Currently, APHA has a policy on its books that opposes both drug legalization and decriminalization.
Pharmacy Times® interviewed Vibhuti Arya, PharmD, MPH, FAPhA, professor at St. John's University College of Pharmacy and Health Sciences and clinical advisor to the New York City Department of Health and Mental Hygiene, and Adrienne Simmons, PharmD, MS, BCPS, director of programs at the National Viral Hepatitis Roundtable, as well as St. John’s University College of Pharmacy and Health Sciences PharmD Class of 2023 students Noor Khawaja and Lauren Merkovich, on her presentation at the APhA 2023 Annual Meeting & Exposition titled “Public Health over Punishment: Drug Decriminalization as an Alternative to the Failed War on Drugs.”
Pharmacy Times: What does drug decriminalization have to do with mental health and access to care?
Adrienne Simmons, PharmD, MS, BCPS: So I think it's important for us to maybe start by defining what drug decriminalization is. So thinking about the substance use and opioid crisis that we have in this country, we have historically really approached substance use disorder as a criminal behavior as opposed to a health problem. And so, as a result of that, we have relied on criminal penalties like arrest and incarceration as the answers to a public health issue or substance use disorder.
What decriminalization is it actually removes criminal penalties, like arrest and incarceration, for the possession and use of illicit substances. It reduces those penalties from a crime to a civil offense, and so a civil offense would be something like a fine. You can think of the example of if you're jaywalking, if you're crossing the street when you're not supposed to, you would get fined, and it might be a misdemeanor, as opposed to being arrested, possibly incarcerated, and in many cases being charged with a felony.
So the impact of us treating substance use in this country as a criminal issue as opposed to a health issue has had long standing impacts on people's lives. As you can imagine, any sort of arrest or incarceration, regardless of what the reason is, that's something that you carry with you for the rest of your life. Incarceration ultimately has an impact on things like whether or not you can get a job, whether you can seek education, it tears families apart, it may impact whether or not you qualify for housing. And so any sort of criminal penalty has these long-lasting effects, and in the context of substance use disorder, we are really treating a health issue as a criminal issue.
The results of that have meant that we have incarcerated far too many people that really just needed health care. One in 5 people are incarcerated for substance use. And the United States incarcerates more people than any other country in the world. Those drug arrests and convictions are disproportionately impacting people of color, specifically Black and Latino communities. And so again, thinking about these long-lasting impacts, there are huge inequities in access to not only health care and treatment, and having a pathway to recovery for people who have substance use disorder, but also these long-lasting impacts on people's families, education, job, and housing.
Vibhuti Arya, PharmD, MPH, FAPhA:And I'll add, I think the other thing that we're also really keen to note, and that you can't sort of hide behind is the structural inequities of how this was created in the first place. I think that when you see a lot of people who are impacted by substance use being Black and Brown, primarily, the narrative was very different—moral defamation, and their character flaws. And really, it the onus was put on the individual as though they have to take full responsibility, versus when we see the demographics being shifted more recently to White families, then middle class and upper class, I think that the narrative changes quite a bit. So you see a lot more funding and a lot of things coming to the aid of substance use disorder, even the way we talk about it, the fact that we're using substance use disorder, the terms have changed.
So I think that there's also this underlying issue of the structural racism and health inequities, as Adrienne mentioned, that was created that we also have to think about ways in which we can dismantle that through policies and, and procedures that we that no longer serve our patients. And this idea of harm reduction really is about providing human centered care rather than providing criminal penalties as Adrienne mentioned. So we want to not sort of keep that separate and hold those things together as intersectionality to really understand that this work and the impact that it can have has reverberations. There are ripple effects to this and really understanding how we start to dismantle some of those structural oppression and structural inequities one thing at a time.
Pharmacy Times: In your view, how has the “War on Drugs” impacted mental health care in the United States?
Simmons: Well, to start, unfortunately, in 2021, we saw the highest rate of overdose deaths that we've ever seen in this country—more than 107,000 people died of overdose in 2021. And likely that's an underestimation given that we don't have great data and that there’s certainly some underreporting in the context of the COVID-19 pandemic. And so that's the biggest impact that we've seen the War on Drugs have is that people are dying from overdose.
We have also seen lots of other health related impacts such as the rise of hepatitis C and HIV infections, specifically among people who use drugs, but more specifically among people who inject drugs. And then again, we see all of these impacts on people's lives, like housing and jobs and education.
