Nurses encouraged to use author’s draft email to contact justice minister
By Rahim Kanji
June 13, 2022
Canada is in the midst of a worsening public health crisis due to substance use, with 26,690 overdose deaths recorded from opioids alone between 2016 and 2021 (Public Health Agency of Canada, 2022). A key issue within this crisis is the criminalization of substance possession as many of the associated harms to substance users stem from these problematic federal policies. For example, criminalization contributes to overdoses through indirectly supporting a heavily contaminated and unregulated market and through deterring people who use substances from early treatment due to stigma (Health Canada Expert Task Force on Substance Use [HCETF], 2021a). Although the Controlled Drugs and Substances Act (CDSA, 1996) does not contain discriminatory language, equally concerning is the way it is enforced, disproportionately incarcerating Indigenous and Black people who use substances (HCETF, 2021a).
This is particularly relevant to the nursing profession because the ethical care of people who use substances requires an incorporation of the social determinants of health, many of which are impacted by incarceration (Registered Nurses’ Association of Ontario [RNAO], 2015). Simcoe (2022) outlined the importance of nursing leadership in Canada’s evolution toward drug decriminalization in a previous Canadian Nurse article. In this analysis, I add a socio-political perspective that sheds light on the racial history of drug criminalization. As well, I offer two evidence-based recommendations nurses can propose in an email (see Appendix) to the federal justice minister to ensure successful decriminalization of substances.
Contradiction between best practices and legal frameworks
The current policies of criminalization emerged from a legacy of racist laws beginning with the Opium Act of 1908, which vilified opium use in Chinese immigrants largely due to the growing anti-Asian sentiments in Canada at that time (Owusu-Bempah & Luscombe, 2021). Canada’s opium vilification, however, is widely considered an act of hypocrisy because the drug’s usage in China was actively promoted by Canada’s “mother country,” Britain, which exported opium from British Bengal to China (Virani & Haines-Saah, 2020). Currently under the CDSA, Indigenous and Black people who use substances are arrested at five to nine times the average rate for substance possession despite similar use patterns across all racial groups (Virani & Haines-Saah, 2020). Having a criminal record creates barriers related to key social determinants of health, such as employment, social support and financial security (HCETF 2021a, 2021b). Therefore, nurses who care for Indigenous and Black people who use substances are caught between best practice guidelines for treating substance use, which emphasize improving the social determinants of health of clients, and a legal framework that conflicts with this role.
The savings gained can be invested in government services such as housing, employment insurance and pensions.
Such contradictions to the effective care of people who use substances has led to CDSA amendments, such as allowing courts to divert such people from incarceration to treatment facilities (Jesseman & Payer, 2018). In 2018, prescription heroin was approved to curb the use of contaminated heroin from the unregulated market (Jesseman & Payer, 2018). These amendments, however, are insufficient as Canada now has the fastest-growing overdose mortality rate globally (HCETF, 2021a). Furthermore, the cost of policing people who use substances totalled $6.4 billion in 2017, which diverted funds from areas pivotal to the social determinants of health, such as housing and employment insurance (HCETF, 2021a). Governmental stakeholders are starting to take notice of these gaps in public policies. Most recently, the City of Vancouver requested an exemption from the CDSA in order to decriminalize illicit substance possession (HCETF, 2021a). Although criminalization policies are still the main approach, Vancouver’s request is an example of the readiness among stakeholders to consider alternative strategies. Therefore, not only is the present moment an opportune time for nurses to advocate for drug decriminalization policies, it is also an essential time for decriminalization itself because past strategies are not working from health and financial perspectives. I agree with Hardill (2019) that nurses must join the call for the decriminalization of illicit substances because the ethics of our profession implores us to advocate for upstream policy changes that can improve the lives of marginalized communities.
As noted by Jesseman and Payer (2018), decriminalization is an approach whereby non-criminal penalties such as warnings, nominal fines and treatment referrals are administered for the possession of small amounts of a controlled substance. After reviewing information about the successful decriminalization policies in Portugal, I recommend that nurses write an email (see Appendix) to the federal justice minister with the recommendations below. Portugal and Canada are similar in that both have socialized health-care systems, and like Canada, prior to enacting decriminalization, Portugal was in the midst of an overdose crisis, which makes it a suitable case study to follow (Unlu et al., 2020).
