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Canadian harm reduction policies: A comparative content analysis of provincial and territorial documents, 2000–2015
Abstract
Background:
Access to harm reduction interventions among substance users across Canada is highly variable, and largely within the policy jurisdiction of the provinces and territories. This study systematically described variation in policy frameworks guiding harm reduction services among Canadian provinces and territories as part of the first national multimethod case study of harm reduction policy.
Methods:
Systematic and purposive searches identified publicly-accessible policy texts guiding planning and organization of one or more of seven targeted harm reduction services: needle distribution, naloxone, supervised injection/consumption, low-threshold opioid substitution (or maintenance) treatment, buprenorphine/naloxone (suboxone), drug checking, and safer inhalation kits. A corpus of 101 documents written or commissioned by provincial/territorial governments or their regional health authorities from 2000 to 2015 were identified and verified for relevance by a National Reference Committee. Texts were content analyzed using an a priori governance framework assessing managerial roles and functions, structures, interventions endorsed, client characteristics, and environmental variables.
Results:
Nationally, few (12%) of the documents were written to expressly guide harm reduction services or resources as their primary named purpose; most documents included harm reduction as a component of broader addiction and/or mental health strategies (43%) or blood-borne pathogen strategies (43%). Most documents (72%) identified roles and responsibilities of health service providers, but fewer declared how services would be funded (56%), specified a policy timeline (38%), referenced supporting legislation (26%), or received endorsement from elected members of government (16%). Nonspecific references to 'harm reduction' appeared an average of 12.8 times per document-far more frequently than references to specific harm reduction interventions (needle distribution=4.6 times/document; supervised injection service=1.4 times/document). Low-threshold opioid substitution, safer inhalation kits, drug checking, and buprenorphine/naloxone were virtually unmentioned. Two cases (Quebec and BC) produced about half of all policy documents, while 6 cases - covering parts of Atlantic and Northern Canada - each produced three or fewer.
Conclusion:
Canada exhibited wide regional variation in policies guiding the planning and organization of Canadian harm reduction services, with some areas of the country producing few or no policies. Despite a wealth of effectiveness and health economic research demonstrating the value of specific harm reduction interventions, policies guiding Canada from 2000 to 2015 did not stake out harm reduction interventions as a distinct, legitimate health service domain.
... Historically, society has framed people who use drugs (or other substances) as having moral shortcomings [17][18][19], bad habits [20,21], or engaging in criminal activity [22,23]. These pervasive and stigmatizing typecasts contribute to a morality policy environment (characterized by conflicts over core values regarding what is part of the legitimate scope of service provision for people who use substances [20,[24][25][26][27][28]). There is also a lack of government spending on substance use programs and policy actions with some research identifying as much as a 3:1 imbalance in the ratio between disease burden from substance use, mental/neurological disorders, self-harm, and spending allocated to these conditions [29]. ...
... We had four hypotheses: (1) compared to the Manitoba sample, general public and policy influencers in Alberta would have a lower levels of support on all policy options due to their political conservatism; (2) support for substance use policy among policy influencers would decrease with increased intrusiveness according to the NCB Intervention Ladder [62]; (3) policies focused explicitly on harm reduction (e.g., implementing or increasing access to supervised consumption services, supportive housing, and needle exchange programs) would have less support because of stigma related to continued drug use and morality policy implementation [24,27] women, people with more education, and those politically leaning left would be more supportive of the harm reduction policies [47,63] ...
... The policy option of prohibiting exclusionary municipal zoning practices that prevent sterile needle exchange programs or supervised injection facilities received the least amount of support across samples (~ 30%). Despite Canada's reputation as a leader in harm reduction policy, this result was expected because of the core values that collide in Canadian policymaking about providing harm reduction services to people who use substances, referred to as morality policy [24,27,41]. This clash of values is particularly prominent in Alberta, which is considered the most politically conservative Canadian province [68]. ...
Background
Examining support for substance use policies, including those for harm reduction, among the general public and policy influencers is a fundamental step to map the current policy landscape and leverage policy opportunities. Yet, this is a knowledge gap in Canada. Our paper identifies the level of support for substance use policies in two provinces in Canada and describes how the level of support is associated with intrusiveness and sociodemographic variables.
Methods
Data came from the 2019 Chronic Disease Prevention Survey. The representative sample included members of the general public (Alberta n = 1648, Manitoba n = 1770) as well as policy influencers (Alberta n = 204, Manitoba n = 98). We measured the level of support for 22 public policies concerning substance use through a 4-point Likert-scale. The Nuffield Council on Bioethics Intervention Ladder framework was applied to assess intrusiveness. We used cumulative link models to run ordinal regressions for identification of explanatory sociodemographic variables.
Results
Overall, there was generally strong support for the policies assessed. The general public in Manitoba was significantly more supportive of policies than its Alberta counterpart. Some differences were found between provinces and samples. For certain substance use policies, there was stronger support among women than men and among those with higher education than those with less education.
Conclusions
The results highlight areas where efforts are needed to increase support from both policy influencers and general public for adoption, implementation, and scaling of substance use policies. Socio-demographic variables related to support for substance use policies may be useful in informing strategies such as knowledge mobilization to advance the policy landscape in Western Canada.
... These critiques support initiatives to re-center human rights in drug policy, and refocus harm reduction policy and practice towards addressing structural, rather than personal factors that contribute to harm at the population level ( Albert, 2012 ;Campbell & Shaw, 2008 ). However, calls to better integrate human rights and structural factors have not been reflected in Canadian harm reduction policy documentation, as demonstrated by the Canadian Harm Reduction Policy Project (CHARPP) ( Hyshka et al., 2017 ;Hyshka et al., 2019 ;Wild et al., 2017 ). ...