So ultimately, the War on Drugs, which started back in the 1970s with President Nixon, which ultimately was this increased attention on substance use, on the possession and the manufacturing, and the use of substances, which ultimately led to increased arrest, incarceration, and policing of people who are using or associated with substances. We're now, decades later, still really suffering the consequences of this. And we see it, as I think about how this shows up in the day to day lives of practicing pharmacist. You see it in the quotas that the [DEA] imposes about the number of controlled substances that you can purchase. There's a lot of fear and stigma around this topic, and pharmacy isn't immune to that.
Some of that is rooted in very real experiences that people have had, that, as a result of the opioid crisis and overprescribing of prescription opioids, which then led to us to crack down on the number of prescribed opioids that were circulating in in the country. We then see those impacts at the pharmacy counter when people bring in prescriptions. Now for things like buprenorphine or medication for opioid use disorder, it's not uncommon for pharmacies to say we don't stop that medication today, or we're unable to order that medication, either because they have already been told by the wholesaler that you've met your quota for the year and can't order additional medication, or because there's a very real fear that those pharmacies may be audited by the Drug Enforcement Administration.
I think there are so many kind of artifacts of the war on drugs, which again, started in the 1970s, that we're just now starting to grapple with. But certainly the one that is most chilling for me is the health impacts, and the fact that we are still every day losing people to the overdose crisis, and that people still can't access care. When we incarcerate people, it's very difficult to access medication for opioid use disorder while incarcerated. It's very difficult to access medication for opioid use disorder in rural areas. There are lots of laws and policies that restrict access to really pathways to recovery for a lot of people. So I am eagerly awaiting the day that we treat substance use disorder as a public health crisis and not as a criminal one and more where people have multiple pathways to recovery. But we aren't there yet.
Pharmacy Times: What is the difference between drug decriminalization and drug legalization, and in states that have enacted drug decriminalization, what has been the impact on public health?
Simmons: Yeah, the difference between drug decriminalization and legalization is an important one. So drug decriminalization removes criminal penalties associated with the use or possession of other illicit substances. And so that means that we won't arrest or incarcerate people for using or possessing drugs.
That's very different from the legalization of drugs, which establishes a legally regulated market for the sale and use of substances. And so, in terms of the impacts that we've seen, in other states, there's only been one state so far, Oregon, who has decriminalized illicit substances, and that includes everything from marijuana to things like heroin and cocaine.
Just a couple of years ago, Oregon passed a ballot measure that decriminalized the possession and use of these substances, again, meaning that if someone is found to be using or in possession of these illicit substances, they would be fined as opposed to arrested and ultimately incarcerated. So unfortunately, it's still too early to see what the impact of this new policy has been. But many legal experts who were involved in the development of this proposal have projected that there will be millions of dollars that are saved by offering people access to things like medication for opioid use disorder and other pathways to recovery and harm reduction services as opposed to arresting and incarcerating people.
So we'll have to report back on what the ultimate impact will be. It's a little too early to tell. But while Oregon is the first state, there are other countries that have long decriminalized this. And so we work with data to show that this is not only financially beneficial for a state or a country, but that it also has real tangible and positive impacts on people's health and their lives.
Arya: And I'll add to that, I think that sometimes I hear in discourse with colleagues about the trepidation sort of about decriminalization or legalization. And they're thinking as we're all sort of conditioned to think about extreme scenarios where either there's robberies or sort of some more dramatic explanations or situations that we can think about when it comes to this. But I think the core of the matter really is to think about ways in which we can show up for our patients, putting that empathy so that we're looking at people as people and not just saying, ‘You did something wrong, and now you need to get punished.’ But really, ‘You're doing something that there is something that we can do as a health care community to show up for you in a very human centered way to guide, help, and assist in the best ways that we can,’ utilizing our own tools as health care professionals, medications included, we can show up for our patients.
So I think that there's a nuanced description there that I think all of us, you mentioned about how we can deal with our implicit biases as pharmacists, I think this is another area where that shows up. I've had lots of conversations—Adrienne, and I lead harm reduction topic discussions with our students that we precept, and there's a lot of really wonderful, honest conversations that show up that say, ‘Look, I've been conditioned to look at this condition of substance use as sort of that other thing and anything related to that, and anytime we talk about decriminalization, it sort of brings up this fear or this apprehension that we've all been conditioned to kind of think about.’ And it really challenges us in many ways to think about ways in which we can kind of take a beat, stop, think about the patient, and look at the ways in which we can show up as a pharmacist.
