That people are targeted by police, sent to jail and get stuck in cycles of re-incarceration.
The Toronto Drug Users Union (TDUU) was established in 2010 and is made up of current or former drug users in Toronto, Ontario. TDUU is a member of the Canadian Association of People Who Use Drugs, a national association representing over 30 drug user groups across the country.* People who use drugs have been organizing their own unions/coalitions/ groups since the 60’s and 70’s to address their rights and needs.
About the author: Toronto Drug Users Union (TDUU)
We are a membership based organization and work from the principle of “Nothing About Us, Without Us” and see ourselves as part of solutions, not problems. We advocate to be seen as equals, and to be supported, funded, included, and involved as such when it comes to policies, programs or health care approaches that impact us directly. We believe that using drugs is not a singular experience and so our group represents a variety of voices with different and unique lived experiences.
Contact the Association to find one in your region!
We advocate to improve the lives of people who use drugs. We offer opportunities to join forces, gather, share stories and support each other. Most of our members are people living in poverty, people who have been incarcerated, and who have years of experience using drugs and navigating the world as drug users.
TDUU representatives sit on the City of Toronto’s Drug Strategy Implementation Committee and on other committees to make sure that the voices of people who use drugs and who are experts in their own lives are “at the table”. The war on drugs has had devastating impacts on communities of people who use drugs, especially people of colour and First Nations people. We believe that by coming together, we can address discrimination, stigma and be advocates for changes in drug policy and to help end the war on drugs (and drug users).
The TDUU fights for the health and rights of people who use drugs. We are committed to the principles of mutual aid, harm reduction, peer to peer education, community development and our own self-determination.
We are committed to keeping each other alive. People who use drugs have been hard hit by the epidemics of HIV, Viral Hepatitis; primarily B and C, and overdose deaths. We advocate for access (to treatment, to services, to resources, etc.), support, education, change and the basic things we need for daily survival – from medication to opiate substitution therapies (OST), to sustainable alternatives to cycles of criminalization and incarceration, to access to overdose prevention.
Join the Conversation
It is important for us to participate in conversations about our relationships with health care providers because they are integral to our health and well-being.
People who use drugs often report being discriminated against by health service providers. Stigmatization and mistreatment can happens in subtle and not so subtle ways and impact our ability to access the care we need and deserve. While there are many health services providers who go above and beyond to support people who use drugs and to offer them health services free from discrimination, it is not the norm and the profound mistrust it can fuel can seriously impact our health as we may lead people to avoid or delay seeking care which, in some cases, can be fatal.
Many people who use drugs have complex health issues and need to be accessing health services but decide to not engage with health care systems because they are afraid of how they will be treated. We are often turned away from hospital emergency rooms, not taken seriously, denied treatment for serious conditions like Hepatitis C infection, or denied care because of being labelled as ‘drug seekers’ and so on.
Assessing and improving our relationships with health care providers is essential!
Factors that impact the health of people who use drugs
People have a range of relationships to both illicit and legal drugs. Some of us use drugs in a recreational way, some use them frequently, and others have substance use issues, or are dependent. The reasons why we use drugs are as varied and as complex as there are people who use drugs.
There are some risks and harms associated with using drugs. How it plays out depends on people’s circumstances, their access to resources and supports, or the types of drugs used, but it can range from heightened risk of HIV infection, to viral hepatitis, local and systemic bacterial infections, overdose, dependence, other physical or mental health problems that can be exacerbated by drug use, and accidents, etc.
Many things can contribute to lowering or heightening drug-related risks and harms including social determinants of health, individual behaviours and choices, the environments in which we use drugs, what access we have to resources and social supports, and the laws and policies designed to control drug use.
That last one is key as it has far reaching impacts. The criminalization of drug use creates and intensifies risks and harms for drug users. It leads to discrimination, abusive and corrupt policing practices, restrictive and punitive laws and policies, social inequalities, the denial of life-saving medical care and of harm reduction services.
