Framework for a Public Health Approach to Substance Use

POLICY STATEMENT

The Canadian Public Health Association Framework for a Public Health Approach to Substance Use

PREFACE

Psychoactive substances have been used throughout human history in spiritual and religious rituals, for medicinal purposes, and by significant proportions of populations for individual reasons and as part of social interactions. Examples of psychoactive substances include caffeine, nicotine, alcohol, cannabis, LSD, and heroin. Interaction with these substances ranges from abstinence to a spectrum of use ‒ from beneficial to non-problematic, potentially harmful, and at risk of developing substance use disorders.

Both the use of psychoactive substances and the regulations that govern their use can lead to harm. While a ‘public health approach’ is frequently invoked as a means of mitigating these harms, there is no consensus on what such an approach means in terms of prioritizing diverse values and perspectives within the field of public health, nor on what it entails in practice.

This policy statement provides an overview of what CPHA endorses as a public health approach to substance use across the full range of legal and currently illegal psychoactive substances. It describes the approach that CPHA will use to develop policy advocacy or programmatic work on related topics.

The framework encompasses ten key principles. These principles are interconnected and can be adapted depending on context, populations, settings, or substances. Given the prevalence of the negative effects of stigma related to currently illegal psychoactive substances, it is hoped that the consistent application of these principles will lead to a reduction of that stigma.

This framework does not include all of the levers available nor all of the criteria that may need to be considered. For example, legislative and regulatory levers are important tools of a public health response; the commercial determinants of health may also be relevant. This framework is intended to provide the baseline principles of a public health approach, serving as a starting point, not the end point, of discussions.

While the language used in this document is currently linked primarily to conversations related to illegal psychoactive substances, it should be considered equally applicable to all psychoactive substances regardless of their legal status. For example, the use of the word “drugs”, particularly in the context of people who use(d) drugs (PWUD) or people with lived and living experience (PWLLE), is generally related to currently illegal substances while psychoactive substances such as alcohol or nicotine are not considered a “drug” in common parlance.

While the framework does not offer specific instructions for implementation – since the unique characteristics of any given situation will require a unique response – it can be used to inform the development of policies, procedures, and programs across the substance use spectrum.

KEY TERMS

Substance use refers to the consumption of psychoactive substances – including currently illegal drugs, as well as alcohol, tobacco, and cannabis – that can be used for medical, religious or ceremonial purposes, for personal enjoyment or pleasure, or to deal with stress, trauma or pain (Health Canada, 2023). Substance use can be viewed on a spectrum, from beneficial to low risk to potentially leading to dependence and substance use disorders that impact overall health and well-being.
Note: In this document, the terms ‘substances’ and ‘drugs’ are used synonymously.

People with lived and living experience (PWLLE) refers to people who currently use substances, as well as people who have used substances.
Note: In other contexts, lived and living experience may refer to other experiences such as “lived experience of mental illness.”

People who use(d) drugs (PWUD) refers to people who currently use or have used drugs.
Note: In different contexts, individuals or groups may identify with different terms, including PWLLE, PWUD, or people who use substances (PWUS). For the purposes of this document, these terms will be used interchangeably.

BACKGROUND

In 2014, the Canadian Public Health Association (CPHA) produced a discussion paper titled A New Approach to Managing Illegal Psychoactive Substances in Canada (Canadian Public Health Association, 2014). The goals of this paper were to review the available information concerning the use, management, and harms of illegal substances, and to provide a framework for action. The approaches outlined in that discussion paper formed the basis of CPHA’s understanding of a public health approach to substance use and articulated a vision for 2025.

Following this work, CPHA published Public Health: A Conceptual Framework (Canadian Public Health Association, 2017) in 2017 which expressed CPHA’s definition of a “public health approach” more broadly and the underlying principles that support CPHA’s approach to policy advocacy. At this time, CPHA was also involved in a project and policy advocacy on the legalization of cannabis and applying a public health approach to cannabis. The project focused on cannabis-specific resources for professionals and highlighted the need for a broader public health approach to substance use.