... The CHARPP multiple case study aimed to improve understanding of variation in harm reduction policy and policymaking across Canada and received ethics approval from the University of Alberta Research Ethics Board. The current study is a sub-analysis of the interview data collected as part of CHARPP ( Wild et al., 2017 ). Detailed methods for the qualitative interviews have been previously reported ( Hyshka et al., 2019 ) and are briefly summarized here. ...
... Our findings underscore that weak official policies governing harm reduction (as previously reported through CHARPP ( Hyshka et al., 2017 ;Wild et al., 2017 ) may partially explain why harm reduction strategies struggle to intervene on structural vulnerability. Participants in our study stressed that government policies are not reflective of the intended purpose of harm reduction in alleviating structural conditions for PWUD. ...
Background
Health risks associated with drug use are concentrated amongst structurally vulnerable people who use illegal drugs (PWUD). We described how Canadian policy actors view structural vulnerability in relation to harm reduction and policymaking for illegal drugs, and what solutions they suggest to reduce structural vulnerability for PWUD.
Methods
The Canadian Harm Reduction Policy Project is a mixed-method, multiple case study. The qualitative component included 73 semi-structured interviews conducted with harm reduction policy actors across Canada's 13 provinces and territories between November 2016 and December 2017. Interviews explored perspectives on harm reduction and illegal drug policies and the conditions that facilitate or constrain policy change. Our sub-analysis utilized a two-step inductive analytic process. First, we identified transcript segments that discussed structural vulnerability or analogous terms. Second, we conducted latent content analysis on the identified excerpts to generate main findings.
Results
The central role of structural vulnerability (including poverty, unstable/lack of housing, racialization) in driving harm for PWUD was acknowledged by participants in all provinces and territories. Criminalization, in particular, was seen as a major contributor to structural vulnerability by justifying formal and informal sanctions against drug use and, by extension, PWUD. Many participants expressed that their personal understanding of harm reduction included addressing the structural conditions facing PWUD, yet identified that formal government harm reduction policies focused solely on drug use rather than structural factors. Participants identified several potential policy solutions to intervene on structural vulnerability including decriminalization, safer supply, and enacting policies encompassing all health and social sectors.
Conclusions
Structural vulnerability is salient within Canadian policy actors’ discourses; however, formal government policies are seen as falling short of addressing the structural conditions of PWUD. Decriminalization and safer supply have the potential to mitigate immediate structural vulnerability of PWUD while policies evolve to advance social, economic, and cultural equity.
... In previous work, CHARPP analyzed harm reduction policies written by governments and health authorities. Two studies confirmed that policies were largely produced for rhetorical rather than instrumental purposes, as revealed in documents that avoided clear governance statements (e.g., timelines, funding arrangements, governmental endorsements, references to legislation), and failed to name or support specific harm reduction interventions or key international tenets of harm reduction (i.e., abstaining from substance use is not required to receive health services, stigma and discrimination are often faced by substance users, PWUD should be involved in policy making) [13,14]. A complementary CHARPP study interviewed governmental officials, health system leaders, and people with lived/living experience, confirming that Canadian policies offer weak instrumental support for harm reduction. ...
... Canada is widely recognized as an international leader in harm reduction, starting with early adoption of needle distribution programs in the late 1980s, and more recent implementation of North America's first supervised drug consumption program in Vancouver in 2003, and North America's first clinical trial of prescription heroin in 2005 [45,46]. However, previous CHARPP studies documented relatively weak, rhetorical public policy frameworks governing harm reduction services produced by provincial governments and health authorities [13][14][15]. Further research is needed to explain this disconnect between inadequate policy supports for harm reduction, despite broad support in the general population. ...
... Despite generally favorable opinions toward harm reduction across Canada, weak and rhetorical public policy frameworks currently govern harm reduction services [13,14]. The present study advances this area beyond past efforts to identify sociodemographic correlates of public views of these contentious services, such as political affiliation, education, or age. ...
We described public views toward harm reduction among Canadian adults and tested a social exposure model predicting support for these contentious services, drawing on theories in the morality policy, intergroup relations, addiction, and media communication literatures. A quota sample of 4645 adults (18+ years), randomly drawn from an online research panel and stratified to match age and sex distributions of adults within and across Canadian provinces, was recruited in June 2018. Participants completed survey items assessing support for harm reduction for people who use drugs (PWUD) and for seven harm reduction interventions. Additional items assessed exposure to media coverage on harm reduction, and scales assessing stigma toward PWUD (α = .72), personal familiarity with PWUD (α = .84), and disease model beliefs about addiction (α = .79). Most (64%) Canadians supported harm reduction (provincial estimates = 60% - 73%). Five of seven interventions received majority support, including: outreach (79%), naloxone (72%), drug checking (70%), needle distribution (60%) and supervised drug consumption (55%). Low-threshold opioid agonist treatment and safe inhalation interventions received less support (49% and 44%). Our social exposure model, adjusted for respondent sex, household income, political views, and education, exhibited good fit and accounted for 17% of variance in public support for harm reduction. Personal familiarity with PWUD and disease model beliefs about addiction were directly associated with support (βs = .07 and -0.10, respectively), and indirectly influenced public support via stigmatized attitudes toward PWUD (βs = 0.01 and -0.01, respectively). Strategies to increase support for harm reduction could problematize certain disease model beliefs (e.g., “There are only two possibilities for an alcoholic or drug addict–permanent abstinence or death”) and creating opportunities to reduce social distance between PWUD, the public, and policy makers.
