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Creating Culturally Safe Care in Hospital Settings for People who Use(d) Drugs


Abstract and Figures

Background: St. Paul’s hospital in Vancouver BC is an inner city hospital that serves a highly marginalized population of people who use drugs. Up to 30% of the patients that are admitted to the hospital at any given time have a substance use issue. Despite the presence of an active addiction team many of our patients continue to use drugs while they are in hospital. This has presented an issue for the nursing staff, who have a professional obligation to provide harm reduction services but the hospital has historically had a no tolerance policy towards drug use. A recent ethnographic study revealed that nurses are uncomfortable with patients using unsafely. Key points: The HIV and addictions team at St. Paul’s hospital reviewed the two policies guiding care of this population at St. Paul’s: The Philosophy of Care for Patients and Residents who use Substances at PHC and the Alcohol and Substance Use Policy. Both of these policies have been revised to reflect modern harm reduction principles, including a recognition that not all patients can attain abstinence and the necessity for nursing staff to provide clean and sterile drug use supplies, including syringes and needles and crack pipes. Implications: Engaging nurses in this new policy could present a challenge due to the various opinions that nurses hold about addiction and harm reduction. The methods of engagement that have been developed will be discussed and this presentation will review the process that was undertaken to create this significant change in policy and practice. The experiences of the front line nurses who have been asked to change their practice to reflect this policy will be discussed.
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in Hospital Settings for People who use(d) Illicit Drugs
People who use, previously used or are presumed to use,
illicit drugs face challenges getting good health care and
often have poorer health than the rest of the population.
The stigma and criminalization associated with illicit drug
use is increased for people living in poverty, impacting
health and acting as a barrier to accessing care.1 Negative
experiences in hospitals can lead people to avoid seeking
care and, if admitted, to leave before their care is complete.
Hospital nurses are critical to helping people access the
care they need, shaping patients’ hospital experiences,
and ensuring supports are in place when people leave
the hospital. However, there are few models or guidelines
to help nurses provide ethical, safe and appropriate care
when working with people who use(d) illicit drugs and face
poverty and homelessness.
The concept of cultural safety has been used to guide
nursing practice in ways that counteract the problems
of stigma, discrimination and inequitable access to care,
particularly when working with Indigenous peoples.2
Cultural safety has been endorsed by organizations
such as the Canadian Nurses Association (CNA), the
Canadian Association of Nurses in AIDS Care, the College
of Registered Nurses of British Columbia (CRNBC), the
Canadian Medical Association (CMA) and the Aboriginal
Nurses Association of Canada (ANAC). Nurses working at
Insite, a supervised injection site in Vancouver, Canada,
found cultural safety to be a helpful concept in working
respectfully with both Aboriginal and non-Aboriginal
Our goal was to generate knowledge about what cultural
safety looks like in acute care settings and how this
knowledge could improve the delivery of health care.
AUTHORS: Bernie Pauly RN, Ph.D, Jane McCall,
MN, Joanne Parker, MA, Cat McLaren, BA, Annette
J. Browne, RN, Ph.D, Ashley Mollison, MA
1. What is culturally safe care in acute care settings for
people who use(d) illicit drugs and face multiple social
2. How can nurses enhance delivery of culturally safe,
competent and ethical nursing care to people who identify
as currently or previously using illicit drugs?
We conducted a qualitative, ethnographic study in a large acute
care hospital, exploring patients’ and nurses’ views on culturally
safe care and the role of the hospital environment in fostering
or limiting that care. We did in-depth individual interviews with
34 participants, including 15 patients (8 male, 6 female and 1
transgendered person), 12 nurses and 7 acute care managers
or educators. We also spent time (275 hours over 12 months)
on two dierent hospital units to observe nurses’ work with
patients, and studied the hospital’s organizational policies and
documents (e.g., philosophy of care, mission and mandate,
substance use policies).
People who use(d) illicit drugs and nurses were involved in
all stages of the research through two advisory committees:
one included nurses, and the other included ‘peers’ – from the
Society of Living Illicit Drug Users (SOLID), an organization
run by and for people who use(d) illicit drugs. We worked with
both advisory groups to develop interview questions, interpret
data, and develop and present the ndings. At the end of the
project, we hosted two policy forums to share ndings with
an expanded group of nurses, health care managers, peer-run
organizations that represent people who use(d) drugs.
