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Critical Approaches to Harm Reduction: Conflict, Institutionalization, (De-)Politicization, and Direct Action

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This book is divided into three sections. Entitled Critical Harm Reduction Policy: From Oppositional Social Movement to Institutionalized Public Health Policy, Part One encompasses a diverse array of issues relating to the cost/benefit analysis of harm reduction as measured in the terms of institutionalization and (de-)politicization. Part Two, Critical Harm Reduction Practice: Autonomy, Ideology, and Evidence-Based Interventions, consists of several concrete case studies concerning harm reduction practice in an array of (non-)traditional contexts. Comprised of a unique series of chapters that each interrogates a different issue relating to the philosophical underpinnings of harm reduction, Part Three is entitled Critical Harm Reduction Theory/Philosophy: Depoliticization, Direct Action, and Drug/Service Users’ Experiential Knowledge. Although the emphasis of each section and corresponding set of chapters is remarkably diverse, several themes remain prominent throughout this book, including an overtly critical analysis of the multiplicity of contextual deployments of harm reduction, a recurring focus on elevating the value of experiential knowledge and the fundamentally important, central role of people with direct lived experience. Additionally, the centrality of direct action tactics in the innovation of user-based forms of harm reduction in policy, practice, and philosophically-based contexts are discussed. (Imprint: Nova).
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PUBLIC HEALTH IN THE 21ST CENTURY
CRITICAL APPROACHES
TO HARM REDUCTION
CONFLICT, INSTITUTIONALIZATION,
(DE-)POLITICIZATION,
AND DIRECT ACTION
PUBLIC HEALTH IN THE 21ST CENTURY
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PUBLIC HEALTH IN THE 21ST CENTURY
CRITICAL APPROACHES
TO HARM REDUCTION
CONFLICT, INSTITUTIONALIZATION,
(DE-)POLITICIZATION,
AND DIRECT ACTION
CHRISTOPHER B.R. SMITH, PHD
AND
ZACK MARSHALL
EDITORS
New York
Copyright © 2016 by Nova Science Publishers, Inc.
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Library of Congress Cataloging-in-Publication Data
ISBN: 978-1-63484-878-7
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Published by Nova Science Publishers, Inc. † New York
CONTENTS
Introduction vii!
Part One: Critical Harm Reduction Policy: From Oppositional Social
Movement to Institutionalized Public Health Policy 1!
Chapter 1 Who Needs Naloxone? 3!
Nancy D. Campbell!
Chapter 2 Low Threshold Methadone Program: 13 Years of Experience
in Portugal 23!
Paulo Lopes, Hélder Trigo, Rodrigo Coutinho, Emília Leitão,
Nuno Miguel and Jorge Oliveira!
Chapter 3 Law Enforcement and Public Health: How North Carolina Became
a Leader in Harm Reduction Policy Change 41!
Lisa de Saxe Zerden, Corey S. Davis, Tessie Castillo,
Robert Childs and Leilani Attilo!
Part Two: Critical Harm Reduction Practice: Autonomy, Ideology,
and Evidence-Based Interventions 53!
Chapter 4 Power, Politics and the Production of Harm: A Critical Look at
the Intersecting, Yet Unequal, Roles of Scientific Evidence, Power,
and Politics in the Provision of Harm Reduction Services for People
Who Smoke Crack 55!
Lynne Leonard and Andrée Germain!
Chapter 5 Rethinking Harm Reduction and Pregnancy: A Study of Women’s
Expectations and Experiences of Specialist Maternity Care and
Opiate Substitution Treatment 73!
Fiona S. Martin!
Chapter 6 “And the World's Alright with Me”: Harm Reduction and Survival
at Blockorama 95!
Syrus Marcus Ware, Keisha Williams and Nik Redman
Contents
vi
Chapter 7 What’s Glitter Got to Do with It?: Re-Imagining Harm Reduction,
Youth Decision-Making, and the Politics of Youth Engagement 113!
Sarah Switzer, Tumaini Lyaruu, Kamilah Apong, Ocean Bell,
Lydia Hernandez, Proud Goddess McWhinney,
Carver Manuel-Smith, Fonna Seidu, Sarah Pariah and Andii Bykes!
Part Three: Critical Harm Reduction Philosophy: Depoliticization,
Direct Action, Drug/Service Users’ Experiential Knowledge 135!
Chapter 8 Everything About Them, Without Them: Sex Work and the Harms
of Misrecognition 137!
Laura Winters!
Chapter 9 Expanding the Mission of Harm Reduction: A Public Health
Population and Its Members’ Perspectives Towards Health 169!
Kelly Szott!
Chapter 10 Recognition, Exploitation, or Both?: Roundtable on Peer Labour
and Harm Reduction 185!
Liam Michaud, Robyn Maynard, Zoë Dodd and Nora Butler Burke!
Chapter 11 Harm Reduction Hipsters: Socio-Spatial-Political Displacement
and the Gentrification of Public Health 209!
Christopher B. R. Smith!
About the Editors 231
About the Contributors 233
Index 243!
INTRODUCTION
Not unlike most aspects of my relationship to academia, this book is the product of sheer
serendipity a happy accident, of sorts. Drawing from my cumulative research-based
exploits among harm reduction practitioners, activists, and people who use drugs in Australia,
Canada, and the U.S. (namely Melbourne, Toronto, Vancouver, New York, and
Philadelphia1), a few years ago I began composing a manuscript that would eventually come
to form the final chapter of this collection, entitled Harm Reduction Hipsters: Socio-Spatial-
Political Displacement and the “Gentrification of Public Health.”