... Canada-alongside the Netherlands, United Kingdom, and Australia-is recognized as an early pioneer of contemporary harm reduction, which developed in the 1980s in response to the HIV/AIDS epidemic amongst PWUD (Erickson, 1999;Riley, Pates, Monaghan, & O'Hare, 2012), and the country continues to be an important contributor to the approach's large and growing international evidence base (Hyshka, Strathdee, Wood, & Kerr, 2012;Kennedy, Karamouzian, & Kerr, 2017;Oviedo-Joekes et al., 2016). However, this reputation belies the fact that harm reduction has been implemented inconsistently across the country (Carter & MacPherson, 2012) and access to services and programs varies widely according to geography (Wild et al., 2017). This disparity reflects Canada's decentralized federal structure, as well as historically variable federal support for harm reduction. ...
... This left the provinces and territories as the main stewards of harm reduction. Although those jurisdictions had the power to articulate harm reduction policy and funding commitments irrespective of federal political opposition (Wild et al., 2017), efforts to expand services were modest at best during this period (Carter & MacPherson, 2012). Despite growing national concern over sharp increases in opioidrelated morbidity and mortality (Fischer, Gooch, Goldman, Kurdyak, & Rehm, 2014;Fischer, Rehm, & Tyndall, 2016), until the end of 2016, supervised consumption services and injectable opioid agonist treatment (i.e. ...
... We found that provincial/territorial harm reduction policy documents produced through 2015 were largely rhetorical and vague (Hyshka et al., 2017;Wild et al., 2017). Very few identified governance of harm reduction services as their primary named purpose (Wild et al., 2017). ...
Introduction
Canada is experiencing a new era of harm reduction policymaking and investment. While many provinces and territories are expanding access to these services, harm reduction policy and policymaking varies across the country. The present study, part of the Canadian Harm Reduction Policy Project (CHARPP), described policy actors’ views on formal harm reduction policies in Canada’s 13 provinces and territories.
Methods
As part of CHARPP’s mixed-method, multiple case study, we conducted qualitative interviews with 75 policy actors, including government officials, health system leaders, senior staff at community organizations, and advocates with self-identified lived experience of using drugs. Interviews were conducted in English or French, and recorded and transcribed verbatim. We used latent content analysis to inductively code the data and generate main findings. NVivo 11 was used to organize the transcripts.
Results
Participants expressed divergent views on formal provincial/territorial policies and their impact on availability of harm reduction programs and services. While some identified a need to develop new policies or improve existing ones, others resisted bureaucratization of harm reduction or felt the absence of formal policy was instead, advantageous. Instances where harm reduction was advanced outside of formal policymaking were also described.
Discussion
Previous CHARPP research documented wide variability in quantity and quality of formal harm reduction policies across Canada, and characterized official policy documents as serving largely rhetorical rather than instrumental functions. The present findings highlight diverse ways that actors used their discretion to navigate these weak policy contexts. Participants’ views and experiences sometimes referred to strengthening policy support, but institutionalization of harm reduction was also resisted or rejected. Results suggest that actors adopt a range of pragmatic strategies to advance harm reduction services in response to policy vacuums characteristic of morality policy domains, and challenge assumptions about the utility of formal policies for advancing harm reduction.
Keywords
Harm reductionPolicymakingCanadaOpioid crisisQualitative researchKey informant interviews
... This paper reports the results of a comprehensive search and comparative analysis of Canadian harm reduction policy documents. In a previous analysis, we used Lynn et al.'s [40] reduced form logic of governance to describe Canadian harm reduction policy texts in relation to the strength of their instrumental functions [41]. This included assessing the extent to which policies reference legislation, are endorsed by elected officials, indicate funding commitments and timelines, and assign responsibilities to specific actors. ...
... This included assessing the extent to which policies reference legislation, are endorsed by elected officials, indicate funding commitments and timelines, and assign responsibilities to specific actors. We found that historically, across provincial and territorial policy frameworks, few policies articulate specific managerial or structural components to guide comprehensive, accountable, and transparent governance of harm reduction services in Canada [41]. Although useful for evaluating features of governance in a specified policy domain, a weakness of Lynn et al.'s [40] logic of governance is that it does not refer to communicative functions of policy. ...
... Our systematic search strategy, comprehensive inclusion and exclusion parameters, and screening methods have been described in detail elsewhere [41] and are thus reviewed only briefly here. We employed an iterative search and screening process to generate a corpus of policy texts for the present analysis. ...