Cultural safety is based on the principle that the people
receiving care decide what is safe or unsafe.4 Thus, there is a
shift of power from providers to recipients of care. Cultural
safety encourages nurses to a) learn how stereotyping,
discrimination and other assumptions operate in health care
settings, b) reect on hospital policies that negatively impact
BULLETIN #11 December 2013
2Centre for AddiCtions reseArCh of BC
patients, c) understand how social inequities shape patients’
access to health care, and d) convey unconditional acceptance
of patients regardless of their decisions or circumstances and,
e) treat patients with dignity and respect at all times.5 Below,
we highlight ve elements of culturally safe care for people
who use(d) illicit drugs. These elements emerged from our
understanding of cultural safety, the ndings of this research
and our collaboration with nurses and people who use(d) illicit
drugs, and are meant to help guide nurses’ practice.
1. Culturally safe care fosters engagement and
participation of people who have experience with
substance use and marginalization in shaping the
care they and their peers receive.
In hospital, people who use(d) illicit drugs often feel excluded
and judged. Patients in our study had experienced hospital care
that they described as disrespectful and lacking compassion. A
common fear expressed by patients – and reinforced by our peer
advisory – was that in hospital they would be judged, labelled
and blamed for their current health problems and drug use.
…I’ve seen the way they treat people when they’ve had
drugs: you’re a drug addict, you know, you’re considered a
drug addict. It’s like a label, you know, ‘drug addict’, and they
just discard you.
—Patient participant
Patients described worries that they would be written o, not
listened to, or seen as undeserving of care. As a consequence,
they felt they would receive poorer quality care. It helped
patients to feel safer when nurses listened to and believed what
they said. We recommend that nurses, managers and others in
health care:
Actively listen to and acknowledge concerns expressed by
patients about their care.
Seek opportunities to learn from patients – about their lives,
their needs, their preferences, and their perspectives on
good hospital care.
Accommodate patients’ preferences for care, to the extent
Ensure that patients know their rights and what they can
expect when receiving health care.
Create and promote opportunities for sta to engage
in experiential learning in community settings, such as
harm reduction outreach, street nursing programs, and
community health clinics.
Involve people who use drugs and peer advocacy
organizations in the development and delivery of
education about hospital care for people who use(d) drugs.
2. Culturally safe care recognizes that people’s
health, health care, priorities and experiences are
inuenced by history and policies that criminalize
drug use.
Canada’s history of criminalizing drug use and poverty has
fueled negative attitudes towards people who use(d) illicit
drugs. There is increasing recognition that current drug policies
can be a barrier to obtaining health care, and the establishment
of appropriate health care services.6, 7 In our study, patients
described feeling ‘under surveillance’ while they were in hospital.
Some patients indicated that if anything went wrong or missing
on the unit, they would be the rst ones accused, and some felt
under constant suspicion of drug use.
I just left; it was 11:00 at night, the guy is demanding a
urinalysis from me… I said ‘what for?’ He said ‘because
you’ve been going out for walks a lot’. I said ‘Because I’m
going out, I’m getting fresh air, that means that you’re
suspecting me for doing drugs?’
—Patient participant
Even more concerning is that patients in this study told us they
were afraid to ask nurses or doctors for pain medication for fear
of being labelled as ‘drug seeking’.
If you’re in pain and you’re asking for pain medication, they’ll
doubt it… half the time they’ll think ‘oh, he just wants to get
high’ instead of ‘this guy is really hurting’.
—Patient participant
Nurses said that the hospital had a harm reduction philosophy
but hospital policies indicated zero tolerance for substance use.
Most nurses were unclear as to exactly what the harm reduction
policy said, or what they can or should do when they become
aware of active drug use. Nurses responded in various ways,
such as ignoring drug use, reporting it to their manager, or
trying to ensure patients’ safety.
I remember seeing [clean needles] in, like she had a little
makeup bag. I didn’t take them away. Because to me that’s
not, that’s not harm reduction at all. If I take them away, you
know, I might be putting her in a position where she’s got to
go and share with somebody else.
—Nurse participant
Only a few nurses mentioned promoting safer drug use, for
example, by providing supplies or education for safer use.
Hospital policies emphasizing zero tolerance of substance
use, and the lack of explicit harm reduction policies, leave
nurses caught between professional ethical commitments
to health promotion and ocial policies more aligned with
criminalization. To enhance culturally safe care, nurses, their
managers and health care leaders can:
Reect on their own attitudes and beliefs about illicit drug
use and people who use(d) illicit drugs. Consider how drug
policies have shaped these attitudes.