Recommendation 1: decriminalize possession of illicit substances for personal use
Nurses should ask the justice minister to propose a bill to the House of Commons for the decriminalization of the possession of all illicit substances in Canada for personal use. Since people who use substances have varying purchasing habits that often are tied to socio-economic status (i.e., buying in bulk may be the only option for some people because of financial limitations), they should be consulted through some formal process to determine the legal threshold for personal use (HCETF, 2021a). Through decriminalization, Portugal significantly decreased people’s fear of prosecution, which resulted in a record-breaking 40,000 visits to treatment programs in 2020 and 5.5 times fewer overdose-related deaths than the European average (Unlu et al., 2020). Equally important, Portugal’s incarceration rates fell by 50 per cent, which reduced total societal costs by 12 per cent (Unlu et al., 2020). Therefore, an approach like this in Canada could produce significant positive health outcomes for people who use substances without sustaining the current disproportionate incarceration rates of Indigenous and Black people. The savings gained can be invested in government services such as housing, employment insurance and pensions. Such expansions would help Canadian nurses link their patients to necessary social services to better incorporate social determinants of health into their care (RNAO, 2015).
Recommendation 2: scale up prevention, treatment and harm reduction facilities
Nurses should also recommend to the justice minister that provincial/territorial ministries of health will need to immediately scale up prevention, treatment and harm reduction facilities according to expected jurisdictional needs to successfully prepare for decriminalization. As indicated by Jesseman and Payer (2018), one of the lessons learned from countries such as Mexico is that without a parallel expansion of health-care infrastructure, decriminalization does not improve health outcomes in people who use substances. In fact, much of Portugal’s success is owed to its two-year expansion of health infrastructure prior to decriminalization (Jesseman & Payer, 2018). As stated by RNAO (2015), the current funding scheme for harm reduction and treatment services must be expanded for nurses to be able to effectively reduce health inequities in people who use substances.
Although amendments have been made to the CDSA, the current framework of criminalization is costly, contributes to rather than decreases overdoses, and amplifies health inequities, especially in Indigenous and Black people who use substances (HCETF, 2021a). I have outlined two concrete action items nurses can include in emails to the minister of justice: (1) introduce a bill for the decriminalization of all illicit substances for personal use and (2) work with provincial/territorial ministries of health to scale up prevention, treatment and harm reduction facilities. The racist legacy of these policies is a part of our history; however, decriminalization not only offers hope for an ongoing crisis but also a possibility for reconciliation with Indigenous and Black people who use substances.
Controlled Drugs and Substances Act, SC 1996, c 19.
Hardill, K. (2019). That look that makes you not really want to be there: How neoliberalism and the war on drugs compromise nursing care of people who use substances. Witness: The Canadian Journal of Critical Nursing Discourse, 1(1), 13-27. doi:10.25071/2291-5796.15
Health Canada Expert Task Force on Substance Use. (2021a, May 6). Report #1: Recommendations on alternatives to criminal penalties for simple possession of controlled substances. Health Canada. Retrieved from https://www.canada.ca/content/dam/hc-sc/documents/corporate/about-health-canada/public-engagement/external-advisory-bodies/reports/report-1-2021/report-1-HC-expert-task-force-on-substance-use-final-en.pdf
Health Canada Expert Task Force on Substance Use. (2021b, June 11). Report #2: Recommendations on the federal government’s drug policy as articulated in a draft Canadian Drugs and Substances Strategy (CDSS). Retrieved from https://www.canada.ca/content/dam/hc-sc/documents/corporate/about-health-canada/public-engagement/external-advisory-bodies/reports/report-2-2021/report-2-HC-expert-task-force-on-substance-use-final-en.pdf
Jesseman, R., & Payer, D. (2018, June). Decriminalization: Options and evidence. [Policy brief]. Ottawa: Canadian Centre on Substance Use and Addiction. https://www.ccsa.ca/sites/default/files/2019-04/CCSA-Decriminalization-Controlled-Substances-Policy-Brief-2018-en.pdf
Opium Act, SC 1908, c 50.