Background
In Canada, funding, administration, and delivery of health services—including those targeting people who use drugs—are primarily the responsibility of the provinces and territories. Access to harm reduction services varies across jurisdictions, possibly reflecting differences in provincial and territorial policy commitments. We examined the quality of current provincial and territorial harm reduction policies in Canada, relative to how well official documents reflect internationally recognized principles and attributes of a harm reduction approach. Methods
We employed an iterative search and screening process to generate a corpus of 54 provincial and territorial harm reduction policy documents that were current to the end of 2015. Documents were content-analyzed using a deductive coding framework comprised of 17 indicators that assessed the quality of policies relative to how well they described key population and program aspects of a harm reduction approach. ResultsOnly two jurisdictions had current provincial-level, stand-alone harm reduction policies; all other documents were focused on either substance use, addiction and/or mental health, or sexually transmitted and/or blood-borne infections. Policies rarely named specific harm reduction interventions and more frequently referred to generic harm reduction programs or services. Only one document met all 17 indicators. Very few documents acknowledged that stigma and discrimination are issues faced by people who use drugs, that not all substance use is problematic, or that people who use drugs are legitimate participants in policymaking. A minority of documents recognized that abstaining from substance use is not required to receive services. Just over a quarter addressed the risk of drug overdose, and even fewer acknowledged the need to apply harm reduction approaches to an array of drugs and modes of use. Conclusions
Current provincial and territorial policies offer few robust characterizations of harm reduction or go beyond rhetorical or generic support for the approach. By endorsing harm reduction in name, but not in substance, provincial and territorial policies may communicate to diverse stakeholders a general lack of support for key aspects of the approach, potentially challenging efforts to expand harm reduction services.
... Documents could be both analog and digital and the process of interpreting the text is done with aim to elicit meaning and gain empirical and theoretical understanding (Corbin & Strauss, 2008). It could be used as a standalone method when investigating specific forms of communication on a subject (Wild et al., 2017;Connell et al., 2001) and within interpretive paradigm (Bowen, 2009). Documents have different functions as pointed out by Bowen (2009). ...
SALAR, Sweden’s largest employer association, advises the public sector on how to build management rules and processes. How SALAR relates to work environment policy and routines regarding the handling of mistreatment at work is yet unexplored. This research looks into SALAR’s advice to public-sector management on how to handle mistreatment. The study’s goal is to identify policy recommendations for the development of public-sector policies. The empirical source for this study was the SALAR website. As a result, document analysis was chosen as the method. The concept of juridification has been used to describe how professional life has grown increasingly linked with legal thinking. It is utilized as a lens in this study to understand the advancement of workplace misconduct policy in Sweden’s public sector. According to the data, SALAR views workplace mistreatment as a transaction issue rather than a work environment issue. Furthermore, the policy provides an ambiguous definition of workplace mistreatment, strengthens an individual’s perspective on workplace mistreatment, and suggests bullying investigations as the only management. The conclusion is that SALAR’s recommendations have been clouded by the logic fallacy of the juridification process and dismiss workplace mistreatment as a work environment problem. The recommendations are insufficient for decision-makers to understand workplace mistreatment, thereby increasing the risk for employees exposed to mistreatment in Sweden’s public sector.
... For those at risk of harm or those experiencing a substance use disorder, a variety of evidence-based harm reduction and treatment interventions exist. However, Canada's substance use service systems are highly fragmented; often siloed from mainstream health and social care; out-of-step with current evidence; and do not effectively address underlying structural factors (poverty, racism, homelessness, and colonization) known to increase the risk of drug-related harm (National Treatment Strategy Working Group 2008;Wild et al. 2017;Hyshka et al. 2019). Reforming service systems to ensure that all people in Canada who require support are able to access effective, tailored substance use care in a timely manner is long overdue. ...
The International Guidelines on Human Rights and Drug Policy recommend that states commit to adopting a balanced, integrated, and human rights-based approach to drug policy through a set of foundational human rights principles, obligations arising from human rights standards, and obligations arising from the human rights of particular groups. In respect of the Guidelines and standing obligations under UN Treaties, Canada must adopt stronger and more specific commitments for a human rights-based, people-centered, and public health approach. This approach must commit to the decriminalization of people who use drugs and include the decriminalization of possession, purchase, and cultivation for personal consumption. In this report, we will first turn to the legal background of Canada's drug laws. Next, we will provide an overview of ongoing law reform proposals from civil society groups, various levels of government, the House of Commons, and the Senate. We end with a three-staged approach to reform and a series of targeted recommendationscr.
... Since 2016, while people who use drugs have continued to be criminalized in Canada,34,355 people have died from opioid-related overdoses-more than all major causes of accidental death combined (Fischer, 2023;Government of Canada, 2023). The inadequacy of a solely policing response opened the door for the introduction of low-cost public health responses centered on harm reduction Wild et al., 2017) 1 . Despite these innovations, in recent years, academic, public health, community activist groups, and even some branches of law enforcement (Canadian Association of Police Chiefs, 2020; Zimonjic, 2020), have called for more robust policy reform such as the decriminalization of illegal drugs and the implementation of wide-reaching safe supply programs (Bonn et al., 2020;CAPUD, 2019;Ivsins et al., 2020). ...
Introduction
In light of North America's persisting drug toxicity crisis, alternative drug policy approaches such as decriminalization, legalization, regulation, and safer supply have increasingly come to the forefront of drug policy discourse. The views of people who use drugs toward drug policy and drug law reform in the Canadian context are essential, yet largely missing from the conversation. The aim of this study was to capture the opinions, ideas, and attitudes of people who use drugs toward Canadian drug laws and potential future alternatives.
Methods
This paper was developed as part of the Canadian Drug Laws Project, a cross-jurisdictional qualitative study conducted in British Columbia, Canada between July and September 2020. The qualitative data are from 24 semi-structured interviews with a diverse sample of people who use illegal drugs. Interviews were recorded, transcribed, coded, and analyzed thematically by the research team.
Results
Two main themes and corresponding sub-themes are presented: (1) The experience of stigma as a consequence of criminalization; (2) The perceived benefits of drug law reform. Participants spoke in-depth about their experiences living within a criminalized drug policy context and offered suggestions for new pathways forward. Their perspectives illuminate how Canada's drug laws may shape public attitudes toward people who use drugs and the consequent manifestations of structural, social, and self-stigma experienced by people who use drugs.