In January 2020, CPHA was funded through Health Canada’s Substance Use and Addictions Program (SUAP) for a project the goal of which was to build professional and community capacity to implement a public health approach to substance use. Defining such an approach was a necessary first step.

While progress has been made since 2014, cannabis legalization/commercialization and the ongoing toxic drug supply crisis have highlighted the lack of coordination across services for people who use drugs (PWUD), ongoing stigma surrounding drug use, and the continued harms associated with the criminalization of the use of certain drugs. It is important, therefore, for CPHA to clearly and publicly affirm its definition of a public health approach to substance use to provide a foundation for greater coordination in the response to substance use. This action is further justified by the lack of consensus among professionals (Watson, 2023) and in the literature about what defines a public health approach to substance use and by the fact that most attempts to define a public health approach have not centered the voices of PWUD.

CPHA has engaged public health, public safety, health and social service providers, and people with lived and living experience of substance use (PWLLE) to identify priority action areas and barriers to implementation, and to inform the framework for a public health approach to substance use. As with other works published by CPHA, this framework is not intended to be the definitive treatise on the topic, but rather to define the perspective that CPHA – in collaboration with communities and stakeholders – has established as being foundational to future work.

DEVELOPMENT OF THE FRAMEWORK

The development of the framework began in 2020 with a broad definition of a public health approach, as articulated in Public Health: A Conceptual Framework (Canadian Public Health Association, 2017):

Public health practice can be viewed as an approach to maintaining and improving the health of populations that is based on the principles of social justice, attention to human rights and equity, evidence-informed policy and practice, and addressing the underlying determinants of health.

The development of the framework has been an iterative process, placing significance on meaningfully engaging PWUD. The pillars outlined in this framework have been informed and supported by a range of sources, including peer-reviewed evidence, grey literature, a survey of relevant professionals, as well as input gathered through focus groups and community engagement activities.

Supporting Research

A rapid scan of grey and academic literature on a public health approach to substance use was conducted to inform the first iteration of this framework. The methodology for this review was published in September 2022 (Kosteniuk B, 2022). Based on the preliminary findings of this review, the components presented in this framework are aligned with the literature reviewed.

Community Engagement

The development of this framework was informed by individuals and communities across Canada through key informant interviews with PWLLE, public health practitioners, health and social service providers, and other professionals. Community partners and PWLLE participated in focus groups to provide insight into barriers to implementing a public health approach, including service provider knowledge and capacity gaps. Based on this input, a working list of principles for a public health approach was drafted and presented during knowledge exchange forums with community partners (Manitoba Harm Reduction Network, Thunder Bay Drug Strategy and Mainline Needle Exchange [a program of the Mi’kmaw Native Friendship Centre]). Participants were prompted to provide feedback on each pillar of the framework and to consider the current barriers to a public health approach that exist in their communities.

In 2021, a national survey of public health, public safety, and other health and social service professionals was conducted to better understand key stakeholder beliefs, knowledge, individual and organizational capacity, and access to information, resources, and training related to substance use. The Final Report provides insight into professionals' understanding of a public health approach. Finally, an Expert Reference Group, comprised of PWLLE of substance use, health and social service providers, and public safety professionals, were engaged throughout the process to provide feedback and input on the approach. At each stage of community engagement, the framework was adjusted based on the priorities and feedback provided.

A FRAMEWORK FOR A PUBLIC HEALTH APPROACH TO SUBSTANCE USE

CPHA understands a public health approach to substance use as one that:

• Respects the autonomy and right to self-determination of people who use substances.
• Acknowledges that substance use exists on a spectrum, with both harms and benefits, and focuses on reducing potential harms and maximizing potential benefits.
• Approaches substance use through a health and human rights framework, not a criminal justice framework, while acknowledging the historic and current harms of drug policy.
• Recognizes and collaborates with people with lived and living experience of substance use as experts, and fairly compensates them for their work.
• Supports the underlying determinants of health and addresses health inequities.
• Works to protect and promote the freedom, health, wellness, and safety of people who use substances.
• Is collaborative and comprehensive, and ensures a continuum of programs and services are available to meet people where they are at.
• Is trauma- and violence-informed, gender transformative, anti-racist, anti-oppressive and culturally safe.
• Works to end stigma and discrimination.
• Is pragmatic and evidence-informed.