Throughout the many different drafts, revisions, and iterations of this manuscript, I
received a number of strange and interesting comments, responses, and rejection letters,
owing in large part to what one journal editor described as the “highly polemical” nature of
the work. Almost without exception, friends and/or colleagues to whom I sent various
different versions of this manuscript responded with almost the exact same tone of grave
concern: “you don't think that I’m a ‘harm reduction hipster’ do you?” My standard response
was that I merely sought to gain critical feedback from my peers and critical/creative co-
conspirators, insisting that the arguments weren’t directed at anyone in particular. Some
individuals with whom I shared early, unpublished drafts of the work even went so far as to
concede their status as “harm reduction hipsters” in a tone of wariness intermingling with
defeat. As I implicitly suggest at several points throughout the chapter, however, this is
something that a 21st century hipster would rarelyif everactually do.
Overhearing my initial thoughts on the subject prior to even beginning to sketch out my
arguments in writing, at least one prominent Canadian harm reduction advocate and drug
policy reform activist interjected, insisting that the “mainstreaming” of harm reduction could
only ever be a good thing, irrespective of the (decidedly hipster) demographics of those
jumping on the bandwagon. My immediate counter to this assertion was that the
“mainstreaming” of harm reduction was not in and of itself an inherently “bad” thing. The
primary focus of my critique, as I went on to explain, was that popular acceptance of harm
reduction policy and practice often came at the expense of diluting, sanitizing, or negating the
fundamentally oppositional political origins of the harm reduction movement in North
America. This argument in many ways extended from an earlier article I published regarding
1 Starting in January 2010, I completed a two-year Postdoctoral Fellowship funded by the Social Science and
Humanities Research Council of Canada (SSHRC) at the breeding ground for privilege and elitism that I
affectionately came to refer to as the “Poison Ivy Leaguethat is, the University of Pennsylvania under the
supervision of internationally renowned medical anthropologist Dr. Philippe Bourgois.
Christopher B. R. Smith
viii
the “cost/benefit analysis of harm reduction as measured in terms of the close,
interdependent relationship between institutionalization and depoliticization (cf. Smith,
2012).
In response to my submission of a much earlier and less developed draft of this piece, one
of the top-ranked, international “addiction” journals decided “not to send it out for peer
review,” adding that the manuscript had been found “not suitable for publication.” “I must
confess that it is difficult to know what to recommend,” concluded a senior associate editor in
true (albeit aging) harm reduction hipster form.
After receiving numerous and some not so politerejection letters from various
“addiction” journals, I eventually became swept away by other projects, forcing me to
temporarily shelve this work. Several months later, however, in response to a Call for Papers I
received from Nova Science Publishers regarding an edited collection provisionally entitled
Harm Reduction: Principles, Perceptions, and Programs, I dusted off the manuscript, made a
few additional, last minute revisions, and submitted it for consideration in the proposed
collection. Upon receiving a pleasantly surprising and unexpectedly prompt notification of
acceptance, I then contacted Nova to inquire as to who was responsible for editing the book.
Even before receiving a response to this query, I received the page proofs for the chapter,
which I promptly added to the list of publications corresponding to my profile on the nerdy
academic social networking websites I have somewhat hesitantly, reluctantly come to
frequent. Shortly thereafter, I was informed by a Nova representative that the proposed book
for which my manuscript was accepted had not yet been assigned an editor. Given my
longstanding academic and professional research involvements, advocacy work, and activism
in the general field of harm reductionfrom Canada to Australia, to the U.S., and the U.K.
I therefore offered to serve as editor for this collection, and within less than a week I had
signed and returned the formal contract.
Particularly given the fact that everything really and truly did happen in reverse, I felt it
was imperative to carefully explain this order of events for fear of being perceived as an
opportunistic, flagrantly self-promoting academic, a tendency that has become all too
common in the age of the neoliberal, corporate university. To clarify in no uncertain terms,
therefore, my paper was accepted for publication before I took on the role of editor.
Having said that, ever since adding the title and abstract for this article to the publications
listed on my academic social networking profiles, Harm Reduction Hipsters has generated
significant international interest. According to the most recent statistics the abstract has been
viewed more than 320 times during a 10 month period by scholars from more than 44
separate countries, encompassing North and South America, Europe, Scandinavia, Australia,
East and South Asia, Africa, and the Middle East.
Coincidentally, the acceptance of this article and my contractual appointment as editor to
this collection took place simultaneous to the final stages of negotiation for the position I now
occupy as Assistant Professor in the School of Social Work at Memorial University of
Newfoundland (MUN), located in St. John’s, Newfoundland, the most eastern city in North
America. Shortly after relocating to Newfoundland, as I was preparing for my first teaching
term and beginning the slow process of acclimatizing not only to a new city, but also to the
culture and character of a new academic institution, I received an unexpected email from a
doctoral candidate in MUN’s Division of Community Health and Humanities (Faculty of
Medicine) who was familiar with some of my published work in the area of harm reduction.