Conclusion
Participants openly and profoundly believed that current drug laws produced and propagated the public attitudes and structural inequities experienced by people who use drugs in Canada. This matters, not only because our findings highlight the fact that people who use drugs experience stigma in tangible and clearly impactful ways, but it also suggests that the criminlilization of drugs shapes the experience of structural, social, and self stigma. Finally, participants believed that efforts to destigmatize people who use drugs would be ineffectual without the enactment of more robust forms of drug law reform such as the decriminalization of illegal drugs.
... So far, this approach has been used to investigate government documents (Wild et al., 2017;Huang et al., 2010;Daugbjerg et al., 2009;Cho et al., 1996). To understand to what extent issues related to national energy security of supply has permeated the Italian energy policy, we have analyzed the reports on the national energy situation available from 2000 to (Table 1) drawn up by the Ministry of ecological transition (Ministero della Transizione Ecologica, 2018-2020), and the Ministry of Economic Development (Ministero dello Sviluppo Economico, 2014. ...
In recent years, the number of countries affected by deep geopolitical crises has grown, with global economic effects and implications on energy. The ongoing Russia-Ukraine conflict has highlighted the energy security of supply problems that characterize the European Union, heavily dependent on imported fossil sources from Russia. Italy is still very dependent on foreign energy imports. In this framework, it is crucial to investigate how much issues related to energy security have been considered by Italian governments to protect country's economic interests. The aim of this paper is to analyze to what extent energy security issues have been addressed in Italian energy policies and what actions have been implemented, using a content analysis approach. We have analyzed the reports published by Italian energy authorities in the period 2000-2020. According to our findings, several actions have been undertaken to address security of supply in Italy. The country is trying to diversify its fossil fuel mix and suppliers, even if a higher coordination among policy intervention is required. Several indicators such as CO2 emissions and geographical origin of imports confirm the difficulty to substitute fossil fuels usage in economic activities. However, other indicators, such as renewable energy sources consumption and carbon intensity of industry consumption show a positive trend. The results obtained reveal useful insights into changing policy priorities in security of supply.
... The conceptual analysis consists in identifying research questions and choosing samples, while the relational one analyzes the relations among concepts (Boettger and Palmer, 2010). So far, this approach has been used to investigate government documents (Wild et al., 2017;Huang et al., 2010; This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=4237302 ...
The aim of this paper is to examine the relationship between three determinants – environmental patents, environmental taxation and trade globalization – and the environmental-economic efficiency of 29 OECD countries between 2005 and 2020. Using the Global Malmquist-Luenberger index, this research computes the environmental productivity growth and its main drivers – the catch-up and the frontier shift terms. Besides, dynamic panel linear models are applied to investigate how the three institutional variables affect the dynamics of the computed efficiency indices. Results are as follows: firstly, eco-innovation is the most relevant factor in boosting the environmental productivity growth, pushing forward the technological frontier, and spurring the catch-up term. Secondly, environmental taxation is an ineffective policy instrument in promoting the sustainable growth and technological frontier advancements, having positive impacts only on the catch-up term. Thirdly, trade globalization reveals to hinder the sustainable growth and its two main drivers.
... While past THN guidelines offer valuable information, we identified a gap in guidelines developed specifically for community THN distribution programs, which have different informational needs and challenges compared to professional groups. The Canadian harm reduction context may differ from other countries as there is regional variation regarding the scope and quantity of harm reduction policies [15], available harm reduction services [16], and THN distribution programs [4] within Canada. Additionally, harm reduction science continues to develop. ...
Background
Take-Home Naloxone (THN) is a core intervention aimed at addressing the toxic illicit opioid drug supply crisis. Although THN programs are available in all provinces and territories throughout Canada, there are currently no standardized guidelines for THN programs. The Delphi method is a tool for consensus building often used in policy development that allows for engagement of stakeholders.
Methods
We used an adapted anonymous online Delphi method to elicit priorities for a Canadian guideline on THN as a means of facilitating meaningful stakeholder engagement. A guideline development group generated a series of key questions that were then brought to a 15-member voting panel. The voting panel was comprised of people with lived and living experience of substance use, academics specializing in harm reduction, and clinicians and public health professionals from across Canada. Two rounds of voting were undertaken to score questions on importance for inclusion in the guideline.
Results
Nine questions that were identified as most important include what equipment should be in THN kits, whether there are important differences between intramuscular and intranasal naloxone administration, how stigma impacts access to distribution programs, how effective THN programs are at saving lives, what distribution models are most effective and equitable, storage considerations for naloxone in a community setting, the role of CPR and rescue breathing in overdose response, client preference of naloxone distribution program type, and what aftercare should be provided for people who respond to overdoses.
Conclusions
The Delphi method is an equitable consensus building process that generated priorities to guide guideline development.
... Além disso, a redução de custos de saúde tem sido alcançada onde as estratégias de redução de danos estão em vigor. [2][3][4] A RD foi o primeiro movimento a criticar o modelo internacional de proibição às drogas, viabilizando possibilidades concretas na prevenção de agravos em saúde. Na perspectiva de alguns avaliadores, a proposta de Guerra às drogas, ao longo dos anos, não demonstrou efetividade, pois além de dificultar a adesão ao tratamento daquelas pessoas que não querem ou não conseguem parar de usar drogas, contribuiu para as disparidades raciais e o aumento de gastos públicos. ...
