, drug rehabilitation is better than prison. But, if we define addiction as a chronic relapsing brain disease that compromises free will and requires treatment, like the National Institute on Drug Abuse in the US does, clinicians will have unprecedented power over people who use drugs. They could impose long-term residential programmes and insist on lifelong abstinence from all drugs, including alcohol and psychoactive medications. They could deny custody of children and separate people from their community, all in the name of treatment.

If the notion of “addiction is a disease” runs its logical course, we will have turned prisoners into patients and patients into prisoners. We will go full circle, but people will have to pay for their incarceration this time.

The second myth is that “demon drugs” are responsible for most social problems communities face. In reality, unemployment, school dropout rates, theft, robbery, rape, gender-based violence and murder are not caused by any “demon drug”.

Almost all the issues blamed on drugs and people who use them exist independently of drug use. Research confirms that many of the social ills ascribed to drug use are, in fact, predictive of drug use and drug dependence.

In short, drugs do not “possess” the consumer. A capacity for violence, criminal activity and anti-social behaviours pre-exists. Contrary to popular belief, most heroin users living on the street do not live off criminal enterprise. Heroin (nyaope/whoonga/unga) relieves physical and emotional pain. It allows people to tolerate intolerable circumstances. They need to buy R20 to R50 of heroin every four to six hours or face painful withdrawal. This requires a regular income through activities like recycling, guarding or washing cars, carrying groceries, subsistence drug sales or casual labour.

For sure, opportunistic crime occurs — but it is the exception, not the rule.

The “demon drug” narrative creates a politically expedient target on which to blame a multitude of problems. It also blinds us all to government failures. Importantly, it also abdicates responsibility for solving social issues to the criminal justice or the health system.

What would happen if we somehow managed to stop the supply of all drugs in our communities? We would see no significant changes in unemployment, homelessness, hopelessness, violence or crime.

By contrast, if we improved education, reduced unemployment, kept families unified, and ensured that social and health services were easily accessible to all, the levels of drug use and related harms would drop significantly.

Instead of blaming an imaginary “demon drug,” we need to hold the government, our leaders and ourselves accountable. For many young people, drugs are not the problem but the solution.

Finally, we must abandon the unattainable and dystopian vision of “a drug-free world”. Where there is a market, there will be a supply. Always. Since the beginning of time, humans have altered their perceptions and enhanced their existence through the use of mind-altering drugs. Despite spending multiple billions of dollars every year to stop the drug trade, there has not been a single instance where the supply of drugs has successfully been disrupted for any significant length of time. A “drug-free world” is an impossibility.

But is it even desirable? No. Consider that almost all unregulated drugs have pharmaceutical analogues. These meet multiple medical needs. We all need “our drugs”.

Continued attempts to create a “drug-free world” mean that limited financial resources will be used to further militarise and increase the power of law enforcement agencies. People from already marginalised and underserved communities will face more harm, stigma and exclusion.

Ironically, any concerted effort to create a drug-free world will increase the profitability of the market, the demand for drugs and increase the risks and harms associated with the use of unregulated drugs.

But what works?

We should do at least three things: We should not pathologise people. We should debunk the myth of the “demon drug”. And we must abandon the wrong-headed dream of a “drug-free world”.

But doing all this in no way guarantees effective drug services. Change happens when service providers dismantle their hierarchies to meet people who use drugs where they are, and no matter whether they wish to stop, continue or reduce their drugs use, help reduce harm, hear their stories, and build trusted relationships without expectations.

Change occurs when we see beyond the drugs and treat people who use drugs as people.

“People who use drugs” can be abbreviated to a single word: People. DM

Shaun Shelly is a researcher with the University of Pretoria’s Department of Family Medicine and directs drug policy at TB/HIV Care.

Views expressed are not necessarily GroundUp’s.

First published by GroundUp.