Knowing next to no one in St. John’s, and eager to begin mapping out the harm reduction and
Introduction
ix
critical drug studies “scene” in Newfoundland and Atlantic Canada more generally, I wasted
no time arranging to meet in person the following week. Within the first ten minutes of our
initial meeting it became acutely apparent that this individual possessed an intimate
familiarity with the harm reduction research, policy, and practice landscape across Atlantic
Canada, and during our remaining time together we unknowingly planted the seeds of what
would become both an invaluable, ongoing friendship, and moreover, a highly
complementary collaborative relationship. Within the first hour of our first meeting, in other
words, I formally invited Ph.D. candidate and Canadian Institutes of Health Research (CIHR)
Fellow Zack Marshall to co-edit the book that you now hold in your hands. With a palpable
sense of excitement regarding this collaborative endeavor, our meeting concluded by setting a
date to sketch out the Call for Papers (CFP).
During our second meeting, Zack and I discussed our respective visions for the project,
composed a list of relevant themes and issues to include in the CFP, and established a title for
the book that reflected our mutual interests: Critical Approaches to Harm Reduction:
Conflict, Institutionalization, (De-)Politicization, and Direct Action.
Representing another instance of sheer serendipity, the composition and publication of
this incredibly diverse and highly political critical/creative collection of chapters happened to
coincide with a radically changing political climate concerning harm reduction in North
America. In Canada, for instance, we recently witnessed the dramatic implosion of almost ten
years of regressive drug policy measures under the Stephen Harper’s federal Conservative
party, while watching in disbelief as the U.S.birthplace of the now global “war on drug
users”—has arguably adopted increasingly progressive, harm reduction-based drug policy
measures under President Barak Obama.
Canada, by contrast, introduced harm reduction with the federal adoption of Canada’s
Drug Strategy in 1987. Within six months of taking office in 2006, however, Prime Minister
Stephen Harper attempted to effect a complete erasure of harm reduction by replacing
Canada’s Drug Strategy with the National Anti-Drug Strategy (2007), a document that
consciously omitted harm reduction from Canada’s national drug policy landscape. Clearly
signaling a regression to moral-criminological ideologies regarding substance use, not only
did Harper’s National Anti-Drug Strategy shift responsibilities for national drug policy from
Health Canada to the Department of Justice, but the federal Conservatives moreover
challenged the evidence-based success of Vancouver’s Insite, North America’s firstand, to
date, onlyformally sanctioned supervised injection facility (SIF) in both the British
Columbia provincial Supreme Court, and subsequently the Supreme Court of Canada, losing
on both occasions. During the same approximate time period, by contrast, the U.S. legalized
the recreational sale and use of marijuana, dramatically expanded overdose prevention efforts
by implementing widespread naloxone training programs (an initiative Canada is just
beginning to adopt on a large scale), and ushered in significant changes to the criminal code
relating to minor, non-violent drug offenses.
Canada’s recent federal election on Oct. 19th, 2015, however, put an end to nearly a
decade of repressive Conservative rule. The federal Liberal Party’s majority win under the
leadership of Prime Minister Justin Trudeau, moreover, provided cause for cautious optimism
among harm reduction activists and advocates in Canada owing to the Party’s pro-harm
reduction, evidence-based stance on drug policy, and overt campaign promise to legalize
marijuana. The significantyet often misunderstooddistinction between notions of
decriminalization and legalization notwithstanding, the potentially significant changes
Christopher B. R. Smith
regarding harm reduction and drug policy in Canada under Trudeau’s Liberal Party are
clearly illustrated by the Liberal’s response to a questionnaire distributed to all major political
parties prior to the election by the Canadian Drug Policy Coalition (CDPC). Founded in
2009, and composed of an “independent civil society network of organizations and
individuals working to improve Canada’s drug policies” (CDPC, 2011), approximately six-
weeks prior to the Federal election, the CDPC invited all the major political parties in Canada
to complete a questionnaire regarding their opinions on the rapidly shifting state of drug
policy in Canada and beyond (CDPC, 2015a).
Perhaps unsurprisingly, the Conservatives were the only political party who neglected to
respond to the CDPC’s questionnaire. Among the remaining parties, however, in spite of
subtle differences between their respective approaches, all agreed in no uncertain terms that
“harm reduction need[ed] to return as a key pillar in Canada’s national drug strategy” (CDPC,
2015a).
The Liberal government’s priority, as the Party’s formal response begins, will be rooted
in “evidence-based policies that reduce harm and protect public safety,” including the
proliferation of supervised drug consumption sites, which were explicitly framed as “an
integral party of a broader, evidence-based national drug policy that promotes public health
and […] decrease the risk of death and disease” (CDPC, 2015b). In response to a question
concerning the expedition of overdose prevention efforts, the Liberals articulated their
support for Health Canada to “examine the risks and benefits of amending the Controlled
Drugs and Substances Act to allow for Good Samaritan legislation,” thus following the
precedent set by the U.S.
As editors, therefore, the specific focus and tone we attempted to cultivate for this book
was in large part informed by the broad political backdrop that has served to inform harm
reduction policy, practice, and theory/philosophy both throughout North America and on the
global stage in recent years, as encapsulated in the title we have adopted for this work,
Critical Approaches to Harm Reduction: Conflict, Institutionalization, (De-)Politicization,
and Direct Action. Consequentially, the themes that make up the various chapters we have
curated for this collection directly reflect many of the debates, controversies, and issues that
have emerged in response to the ever more contested and dizzying political landscape
surrounding the diverse multiplicity of policies, programs, and interventions that comprise the
increasingly fluid and amorphous concept of “harm reduction.” The similarly diverse series of
in(ter)dependent chapters that comprise this book are therefore organized into three separate
and distinctalthough inherently inter-relatedsections, each corresponding to the broad,
overlapping areas of harm reduction policy, practice, and philosophy.