Recognize that people may feel under surveillance while in
hospital. Be sensitive to giving people space.
Ensure that the hospital environment is free of the threat of
Assess patients for pain and manage pain accordingly, rather
than assuming they are ‘drug-seeking’ based on their history.
Resist assuming that people using illicit drugs will not
require pain medication.
Ensure nurses have training in withdrawal management.
Expect to talk to patients about drug use as it relates to
their care. Ensure privacy, choose the right moment, explain
any specic concerns, and focus on health and safety –
avoid lectures or judgment.
Look at the existing evidence base showing the
eectiveness of harm reduction strategies.
Ensure that patients who use illicit drugs have access to
harm reduction supplies and services.
Ensure that patients who are ready to stop or reduce drug
use have access to detox, replacement therapies and other
treatment options.
Establish and clearly communicate harm reduction policies
to nurses and others.
Provide and promote opportunities for leaders and front-line
sta to question assumptions through open discussions of
drug policy, criminalization, marginalization and stigma.
3. Culturally safe care considers how past histories
of trauma and violence, layers of disadvantage
and stigma may affect patients’ ability to engage
with providers and care plans.
Some nurses said they know that people come to hospital feeling
distrustful and fearful of how they will be treated. Many were
aware that patients are sometimes treated poorly, disrespected
or dismissed, and do not always have their needs met.
I like to think everybody is the same, but I think people who
are more marginalized often times might have like more
abuse and trust issues. So I think you have to just work a little
bit extra hard at that.
—Nurse participant
4Centre for AddiCtions reseArCh of BC
Nurses described having to ‘think dierently’ about drug use
and people who use drugs, recognizing stereotypes and societal
conditions that contribute to the harms of drug use.
Patients highlighted that nurses’ attitudes and mannerisms are
as important as what they say and do. Patients repeatedly told
us that when nurses took time with them and provided honest
explanations, it helped them feel more comfortable.
You ask for things; if they’re there, they’ll give it to you, if
not, they’ll explain why. They don’t just say ‘no, there isn’t’,
you know.
—Patient participant
Explaining actions and decisions was important for many
reasons: to show respect, to avoid surprising patients, and to
give patients control over their own health care. To promote
cultural safety, nurses can:
Recognize that angry or frustrated behaviours often stem
from life situations and health problems, and are not a
personal attack on the care provider.
Encourage and help other sta members to see each
patient’s behaviour in the context of their life and possible
past experiences.
Recognize that people may be ‘on guard’ if they have
experienced abuse, homelessness or victimization.
Be prepared to go the extra mile in providing people with
options – be explicit about supporting their choices, and
avoid unnecessary power struggles.
Explain what you want to do before you do it to prevent
Explain decisions rather than just saying yes or no – so
that patients do not feel as if they are being criminalized,
dismissed or punished.
Avoid a rushed or hurried manner. People may be very
sensitive to body language that can be interpreted as
Be exible in helping to create a safer environment in
hospital. For example, people who have experienced
trauma may not feel safe in a mixed-gender room; some
may want to sleep with the lights on, etc.
Ensure opportunities for sta to develop competencies in
caring for people who have experienced trauma related to
life circumstances.
4. Culturally safe care emphasizes relationships and
trust as priority outcomes.
Developing trust is critical to facilitating access to health care
services 8, 9 and consistent with principles of cultural safety.
Building positive relationships with people who use(d) illicit
drugs should be a high priority for nurses.
The whole thing that motivates me is to maybe plant a seed
of safety, trust… Because a large proportion of our patients
have a really hard time trusting people; it’s really hard for
them to access any kind of treatment or services. I don’t
really think our patients need any more people judging them.
—Nurse participant
In this study, we found that patients felt safer, more welcome
and comfortable when they felt that nurses trusted them.
For example,
You can roam around, do what you want. As long as you let
them know what you’re doing…They don’t mind, as long as
you don’t… cause trouble or get out of hand or get ornery,
you’re ne. They’ll let you be, right? They check on you, right,
see how you’re doing and they ask you if you need anything.
—Patient participant
Patients also felt more comfortable knowing that nurses could
be trusted to recognize and respect their physical as well as
emotional space.
[The nurses are] caring; they care. They make sure that you’re
really comfortable…it’s like, they know me, they’re able to
say ‘OK, well, she doesn’t feel comfortable talking about that’,
and switch to another subject.
—Patient participant
Repeatedly, patients recounted times when nurses did ‘little
things’ that made them feel safer and more comfortable.
