Until we stop viewing every drug use and every overdose as a problem of “addiction” and “substance use disorder,” we will continue to miss the mark in overdose prevention. Historically, overdose has been viewed as a strong indicator of addiction, but this has never been the best way to understand it, given that a person who uses drugs early on is potentially at higher risk than someone who uses chronically and has developed tolerance. The unpredictability of the drug supply has further weakened the link between overdose and chronic use, as anyone—whether a long-time user or a new user—can overdose on drugs that are more potent than expected or that contain substances such as fentanyl.
I was using opioids, benzodiazepines, and amphetamines for almost four years before my family noticed. During this time, I completed 102 college credits and was elected to the local village council. Most of my drug use was beneficial; it made me work harder, helped me cope with depression and made me a more sociable and less anxious person.
Most people who use drugs do not consider themselves “addicts” and do not meet the criteria for an addiction diagnosis. In most cases, drug use does not result in addiction, and many people stop using drugs on their own, without treatment. Not all of them are “suffering” and waiting for salvation. People use drugs for logical reasons: to relieve pain, feel happy, worry less, and escape. If they didn't serve a purpose, most people wouldn't use them.
The next time you take a sip of wine or drink a beer, imagine if we considered everyone who drank any amount of alcohol an “alcoholic” or called all alcohol use an “alcohol use disorder.” A teenager who takes 10 shots in 10 minutes (that was me at 15) will likely overdose, although the experience itself will be labeled a “bad night” rather than the sole basis for a diagnosis of alcohol use disorder.
The difference between views on alcohol and drugs reflects our laws, culture and dominant religious philosophy. In many Islamic countries, alcohol use is restricted in the same way as heroin or cocaine. In some parts of South America, the coca plant (where cocaine comes from) is consumed daily in the same way we drink caffeine. In Mormon communities, caffeine is considered taboo. If our definitions of “acceptable” drug use can vary so widely across borders and religions, then perhaps the real problem isn't drugs in general, but the conditions we've created for their use.
There are real dangers in drug use, but many of these dangers are not related to the drugs themselves. Illegal drug shipments are completely unregulated and their effectiveness varies greatly from one batch to the next. It's like if you drank a cup of coffee one day and it was normal, but the next day it had 200 times more caffeine, but you couldn't tell the difference until it was too late. Legal consumer products like coffee or prescription drugs are regulated and consistent—regardless of whether experts or the prevailing culture consider their use to be healthy—but illegal substances are not covered by our most basic principles of consumer protection.
For decades, the dominant approach has been to criminalize drugs and the people who use them. These policies encourage people to use drugs alone, and hiding drug use is deadly. In CaliforniaMore than 80% of overdose deaths that occur in the private sector occurred in the deceased's own home. People who die from an overdose often have homes, jobs, parents, caregivers, neighbors, and friends. They die quietly in bedrooms and bathrooms because shame and fear make isolation safer than disclosing their use, even to the people who love them most. Half of all deaths occurred while a bystander was nearby who did not react to the overdose, either because they were separated, such as being in another room (45.7% of the time), or because they did not know the deceased was using drugs (25.9%).
The risk of disclosure during active use can be catastrophic. People are losing jobs, custody, housing, partners and freedom. Courts and child welfare systems view all drug use as criminal behavior that is incompatible with child rearing. Even within treatment systems, return to use is often punished and unsympathetic.
Criminalizing drugs doesn't stop people from using drugs, but it does push them underground and make them more dangerous. According to a recent report from California Correctional Health Services.Overdose is not only the leading cause of death for prisoners, but also the leading cause of death for people leaving prison in California.
As an alternative to imprisonment, there is a growing movement for involuntary hospitalization, where people are forced into closed institutions. When we take away someone's autonomy under the guise of “saving”, we are repeating the same moral logic that leads to punishment: people who use drugs cannot be trusted with their lives. In Massachusettswhere we have been involuntarily incarcerated for decades, studies have shown that within the first 30 days of release they have a 41% increased risk of death from an overdose compared to people who seek help on their own.
Overdose prevention is treated as synonymous with drug addiction treatment, as if the only way to save lives is to get people to “get better.” But what if prevention also means creating an environment where people can be safe even if they are still using drugs? What if this means recognizing that drugs can have positive effects on people and that the real danger comes from unregulated supply, stigma and isolation?
The next phase of overdose prevention must move beyond punishment and the fantasy that everyone who uses drugs is broken and waiting to be fixed. We can build something better. We can create systems and concepts based on dignity, safety and compassion for everyone, whether they are using drugs, stopping using drugs or using drugs again.
It starts with the way we talk to the people we love. Instead of reacting with fear or judgment, start with curiosity and ask: What's in it for you? How does this help? What could make it safer?
If someone in your life is using drugs, you don't have to approve or condone it to care about their safety. You can keep naloxone on hand and learn how to use it in case of an opioid overdose. You can register without lectures. You can be open about safer uses, such as not using alone, testing your supplies when you can, and starting slow with something new.
And if they trust you enough to be willing to exploit them in your presence, reject the narrative that your role is an opportunity for them. You choose love. You choose connection over hiding. Every overdose we prevent starts with one person deciding to stay and not look away.
This small but radical act of compassion can save a life. It can start with you.
Stephen P. Murray, an overdose survivor turned paramedic and public health advocate, is an associate clinical professor at Boston University School of Public Health. He runs the SafeSpot overdose hotline.