PRINCIPLES OF A PUBLIC HEALTH APPROACH TO SUBSTANCE USE

A public health approach to substance use is one that:

Respects the autonomy and right to self-determination of people who use substances.

Self-determination: the right of a People to freely pursue their economic, political, social, and cultural development (Department of Justice Canada, 2021). The term in Canada is used primarily to refer to Indigenous Peoples’ inherent right to self-determination, a right that is violated through Canada’s colonial policies and practices.

A public health approach to substance use acknowledges that individuals have the right to make decisions about their own health and well-being, including their substance use. This approach recognizes that individuals are best positioned to understand their own needs and preferences. It seeks to empower individuals by respecting their autonomy, supporting them in making informed choices, and ensuring that their voices are centered in decisions about their care. Utilizing this approach fosters a trusting and collaborative relationship between individuals and health care providers, enabling PWUD to actively participate in their own care and make choices that align with their values and goals.

Respecting the principle of autonomy and the right to self-determination is particularly significant when considering the disproportionate impacts of substance use harms on Indigenous people in Canada. Recognizing that their rights have historically been denied, a public health approach acknowledges the current and historic harms of colonization (e.g., intergenerational trauma, social and economic marginalization, dispossession of land, limited access to culturally-appropriate health care and support services) and respects the rights of Indigenous people to make decisions about their own health and substance use care. This involves working in partnership with Indigenous communities to ensure that programs, policies, and services align with their distinct cultural values and traditions.

Acknowledges that substance use exists on a spectrum, with both harms and benefits, and focuses on reducing potential harms and maximizing potential benefits.

Harm Reduction: a political movement, philosophy and set of principles to inform policies, programs and practices that aim to reduce harm associated with drug use, drug policies and drug laws. Harm reduction acknowledges that abstinence or a reduction in substance use is not required to receive respect, compassion, or services (Canadian AIDS Treament Information Exchange (CATIE), n.d.).

A public health approach to substance use requires an understanding of why people use substances, and a focus on reducing harms and maximizing potential benefits associated with substance use. It acknowledges that throughout history, substances have been used for spiritual, medicinal, social, and pleasure purposes. Substance use can be understood on a spectrum (see Figure 1) that includes non-use, beneficial use, lower-risk use, higher-risk use, and addiction or substance use disorders. Individuals may move back and forth along this spectrum or be at different stages for different substances over time (Health Canada, 2022). This spectrum is not linear, meaning an individual may remain in one stage of this spectrum for years and never progress to higher risk use or substance use disorder. Without requiring a reduction in substance use, a public health approach aims to reduce the risks and increase the potential benefits at each stage of this spectrum.

Reducing harms related to substance use includes targeting the harms created by stigma and discrimination, criminalization, and the risk of overdose. While these harms must be acknowledged, it is also necessary to recognize the reasons why people use substances, and the benefits they provide including pain relief, coping with trauma, supporting substance use treatment, social connection, pleasure, recreation, and supporting general mental health and well-being.

Approaches substance use through a health and human rights framework, not a criminal justice framework, while acknowledging the historic and current harms of drug policy.

Health and human rights framework: an approach that provides a set of clear principles for setting and evaluating health policy and service delivery, targeting discriminatory practices and unjust power relations that are at the heart of inequitable health outcomes (World Health Organization, 2023).

Drug policy: laws that prohibit the possession, distribution, and production of illegal substances without authorization, and laws that regulate the production and distribution of legal substances (Canadian Drug Policy Coalition, 2022). Drug policy can also include regulatory frameworks (i.e., regulation and guidance pertaining to the manufacturing, distribution, promotion, and sale of substances).