The first section of the book, for exampleCritical Harm Reduction Policy: From
Oppositional Social Movement to Institutionalized Public Health Policyexplicitly takes up
questions relating to what I have elsewhere described as the cost/benefit analysis of harm
reduction as measured in the terms of institutionalization vs. depoliticization (Smith, 2012).
All loosely related to issues rooted in the notion of harm reduction as institutionalized public
health policy, Part One therefore opens with an historical analysis by Nancy Campbell
explicitly focused on the relationship between the origins of harm reduction in North America
as a grassroots, bottom-up, oppositional social movement, and its contemporary manifestation
as institutionalized, apolitical public health policy, as analyzed through the historical lens of
overdose prevention efforts in the U.S. Building on this theme, the second chapter by Lisa de
Saxe Zerden et al. examine a specific case study of progressive harm reduction policy change
Introduction
xi
in North Carolina concerning the proliferation of naloxone distribution programs and the
corresponding enactment of “Good Samaritan” legislation in an active effort to help combat
the epidemic rise of accidental opioid overdose deaths in a region that has historically been
highly resistant to the adoption of such pragmatic harm reduction oriented interventions. The
first section of the book then closes with a chapter from Lopes et al. that examines the long-
term success of a low-threshold methadone treatment program targeting street-based opioid
dependent individuals that was implemented in Lisbon, Portugal more than 13 years ago.
Entitled Critical Harm Reduction Practice: Autonomy, Ideology, and Evidence-Based
Interventions, the second section of the book consists of a series of highly diverse case studies
and critical analyses of harm reduction practice in a number of different non/traditional
contexts. Authored by Lynne Leonard and Andree Germain, the first chapter of this section
interrogates how power and politics served to exacerbate the production of harm in the
specific case of safer crack use harm reduction initiatives in Canada’s capital, Ottawa. Taking
up the issues of specialist maternity care and pharmacotherapies such as methadone and/or
buprenorphine substitution treatment among pregnant women in Australia, the second chapter
of the second section of the book, entitled Rethinking Women and Pregnancy, was written by
Fiona S. Martin. In the third chapter of part two Ware, Williams and Redman examine critical
harm reduction practice in the highly unique context of longstanding events organized by the
Blackness Yes! Collective that take place simultaneous toyet intentionally outside ofthe
mainstream Pride celebration in Toronto, specifically intended for black queer and trans
communities. Concluding the second section on Critical Harm Reduction Practice is a
chapter devoted to an analysis of how young people have been actively involved in harm
reduction, HIV, and/or sexual health-related programming and service delivery in Toronto.
Mobilizing ‘glitter’ as a critical metaphor, Switzer et al.’s chapter is the product of direct
collaboration with a number of youth harm reduction works and/or peer educators,
representing an exemplary instance of the founding spirit of user-centred and user-driven
harm reduction practice.
The third and final section of the bookCritical Harm Reduction Philosophy:
Depoliticization, Direct Action, and Drug/Service Users’ Experiential Knowledgeis
comprised of a similarly diverse, unique, and politically-engaged series of chapters, each of
which takes up a different issue relating to the underlying theory or philosophy of harm
reduction. Each of the four chapters that compose this section of the book thus consciously
interrogate various issues, topics or themes that are often overlooked, neglected, ignored or
silenced in the context of contemporary, institutionalized, “mainstream” harm reduction
policy and practice. Opening this section, Laura Winters’ chapter entitled Everything About
Them, Without Them: Sex Work and the Harms of Misrecognition, critically explores the
application of harm reduction theory and/or philosophy in relation to sex work and workers in
St. John’s, Newfoundland. Asserting that the most significant harms endured by those
involved in sex work have little, if anything, to do with the nature of the work itself, Winters
suggests that these harms are in fact produced and perpetuated by the larger social, political
and legal forces responsible for further marginalizing and relegating sex work, sex workers,
and their clients to the socio-spatial margins of the contemporary capitalist cityscape.
Following Winter’s chapter, Kelly Szott critically investigates the various means through
which U.S.-based populations of injection drug users (IDU) have been governed and
regulated as a typology of “deviance” and “risk.” A collaborative undertaking involving four
people with direct lived experience working in peer-based harm reduction capacities, the
Christopher B. R. Smith
xii
second chapter of part three, Recognition, Exploitation, or Both?: A Roundtable on Peer
Labour and Harm Reduction, adopted a roundtable discussion format, involving two
individuals from the Toronto harm reduction scene, and two from Montreal. Here, the authors
debate the various context-specific definitions of the term “peer,” suggesting that the dramatic
rise in “peer”-based programming has in part been inspired by increasing recognition of
public health authorities concerning the fundamental value and importance of drug/service
users’ lived experience. Concluding both the third section and the book on the whole, the
final chapter included in this collection was discussed at length in the opening paragraphs of
this preface: Harm Reduction Hipsters: Socio-Spatial-Political Displacement and the
“Gentrification of Public Health.”
While the specific focus of each section and corresponding chapter contained in this
collection is remarkably diverse, one theme remains prominent throughout; namely, an
explicitly critical analysis of the multiplicity of contextual deployments of harm reduction.