Objective:
to evaluate harm reduction strategies in the Psychosocial Care Network of a small city in the southern region of Brazil.
Method:
qualitative study, using the methodological assumptions of the Empowerment Evaluation. The research was carried out in the Psychosocial Care Network of a small city in Rio Grande do Sul, Brazil, from March to December 2017. Forty-two managers and workers of the psychosocial care network services and the intersectoral network for drug users participated in the study. Thematic analysis was used for data analysis.
Results:
the mission of the network under study involved a work proposal aimed at harm reduction. In the knowledge of the current situation, the integrated action of the harm reduction team to the other services in the network was identified and the need for greater understanding of the specifics of this work. Concerning the perspectives for the future of the network, efforts were made to strengthen harm reduction strategies that redeem the potential of individuals and investments in human and structural resources in damage reduction teams.
Conclusion:
the study presents support for the construction of harm reduction proposals integrated into the psychosocial care network, which can guide the prioritization of investments and improvements in the decision making of network managers and workers.
... Bardwell et al., 2018;Gillespie et al., 2018;Greer, 2019;Kennedy et al., 2019;Wagner et al., 2013), is an indicator that they are a key element in addressing the overdose crisis in BC. BC has some of the most progressive harm reduction policy compared to other provinces in Canada (Hyshka et al., 2017;Wild et al., 2017). BC is also known as a leader in harm reduction internationally, given the establishment of Insite, North America's first officially sanctioned supervised injection site, establishment of overdose prevention sites, outreach services and a province-wide take home naloxone program, among other interventions (Banjo et al., 2014;Kerr, Mitra, Kennedy & McNeil, 2017; 2019; Young, Williams, Otterstatter, Lee & Buxton, 2019). ...
Background
The province of British Columbia (BC), Canada is amid dual public health emergencies in which the overdose epidemic declared in 2016 has been exacerbated by restrictions imposed by the Coronavirus Disease of 2019 (COVID-19) pandemic. Experiential workers, commonly known as ‘peers’ (workers with past or present drug use experience) are at the forefront of overdose response initiatives and are essential in creating safe spaces for people who use drugs (PWUD) in harm reduction. Working in overdose response environments can be stressful, with lasting emotional and mental health effects. There is limited knowledge about the personal meaning that experiential workers derive from their work, which serve as motivators for them to take on these often-stressful roles.
Methods
This project used a community-based qualitative research design. The research was based at two organizations in BC. Eight experiential worker-led focus groups were conducted (n = 31) where participants spoke about their roles, positive aspects of their jobs, challenges they face, and support needs in harm reduction work. Transcripts were coded and analyzed using interpretative description to uncover the meaning derived from experiential work.
Results
Three themes emerged from focus group data that describe the meanings which serve as motivators for experiential workers to continue working in overdose response environments: (1) A sense of purpose from helping others; (2) Being an inspiration for others, and; (3) A sense of belonging.
Conclusion
Despite the frequent hardships and loss that accompany overdose response work, experiential workers identified important aspects that give their work meaning. These aspects of their work may help to protect workers from the emotional harms associated with stressful work as well as the stigma of substance use. Recognizing the importance of experiential work and its role in the lives of PWUD can help inform and strengthen organizational supports.
... North American research related to substance use treatment tends to focus on producing abstinence from, or a reduction in, substance use (Hallgren et al., 2016;Kampman, 2019). This contrasts with harm reduction and alternative approaches, which have been more accepted in the UK and parts of Europe (Kalk et al., 2018) compared with the USA (Barry et al., 2019) and Canada (Wild et al., 2017). Nonetheless, epistemological positions are often not clearly stated, and assumptions are made from scientific, biomedical perspectives (Hellman, 2011), particularly when defining and categorising 'substance' and 'substance use'. ...
Social work and substance use research often neglect to make epistemological perspectives explicit in their studies, inadvertently embedding numerous assumptions
that remain invisible and uncontested. Consequently, the unchallenged dominance of
post-positivist epistemologies in Western European countries becomes (re)produced in
social work and substance use education, policies and practices, limiting space for alternative viewpoints. This narrative review examines some of the social work and substance use literature, highlighting the value of making epistemology more explicit
and the importance of applying critical epistemologies to counter dominant paradigms.
This article makes a unique contribution to substance use literature by examining
substance use from post-positivist, social constructivist and critical paradigms and
by promoting a critical social work lens. A critical paradigm is particularly useful for
questioning prevailing assumptions of substance use as a medical problem requiring
professional treatment and for generating greater attention to structural policies that
promote a more equitable society. Social work’s commitment to human rights and social
justice effectively positions the discipline to apply a critical paradigm to the field
of substance use studies.
Keywords: Critical social work, epistemology, methodology, social justice, substance
use, theoretical paradigms
... Kingdon notes, "Proposals that don't fit with specialists' values have less chance of survival than those that do" (2011,(132)(133)). An analysis of policy documents on harm reduction found that Alberta was just one of two provinces to have a provincial level stand-alone harm reduction policy (Hyshka et al. 2017, 5;Wild et al. 2017). Though the study identifies that the existence of a harm reduction policy does not necessarily translate into the provision of a robust array of services, it does indicate that the proposal to establish SCS in 2017 was already in alignment with the values of Alberta's existing harm reduction policies. ...