They’ll take that extra couple of minutes. And, you know, see
that you’re okay… ‘let me grab a blanket’ or, you know, ‘are
you sure you don’t need something for pain?’ You know, you
can tell by just even their voice that there’s genuine concern.
—Patient participant
When patients expect to face stigma and discrimination, little
things matter and help patients to feel seen and respected
rather than written o or discarded. To promote cultural safety,
nurses can:
Resist assuming that people trust you because you are a
health care provider.
Prioritize building a trusting relationship as a key pathway
and outcome of good care.
Be aware that showing trust is a good way to build patients’
trust in you.
Show genuine concern and empathy, call patients by name,
oer small things, and get to know something about the
patient – these can become profound acts.
Seek and promote educational opportunities that focus on
developing relational skills.
5. Culturally safe care requires a culture of respect
and safety within the unit or workplace, where all
patients are valued and seen as deserving of care.
Culturally safe care is easier to provide in a supportive
environment where the health care team shares similar values
and consistent approaches to care. In our study, we found that
sta turnover and resource constraints posed challenges to
creating culturally safe environments, and heightened tensions
around who is most deserving of care. Shared approaches and
understandings of substance use are important to creating a
health care culture that fosters cultural safety. Conversely, many
nurses indicated that they had few opportunities within their
basic or continuing education to develop skills related to care
for people dealing with substance use and social disadvantages.
We recommend that nurses, managers and educators:
Build strength within interdisciplinary teams: provide
education on drug policy and substance use to all sta,
including physicians, nurses, pharmacists and other
Encourage peer-to-peer support, and work as a team to
manage and debrief dicult situations or behaviours.
Use respectful and non-stigmatizing language at all times,
and avoid stereotyping. Overhearing sta conversations
can reinforce patient fears and mistrust; health care
providers also benet from consistent messaging and role-
modelling of respectful treatment by health care leaders.
Address stang shortages and policies that can limit
nurses’ ability to engage with patients and build their trust.
Promote mentorship opportunities for new nurses, support
them to develop expertise and skills, and to understand
unit norms and expectations related to substance use and
cultural safety.
Cultural safety is especially relevant in the provision of nursing
care for people who use(d) illicit drugs and live with social
disadvantages such as poverty and homelessness. Specic
attention to these ve elements of culturally safe care holds
promise for improving nursing practice in ways that can foster
equity and social justice in health care.
© Centre for Addictions Research of BC 2013 |
We gratefully acknowledge research funding from Michael
Smith Foundation for Health Research (MSFHR), under the
British Columbia Nursing Research initiative.
We acknowledge with deep gratitude and respect the
advisory committees for this project. Special thanks to the
Society of Living illicit Drug Users (SOLID), and the nurse
advisors who gave their time to review interview questions
and interpret the ndings.
Thank you to all the nurses, managers, peers, and advocates
who participated in the study and the policy forums in
Vancouver and Victoria.
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practice. Canadian Nurse, 2009. 105(4): p. 16-22.
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Zealand experience. International Journal of Qualiative Health
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5. Browne, A.J., et al., Cultural safety and the challenges of
translating critically oriented knowledge in practice. Nursing
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on Canadian Drug Policy. 2013, Simon Fraser University:
Vancouver, BC.
8. Pauly, B.M., Close to the street: Nursing practice with
people marginalized by homelessness and substance use.
Homelessness and Health in Canada, ed. S. Hwang and M.
Younger. in press.
9. Browne, A.J., et al., Access to primary care from the perspective
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... When nurses took time to get to know them and understand their concerns, they felt welcome and less judged. 27 While patients felt under surveillance, nurses refuted seeing their patients as criminals and saw the criminal justice systems approach to people who use illicit drugs as the real problem. 26 ...
... Following the forum, these recommendations were further refined with the assistance of a local drug user group, the Society of Living Illicit Drug Users and a research bulletin was created. 27 Among the recommendations that we developed were that culturally safe care needs to foster the engagement and participation of people who have experience of substance use and marginalization in the delivery of care. Care givers need to recognize that people's health, health care, priorities and experiences are influenced by history and policies that criminalize drug use. ...
... plant a seed of safety . . .". 27 Specific attention to the elements of culturally safe care that are outlined in this paper holds promise for improving nursing practice in ways that can foster equity and social justice. ...
