Erwin Goffman was the first to make a conceptualization about the stigma: he defined it as a negative and deeply discrediting attribute, built from the regulation and values accepted by society, which generates actions of rejection and contempt towards those who have this condition (Goffman, 1986). However, in the last 20 years, research has begun to explore more closely the complexity of the stigma phenomenon; in this sense, Link and Phelan (2006) complement Goffman’s initial concept, and they define it as a process that involves five components: labeling, construction of stereotypes, the distinction between those who are stigmatized and those who are not, loss of status, and discrimination, which coincide in an unequal power situation.

People who use drugs and especially those with substance use disorder are stigmatized in most cultures (Corrigan et al., 2009) because they are presumed to be dangerous, unable to make decisions (Yang et al., 2017), immoral, weak of character, and with a tendency to commit crimes, for which they are blamed for their condition (Can & Tanriverdi, 2015) and situation which can have a detrimental effect on their health (von Hippel et al., 2018) and which contribute to limiting access to adequate treatment (Muncan et al., 2020).

Public policies are designed to address social problems; however, the dominant ideas on some issues can intervene in the way that political actors think and make decisions (Fischer, 2003). Drug policies do not escape from this situation, and since consumption is socially considered “bad” (Porter, 2020), it is possible to understand the repressive action of policymakers in front of people who use them (Husak, 2004).

This research aims to understand the meaning of stigma about illicit drug consumption and its contribution to policymaking of demand reduction in Colombia from the perspective of experts on this topic.

Methods

Type of Study and Approach

Hermeneutic research used techniques of analysis of grounded theory (GT) to collect and analyze information as a result of the experience of people in a specific context and analyzed systematically with a constant process of comparison, with the intention of generating conceptualizations to understand phenomena of social interaction (Glaser & Strauss, 1999).

The theoretical support of GT is the sociological current called symbolic interactionism, which invites us to understand that the social behavior of people depends on the meaning for them about the phenomena they experience, arising from interaction with others and being modified by the interpretation that each human being makes of them (Blumer, 1986).

Participants, Sampling, Techniques, and Data Generation Process

The participants were 20 professionals with experience in the design of norms, plans, or programs and who had participated in the making, design, or implementation of policies aimed to reduce the demand for illicit drugs in Colombia. Their profiles included technical staff at the ministerial level of the Government, decision-makers in the political sector, academics, researchers, advisers, and experts (Table 1).

Table 1 Characterization of the experts interviewed about the drug use policies in Colombia
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The sampling of the study was initially selective and intentional from searching databases about these policies in Colombia and their original speakers. This allowed the identification of the first ten informants.

To the extent that analyses advanced, the sampling was theoretical, as it was attended by people who maximized the understanding of the phenomenon and the opportunities to discover variations between the concepts and theories about the meaning of stigma on the consumption of illicit drugs, trying to include different voices in terms of their profession, age, professional experience, and background in order to discover the full range of perspectives on the topic of research. Ten other experts were selected to study these emerging aspects (Glaser, 1978).

The data collection technique was the semi-structured in-depth interview (Taylor & Bogdan, 1992) since it offers the possibility of an approach as natural as possible, but with care and detail regarding the phenomenon of study. The interviews were conducted in 2017, lasted between 60 and 90 min, and explored issues such as the environment of the norms, plans, or programs of demand reduction in Colombia, the positions defended in public debates, about the morale of drug advisors and rulers and their influence on decision-making, affecting the image of rulers, among others topics. The interviews were recorded and then transcribed, verifying that the written text coincided with the respective audio.

Analysis and Interpretation of the Information

The analysis was performed through open coding or microanalysis involving the initial conceptualization of the transcribed text in detail. These codes were grouped into initial categories according to their affinity, and within these categories, properties and dimensions specific to GT were identified, which allowed higher levels of abstraction (see Table 2).

Table 2 Initial categories built from the codes emerged in open coding
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Later, from the axial and selective coding, and the construction of the paradigm matrix, the phenomenon was identified with its respective context, conditions, relations of action and interaction, and consequences. In the end, a final category was constructed that accounts for the basic social process that emerged from the consequential conditional matrix (Corbin & Strauss, 2014).