... Victoria is the capital of BC and one of the top three townships in the province impacted by overdose deaths. As well, the city has a history of documented challenges related to the establishment and expansion of harm reduction services [32][33][34] even though the province of BC is known as a world leader in harm reduction with the most robust and progressive provincial harm reduction policies in Canada [35,36] There were four potential OPSs in Victoria, All four were contacted, with three agreeing to participate in this research project. A fourth agency expressed support but was unable to facilitate the research in the agency in the short timeframe. ...
The primary objective of this study was to examine the impacts associated with implementation of overdose preventions sites (OPSs) in Victoria, Canada during a declared provincial public health overdose emergency. A rapid case study design was employed with three OPSs constituting the cases. Data were collected through semi-structured interviews with 15 staff, including experiential staff, and 12 service users. Theoretically, we were informed by the Consolidated Framework for Implementation Research. This framework, combined with a case study design, is well suited for generating insight into the impacts of an intervention. Zero deaths were identified as a key impact and indicator of success. The implementation of OPSs increased opportunities for early intervention in the event of an overdose, reducing trauma for staff and service users, and facilitated organizational transitions from provision of safer supplies to safer spaces. Providing a safer space meant drug use no longer needed to be concealed, with the effect of mitigating drug related stigma and facilitating a shift from shame and blame to increasing trust and development of relationships with increased opportunities to provide connections to other services. These impacts were achieved with few new resources highlighting the commitment of agencies and harm reduction workers, particularly those with lived experience, in achieving beneficial impacts. Although mitigating harms of overdose, OPSs do not address the root problem of an unsafe drug supply. OPSs are important life-saving interventions, but more is needed to address the current contamination of the illicit drug supply including provision of a safer supply.
... As challenges to improve access to OAT persist in rural BC(32), it is unsurprising that we observed lower retention and engagement in PWOUD located in rural regions. Remote and rural regions of BC have historically faced numerous barriers in supporting substance use-related interventions with limited infrastructure and capacity for service delivery (65). It is reported that many health care providers trained to prescribe OUD medication do not offer the treatment(66), suggesting training may not be adequate to address the shortage of providers in rural settings (58). ...
Background and aims:
The 'cascade of care' framework, measuring attrition at various stages of care engagement, has been proposed to guide the public health response to the opioid overdose public health emergency in British Columbia (BC), Canada. We estimated the cascade of care for opioid use disorder and identified factors associated with care engagement for people with opioid use disorder (PWOUD) provincially.
Design:
Retrospective study using a provincial-level linkage of four health administrative databases.
Setting and participants:
All PWOUD in BC from January 1st, 1996 to November 30th, 2017.
Measurements:
The eight-stage cascade of care included diagnosed PWOUD, ever on opioid agonist treatment (OAT), recently on OAT, currently on OAT, and retained on OAT: ≥1m, ≥3m, ≥12m, ≥24m). Health care use, homelessness and other demographics were obtained from physician billing records, hospitalizations and drug dispensation records. Receipt of income assistance was indicated by enrollment in Pharmacare Plan C(48).
Findings:
A total of 55,470 diagnosed PWOUD were alive at end of follow-up. As of 2017, a majority of the population (N=39,456; 71%) received OAT during follow-up; however, only 33% (N=18,519) were currently engaged in treatment and 16% (N=8,960) had been retained for at least one year. Compared with those never on OAT, those currently engaged in OAT were more likely to be under 45 years of age (adjusted odds ratio: 1.75; 95% confidence interval: 1.64,1.89), male (1.72; 1.64,1.82), with concurrent substance use disorders (2.56; 2.44,2.70), HCV (1.22; 1.14,1.33) and either homeless or receiving income-assistance (4.35; 4.17,4.55). Regular contact with the healthcare system - either in outpatient or acute care settings - was common among PWOUD not engaged in OAT regardless of time since diagnosis or treatment discontinuation.
Conclusions:
People with opioid use disorder in British Columbia, Canada show high levels of outpatient care prior to diagnosis. Younger age, male sex, urban residence, lower income level, and homelessness appear to be independently associated with increased opioid agonist treatment engagement.
... Also, after 2006, papers using qualitative methods have spiked including those focused on DCR clients or staff [70][71][72][73][74][75][76][77][78][79][80][81][82][83][84][85][86][87][88], and on other stakeholders [89][90][91][92][93][94][95][96][97][98][99]. Since 2013, an increasing number of papers analysed SIF-related laws [100][101][102][103][104][105][106][107][108][109][110][111][112][113][114][115][116] and policies [117][118][119][120][121][122][123][124][125][126][127][128][129][130][131][132][133]. In 2016 and 2017, a larger number of publications emphasised the need to expand DCRs/SIFs [9,[134][135][136][137][138][139][140][141][142][143][144][145][146], including studies that examined the willingness to use SIFs/DCRs among people who use drugs (PWUD) [13,[147][148][149][150][151][152][153][154][155][156][157][158][159][160][161], community support for these services [162][163][164][165] and costeffectiveness of scaling them up [166][167][168][169][170][171][172][173][174][175] (Figure 2). ...
Issues
Drug consumptions rooms (DCR) and supervised injecting facilities (SIF) are expanding internationally. Previous reviews have not systematically addressed evaluation methodologies.
Approach
Results from systematic searches of scientific databases in English until June 2017 were coded for paper type, country and year of publication. For evaluation papers, study outcome, methodology/study design and main indicators of DCR/SIF ‘exposure’ were recorded.