Public Health Agency of Canada. (2022, March). Opioid- and stimulant-related harms in Canada. https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants#fn1
Registered Nurses’ Association of Ontario. (2015, March). Engaging clients who use substances. Retrieved from https://rnao.ca/sites/rnao-ca/files/Engaging_Clients_Who_Use_Substances_13_WEB.pdf
Simcoe, S. (2022, January 17). Nurses’ leadership is vital to shape Canada’s evolving model of drug decriminalization. Canadian Nurse. Retrieved from https://www.canadian-nurse.com/blogs/cn-content/2022/01/17/nurses-leadership-is-vital-to-shape-canadas-evolvi
Unlu, A., Tammi, T., & Hakkarainen, P. (2020). Drug decriminalization policy literature review: Models, implementation and outcomes. Helsinki: Finnish Institute for Health and Welfare. Retrieved from https://www.julkari.fi/bitstream/handle/10024/140116/URN_ISBN_978-952-343-504-9.pdf?sequence=1&isAllowed=y
Virani, H. N., & Haines-Saah, R. J. (2020). Drug decriminalization: A matter of justice and equity, not just health. American Journal of Preventive Medicine, 58(1), 161-164. doi:10.1016/j.amepre.2019.08.012
Appendix: email to the federal minister of justice
Review the ministry’s contact us page for details.
[Minister’s full name, including honorary title(s) if applicable]
Minister of Justice and Attorney General of Canada
House of Commons
Ottawa, ON K1A 0A6
[Minister’s email address]
Dear Minister [last name],
My name is [full name], and I am a nurse practising in [practice setting]. I am writing this email because I am deeply concerned about the current criminalization strategy used by the federal government to address illicit substance possession in Canada.
As you likely know, our country is not only overcoming the COVID-19 pandemic but also a worsening public health crisis owing to substance use, with 26,690 overdose deaths recorded from opioids alone from 2016 to 2021 (Public Health Agency of Canada, 2022). Although the Controlled Drugs and Substances Act (1996) does not contain discriminatory language, equally concerning is the way it is enforced, incarcerating Indigenous and Black people who use substances at five to nine times the average rate for substance possession despite similar use patterns across all racial groups (Virani & Haines-Saah, 2020).
Although I recognize that some amendments have been made in the implementation of criminalization policies, they are insufficient as Canada now has the fastest-growing overdose mortality rate globally (HCETF, 2021a). As a health-care provider, I urge you to consider the following recommendations:
Recommendation 1: Immediately propose a bill to the House of Commons to decriminalize all substances in Canada for personal use
Decriminalization is an evidence-based policy that decreases stigma and allows people who use substances to seek treatment before serious consequences occur. In Portugal, decriminalization led to a significantly decreased fear of prosecution and a record-breaking 40,000 visits to treatment programs in 2020 as well as 5.5 times fewer overdose-related deaths than the European average (Unlu, Tammi, & Hakkarainen, 2020).
Recommendation 2: Work with provincial/territorial ministries of health to scale up prevention, treatment and harm reduction facilities
As indicated by Jesseman and Payer (2018), one of the lessons learned from countries such as Mexico is that without a parallel expansion of health-care infrastructure, decriminalization does not improve health outcomes in people who use substances. Much of Portugal’s success is owed to its two-year expansion of health infrastructure prior to decriminalization (Jesseman & Payer, 2018). Therefore, it is advisable for each province/territory to scale up prevention, treatment and harm reduction facilities according to expected jurisdictional needs to successfully prepare for decriminalization.
I strongly believe that by implementing these two recommendations, Canada can decrease preventable deaths and demonstrate reconciliation with Indigenous and Black communities, which have been marginalized by the current criminalization strategies.
[Signature and/or full name, designation and address]
[Include the following note in your email:]
References available at https://www.canadian-nurse.com/blogs/cn-content/2022/06/13/decriminalizing-illicit-substances-in-canada-a-bri
Rahim Kanji is a fourth-year undergraduate nursing student and research assistant at Toronto Metropolitan University.