The war on drugs has extremely negative consequences on people’s health and on the health of our families and our communities. It criminalizes us because of the substances we choose to put in our bodies, whether or not it has any impact on anyone else or why we may be using in the first place. The war on drugs is a blunt tool that disproportionately targets people living in poverty, people of colour, Indigenous people, women and youth.
In real terms, it can mean
That people lose their housing, one of the most stabilizing force in people’s lives, because of being in and out of jail.
That family connections are jeopardized or severed.
That work opportunities are reduced once people are released.
That people face higher risks of contracting HIV and/or Hepatitis C because of the police surveillance of harm reduction services, the destruction of drug paraphernalia, of funding cuts to programs aimed at serving people who use drugs, the fear of being caught with harm reduction material – especially when someone has release conditions that prohibits having them, and the fact that there are no needle exchange programs in Canadian prisons.
That communities are controlled through racial profiling mixed with drug policing.
That women/parents who use drugs are often separated from their children, temporarily or permanently, especially if they are poor.
That the suspicion of drug use, regardless of actual ability to parent, is often sufficient for losing the custody of children, which causes immeasurable grief and trauma when it occurs.
That being poor and insecurely housed can exacerbate the risk of HIV, viral hepatitis, and overdose/overdose death, with little being done to mitigate those risks.
In a nutshell, this approach to drug use and drug users is not so good for our health. Considering the ways in which it can significantly impact it, it would seem that access to health care should be facilitated. That said, many people who use drugs report serious barriers when trying to access medical care.
Barriers to Health
Many of the barriers are attitudinal and revolve around prejudices held by individual health care practitioners and/or entrenched in institutional policy. Other barriers include a health care system that is not well designed to deal with health prevention, complex health issues or to provide supports that address social determinants of health.
Those of us who use drugs are often afraid to access health care, including sexual and reproductive health services. The fear of being discriminated against in health care settings and worrying about being judged and shamed can really impact our willingness to access and/or engage with health care systems. For pregnant or parenting people who use drugs (especially women), the fear of Children’s Aid involvement can also impact whether or not someone seeks reproductive health care.
People on Opiate Substitution Therapies also experience discrimination in pharmacies when they need to pick up their medication with diminished hours of availability and mandatory strict routines including having to take their medication in public and having to submit to frequent urine tests.
What’s your relationship status?
Some people and organizations have worked hard to build rapport and trust with people who use drugs, especially those of us living in poverty and/or who are homeless, but it is generally the exception to the rule. There is mutual mistrust between people who use drugs and medical professionals.
Accessible and non-judgemental health care can be instrumental in creating a positive space for us to build a sense of individual and collective well-being.
Drug use is a powerful source of stigma and discrimination and it can certainly manifest in the relationships between health care providers and people who use drugs. The stigma attached to drug use and then the active discrimination of those who are ‘known’ as drug users may be reinforced by the fact that it is an illegal and covert activity, and that there is no legal protection available to people who use drugs.
If you use drugs, you don’t care about your health. Alternatively, that your health and/or health issues like HIV, Hepatitis C and other conditions are not a priority.
That drug use is always this all-consuming thing that erases all other priorities in someone’s life.
That you can’t be reliable or responsible.
That you are a ‘drug seeker’, manipulative, not to be trusted or believed.
That people who use drugs are criminals, are dangerous, prone to violence, and should be feared.
That people don’t care about you, that you don’t have a family, or that if you have one, that you are estranged from them. That you have no community.
That you are an unfit parent.
That you are a junkie, not valuable, that “you are the lowest of the low”, that you have nothing to contribute to society.
That you bring what happens to you upon yourself.
That you are out of control, have no will-power, are weak.
That addiction is a sign of moral failing.
How can we make it better?
Stigma and judgment around drug use can lead to being treated differently by your healthcare providers. It can mean that you care team is completely focused on your drug use which can get in the way of proper care and choices they make about treatment. Sometimes, stereotypes about us or fear based information about drugs and drug use can lead healthcare providers to assume risky behaviors which can lead to ‘judgement calls’ to involve security services, police or Children’s Aid Society. It can mean that we are not believed when we talk about our health, our bodies, or pain we experienced. It can mean avoiding going to the doctor altogether to avoid another round of being treated like a ‘disposable junky’.