The analysis process was systematic since it went from a descriptive level to an analytical one and then an interpretative one. It was iterative to the extent that it allowed the transition from data to codes, from there to the categories in inductive and deductive logic, but it was also interactive to coordinate the voices of the interviewees, with the analysis of the researchers and the references reviewed in the process (Charmaz, 2006).

To ensure data quality, abstractions were compared between the three researchers throughout the process. The writing of analytical, theoretical, and reflective memos allowed to develop the ideas that were emerging in the constant comparative analysis, which helped to focus the areas of interest for the interviews and guided the search for scientific literature in this regard (Glaser, 1992). The analysis performed sought the alleged theoretical saturation, to the extent that, by varying the way of investigating and exploring the new nuances of what emerged, new information will not be provided which would substantially modify what had been found until that moment (Glaser, 2002). At the end of the study, a summary of the results was sent to the interviewees and their considerations were followed.

The reflective process by the three researchers was present during the development of the interviews and the generation and the analysis of the data, meeting the criteria of rigor for qualitative research, as researchers are intended to identify which elements of their subjectivity can influence the data generation process, the analysis, and interpretation (Engward & Davis, 2015). This research was approved by the Research Ethics Committee of Universidad de Antioquia in session No. 129 of November 4, 2015.

Results

Twenty professionals who have participated in the formulation of demand reduction policies in Colombia were interviewed, of whom nine were women. The average time of experience and participation in the design of public policies was 17 years. Other data about the participants are presented in Table 1.

Below are the findings of the research, which follow the structure of the paradigm matrix with its phenomenon, the context in which it is developed, the conditions, the strategies to confront it, and its consequences, realizing the basic social process found (see Fig. 1).

Fig. 1
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Matrix of the constructed paradigm

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Main Category: the Social Meaning Built on the Consumption of Illicit Drugs and the Fear of Being Stigmatized as a Promoter of More Liberal Public Policies, Contributes to the Policymaking of Demand Reduction in Colombia

The results presented below indicate how the meaning of drug use and the fear of being stigmatized as a promoter of more liberal public policies contribute to repressive policymaking. To do so, the analysis is carried out from the context, the conditions, the consequences, and the relations of action interaction, according to the methodological assumption of the grounded theory.

Regarding the context, in the analysis of the data, it was found that the interviewees decided to assume a position that did not contradict the social imaginary built in Colombia regarding drug use, due to the possible implications this would have for their political careers. In relation to the conditions, the participants mentioned that the social pressure exerted by state control agencies, the media, and economic groups about the political decisions that are made in relation to drugs makes the leaders carefully assess the political risk that it could have for their careers, which make a different decision from the position of the dominant groups of power.

In relation to the issue about the action interaction relations, the analysis of the data showed that rulers are afraid of losing their image and therefore the continuity in their positions, which is why they prioritize the investment of the state budget in less controversial issues, and in relation to the consequences, the data indicates that the fear of being stigmatized as a promoter of more liberal public policies contributes to leaders to make repressive policies, which could affect the rights of people who use drugs.

Phenomenon: the Fear of Being Stigmatized as a Promoter of More Liberal Public Policies

The analysis of the data showed that social stereotypes built on the drug use, which understand people who use them as possible criminals on whom the full weight of the law must apply, cease to be a matter “of the other” to become “something of their own,” when leaders feel they can be singled out as promoters of more liberal public policies if they handle a speech that advocates for the rights of drug users, which is why they prefer to handle a low profile when discussing these issues.

The paradox is that this, instead of generating spaces for argumentative political debate, on the contrary, reproduces similar behaviors to those practiced by people who use drugs, such as hiding or self-excluding, as the leaders do for fear of losing their political power. The foregoing leads decision-makers for fear of public accusations and embarrassment, which prefer to handle a speech that suits the imaginaries of public opinion on this issue.