Full-text available
This paper reviews the concept of cultural safety from the perspective of people who use illicit drugs and nurses in a hospital setting. Background Illicit drug use is often highly stigmatized and people who use illicit drugs often report negative healthcare experiences contributing to inequities in health and access to healthcare. Registered nurses play a key role in the delivery of healthcare when people who use drugs are hospitalized but often face difficulties in the provision of care. We explored understandings and meanings of cultural safety in healthcare as an approach to mitigate stigma and to promote health equity.
... Culturally safe relational practice can be achieved "by taking the lead of the family" (Doane & Varcoe, 2005, p. 312) which informs the nurse of the meaning, significance and importance of issues. Pauly et al. (2013) has highlighted is that the PHNs had (largely unconsciously) applied a cultural safety lens to this and other processes used in their everyday practice, and repositioned their role in the interview. In this way, they were able to move from a purely nurse-led interview process to a collaborative, family-centred approach. ...
... Both groups were involved in planning a final policy forum and developing recommendations from the findings. 37 Data collection consisted of in-depth interviews with a purposive sample of nurses ADVANCES IN NURSING SCIENCE/APRIL-JUNE 2015 and patients, participant observation, and reviewing hospital policy documents. In total, we interviewed 34 people, including 15 patients (8 men, 6 women, and 1 person who identified as transgendered) and 19 nurses (12 front-line staff nurses and 7 nurse managers and educators). ...
Full-text available
As a group, people who use illicit drugs and are affected by social disadvantages often experience health inequities and encounter barriers such as stigma and discrimination when accessing health care services. Cultural safety has been proposed as one approach to address health inequities and mitigate stigma in health care. Drawing on a qualitative ethnographic approach within an overarching collaborative framework, we sought to gain an understanding of what constitutes culturally safe care for people who use(d) illicit drugs. The findings illustrate that illicit substance use in hospitals is often negatively constructed as (1) an individual failing, (2) a criminal activity, and (3) a disease of "addiction" with negative impacts on access to care, management of pain, and provision of harm-reduction supplies and services. These constructions of illicit substance use impact patients' feelings of safety in hospital and nurses' capacity to provide culturally safe care. On the basis of these findings, we provide recommendations and guidance for the development of culturally safe nursing practice.
... Some knowledge brokers also appreciate opportunities to co-author presentations and research papers as well as ongoing education opportunities that enhance their complex combination of networking, research, policy and practice skills. In a research project with SOLID on addressing problems of stigma and drug use in hospitals (Pauly et al., 2013), Pauly engaged SOLID's staff person to act as a knowledge broker, which greatly facilitated SOLID's role as an advisory group. A paper outlines the use of knowledge brokers in this context (Mollison et al., 2013). ...
Full-text available
Health inequities between groups result from the unequal distribution of economic and social resources, including power and prestige. Social processes where unequal power relationships exist lead to the social exclusion of individuals or groups. Social inclusion strategies are well suited to contribute to addressing health inequities. Community organizations can enhance marginalized community members’ inclusion in decision-making structures that affect their lives. In this paper, we discuss the role of community organizations in contributing to action on health inequities through social inclusion. We consider the social determinants of health and of inequities. We provide an overview of the impact of social exclusion on health inequities and on community capacity to address them. We explore the theoretical basis of addressing health inequities through social inclusion, both in collective action and in research strategies. We link theory to practice with examples from our experiences and describe the challenges of involving members of vulnerable populations. We conclude by offering suggestions as to how community organizations can foster social inclusion and some directions for future research.
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In this article, we discuss findings from an ethnographic study in which we explored experiences of access to primary care services from the perspective of Aboriginal people seeking care at an emergency department (ED) located in a large Canadian city. Data were collected over 20 months of immersion in the ED, and included participant observation and in-depth interviews with 44 patients triaged as stable and nonurgent, most of whom were living in poverty and residing in the inner city. Three themes in the findings are discussed: (a) anticipating providers' assumptions; (b) seeking help for chronic pain; and (c) use of the ED as a reflection of social suffering. Implications of these findings are discussed in relation to the role of the ED as well as the broader primary care sector in responding to the needs of patients affected by poverty, racialization, and other forms of disadvantage.