A public health approach to substance use involves consistently using a health and human rights framework, rather than the criminal justice approach that is used to address certain classes of drugs in Canada. The criminal justice approach disproportionately harms those who already experience broad systemic inequities, including people living with mental illness as well as Black and Indigenous communities. There is growing evidence that punitive measures and criminalization do not achieve the intended outcomes of reducing drug use and its associated harms (Canadian Public Health Association, 2014). Rather than treating substance use as a criminal offense or using punitive approaches, a public health approach prioritizes equity and supports the health and human rights of PWUD. This approach is guided by the Canadian Charter of Rights and Freedoms and the United Nations Universal Declaration of Human Rights.

Recognizes and collaborates with people with lived and living experience of substance use as experts, and fairly compensates them for their work.

Meaningful, equitable, and respectful partnership with PWLLE of substance use is an integral part of a public health approach to substance use. These partnerships are needed to disrupt existing power imbalances between those in positions of power (e.g., health care workers, public safety) and PWLLE to ensure that the perspectives of PWLLE are prioritized. Efforts towards meaningful partnership promote equity and accessibility, build capacity to respond to community needs, and result in work that more effectively addresses the barriers experienced by PWLLE.

A public health approach must avoid tokenism by engaging a variety of people with intersecting identities and diverse perspectives and consider that each individual experiences substance use and its related stigma differently. Those who are most affected by harmful systems must be prioritized, specifically Black and Indigenous people. To ensure a partnered approach, PWLLE must be fairly compensated for their work, acknowledged for their contributions, and given appropriate job titles. This requires recognizing both lived and professional expertise and ensuring that PWLLE are involved in all phases of policy, program, and resource development.

Supports the underlying determinants of health and addresses health inequities.

Determinants of health: a person's individual characteristics and behaviours, and the social, economic, and physical environments.

A public health approach to substance use plays a crucial role in addressing the underlying determinants of health and reducing health inequities. By recognizing that substance use is influenced by social, economic, and environmental factors, this approach goes beyond solely focusing on individual behaviours and choices. It acknowledges that health outcomes are shaped by broader systemic and structural factors, such as poverty, discrimination, and access to resources. By addressing these determinants, a public health approach aims to create supportive environments and advocate for policies that reduce inequities, provide equitable access to services, and promote harm reduction, prevention, and treatment options that are responsive to a diverse range of needs. This approach not only addresses substance use but also seeks to improve the overall health and well-being of populations, ensuring that everyone has a fair opportunity to achieve optimal health outcomes.

Works to protect and promote the freedom, health, wellness, and safety of people who use substances.

A public health approach to substance use aims to protect and promote the freedom, health, wellness, and safety of individuals who use substances. It acknowledges that substance use, like any health behaviour, should not be a basis for discrimination. By adopting a public health approach, interventions seek to ensure that PWUD have equitable access to health care, treatment, and support services. This includes providing non-judgemental and stigma-free environments where individuals feel comfortable seeking assistance without fear of punishment, criminalization or social isolation.

By recognizing and addressing these broader societal factors, a public health approach can create a more just and inclusive society where the rights and dignity of all individuals, regardless of their substance use, are protected and upheld.

Is collaborative and comprehensive, and ensures a continuum of programs and services are available to meet people where they are at.

A public health approach to substance use is characterized by its collaborative and comprehensive nature, encompassing a continuum of programs and services that are designed to meet individuals’ self-identified needs. By offering a range of programs and services, including prevention strategies, harm reduction, social support, or treatment options, a public health approach ensures that support is tailored to meet individuals at their current state of readiness for change and addresses their specific needs.

A comprehensive approach to substance use must provide PWUD with knowledge of and access to a continuum of services including harm reduction services, treatment, and services that address social determinants (e.g., housing), while eliminating the criminalization of drug use. Research has shown that making treatment or recovery the sole or primary objectives of a service provided to PWUD can inadvertently cause harm (Charron, 2019). As such, a public health approach is one that aims to provide support and services to people along the spectrum of substance use (see Figure 1).

