Harnessing the language of overdose prevention to advance evidence-based responses to the opioid crisis

Abstract

Language has significant implications for how we view and respond to public health issues. Conventional moralistic messaging around drug use stigmatizes people who use drugs and inhibits the implementation of evidence-based harm reduction interventions that do not condemn drug use. However, within the context of the unprecedented North American opioid overdose crisis, we argue that shifting conventional moral messaging around overdose prevention and response strategies is key to supporting the rapid roll-out of evidence-based harm reduction interventions. Reframing overdose prevention to highlight the imperative to address the ongoing public health emergency is an important first step in implementing urgently needed response strategies.

Words matter. The recent Associated Press stylebook’s recommendation to stop using “addict” as a noun underscores the need to view disease outcomes as distinct from personhood [1]. Such guidance recalls prior epistemological changes that saw Gay-Related Immune Deficiency become AIDS and Judenkrankheit (“the Jewish disease”) become diabetes [2]. These changes to language shift from alienating ‘othered’ groups to more accurately reflecting the nature of disease or health experiences, and are thus critical to addressing ongoing misconceptions associated with substance use and related interventions. Calls for reframing how we talk about substance use are not new [3], with evidence underscoring the impact of discourse on reinforcing stigma and undermining engagement in needed health and other social services [4]. However, in the throes of a North American opioid overdose crisis, where opioid-related overdoses are now the leading cause of premature death in the US [5] and a significant cause of death in Canada [6], turning attention to the language used to frame overdose prevention strategies may be effective in garnering wider support for the rapid roll-out of life-saving interventions.

In Canada, a language shift occurring within the context of the implementation of a public health emergency strategy has proven critical to opening the way for a robust response to the ongoing, nationwide opioid overdose epidemic. Specifically, the Province of British Columbia supported the rapid implementation of low-threshold supervised injection facilities, termed Overdose Prevention Sites, following the declaration of a public health emergency by the Provincial Medical Officer and an escalation in overdose deaths. Similar to supervised injecting facilities, these sites have served as an effective means of preventing overdose deaths by providing people with spaces to inject – and, in some cases, smoke – drugs under peer or support worker supervision, and be administered naloxone in the event of overdose [7]. The first of these sites was implemented by community activists in British Columbia, and subsequently garnered wide support due to the emphasis on overdose responses in the context of a public health emergency. Further, rebranding these overdose response strategies as Overdose Prevention Sites, and implementing them without approval by the federal government, was made possible by the imperative to address overdoses within the context of a local crisis. Admittedly, Overdose Prevention Sites might be best understood to be overdose response sites insofar as their primary purpose is to provide a space in which naloxone and oxygen can be administered in the event of an overdose, while simultaneously reducing overdose risks by enabling safer consumption conditions. Shifting away from “supervised injection facilities,” terminology that risks evoking moralistic interpretations of harm reduction, the term ‘Overdose Prevention Sites’ refocuses attention away from perceived individual cause and control of drug use [3] to the need for rapid interventions to address a public health issue.

Evolving discourses around substance use in Canada have been critical to emphasizing collective action amid a public health emergency. While efforts to alter language around drug use and intervention strategies needed to mitigate harm in Canada have been amassed over the last decade, this public health emergency has crossed age, racial, and socio-economic boundaries and has incited a continued change in how drug use is discussed. Such language change has altered dialogue in Canada to now include updated drug education curriculums and outreach in schools [8], wide-reaching efforts by parent groups to highlight the damaging effects of stigmatizing language [9], and changing support for overdose prevention interventions [7, 10].

Changing how we speak about drug use and overdose is essential in the US and elsewhere amid the opioid overdose crisis. Research has highlighted how language traditionally used to discuss substance use and people who use drugs (e.g. “substance abuse,” “addicts”) is morally-centered, largely impacting provider attitudes and can create barriers to accessing care [4]. Rather than utilizing clinical terminology to describe substance use, such as a “positive” or “negative” test result or acknowledging drug use as intimately connected to socio-structural contexts [3], discourse has primarily incorporated pejorative phrases such as “dirty” or “clean,” which can exacerbate discrimination for people who use drugs. The limits of this language have significant implications for acquiring needed support to rapidly respond to the current public health crisis. Further, these morally-centered discourses have been exacerbated by US policy, which has historically prioritized drug criminalization and abstinence-based approaches over evidence-based public health initiatives for people who use drugs [11]. Such methods in America’s ‘war on drugs’ have harnessed criminalizing language that has not only reified the stigmatization and marginalization faced by minority populations who use drugs, but has stalled the implementation of evidence-based harm reduction strategies, including syringe exchange services, naloxone distribution, and opioid agonist therapy at the federal level [12]. Within such discourses, a focus on individual behaviours, including drug consumption practices, has been key in fostering resistance to the implementation of overdose prevention strategies [13], referencing notions of a dangerous and uncontrollable ‘other.’ For example, rhetoric used to oppose harm reduction services have often drawn on the rationale of ‘public safety’ suggesting that such services enable people who use drugs to further engage in public disorder, rather than focusing on how such services mitigate adverse outcomes of drug use (e.g. fatal overdose).