Another theme common to almost all articles in this book directly relates to the fundamentally
important, central role of people who use drugs (PUD) and/or people with direct lived
experience of substance use. Throughout the preceding pages, I have addressed not only some
of the more recent instances of conflict and contestation surrounding harm reduction in North
America, but also the intimate, inherently entangled notions of institutionalization and its
relationship to depoliticization. I therefore conclude this preface by addressing an issue
contained in both the title of the book, and its third section: direct action. By titling this book
Critical Approaches to Harm Reduction, we explicitly intended to convey the fact that in
reality, institutionally-based harm reduction interventions often constitute little more than
thinly disguised efforts to monitor and regulate not only the perceived ‘disorder of drugs,’ but
also the bodies and behaviors of people who use drugs, who are all too often perceived and
positioned as agents of (moral) contagion and (socio-spatial) infection (Fischer et al., 2004;
McLean, 2011; Roe, 2005; Smith, 2010, 2012). Here it is worth noting, however, that in the
original founding philosophy of harm reduction, people who use drugs were overtly situated
and understood as the central driving force behind the movement, an aspect of the founding
philosophy of harm reduction that has become obscured or eclipsed during its
institutionalization as (apolitical) public health policy. The undeniable truth, however, is that
almost without exception, interventions that fall under the guise of harm reduction were not
dreamed up by the white-collar bureaucrats who dictate public health policy, but by the
‘unsanctioned,’ underground, and explicitly direct action-based tactics of people who use
drugs and their allies (Kerr et al., 2006; McNeil et al., 2013, 2015; Smith, 2012; Wood et al.,
2003; Zinn, 1999). I therefore close with an excerpt from a publication entitled Manifesto for
a Drug User Liberation Movement by the Vancouver Area Network of Drug Users
(VANDU), arguably the most accomplished and militant autonomous user-based organization
in North America. “At this point in history the question of how drug users are organized and
represented in this liberation movement is decisive,” VANDU’s (2010) manifesto asserts:
This is a challenge to academics, policy experts and service providers: we do not
want to be used as cheap labour, we do not want to be studied while we die, or be turned
into clients while resources are given to ‘service’ agencies. We will not tolerate actions
that exploit the labour, activist work, or experiences of people who use drugs. Finally, we
expect responsible researchers, experts and academics to support us (p.2-3).
Introduction
xiii
As the editors of this highly diverse and inherently critical book, therefore, it is our hope
that the chapters that follow represent the first seeds towards reconceptualizing a truly
meaningful, supportive, direct, and active engagement with people who use drugs, who
represent the central driving force behind repoliticizing harm reduction in Canada and
beyond.
REFERENCES
Canadian Drug Policy Coalition (CDPC) (2011). We are working to transform our approach
to alcohol, tobacco, and other drugs. Vancouver: CDPC. Retrieved from
http://drugpolicy.ca/about/.
Canadian Drug Policy Coalition (CDPC) (2015a). The political parties response to our drug
policy questionnaire. Vancouver: CDPC. Retrieved from http://drugpolicy.ca/
2015/10/questionnaire/.
Canadian Drug Policy Coalition (CDPC) (2015b) Liberal Party of Canada Response.
Vancouver: CDPC. Retrieved from http://drugpolicy.ca/wp-content/uploads/2015/
10/LPC-Response-Election-2015.pdf.
Fischer, B., Turnbull, S., Poland, B. & Hayden, E. (2004). Drug use, risk and urban order:
examining supervised injection sites (SIS) as “governmentality.International Journal of
Drug Policy, 15, 357-365.
Kerr, T., Small, W., Peeace, W. Douglas, D., Pierce, A., & Wood, E. (2006). Harm reduction
by a “user-run” organization: A case study of the Vancouver Area Network of Drug
Users (VANDU). International Journal of Drug Policy, 17, 61-69.
McLean, K. (2011) The biopolitics of needle exchange in the United States. Critical Public
Health, 21(1), 71-79.
McNeil, R., Small, W., Lampkin, H., Shannon, K., & Kerr, T. (2013). “People knew they
could come here to get help”: An ethnographic study of assisted injection practices at a
peer-run “unsanctionedsupervised drug consumption room in a Canadian setting. AIDS
Behaviour, 18(3), 473-485. DOI 10.1007/s10461-013-0540-y.
McNeil, R., Kerr, T., Lampkin, H., & Small, W. (2015). “We need somewhere to smoke
crack”: An ethnographic study of an unsanctioned safer smoking room in Vancouver,
Canada. International Journal of Drug Policy, 26, 645-652. http://dx.doi.org/
10.1016/j.drugpo.2015.01.015.
Smith, C.B.R. (2012). Harm reduction as anarchist practice: A users’ guide to capitalism and
addiction in North America. Critical Public Health, 22(2), 211.
Smith, C.B.R. (2010). Socio-spatial stigmatization and the contested space of addiction
treatment: Remapping strategies of opposition to the disorder of drugs. Social Science
and Medicine, 70(6), 859-866.
Wood, E., Kerr, T., Spittal, P.M., Small, W., Tyndall, M.W., O’Shaughnessy, M.V., &
Schechter, M.T. (2003). An external evaluation of a peer-run “unsanctioned” syringe
exchange program. Journal of Urban Health: Bulletin of the New York Academy of
Medicine, 80(3), 455-464.
Christopher B. R. Smith
xiv
Vancouver Area Network of Drug Users (VANDU) (2010). VANDU Manifesto for a Drug
User Liberation Movement. Vancouver: VANDU. Retrieved from www.vandu.org/
documents/VANDU-manifesto-july-2010.doc.
Zinn, C. (1999). Nuns to run first heroin injecting room. British Medical Journal, 319, 400.