Full-text available
Cultural safety is a relatively new concept that has emerged in the New Zealand nursing context and is being taken up in various ways in Canadian health care discourses. Our research team has been exploring the relevance of cultural safety in the Canadian context, most recently in relation to a knowledge-translation study conducted with nurses practising in a large tertiary hospital. We were drawn to using cultural safety because we conceptualized it as being compatible with critical theoretical perspectives that foster a focus on power imbalances and inequitable social relationships in health care; the interrelated problems of culturalism and racialization; and a commitment to social justice as central to the social mandate of nursing. Engaging in this knowledge-translation study has provided new perspectives on the complexities, ambiguities and tensions that need to be considered when using the concept of cultural safety to draw attention to racialization, culturalism, and health and health care inequities. The philosophic analysis discussed in this paper represents an epistemological grounding for the concept of cultural safety that links directly to particular moral ends with social justice implications. Although cultural safety is a concept that we have firmly positioned within the paradigm of critical inquiry, ambiguities associated with the notions of 'culture', 'safety', and 'cultural safety' need to be anticipated and addressed if they are to be effectively used to draw attention to critical social justice issues in practice settings. Using cultural safety in practice settings to draw attention to and prompt critical reflection on politicized knowledge, therefore, brings an added layer of complexity. To address these complexities, we propose that what may be required to effectively use cultural safety in the knowledge-translation process is a 'social justice curriculum for practice' that would foster a philosophical stance of critical inquiry at both the individual and institutional levels.
Full-text available
Insite, a supervised injection facility in Vancouver, British Columbia, is an evidence-based response to the ongoing health and social crisis in the city's Downtown Eastside. It has been shown that Insite's services increase treatment referrals, mitigate the spread and impact of blood-borne diseases and prevent overdose deaths. One of the goals of this facility is to improve the health of those who use injection drugs. Nurses contribute to this goal by building trusting relationships with clients and delivering health services in a harm reduction setting. The authors describe nursing practice at Insite and its alignment with professional and ethical standards of registered nursing practice. Harm reduction is consistent with accepted standards for nursing practice as set out by the College of Registered Nurses of British Columbia and the Canadian Nurses Association and with World Health Organization guidelines.
Full-text available
The concept of cultural safety arose from the colonial context of New Zealand society. In response to the poor health status of Maori, the indigenous people of New Zealand, and their insistence that service delivery change profoundly, nursing has begun a process of self examination and change in nursing education, prompted by Maori nurses. Nursing and midwifery organizations moved to support this initiative as something which spoke truly of nursing and New Zealand society. Cultural safety became a requirement for nursing and midwifery courses in 1992. But its introduction into nursing education has been controversial. It became highly publicized in the national media, and the role and function of the Nursing Council of New Zealand was questioned. This paper discusses the New Zealand experience of introducing cultural safety into nursing education. Copyright © 1996 Elsevier Science Ltd.
A heavy load of symbolism surrounds psychoactive substance use, for reasons which are discussed. Psychoactive substances can be prestige commodities, but one or another aspect of their use seems to attract near--universal stigma and marginalization. Processes of stigmatization include intimate process of social control among family and friends; decisions by social and health agencies; and governmental policy decisions. What is negatively moralized commonly includes incurring health, casualty or social problems, derogated even by other heavy users; intoxication itself; addiction or dependence, and the loss of control such terms describe; and in some circumstances use per se. Two independent literatures on stigma operate on different premises: studies oriented to mental illness and disability consider the negative effects of stigma on the stigmatized, and how stigma may be neutralized, while studies of crime generally view stigma more benignly, as a form of social control. The alcohol and drug literature overlap both topical areas, and includes examples of both orientations. Whole poverty and heavy substance use are not necessary related, poverty often increases the harm for a given level of use. Marginalization and stigma commonly add to this effect. Those in treatment for alcohol or drug problems are frequently and disproportionately marginalized. Studies of social inequality and substance use problems need to pay attention also to processes of stigmatization and marginalization and their effect on adverse outcomes.
Harm reduction and currently illegal drugs: Implications for nursing policy, practice, education and research
Canadian Nurses Association, Harm reduction and currently illegal drugs: Implications for nursing policy, practice, education and research. 2011, Canadian Nurses Association: Ottawa.
Getting to tomorrow: A Report on Canadian Drug Policy
  • C Carter
  • D Macpherson
Carter, C. and D. MacPherson, Getting to tomorrow: A Report on Canadian Drug Policy. 2013, Simon Fraser University: Vancouver, BC.
Close to the street: Nursing practice with people marginalized by homelessness and substance use. Homelessness and Health in Canada
  • B M Pauly
Pauly, B.M., Close to the street: Nursing practice with people marginalized by homelessness and substance use. Homelessness and Health in Canada, ed. S. Hwang and M. Younger. in press.