So I just want to put that there as well, because I think that a lot of the questions around some of those scenarios kind of bring this up, but also how it has to do with mental health, how it all has to do with us as a collective and how we show up for our patients, all of these little things make a big difference. And this is just one step that we have in saying that we can see patients and hear them and treat them as individuals who actually can be helped through this, and who, if they choose to show up and say I would like to get off of substances, this is not something that we need to judge them on, but really show up as empathetic health care professionals who can be there for that journey for them and support them.
Pharmacy Times: What are some ways pharmacy professionals can help destigmatize mental health and substance use disorders?
Simmons: I really think that this starts with us as individuals. We have to educate ourselves about this topic, and do some internal reflection about the ways in which we may be perpetuating stigma against people who have a substance use disorder. And so I often think about decriminalization and criminal penalties and our approach to substance use disorder more broadly, the same way that I think about a kid who is a picky eater that refuses to eat vegetables—so, I was lucky as a kid, and I remember so many nights where my mom would say, you can't get up from the dinner table until you eat your vegetables. And her saying that never made me actually eat my vegetables. It sometimes would even escalate to, ‘Okay, well, maybe you're going to be in timeout for the rest of the night, or you won't be able to watch TV tonight.’ And again, it never made me eat my vegetables. It wasn't until, I saw one of my peers, maybe at school, eat their vegetables—a friend, someone that I trusted—that I was like, well, maybe I'll give these vegetables a try.
As I'm older, I certainly appreciate the benefits of eating healthy. And I'm like, ‘Okay, well, I'm open to eating more vegetables now, but ultimately, the punishment as a child, that's something that was not going to lead me to eat my vegetables.’ And I think about substance use in the same way, that penalizing someone or punishing someone is ultimately not going to put them on a pathway to recovery, and that ultimately, that has to be a choice that makes sense for them. And we have to provide all of the other support that's needed as it relates to making sure that people have safe housing and that they have a stable income and that they have a job and an education—there are all these social determinants of health that ultimately are the recipe for someone to find the pathway to recovery on their own terms.
So I think that we as a pharmacy community have to educate ourselves about the psychology and kind of human behaviors related to substance use disorder to understand that this is a chronic illness just like any other chronic illness; this isn't a choice that people are making. And we can start by educating ourselves but then certainly also educating policymakers, other community members, including people like law enforcement on the benefits of decriminalization and other harm reduction practices. I think we could do a better job of integrating harm reduction into the pharmacy school curriculum.
Pharmacists are really kind of frontline staff members in terms of being the gatekeepers to harm reduction services. We are able to offer things like clean syringes or Naloxone or medication for opioid use disorder. And so making sure that we are training even the earliest the youngest professionals in our in our profession is really important. And then as a practitioner, providing unrestricted harm reduction services that address social determinants of health is another way to advocate for decriminalization as well as harm reduction.
We are actually introducing a policy into the APHA House of Delegates this year for consideration. Currently, APHA has policy on its books that opposes both legalization and decriminalization. And so we're proposing an amendment to that policy that would actually support decriminalization, so it would support removing criminal penalties like arrest and incarceration for people that are found to be using or in possession of illicit substances. So we're hoping that people will support that policy—we're the only medical association that has policy on the books supporting criminal penalties. And I think we've done a really fantastic job in supporting substance use disorder using a public health approach in many other ways. So we have policies that support access to Naloxone and support access to medication for opioid use disorder, as well as syringes and other sterile supplies for drug use. But then we have this kind of conflicting policy that supports criminal penalties for the very community that we are trying to help serve through some of these other policies.
Arya: And I'll add a couple of things that we can also do as a community. One of the things that I think shows up time and time again, and a lot of people have a really hard time getting into, and Adrian alluded to this as really the idea about our own conditioning and implicit biases and how we all see harm reduction, and decriminalization and substance use in general, I think that it's really important to unpack those.
We saw this back when seatbelts were not mandated, and people were like, well, now everybody's going to drive recklessly because you have a mechanism by which it's going to save their life like having a seatbelt, or we saw this with trepidation around the HPV vaccine, that now maybe 12-year-olds are going to be promiscuous, because now this saves them, or has some preventative impact.