Considering that deep mistrust exist between people who use drugs and their health care providers, be mindful of building the type of relationship where people feel safe disclosing information about themselves.
Understand that it may take time to build trust before people feeling comfortable enough to disclose drug use. There are very good reasons to want to have that information (for example, the ability to diagnose someone properly or to inform someone of possible interactions with other medications, etc.) but there are also good reasons for people to be cautious about when and how they share that information.
Poor people who use drugs are most at risk of mistreatment in the context of their health care relationship, especially if someone is also living with mental health issues. Assumptions should not be made about why they are coming to see you, that they are drug seeking, exaggerating or do not know what could be wrong with them. People should be believed, listened to and treated with care and compassion.
Make your practice person-centered, trauma-informed, nonjudgmental, based on trust and flexible about how often and when people come to see you.
Be mindful of the risks that people navigate when disclosing their drug use to health care providers. Protect your patients’ privacy and confidentiality. More and more providers are sharing information about their patients with each other. This can sometimes skew how people are being treated in other services and/or hinder their access to them. Explain how their information is shared and with whom and provide people with the information they need to decide if they wish to lock that information, even from other providers in their circle of care.
When supporting someone who uses drugs, it is important to consider their life as a whole and to avoid focusing the intervention their drug use only. Respond to the needs identified.
Do not assume it is appropriate to involve the police or Children’s Aid Society solely based on someone using drugs. Assess the specific risks and respond accordingly. Always be open and clear about duties to report, about limits to confidentiality and about processes you may need to follow.
Train emergency workers, paramedics, hospital and clinic workers, including all of those who support the work of health care providers, on the ways that stigma show up in health care settings and how it is a barrier to health care for people who use drugs.
Bring everyone on board and ensure that the educational opportunities are shared. People want to be treated with respect from the moment they walk in, not with fear and mistrust. It’s important that all staff greets you with kindness, this includes reception, nurses, the person taking your blood.
Train hospital and clinic workers on de-escalation techniques that can help avoid involving police services. People who use drugs often have an antagonistic relationship with the police due to the criminalization of poverty and drug use. For example, in an overdose situation, the very real fear of the police showing up at the scene has made many people reluctant to call 911. People are afraid they will face violence or be arrested by the police. Unfortunately it means that people die from overdosing because those who surround them assess that calling for help is too risky.
Mandate harm reduction training for all people working the services (including front-desk). Offer harm reduction materials in your services.
Inform yourself of the specific risks faced by people who use drugs and how they are exacerbated or mitigated depending on context. For example, people who are just released from jail are at higher risk of overdosing. Advocate for programs that address these specific risk, like the distribution of opiate blocker kits.
Do not deny treatment solely on the basis of drug use. Make sure you assess the actual strengths and limitations of someone’s circumstances when looking into treatment plans with them. For example, while some doctors do not want to treat people with Hep C who are using drugs, the Canadian hepatitis C treatment guidelines points out that active drug use is not considered a valid reason to deny treatment to someone.
Fund, staff and/or support increased access to afterhours care that serves people who are homeless, use drugs or alcohol, are sex working, and/or have mental health issues.
Be mindful of your language and speak up when you hear colleagues make disparaging comments about patients. It is not ok to call someone a ‘druggy’, ‘crack head’ or a ‘junkie’ or to make jokes at patients’ expenses.
Inform yourself about the realities of poverty and its impact on health – be mindful of the disparity in privilege and how class based discrimination can play out in the health care context. The drug users who are most criminalized, stigmatized, discriminated against and mistreated are those who are living in poverty and/or come from racialized communities. Make it your mission to take on health disparities.
Support your patients in making informed choices about their own health care. This means ensuring that patients understand diagnoses, tests, the need for follow-up with treatment. Make them partners in their care, use plain language, make the appointment conversational. Have material ready that is accessible for diverse communities and levels of literacy.
If possible, look into increasing the flexibility of your services. For example, permit walk-ins.
Become a leader in your community to address the barriers faced by people who use drugs in the context of health care and be an advocate for the policies, programs and laws that can address health disparities.
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