Is trauma- and violence-informed, gender transformative, anti-racist, anti-oppressive and culturally safe.

Trauma- and violence informed practice: a way of working and designing programs, policies and service systems that recognize the prevalence and ongoing impact of trauma and violence on the lives of those accessing health care and social services.

Gender transformative: approaches that focus on the dual goals of improving health, social or economic status as well as gender equity (Greaves, 2014).

Anti-racist: actions or practices which not only confront or oppose racism, but actively identify and eliminate racism by changing systems, policies, practices, and attitudes, so that power is redistributed and shared equitably (Calgary Anti-Racism Education, 2020).

Anti-oppression: actions or practices that confront individual or social forms of discrimination, violence, and oppression that occur when one group in society holds economic or political power over another (The Anti-Oppression Network, n.d.).

Cultural safety: an outcome based on respectful engagement that recognizes and strives to address power imbalances inherent in the health care system. It results in an environment free of racism and discrimination, and empowers individuals to draw strengths from their culture, identity, and community (First Nations Health Authority, n.d.).

A public health approach to substance use acknowledges the well-established relationship between trauma and substance use and works to ensure that systems, policies, and programs that impact PWUD are trauma- and violence-informed (Greaves et al., 2020). The goal of trauma- and violence-informed practice (TVIP) is to create an environment where PWUD are supported to make decisions for themselves, and do not experience further traumatization or re-traumatization. By adopting a gender transformative perspective, a public health approach recognizes and addresses how power dynamics affect how people start or stop using substances and respond to programs or policies, and how gendered roles and identities affect stigma, help-seeking, and substance use‒related harms.

Health and social systems, institutions, and structures can perpetuate oppression and racism, and worsen the harms of substance use by increasing stigma, vulnerability to criminalization, and preventing access to health care. A public health approach actively seeks to disrupt these systems of oppression, while fostering cultural safety. This requires acknowledging the impacts of colonization, power imbalances, and discrimination of substance use and PWUD, and a specific focus on meaningful partnership with Indigenous communities. A public health approach encourages efforts to bridge knowledge gaps and develop tailored interventions that consider the impacts of trauma, violence, culture, race, and gender.

Works to end stigma and discrimination.

Stigma: a deeply held set of false beliefs about a group of people, in this case, people who use substances. Stigma is a negative stereotype that can result in judgement, oppression and discrimination (Health Canada, 2022). Various forms of stigma exist, including perceived stigma, internalized or self-stigma, enacted or social stigma, structural stigma and intersectional stigma.

Discrimination: negative behaviours towards people who deviate from societal norms or, in other words, those who are stigmatized. Discriminatory practices result in exclusion and maintain inequities for the stigmatized group (Canadian Mental Health Association, n.d.).

A public health approach to substance use acknowledges the harmful impacts of stigma and discrimination on PWLLE of substance use, and actively works to reduce them. This approach recognizes that stigma and discrimination not only exacerbate the challenges faced by people who use substances but also hinder effective prevention, treatment, and harm reduction efforts.

Stigma is pervasive and operates within communities, institutions, and systems. Deeply held stigmatizing attitudes result in the discrimination of PWUD in various settings, including employment, health care, housing, and social support. This is exemplified when PWUD are unfairly denied employment or are labelled as drug-seeking by health care providers. This stigma can be internalized by PWUD, leading to feelings of shame and further reducing the accessibility of services. Many other stigmatizing and discriminatory practices go beyond individual interactions, and are embedded within policies, practices, programs, and laws. Such examples include abstinence-based requirements to access care or housing, inaccessible hours of operation, or the underfunding of harm reduction and substance use health services. A public health approach to substance use seeks to reduce stigma and discrimination at both individual and systemic levels. This can be achieved by centering the voices of PWLLE, developing educational resources, encouraging organizational assessments, and advocating for responsible media representation, and through drug policy reform.

Is pragmatic and evidence-informed.