C. B. R. Smith, December 2015, St. John’s, Newfoundland, Canada.
ABOUT THE EDITORS
Christopher B.R. Smith, PhD
Memorial University of Newfoundland (MUN)
P.O. Box 4200 230 Prince Philip Drive
St. John's, NL, Canada, A1B 3P7
csmith13@mun.ca
Zack Marshall
Memorial University of Newfoundland (MUN)
P.O. Box 4200 230 Prince Philip Drive
St. John's, NL, Canada, A1B 3P7
marshall.zack@gmail.com
Editors
Christopher Smith
School of Social Work
Memorial University
St. John’s, Newfoundland and Labrador, Canada
Zack Marshall
Division of Community Health and Humanities
Memorial University
St. John's, Newfoundland and Labrador, Canada
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Table of Contents:
Introduction
Part One: Critical Harm Reduction Policy: From Oppositional Social Movement to
Institutionalized Public Health Policy
Chapter 1. Who Needs Naloxone?
(Nancy D. Campbell, School of Humanities, Arts, and Social Sciences, Rensselaer
Polytechnic Institute, New York, USA)
Chapter 2. Low Threshold Methadone Program: 13 Years of Experience in Portugal
(Paulo Lopes, Hélder Trigo, Rodrigo Coutinho, Emília Leitão, Nuno Miguel and Jorge
Oliveira, Ares do Pinhal – Low Threshold Methadone Program, Lisbon, Portugal)
Chapter 3. Law Enforcement and Public Health: How North Carolina Became a Leader in
Harm Reduction Policy Change
(Lisa de Saxe Zerden, Corey S. Davis, Tessie Castillo, Robert Childs, and Leilani Attilo,
University of North Carolina Chapel Hill School of Social Work, Chapel Hill, North
Carolina, USA)
Part Two: Critical Harm Reduction Practice: Autonomy, Ideology, and Evidence-Based
Interventions
Chapter 4. Power, Politics and the Production of Harm: A Critical Look at the Intersecting,
Yet Unequal, Roles of Scientific Evidence, Power, and Politics in the Provision of Harm
Reduction Services for People Who Smoke Crack
(Lynne Leonard, and Andrée Germain, HIV and HCV Prevention Research Team, School of
Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa,
Ontario, Canada)
Chapter 5. Rethinking Harm Reduction and Pregnancy: A Study of Women’s Expectations
and Experiences of Specialist Maternity Care and Opiate Substitution Treatment
(Fiona S. Martin, Department of Sociology and Social Anthropology, Dalhousie University,
Nova Scotia, Canada)
Chapter 6. And the World's Alright with Me”: Harm Reduction and Survival at Blockorama
(Syrus Marcus Ware, Keisha Williams and Nik Redman, Blackness Yes!/Blockorama,
Faculty of Environmental Studies, York University, Toronto, Ontario, Canada)
Chapter 7. What’s Glitter Got to Do with It?: Re-Imagining Harm Reduction, Youth
Decision-Making, and the Politics of Youth Engagement
(Sarah Switzer, Tumaini Lyaruu, Kamilah Apong, Ocean Bell, Lydia Hernandez, Proud
Goddess McWhinney, Carver Manual-Smith, Fonna Seidu, Sarah Pariah and Andii Bykes,
Faculty of Environmental Studies, York University, Toronto, Ontario, Canada)
Book Description:
This book is divided into three sections. Entitled Critical Harm Reduction
Policy: From Oppositional Social Movement to Institutionalized Public
Health Policy, Part One encompasses a diverse array of issues relating to
the cost/benefit analysis of harm reduction as measured in the terms of
institutionalization and (de-)politicization. Part Two, Critical Harm
Reduction Practice: Autonomy, Ideology, and Evidence-Based
Interventions, consists of several concrete case studies concerning harm
reduction practice in an array of (non-)traditional contexts. Comprised of a
unique series of chapters that each interrogates a different issue relating to
the philosophical underpinnings of harm reduction, Part Three is entitled
Critical Harm Reduction Theory/Philosophy: Depoliticization, Direct
Action, and Drug/Service Users’ Experiential Knowledge. Although the
emphasis of each section and corresponding set of chapters is remarkably
diverse, several themes remain prominent throughout this book, including
an overtly critical analysis of the multiplicity of contextual deployments of
harm reduction, a recurring focus on elevating the value of experiential
knowledge and the fundamentally important, central role of people with
direct lived experience. Additionally, the centrality of direct action tactics in
the innovation of user-based forms of harm reduction in policy, practice,
and philosophically-based contexts are discussed.
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Chapter
Full-text available
Fatalities from accidental drug overdose are endemic across the country and have risen to epidemic levels. To curb this epidemic, several states including North Carolina have recently adopted new laws or practices to help reduce the rates of accidental overdose. This chapter focuses on the development and implementation of two harm reduction laws that passed in the 2013 legislative session in North Carolina, a Southern state with a political and social climate traditionally resistant to harm reduction pragmatism. Analysis is offered as to how these laws were successfully championed by harm reduction advocates, Republican sponsors, and with the support of law enforcement associations. Additionally, preliminary data on a study to train law enforcement officers on these new policies is presented. North Carolina’s ability to pass and promote these two laws serves as a guide for how other jurisdictions can be successful in promoting pragmatic policies despite steep opposition to traditional harm reduction principles.