¿What does the decision maker do? Calibrate his decisions versus his responsibility. You have a script of what you have to do, of what your powers are and you as a leader has to do it, because if you do not do it there is omission; besides, there are personal postures, that is a combination. Read people, look at your script, define what you have to do and what is your personal stance and combine. (Interview 15, with a man representing the government)

Context: Colombia’s History and the Formulation of Policies to Reduce Drug Consumption

The recent political history of Colombia has been crossed by internal conflict, drug trafficking, and the war on drugs, which contribute to the social perception built about consumption and people who use drugs.

In this sense, the interviewees stated that for a ruler, regardless of his personal position on drug use, it is preferable to assume a position that does not contradict the social imaginary built against drugs, since doing so could mean political death for them because they take the risk of being appointed as promoters of more liberal public policies if they contradict the moral requirements demanded by their position.

It is an issue that is not easy to deal openly because the political cost can become very high (...) there are some interests that we all have to take care of: our work, our good name, our resume, our reputation, etc. (Interview 14, with a woman representing the government)

Taking a stand of respect for the right to consumption is not an easy task in Colombia, because the history of the country has been linked to drug trafficking and this has left deep traces in the social imaginary regarding the issue. In this sense, the interviewees mentioned that is frequent that officials who work in the design of policies are singled out and excluded from the public debate, as shown by the following account of a participant who worked as a drug policy advisor and was fired when he proposed the implementation of a harm reduction program, oriented not to the abstinence, but to the responsible consumption.

The major called and told me: doctor you have some advanced ideas, but at this moment for the country they cannot be possible, and even less for the city, please send me your resignation letter, so that, I can declare it unsubstantiated. (Interview 1, with a male academic representative)

Conditions: the Control of Public Management by Influential Power Groups

The analysis of the data indicates that permanent inspection that power groups make about the actions and ways of thinking of the rulers contributes to their assuming a conservative position on the subject, since the fact of publicly recognizing people who use drugs as subjects of law can be interpreted as a discourse that stimulates and promotes consumption by control organisms.

In the City Council it is impossible to think that we are going to give place to recreational consumption or that we are going to accept it as part of daily life (…) I am basically talking about the Council, which is where those who exercise political control are (…) because finally, that is where important decisions are made for the city. (Interview 16, with a female government representative)

In addition to the above, the interviewees mentioned that as rulers, they are under the gaze of conservative and influential sectors of society, such as the media, large companies, and the church, who also have a strong influence on decision-making in this regard, a situation that leads to analyze these issues from the interests that move around the power, since behind a decision private interests and enormous political pressure are hidden in order to govern under the established parameters, by the sectors mentioned.

The power of the press is controlled by the businessmen; the companies have interests in their rulers and are awaiting about their decisions. The church in the city is very influential (...) it is very aware of things.... (Interview 15, with a male government representative)

In this order of ideas, the participants stated that making decisions about drug issues is a complex topic in Colombia because the leaders must evaluate their personal position about the matter and decide whether they want to take the political risk that assuming a position that contradicts the opinion of the influential groups in power and the constitutional bodies that legislate in the cities. Next, the story of a ruler is presented that shows how the control exercised by the groups behind the power influences decision-making.

When you are in those roles, you are in the political game; and part of the political game is knowing how to read what the board of directors of the city want; what do scientists think, what do parents think and what do the people want, because I am a politician. So, you calibrate, ¿will this decision have a political cost? and ¿is it worth taking the risk? (Interview 15, with a male government representative)

Action Strategies: Prioritize Fewer Sensitive Issues

In the collective social imaginary, there is the idea that people with drug addiction are responsible for their situation for having made a bad decision (drugs consumption), which is why the State should not be responsible for their treatment, rehabilitation, and social reintegration, since an individual matter should not affect the public treasury. In this sense, the participants mentioned that demand control policies, especially risk mitigation and harm reduction policies, are not considered a priority issue, since there are other issues of interest in public health that affect a greater number of people, and for this reason, they demand a more expeditious response from the government.

In many of these instances, they feel that they are people who are not worth investing in due to they are in that specific situation because they sought it out (…) also, because there are always other priorities in a country like ours, there are weather, epidemic issues, etc., that compete with these other priorities that affect a minority of the population (Interview 14, with a female government representative).

