People who Use Drugs and Mental Health
This statement was published jointly on 10 June, 2021 by Harm Reduction International and INPUD.
Ongoing discussions, including among key international donors, have raised concerns within Harm Reduction International and the International Network of People who Use Drugs (INPUD) about the proposed inclusion of mental health within the harm reduction package and more generally about conflating drug use and mental health. This paper aims to stimulate and clarify the discussion around this.
Although there are people who use drugs who may experience mental health issues, drug use and drug dependency itself is not a mental health condition. The concerning conflation of drug use and dependency with mental health issues is inaccurate, stigmatising and might have long term harmful consequences to the community, including removing the agency and capacity of people who use drugs to make decisions about their own bodies and lives. It could reduce resources available for harm reduction and community-led services, and lead to deprioritizing evidence-based, lifesaving public health interventions in national and international guidelines. A lack of political will and insufficient funding are major barriers to implementing harm reduction at scale, and this conflation could seriously disrupt availability, access and delivery of essential services.
Despite there being virtually no data to support it, the notion that drug “addiction” is a brain disease provides an attractive narrative that is simple and reassuring. This theory contributes to unrealistic, costly, and harmful drug policies, and removes any consideration of the role of socioeconomic factors such as poverty, homelessness, and race. It also ignores the stigmatising effect of the drug “addiction” construct.
Over the past decades, we have been able to somewhat shift from a solely biological, medicalised approach to drug use focusing on personal responsibilities, towards a more holistic approach acknowledging the social and structural aspects of drug use. The new approach recognises that drug related harms are not distributed evenly throughout society, but disproportionately affect stigmatised and marginalised communities. Conflating mental health problems and drug use is a huge step back from this progress.
The inclusion of ‘substance use disorder’ in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) misrepresents drug use. The term “substance use disorder” blurs together mental health issues with drug use and/or drug dependency and has the effect of alienating people who use drugs who would not conflate their drug use with any form of “disorder”. At the core of the DSM-V definition is the idea that drug use “disorders” are due to changes in the brain, while the definition itself uses 11 criteria to measure the “disorder”. These criteria relate to social functioning, social compliance and economic productivity (e.g. “not managing to do what you should at work, home, or school because of substance use” and/or “giving up important social, occupational, or recreational activities because of substance use”), alongside other indicators related to the physical effects of the drugs (e.g. tolerance, withdrawal).
INPUD prefers “drug dependency,” a term that is used by the United Nations Office on Drugs and Crime (UNODC) and the International Statistical Classification of Diseases (ICD), both for its more neutral associations and for the fact that it distinguishes between physical, physiological and psychological dependence. The term encompasses the difference between these forms, which the pathologizing “substance use disorder” fails to do.
Mental health issues can occur alongside drug use or drug dependency, but this does not indicate that they are always either a result of drug use nor preface drug use. It is important to underline that mental health issues and drug dependency can emerge from the same structural factors, like poverty, lack of access to healthcare and other services, homelessness, and stigma and discrimination. In some, not all, cases, people start or continue using drugs to deal with mental health issues, and in some instances, drugs can help people to manage their mental health symptoms, as well as life’s challenges.
People who use drugs, like all people, should have appropriate access to mental health support as needed. We have to find ways to encourage better access to mental health services for people who use drugs without framing drug use and/or dependence as mental health issues in absolute terms. Furthermore, we must seek to continually challenge ideas that pathologise drug use and people who use drugs that deny will and agency to people who use drugs, removing the right to make choices regarding their physical and mental health. People who use drugs consume substances for a variety of reasons, including for the rational pursuit of pleasure and regulation of emotions. We must find better models that embrace the complexity and multitude of rationalities for drug use and dependency; and continue to question and challenge simplistic models that could potentially constitute more harm and damage.
With this short discussion paper HRI and INPUD want to generate an evidence-based, and productive discussion around these issues and the risks of conflating drug use and mental health into a narrative that move us backward.
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