A pragmatic and evidence-informed approach to substance use acknowledges the importance of scientific evidence, while recognizing that evidence alone, without contextual understanding, falls short in guiding decision-making.

Pragmatism in public health aims to bridge the gap between scientific evidence and practical application. A public health approach to substance use is pragmatic when it prioritizes practical, measurable outcomes that can be achieved within the existing social, economic, and political realities. A pragmatic approach recognizes that individuals and communities face unique needs and challenges related to substance use. As such, public health interventions should consider cultural, social, and economic factors and be adapted to fit different contexts. Pragmatism is a key concept underpinning harm reduction, which recognizes that eliminating all substance use is not realistic, achievable, or in many cases, necessary, to improve health outcomes. A pragmatic approach focuses on minimizing harms and maximizing potential benefits of substance use through interventions like needle exchange programs, naloxone distribution, safe consumption sites, and safe supply. By reducing some of the harms of substance use, pragmatic approaches can protect and promote the health of individuals and communities while acknowledging the complexities of substance use.

Approaches to substance use must also be informed by current, relevant evidence that reflects the needs and voices of PWUD. Unlike evidence-based decision making, which relies primarily on scientific evidence, evidence-informed approaches consider a wide range of evidence sources, including research studies, systematic reviews, local data, professional experience, lived and living experience, and stakeholder perspectives to inform decision-making and shape interventions or policies.

CONCLUSION

The framework for a public health approach to substance use includes a variety of interconnected principles that can act as a foundation for developing policies, programs, and resources related to substance use. This framework will continue to evolve based on input from PWLLE of substance use, public health professionals, health and social service providers, and public safety professionals.

REFERENCES

Calgary Anti-Racism Education. (2020). Our Glossary. Calgary: CARED. 
Canadian AIDS Treament Information Exchange (CATIE). (n.d.). General harm reduction. Toronto: CATIE.
Canadian Drug Policy Coalition. (2022). Legal Regulation. Vancouver: CDPC.
Canadian Mental Health Association. (n.d.). Stigma and Discrimination. Toronto: CMHA.
Canadian Public Health Association. (2014). A new approach to managing illegal psychoactive substances in Canada. Ottawa: CPHA. 
Canadian Public Health Association. (2017). Public Health: A Conceptual Framework. Ottawa: CPHA. 
Charron, E., Maler, K., & Smirl, E. (2019). Forest for the Trees: Reducing Drug and Mental Health Harms in the Inner City of Winnipeg. Winnipeg: Canadian Centre for Policy Alternatives. 
Department of Justice Canada. (2021). Principles respecting the Government of Canada's relationship with Indigenous peoples. 
First Nations Health Authority. (n.d.). Creating a climate for change. Vancouver: First Nations Health Authority.
Greaves, L., Pederson, A., & Poole, N. (2014). Making it Better: Gender Transformative Health Promotion. Toronto: Canadian Scholars’ Press.
Greaves, L., Poole, N., Brabete, A. C., Hemsing, N., Stinson, J., & Wolfson, L. (2020). Integrating Sex and Gender Informed Evidence into Your Practices: Ten Key Questions on Sex, Gender & Substance Use. Vancouver: Centre of Excellence for Women’s Health. 
Health Canada. (2022, 06 21). Stigma: Why Words Matter. 
Health Canada. (2022, 06 03). Substance Use Spectrum.
Health Canada. (2023). About substance use. 
Kosteniuk, B., Speed, K., Candler, E., Campbell, S., Penney, G., Moen, K., & Hyshka, E. (2022). Public health approaches to substance use: a scoping review protocol. JBI Evidence Synthesis, 20(9), 2395-2407. doi.org/10.11124/jbies-21-00353
The Anti-Oppression Network. (n.d.). What is anti-oppression? 
Watson, T. M., Penney, G., MacIntosh, K., Cochla, S., & Kim, A. (2023). Final Report: Survey of Public Health, Public Safety, Health and Social Service Professionals on a Public Health Approach to Substance Use. Ottawa: CPHA. 
World Health Organization. (2023). Human rights.