On the other hand, the interviewees stated that it is common for people who use drugs to be seen by the rulers as an economic burden for the health system, and since it is not easy to reach the drug abstinence indicator, this is understood by decision-makers as a failure; therefore, risk mitigation and harm reduction programs are postponed since it is preferable to invest in less sensitive issues and with better results.

In this sense, the analysis of the data indicates that this situation makes the rulers stop investing in this type of policies and do so in others that are considered more necessary and with more tangible results, due to the fear of the political costs that could imply having more liberal position respect to the drug use (risk mitigation and harm reduction actions).

The State invests in resources that are lost in these people, and when they are lost, they are negative experiences. So, they become a burden because of the cost-benefit, they make the State see that it is expensive to put money there, versus other public health programs. (Interview 15, with a male government representative).

It has been very difficult to advance on harm reduction issues (…) I was in a city last week and a government official explicitly said that he was not going to spend a single peso on a syringe because he had other public health priorities, which are more valid from the moral and social point of views such as attention to children and adolescents, as if one thing were against the other, ¿do you understand me? as if they were opposites. (Interview 14, with a female government representative)

Consequences: Repressive Public Policies and Violation of the Rights of People Who Use Drugs

The participants mentioned that drug use is often not understood by public management as a “social phenomenon” but as a “problem” linked to marginality, criminal issues, poverty, and disease.

In this sense, it would be foreseeable that when reducing a “macro-structural phenomenon” in terms of a “problem,” the response of the State is not consistent with the complexity of the issue that is talked about, and the public policies are reduced to interventions with short-terms responses, without a deep and contextualized situational analysis that generates inclusive and grounded alternatives to the reality that the country is experiencing.

Considering this, the data analysis revealed how the stigmatizing speech, sometimes lacking scientific bases, but product of decades of construction of a social meaning about drug use, has greater weight and political support when it comes to intervening the issue.

The following story illustrates that there is little coherence between what the scientific evidence proposes and the way in which decisions are made regarding drug issues; although the effectiveness of risk mitigation and harm reduction actions are known, the meanings formed from the moral conceptions have greater relevance when formulating proposals for intervention in this regard.

The technical people are absolutely convinced of the idea of ensuring hygienic injection equipment for people who inject drugs, but at the political level there is no one who supports it, they are scared to death, and they consider this to be matchmaking. (Interview 14, with a female government representative)

Finally, the interviewees mentioned that the use of punitive and disqualifying language is frequent by the political leaders in the country, toward people who use drugs, trying with this not to contradict the moral ideologies of the powerful groups that seek repressive actions towards those who go against the established social regulations and values, and in this way be able to count on the endorsement of the majority in the voting.

“We have to put people who use drugs in jail or we have to put them to forced labor, that was what the man who had just been a candidate for mayor of the city told us a few years ago. (Interview 4, with a female representative of the academy)

Discussion

The article explained, from the perspective of the interviewees, how the meaning built on drug use and the fear of being stigmatized as a promoter of more liberal public policies about this subject contributes to the drug demand reduction policymaking in Colombia. Next, the findings are discussed according to the categories built in the paradigm matrix.

In relation to the fear of being single out as promoters of more liberal public policies if the social speech constructed against drug use is contradicted, Thoumi (2003) states that policymaking about drugs depends, among many factors, on its coherence with the customs and social values, and since in the social imaginary there is the belief that drugs are bad (Porter, 2020), the implementation of prohibitionist policies is justified as an argument of social control (Husak, 2004), because the decision-makers can be labeled as liberals or conservatives depending on the position they want to take in the public debate about drug use (Monaghan, 2014). These arguments coincide with the approaches of Drucker (2012) who argues that the most conservative politicians want to show themselves as the toughest against drug use, since any sign of weakness exposes them to different types of attacks by society.

Similarly, our findings indicate that decision-makers prefer to keep a low profile when discussing drug use. The foregoing could have an explanation in the sensitivity of the issue from a political point of view (Monaghan, 2014) and with the fact the decisions of the rulers are influenced by the social perceptions built on the use of drugs, by the moral judgment of decision-makers in this regard, and by the pressure exerted by public opinion (Lancaster, 2014).