Article
Full-text available
In spite of its origins as an illegal, clandestine, grassroots activity that took place either outside or in defiant opposition to state and legal authority, there is growing evidence to suggest that harm reduction in North America has become sanitized and depoliticized in its institutionalization as public health policy. Harm reduction remains the most contested and controversial aspect of drug policy on both sides of the Canada–US border, yet the institutionalization of harm reduction in each national context demonstrates a series of stark contrasts. Drawing from regional case study examples in Canada and the US, this article historically traces and politically re-maps the uneasy relationship between the autonomous political origins of harm reduction, contemporary public health policy, and the adoption of the biomedical model for addiction research and treatment in North America. Situated within a broader theoretical interrogation of the etiology of addiction, this study culminates in a politically engaged critique of traditional addiction research and drug/service user autonomy. Arguing that the founding philosophy and spirit of the harm reduction movement represents a fundamentally anarchist-inspired form of practice, this article concludes by considering tactics for reclaiming and re-politicizing the future of harm reduction in North America.
Article
Full-text available
This paper problematises the emergence and functioning of the recent phenomenon of ‘supervised injection sites’ (SISs) as a case study of post-welfarist governmentality. We propose that SISs arose as an unprecedented intervention in the late 20th century to deal with the increasing challenge of ‘urban drug scenes’ towards public order interests ‘entrepreneurial city’. Under predominant discourses of ‘public health’ and ‘harm reduction’, SISs became possible within a wide variety of political interests as a technology for purifying public spaces of ‘disorderly’ drug users to present the ‘new city’ as an attractive consumption space. Thus, SISs can be meaningfully understood as one element of socio-spatial ‘exclusion’ of marginalised populations from urban cores to ghettoised, peripheral spaces, even as they more benignly seek to better meet the unique needs of drug user populations. Further, the inner workings of SISs illustrate these facilities as powerful surveillance and discipline sites, defining the drug user as an agent of omnipresent risk being responsibilized in the care of the self and body, but also multiple aspects of behaviour and lifestyle reaching beyond drug use; thus construing the drug user as a ‘normalised’ citizen/consumer. We suggest that pressures to answer to powerful interests promoting ‘order’ are concretised as practices of ‘risk management’ ‘on the shop floor’, raising serious questions about the extent to which the ability to meet user needs is compromised in the interest of social control, surveillance, ‘management’, ‘education’, and ‘rehabilitation’, particularly in the current socio-political context (characterised as it is by a persistence, and indeed concomitant hardening, of repressive measures ‘on the street’).
Article
Full-text available
Needle exchange began in the United States as a fragmented and illegal practice initiated by actors at the grassroots level; since the late 1980s, needle exchange has achieved increasing yet variable levels of institutional support across the country, receiving official sanction and funding from state and municipal governments. In turn, the practice(s) and discourse(s) of needle exchange have shifted significantly in many locales, becoming the purview of professional administration that advocates needle exchange as a necessary public health measure. This article is interested in the ways in which needle exchange has become implicated in and appropriated by networks of power seeking to discipline and regulate injection drug use. Drawing theoretically on Michel Foucault's writings concerning biopower and governmentality, it will examine the proliferation of discourses, knowledges, and rules surrounding needle exchange in the United States. At the same time, this article will avoid a characterization of needle exchange that envisions the unilateral control of drug users by governmental power, illuminating instead both its negative and productive effects for drug users. Namely, it will explore how needle exchange creates both subjects of interest and subjects of resistance among drug users - that is to say, the governmentalization of needle exchange and its 'clients'.
Article
Full-text available
In recent years, the Not-In-My-Back-Yard (NIMBY) phenomenon has become increasingly prevalent with regard to harm reduction sites, addiction treatment facilities and their clients. Drawing from a case study of community conflict generated by the relocation of a methadone clinic into a rapidly gentrifying neighbourhood in downtown Toronto, Canada, this article offers a unique analysis of oppositional strategies regarding the perceived (socio-spatial) 'disorder of drugs'. Based on interviews with local residents and business owners this article suggests the existence of three interrelated oppositional strategies, shifting from a recourse to urban planning policy, to a critique of methadone maintenance treatment (MMT) practice, to explicit forms of socio-spatial stigmatization that posited the body of the (methadone) 'addict' as abject agent of infection and the clinic as a site of contagion. Exploring the dialectical, socio-spatial interplay between the body of the addict and the social body of the city, this article demonstrates the unique aspects of opposition to the physically, ideologically and discursively contested space of addiction treatment. Representations of the methadone clinic, its clients and the larger space of the neighbourhood, this paper suggests, served to situate addiction as a 'pathology (out) of place' and recast the city itself as a site of safe/supervised consumption.