More recently, messaging around the opioid overdose crisis and response strategies has emphasized individual responsibility (e.g. drug use as a ‘choice’), suggesting people who use drugs knowingly consume too much (e.g. overdose vs. poisoning) [14]. However, the use of such language conceals the underlying factors perpetuating the overdose crisis (e.g. contaminated drug supply, social isolation, inadequate distribution of naloxone, lack of social supports). In the face of the opioid overdose epidemic and the emergence of rapid opioid-related HIV and HCV outbreaks (e.g. Scott County, Indiana) in the US [15], there is a moral imperative to address these public health emergencies and expand interventions that can serve to improve the overall health of people who use drugs. Using commentary language that evokes compassion within the context of a crisis is thus a critical step to rapidly implementing response strategies. Further, moving away from stigmatizing discourses can shift attention to the broader social-structural factors contributing to and exacerbating the epidemic (e.g. poverty, dearth of harm reduction services), and is critical to acquiring support from diverse actors (i.e. health professionals, policymakers, concerned parents’ groups). Reflecting on the HIV epidemic in North America highlights the significance of language in dictating how public health issues are viewed and addressed. Specifically, moving from discourses that described HIV as an ‘imminent danger’ and individual-focused risk behaviours, to a recognition of social and structural contexts shaping risk, contributed to a more rights-based public health approach in addressing HIV [16]. A similar health and human-rights focused language transition is now needed in public health and policy responses to overdose.

Since 2015, the US has seen an increase in institutional motions to reconsider harm reduction approaches that were once seen as inappropriate or enabling. As demonstrated by recently introduced congressional bills, including efforts to expand opioid treatment programs, addiction medicine research, and naloxone access for first responders [e.g. 17, 18], evidence-based responses to the opioid epidemic are now being considered. For example, Boston’s Healthcare for the Homeless program has been successful in integrating interventions to support people who use drugs, including medical monitoring for individuals who are over-sedated and naloxone training [19]. Additionally, the past Surgeon General has called for comprehensive approaches to substance use (e.g. recovery services, integrated addiction services) [20], with various state governments aiming to scale-up opioid agonist therapies. While these institutional motions have used language that frames the overdose crisis as a public health emergency, recent prohibition discourse [21] suggests that approaches to address the opioid crisis may be reverting to punitive tactics focused on supply-side rather than focusing on the health of people who use drugs. Such a reversal risks undermining the advances made thus far in the US and reifying the marginalization of people who use drugs. So how do we proceed within the context of a growing overdose epidemic and increasing support for evidence-based overdose responses?

In July 2017, the White House Opioid Commission released their interim report on the opioid overdose crisis [22], urgently calling for it to be declared a national emergency as the widespread effects of the crisis span geographic regions, socioeconomic class, and race. Although this signifies a transition from an individualistic to a societal framing of a public health issue, overdose prevention and intervention strategies in the US must also utilize the same language. A similar reframing was used in the most recent report put forth by the Global Commission on Drug Policy in October 2017 [6], which further highlighted how underlying social-structural factors and systemic discrimination have shaped drug policy in ways that have proven ineffective. As such, the Commission emphasized the need to address the North American overdose epidemic through decriminalized tactics that encourage engagement in health services. The use of decriminalizing discourse within the Commission’s recommendations places the onus of the current crisis on macro-level social and structural factors (e.g. economic recession, expansion of pharmaceutical market), which is not only important in shifting public perceptions of people who use drugs, but also in seeking comprehensive approaches to address the epidemic.

While the complexities of the opioid overdose crisis cannot be addressed by language alone, altering how we speak about this public health emergency is key. Utilizing destigmatizing language (i.e. “overdose prevention”) in conjunction with drug policy reforms can help us realize our moral imperative to provide rapid public health interventions in the throes of a national crisis, and is thus an important first step in saving lives.