In view of the above, Stevens (2019) argues that drug decision-makers present themselves to the population as moral agents capable of safeguarding society from external evils, which, in Drucker’s terms (2012), silences the political debate about the subject and excludes the academic discussion about the importance of scientific evidence in terms of public health, to focus on the punishment and criminalization of people who uses drugs, similar aspects to those found in this research.

In relation to the political control exercised by certain sectors of society, Ritter and Lancaster (2013) mention that drug policymaking is influenced by public opinion, powerful groups, religious groups, and conservative parties. The foregoing coincides with the findings of this study in terms of the use of punitive language in order to ensure the permanence of leaders in power, since the simple fact of saying that “using drugs is wrong” ends up being the most convincing argument to support their political campaigns in front of public opinion (Husak, 2004); arguments that are supported by Thoumi (2003) who states that zero-tolerance policies for consumption have traditionally had the support of the legislative, executive, and judicial powers in modern democracies.

Regarding the low investment in demand reduction policies, the prioritization of less sensitive issues and with better results, Porter (2020) indicates that because of the use of drugs which is considered a “vice,” the people who consume them do not deserve an investment of public spending on them by taxpayers, or by decision-makers, a matter that is explained by Stevens (2019) who argues for many conservative politicians; the principle of State efficiency implies the proper management of public spending, so it is preferable to invest in policies that benefit larger population groups, leaving aside the drugs issue. This information coincides with the historical reports of investment in demand reduction in Colombia, which does not exceed 4% in terms of prevention, treatment, and rehabilitation (Thoumi, 2003).

Faced with the issue of the rights of people who use drugs, Husak (2004) argues that addiction is incompatible with the conception of what is considered “good,” and given that drug use is considered something “bad,” letting people who use them suffer seems to be fairer than the idea of providing help, protection, and health (Porter, 2020) since in moral terms, what is fair is that people get what they deserve: happiness and well-being if they or their actions are virtuous or unhappiness and punishment if they or their actions are vicious (Buchanan et al, 2003).

The foregoing, in terms of Stevens (2019), denies people who use drugs the status of being human and affects their rights as citizens, which, according to the findings of this study, translates into short-term interventions and without a deep situational analysis. These issues in terms of Thoumi (2003) lead to drug policies’ failure, since such a complex problem cannot be solved with isolated government policies and that do not consider multidimensional aspects such as anthropological, social, economic, moral, environmental, judicial, and public health, for which this author proposes that it is necessary for the rulers to rely on research and academy to legislate in this regard, with the aim that decision-making is not based only on their personal experience, but on scientific evidence (Csete et al., 2016) (Monaghan, 2014).

It is concluded from the perspective of the interviewees that the fear of being stigmatized as promoters of more liberal public policies that go against what social and power classes expect leads the rulers to handle a low-profile speech about the subject so as not to assume the political costs this would imply for their careers.

As limitations of the study, it is necessary to clarify due to the method used; the data do not reach a level of generalization in population terms as is done from the positivist approach, which considers, within its scientific principles, the significance, the generalization, replicability, precision, and verification (Guba and Lincoln, 1994).

Despite this, qualitative research, according to Ercikan and Roth (2016), allows an essentialist generalization to be made, which makes possible to identify general aspects of the phenomenon that can be applied not only to the informants, but also to other people who can recognize in the phenomenon of study, issues that apply to their specific environment, reason why it is invited to read the findings in the context, and historical temporality in which they were made.

Public policies in terms of demand reduction based on abstinence indicators, moralistic ideologies, and in the complacency of the interest of economic and power groups tend to fail (Thoumi, 2003), so it is recommended to consider broad approaches which include the decriminalization and regulation, reduce violence and other damages of drug surveillance, differentiated treatment and comprehensive care, gender perspective, risk mitigation, and harm reduction (Csete et al., 2016), in addition to the articulation of different state institutions involved, the intervention of macrosocial factors, and the link between the academy and research for decision-making based on evidence (Csete et al., 2016).