Why Do Different Forms of Knowledge Matter in Evidence-Based Drug Policy?

In the introduction to this special issue, the editors introduce the reader to research methodologies and analyses not commonly presented in mainstream health policy literature. Intersectional analysis, for example, is a means of drilling down into how the multiple social categories a person occupies (e.g., gender, class, ethnicity) may influence their experience of inequality. When an intersectional framework was applied to US Behavioral Risk Factor Surveillance System data in 2018 and 2019, for example, gender minority Blacks were identified as having distinctly poor health experiences compared with cisgender Black and other non-Black gender minority populations.¹ Consequently, health policies and monitoring programs that purport to advance health equity must account for multiply marginalized populations such as these.

Looking at drug policy through an intersectional lens reinforces the importance of macrolevel social determinants as they interact with meso- and microlevel factors to influence drug harms and mediate policy and intervention effectiveness² as well as the role of power in excluding certain perspectives, framings, forms of knowledge, and experience.³ Ethnographic, social–scientific, and community-based research methodologies challenge power imbalances by favoring the embodied knowledge of those with lived experience, knowledge gained by direct observation and study of the particular history and economic and political systems in a given location,² as opposed to forms of professional expertise favored by public authorities seeking to govern society at a distance.⁴

This special issue specifically highlights these diverse forms of research. Seven of the articles present ethnographic research, qualitative interviews, or participant observation (Boyd et al., p. S191; Davidson et al., p. S166; McNeil et al., p. S151; Nguyen et al., p. S182; Friedman et al., p. S199; Lopez et al., p. S173; Houborg and Jauffret-Roustide, p. S159), and six are based on community-based interventions (Hansen et al., p. S109; Nguemeni Tiako et al., p. S128; Hughes et al., p. S136) or forms of community action (Simon et al., p. S117; Hansen et al.; Jauffret-Roustide et al., p. S99). Why, however, do the alternate ways of knowing presented in this special issue matter? What does this body of work offer when compared with the technocratic stance associated with most mainstream research approaches? To answer these questions, we critique what Kari Lancaster refers to as the “evidence-based drug policy endeavour” and the types of knowledge this approach favors.⁵

THE KNOWLEDGE THAT WE PRIVILEGE

As with other policy areas, the drug policy field has jumped on the “evidence-based” bandwagon.⁵ In keeping with a neoliberal economic and political paradigm, in which issues associated with drug use are located as “problems” or “risks” carried by individuals rather than attributed to structural inequalities, epidemiological, biomedical, and psychological perspectives have governed what evidence is and how it is produced.²

It is unsurprising, therefore, that gold standard evidence in drug policy is often predicated on findings from randomized controlled trials or systematic reviews in parallel with evidence-based medicine.⁵

DRUG POLICY

Drug policy is contentious, with conflicting moral positions and values,⁵ and empirical research designs such as randomized controlled trials and systematic reviews are thought to neutralize stakeholder subjectivities, leading to robust and effective interventions. A more critical reading of evidence-based drug policy, however, highlights the narrow repertoire from which politicians tend to draw their interventions, heavily influenced by international drug control conventions.⁶ The impact of these so-called supply-side drug policies is the effective criminalization of people who use drugs, which Lopez et al. point out translates into policing that is intimately connected with negative health outcomes and premature death. With an unchallenged presupposition that some interventions, such as drug consumption rooms, are off the table (Jauffret-Roustide et al.; Houborg and Jauffret-Roustide; Nguyen et al.), the objectivity of evidence-based drug policy is already in question.

Furthermore, by favoring evidence-based policy that relies on research methods designed to remove bias between comparison groups, researchers run the risk of rendering invisible how racialized enforcement of drug laws has affected Black and Latinx communities. Lopez et al., for example, highlight issues such as racially charged and punitive applications of drug laws that criminalize Black and Latinx communities but medicalize White people who use drugs. The outcome, then, is a disengagement from and distrust of statutory harm reduction interventions, which are perceived to be linked to unjust drug laws, as opposed to those embedded in grassroots community action (Simon et al.).

