Title: Studying harm from others’ illicit drug use—can stigma really be avoided?
Abstract: Concern around stigma and discrimination when applying a ‘harms to others approach’ to illicit drug use illustrates a general challenge in policy work in the field of alcohol and drugs—how to make a behavior less attractive while avoiding producing more harm by attaching stigma to current users. In their paper ‘Applying a “Harm to Others” research framework to illicit drugs: political discourses and ambiguous policy implications’, Wilkinson & Ritter [1] provide a welcome and critical discussion of using a ‘harms to others approach’ (HTO) to illicit drug use. Although several benefits of this approach are recognized, the paper concludes that if only HTO from individual drug use is considered, discrimination and stigmatization of drug users will outweigh the benefits. The problem of stigmatization is assumed to be especially urgent in the case of illicit drug use, as it is the less well-off users in society who will be most negatively affected. To justify an HTO-approach on illicit drugs, Wilkinson & Ritter claim that it is necessary to include the other major form of HTO with respect to illicit drug use; HTO related to the illicit drug market. This commentary argues that such a focus also entails a risk of stigmatizing users and that the concern of stigma and discrimination raised in this case illustrates a general challenge in policy work in the field of alcohol and drugs. The major form of HTO related to the illicit drug market is drug-related violent crime, which in criminology is classified as three types of violence: (1) violence where drug use occurred among the people involved; (2) violence which is perpetrated in the quest for money to purchase drugs; and (3) violence occurring because of conflicts and competition within the drug market [2, 3]. As suggested by Wilkinson & Ritter, the very operation of the illicit drug market can be regarded as a cause of these harms. However, another perspective is that the foundation of the illicit market is the demand for illicit drugs in the population, i.e. individuals’ drug use. This individual responsibility for harms on the supply side could be revealed by an HTO perspective if the responsibility of users buying and consuming illicit drugs was acknowledged. This perspective has recently been used in the Swedish drug policy debate, where politicians accused drug users of being a main cause of the increasing violence in public places in Sweden, typically involving young victims and young perpetrators. In this case, however, it was not all users or the less well-off users who were accused, but the population of well-off users who were assumed to account for most demand [4]. Stigmatization and blaming of certain subgroups may therefore also arise from emphasizing this type of HTO associated with illicit drug use in public debate, and it is not evident that it is the less well-off who will be subject to blame. The example above also raises the more general question of whether it is possible to avoid stigmatization when studying substance use problems from an HTO perspective. One thought-provoking attempt to avoid stigmatization is to regard all users as part of the problem. This is a key underlying assumption behind the influential total consumption model within alcohol epidemiology, as recently stated in a discussion piece by Livingston & Raninen [5]. They argued that the call for a shift of attention towards the whole population's drinking (total consumption) also implied a shared responsibility across the population for the harms caused by alcohol, because all drinkers were included in the collective drinking culture. It is worth recalling here that, in the early thinking around the total consumption model, a major argument for addressing all users was not only that it was assumed to be effective, but that it avoided blame and stigmatization of specific groups [6]. As a result, policy measures directed to every drinker were selected, e.g. restricting availability and raising taxes. These measures aiming at making alcohol more difficult to obtain are found to be efficient in limiting harms from drinking [7] but also include, as mentioned by Wilkinson & Ritter, a risk that users will be stigmatized. Thus, the concern of causing stigma to drug users raised in this commentary illustrates a general contradiction in policy work in the field of alcohol and drugs—the balance between making a behavior less attractive and avoiding producing more harms by attaching stigma to current users. None. Mats Ramstedt: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; project administration; software; supervision; validation; visualization.