So what we see, time and time again, is that we're not as fickle. Maybe we are fickle as humans, but we do pay attention, and I think that we can evolve. And this new business item is exactly that. It's our evolution as an association to say maybe we thought this before, but now that we're looking into these things, and we have educational sessions, it's really time to update our information based on things that we now know to be true, which is that when we provide compassionate, human centered care to patients, that really makes a difference. So I think checking our implicit bias and having conversations around decriminalization is really important in substance use in general and harm reduction in general.
The other thing is that when you introduce why we're seeing so much about decriminalization, when you introduce the idea of any sort of criminal penalty, there does come an onslaught of our own stress hormones and emotions and conditioning around what we think about the criminal legal system, and who it impacts, how it impacts, and there are a lot of binaries associated with it—the good, the bad, all of these—this language that we use. And so it's really important for us to understand that if you take that criminal piece out of it, probably a lot of people would show up and be more compassionate and humane in caring for those patients. So really, it's an opportunity to remove that part of the conditioning that we have in our own implicit biases to kind of socialize ourselves to be a little bit more progressive and forward thinking there.
The other thing that pharmacists can do is also look at language that we're using around harm reduction. How do we associate adjectives with people who use substances—even language such as calling people an “addict” or using the word “clean” and things like that, that Adrienne and I talk about. She leads a really wonderful discussion on, again, bringing the humanity to our students about how we're visualizing and how we're depicting individuals who have substance use; I think that makes a huge difference, in terms of understanding how we're using language that's, again, more compassionate and bringing dignity back to our patients.
Then the other thing is really to think about community linkages. Communities across the US have programs, there could be things happening within your own communities, and maybe not too far, that actually do help out with social services, and really providing a more humane, compassionate community space for people who use substances. And so how do I, for example, as a community pharmacist, go and learn about some of these communities. I can go and learn about some of these organizations that are helping my patients, and perhaps do something that I can either refer my patients there, I can have some information to provide for my patients, I can even partner with those community organizations. So there are lots of activity also happening that we may not be aware of, because of our own professional circles and social circles, but it is really up to us also, just the way that we always give information to our patients about non pharmacological options. I think social options and connectedness and having that support within the community is also a really great resource for us to learn about in our communities and provide that to our patients as well.
Noor Khawaja: Something regarding harm reduction education, and how I was introduced to it—I was really introduced to it through this rotation with Dr. Arya and our topic discussion with Dr. Simmons as well. From my understanding, again, just touching on what both of you touched on already, we discussed how it centers around a very human centered and compassionate approach to try to protect people who use drugs and from the serious [adverse] effects and the stigma associated with SUD.
It's definitely something I wish that was taught earlier on in our didactic education, for sure, especially considering we are pharmacy students and I believe, as health care professionals, we definitely have a greater responsibility to be aware of how substance use disorder affects our patients and how, like Dr. Arya said, we can show up for our patients in an effort to keep them safe.
Something I definitely appreciated learning about was the compassionate language, human centered language, like you both already mentioned, again, and I'm just reiterating a bit but using person first language to show that the person has a problem and is not the problem. Using more mindful language definitely helps avoid that the negative association and stigma and individual blame and more than anything, I think it taught me how far compassionate care goes, how it should be at the root of every healing approach and how serious and harmful it can be if it's not there. So it's definitely something I hope to incorporate with me into my practice and kind of pass along.
Lauren Merkovich:This rotation of Dr. Arya has really been eye opening. And just like Nora has said, like, this is something that we as health professionals should all be aware about, and the language is so important.
This is something that I personally have had a history with in my family as well of people who have addiction and have the struggles with it. So with harm reduction, I feel like it's impacted a lot of people's lives, more than some people want to admit. So, as health professionals, especially in pharmacy, we are giving access, and we are like one of the first people that people are going to, so we should be more aware of that. And we should have more of that.
Dr. Arya was the first person, again, to really open our eyes to harm reduction. And I feel like there should be more classes and awareness for pharmacy people to have that because we are the easiest people for people to access as health care professionals. There are community pharmacies, retail pharmacies, big chains—they're the first people, so harm reduction is really important and, just in general, I'm really appreciative of having that eye opening experience with her, and I feel everyone should really learn about it and use the compassionate language as well and all that.