TECHNOCRATIC APPROACHES

A technocratic approach implies an expert-led, rational, robust, and transparent policymaking process within governance structures.⁵ In reality, policymakers are able to hide behind the veil of technocracy and be political–tactical in selecting evidence, use evidence to justify action or inaction on an issue, control processes of knowledge production to create policy-based evidence, or systematically exclude specific stakeholders or forms of evidence altogether.⁷ In other words, technocratic drug policymaking is not immune to exercises in power to promote set agendas while claiming ideological neutrality.

For example, Jauffret-Roustide et al. take a sociological perspective on the implementation of drug consumption rooms, a robust evidence-based harm reduction intervention, by comparing its implementation in three countries with very similar social and health policies, the United Kingdom, Denmark, and France. In all three countries, the criminalization of people who use drugs, a moral standpoint thus far resistant to the supposed neutralizing effects of evidence, prevails. Yet, France and Denmark have implemented sanctioned drug consumption rooms, whereas the United Kingdom remains resistant to this intervention.

Looking through the lens of “generous constraints,” a term coined by Gomart to mean constraints that act as pivot points for action or change rather than simply obstructions,⁸ Jauffret-Roustide et al. show that repressive drug policies can create conditions for resistance and transformations, which activist networks of people who use drugs can capitalize on. In other words, the missing ingredient of technocracy or expert-driven approaches to the implementation of morally disputed or controversial interventions such as drug consumption rooms may well be community mobilization and drug user activism.

THE ROLE OF SCIENCE IN DRUG POLICY

Policymakers tend to prefer research data that simplify the understanding of complex realities. Being able to get a clear message across to the public helps politicians control the policy narrative, produce and set boundaries on the associated problems, and define possible solutions.⁹ The range of policy solutions not only needs to have some science behind it but also must be affordable, timely, acceptable, and in keeping with the national mood, vested interests of associated policy coalitions, and legislative turnover.⁹ Sound science, therefore, is at risk for becoming a sound bite to promote more easily understood and politically safe policies (e.g., investing in police and prisons to keep society safe) rather than nuanced, nonbinary, yet more equitable and effective ones (e.g., investing in structures that care for vulnerable citizens and addressing structural inequalities underpinned by racism; Carroll et al., p. S123; Suen et al., p. S112; Boyd et al.; Lopez et al.).

Consequently, science in policymaking ends up being about quantification through cost–benefit analysis or risk evaluation, narrowing the scope of an issue to a single frame.¹⁰ Such reductionist approaches may exclude alternate framings of a policy problem, effectively disadvantaging some (e.g., Black and Latinx communities, who form the majority of the US prison population) to benefit others (e.g., the carceral economy and their lobby groups; Lopez et al.).

CONCLUSIONS

Ultimately, the issues raised here link directly to the inadequacy of the knowledge that we privilege when delivering evidence-based drug policy. For example, our notion of experts and expertise will vary depending on whether we see harm reduction as primarily a technical public health intervention or a grassroots social movement among people who use drugs responding to the harms coming from existing legislation (Lopez et al.; Jauffret-Roustide et al.). With the former, the biomedical model dictates that we see knowledge in terms of at-risk individuals, high-risk behaviors, and disease patterns and that we see that decisions on service provision be made by epidemiological and public health experts.¹¹ The latter perspective, on the other hand, favors a social approach, which validates experiential and contextual accounts of reality (Lopez et al.), permitting collaborative interventions and policies to address structural inequities that underpin drug harms.

Finally, it is not simply methodological pluralism that is required to improve drug policy. Rather, researchers and policymakers must identify the questions that are meaningful in improving the health and life expectancy of people who use drugs and apply appropriate knowledge and research methods to answer those questions. The knowledge we bring in this special issue challenges drug policymakers to seek outcomes, such as community empowerment, mobilization, and development, and reductions in stigma and structural and intersectional inequalities. It focuses on alternate ways of knowing to challenge the systematic exclusion of certain knowledge traditions and to include typically marginalized worldviews and perspectives. In doing so, we hope to contribute to the disruption of unequal power relations and their undue influence on what constitutes valid knowledge in drug policy formulation.