Chapter
The Portuguese capital, Lisbon, is part of a metropolitan area consisting of troubled urban and suburban neighbourhoods. This area has characteristics which intensify and perpetuate the phenomenon of drug addiction, leading to a high number of drug addicts. The personal and social disturbances experienced by these individuals result in a lack of motivation and/or ability to seek treatment, creating street addicts, most of whom are opiate-dependent (polydrug users or otherwise). Successfully reaching this population entails the use of proximity strategies, including an ambulatory medical and psychosocial program with methadone administration in a low threshold program (LTMP-Lx). This report describes the key characteristics of this program, including how the program: (a) supports opiate users (including polydrug users) of legal age, with no social or familial supports; (b) contributes to the diagnosis and improvement of health and social conditions, and reduction in heroin use; (c) facilitates increased contact between this population and health and LTMP-Lx professionals; (d) enhances knowledge about infectious and other diseases; (e) contributes to harm reduction in drug use and sexual practices, and; (f) promotes referrals to other health, social services, and treatment facilities. Method: LTMP-Lx supports approximately 1250 users daily. Taking into account the most recent scientific studies, we will describe in this chapter the main tools and procedures used in LTMP-Lx.Results: We will outline the results regarding: a) demographic characterization (gender, age and housing situation), toxicological history and previous treatments, risk behaviors in drug use, sexual habits and legal situation; b) impact in respect of personal health (HIV, HCV, HBV, tuberculosis and syphilis); and c) impact with regard to public health. Conclusion: Preliminary results reveal that users of LTMP-Lx: i) were mainly male, 39 years old on average, and had several years’ history of illegal drug use, such as heroin and cocaine; around half of them used intravenous injections and showed risk behaviors in drug use and sexual habits before being admitted to LTMP-Lx, and there were a significant number of homeless users who had never gone through any kind of treatment; ii) regarding HIV, the majority did not know their serological status when admitted to the program, and of the few who did, almost half showed a positive result. Almost all users were submitted to medical tracking, after which it transpired that approximately 25% showed positive serology results. With regard to tuberculosis, only a few knew their situation when being admitted to LTMP-Lx, and medical tracking showed that there was a higher occurrence of the disease compared to the general population; the program has had a success rate close to 100% in its treatment with tuberculostatics administration in DOTS (Directly Observed Treatment Short course); iii) these data clearly demonstrate LTMP-Lx to be a fundamental support program to the marginalized population, with a considerable impact when it comes to personal and public health. Final results will be presented later in this chapter.
Article
The Downtown Eastside of Vancouver has experienced ongoing epidemics of HIV infection and illicit drug overdoses since the mid 1990s. In 1997, in response to the emerging health crisis among injection drug users (IDU) and government inaction, individuals gathered in Vancouver to form a drug user-run organization. This group eventually became known as the Vancouver Area Network of Drug Users (VANDU). Because of the growing interest in drug user organizations, this case study was conducted to document the genesis, structure, and activities of VANDU. In accordance with VANDU's philosophy of “user involvement and empowerment,” we employed a community-based case study methodology to achieve these aims. The findings demonstrate that through years of activism, advocacy, and public education, VANDU has repeatedly voiced the concerns of drugs users in public and political arenas. VANDU has also performed a critical public health function by providing care and support programmes that are responsive to immediate needs of their peers. This study indicates that greater efforts should be made to promote the formation of drug user organizations, and that health authorities and policy makers should explore novel methods for incorporating the activities of drug user organizations within existing public health, education, and policy making frameworks.
Article
People who require help injecting are disproportionately vulnerable to drug-related harm, including HIV transmission. North America's only sanctioned SIF operates in Vancouver, Canada under an exemption to federal drug laws, which imposes operating regulations prohibiting assisted injections. In response, the Vancouver Area Network of Drug Users (VANDU) launched a peer-run unsanctioned SIF in which trained peer volunteers provide assisted injections to increase the coverage of supervised injection services and minimize drug-related harm. We undertook qualitative interviews (n = 23) and ethnographic observation (50 h) to explore how this facility shaped assisted injection practices. Findings indicated that VANDU reshaped the social, structural, and spatial contexts of assisted injection practices in a manner that minimized HIV and other health risks, while allowing people who require help injecting to escape drug scene violence. Findings underscore the need for changes to regulatory frameworks governing SIFs to ensure that they accommodate people who require help injecting.
Article
Nuns who run one of Australia’s best known hospitals are to operate the country’s first legal and medically supervised heroin injecting room after a radical overhaul of the drug laws in New South Wales. The 18 month trial will be administered by the Sisters of Charity, who also run Sydney’s inner city St Vincent’s Hospital. An estimated 50000 visits a year by drug users are expected at the centre, which will be staffed by a medical supervisor, a registered nurse, and security staff. The controversial plan will include the provision of clean needles and syringes; users must supply their own drugs. They will be encouraged to seek counselling and treatment for their habit. Dr Tina Clifton, the chief executive of the Sisters of Charity Health Service, said that, although she was in “uncharted waters,” the scheme supports the sisters’ commitment to the preservation of life by moving drug taking from the streets and into a safe environment. “We’ve done a lot of work in trying to establish our position; we’ve reflected on our code of ethics and our traditional Catholic moral teachings,” she said. The room will also have a coffee bar, subsidised cafeteria, and perhaps even showers and clean clothes for those in desperate need, said Dr Alex Wodak, who heads St Vincent’s Hospital’s drug and alcohol programme. Dr Wodak, who has studied injecting rooms in the United States and Europe, said that the security guards were necessary to maintain order and stop drug dealers entering the premises, which will be open for seven hours a day, seven days a week in the Kings Cross red light district. The New South Wales state government’s decision to go ahead was welcomed by many in the medical field. Leading immunologist Professor Ron Penny called it one of the most outstanding advances in public health in the drugs debate for 20 years. He said that it would not just help to control the spread of HIV in injecting drug users: “The overall community will reap enormous rewards from, on one hand, preventing drug use, and, on the other, providing a socially just approach that gives more care and treatment, more attention and rehabilitation to drug users inside and outside jail.” The state premier, Bob Carr, has also announced that a caution instead of a penalty system would apply for those caught with small amounts of heroin, cocaine, cannabis, amphetamines, and ecstasy in a raft of changes that flowed from a drugs summit held last May. But the leader of the New South Wales opposition, Mrs Kerry Chikarovski, was strongly opposed to the trial. “I am still concerned about the message sent to children that injecting drugs can be seen as safe.”