Substance-Involved Crisis Care in Ontario, Canada: A Critical Analysis of Structural and Systemic Context

Increased attention to crisis intervention reflects a growing recognition of its broader implications; however, the role of substances in shaping and responding to a crisis warrants further exploration. Substance-involved crises and their responses are predominantly framed as either biomedical in nature or centred around the criminal-legal system. This paper examines the ways in which biomedical and criminal-legal approaches shape responses to substance-involved crises, foregrounding the need for a more holistic approach that accounts for structural and systemic context. We draw on data from a critical qualitative ethnographic case study of crisis care in Ontario, Canada, including interviews ( n = 53) and open-ended survey responses ( n = 60) from individuals who held roles within community-based organizations, emergency departments, paramedics, police and those with lived experience of crisis. Tensions were identified in relation to medicalized care options, which include medical care as necessary but insufficient as standalone responses and the stigma experienced in medical settings. Participants emphasized that medical care often fails to address broader social and structural needs. Coercive forms of ‘care’ and the influence of criminalization were described as pervasive within substance-involved crisis responses. In contrast, participants highlighted the importance of more holistic, non-medical and non-carceral approaches to care. Our findings reflect the increased demand for a paradigm shift from biomedical and criminalizing approaches towards alternative models of care that integrate medical and social support within community settings, as well as a greater focus on upstream approaches that support crisis prevention. We further discuss that these findings are particularly pertinent in the current and evolving policy contexts of Ontario and Canada more broadly, which are moving away from evidence-informed approaches for substance-involved care. These findings inform further direction for addressing the structural and systemic inequities that create and perpetuate substance-involved crises.