Key Findings
Two hundred and nineteen eligible peer‐reviewed papers were published since 1999: the majority from Canada (n = 117 papers), Europe (n = 36) and Australia (n = 32). Fifty‐six papers reported evaluation outcomes. Ecological study designs (n = 10) were used to assess the impact on overdose, public nuisance and crime; modelling techniques (n = 6) estimated impact on blood‐borne diseases, overdose deaths and costs. Papers using individual‐level data included four prospective cohorts (n = 28), cross‐sectional surveys (n = 7) and service records (n = 5). Individual‐level data were used to assess safer injecting practice, uptake into health and social services and all the other above outcomes except for impact on crime and costs. Four different indicators of DCR/SIF attendance were used to measure service ‘exposure’.
Implications
Research around DCRs/SIFs has used ecological, modelling, cross‐sectional and cohort study designs. Further research could involve systematic inclusion of a control group of people who are eligible but do not access SIFs, validation of self‐reported proportion of injections at SIFs or a stepped‐wedge or a cluster trial comparing localities.
Conclusions
Methodologies appropriate for DCR/SIF evaluation have been established and can be readily replicated from the existing literature. Research on operational aspects, implementation and transferability is also warranted.
... In response, rapid expansion of life-saving harm reduction services is underway with greater public support reported in some parts of the world [1,8,[11][12][13]. Canada, for example, has seen extensive recent growth in supervised injection services (SIS), overdose prevention sites (OPS) and naloxone distribution programs [1,8,14]. Although different terms are used to describe such services, we use 'SIS' for consistency with what is commonly used in our review's identified literature. ...
... University students comprise a population of special consideration for PCE use, presenting higher usage rates than other groups, such as their peers who do not attend university (Ford & Pomykacz, 2016) or working professionals (Franke, Bagusat, Rust, Engel, & Lieb, 2014;Johnston, O'Malley, Bachman, toward tax increases on alcohol to deter use (Macdonald, Stockwell, & Luo, 2011), and rates of cannabis use among youth has been higher in Quebec than Ontario most years between 2004(Leos-Toro, Rynard, Murnaghan, Macdonald, & Hammond, 2019. Additionally, there exists a greater number of harm reduction policies in Quebec than Ontario (Wild et al., 2017). Risk factors for PCE use reported in university students include individual-level factors such as selfreported attention difficulties (Rabiner et al., 2009), recreational drug use (Garnier-Dykstra, Caldeira, Vincent, O'Grady, & Arria, 2012), low GPA (McCabe, Knight, Teter, & Wechsler, 2005), procrastination tendencies and psychological distress (Ponnet, Wouters, Walrave, Heirman, & Van Hal, 2015), and avoidance strategies to cope with stress (Jensen, Forlini, Partridge, & Hall, 2016;Riddell et al., 2018). ...
Background:
Use of prescription stimulants for cognitive enhancement in healthy individuals has been of growing interest to the academic community. University students can be prone to use these pharmacological cognitive enhancers (PCEs) for their perceived academic benefits.
Objectives:
We aimed to understand university students' beliefs about the factors influencing PCE use, the cognitive and health effects of the drugs, and how these conceptions are interrelated.
Methods:
Data were collected through focus groups with 45 students at the University of Toronto in 2015/2016. We used thematic analysis to extract key themes and cooccurrence coefficients to evaluate the overlap between these themes.
Results:
We found that participants perceived users as either struggling students or high-achieving ones. Alleged benefits of PCEs included enhanced focus, attention, memorization, and grades, but did not include increased intelligence or long-term cognitive enhancement. Participants disagreed on whether ADHD diagnosis would affect how PCEs worked and how "needing the drug" was determined. Mentions of nonspecific side effects were common, as was the possibility of misuse (e.g., addiction, abuse). Though not an initial aim of the study, we uncovered patterns pertaining to whom participants used as sources of information about different themes. We propose that social learning theory provides a useful framework to explain how the experiences of peers may shape the conceptions of our participants. Conclusions/Importance: Our findings highlight that conceptions surrounding PCEs are multileveled, and informed by a variety of sources, including peers. This should be considered in the development of interventions geared toward university students.
Introduction
Supervised injecting facilities (SIF) have been shown to reduce negative outcomes experienced by people who inject drugs. They are often subject to intense public and media scrutiny. This article aimed to explore population attitudes to SIFs and how these changed over time in Australia.
Methods
Data were drawn from the National Drug Strategy Household Survey, a national sample collecting data on illicit drug use and attitudes towards drug policy among Australians (2001–2019). Ordinal logistic regression assessed sociodemographic characteristics associated with different attitudes to SIFs and binary logistic regression assessed trends over time and by jurisdiction.
Results
In 2019, 54% of respondents (95% CI 52.9, 55.1) supported SIFs, 27.5% (95% CI 26.6, 28.4) opposed and 18.4% (95% CI 17.7, 19.2) were ambivalent. Support for SIFs correlated with having a university degree (OR 1.75; 95% CI 1.58, 1.94), non‐heterosexual identity (OR 1.81, 95% CI 1.51, 2.17) and recent illicit drug use (OR = 1.74, 95% CI 1.55, 1.94). Male respondents or those living in socioeconomically disadvantaged areas had lower odds of supporting SIFs (OR 0.92, 95% CI 0.85, 1.00; OR 0.64–0.80, respectively). Between 2001 and 2019, support for SIFs increased modestly by 3.3%, those who ‘don't know’ by 7.4%, whereas opposition decreased by 11.7%. Between 2001 and 2019, support for SIFs increased in NSW and Queensland, whereas opposition decreased in all jurisdictions.
Discussion and Conclusions
Opposition to SIFs declined over the past 20 years, but a substantial proportion of respondents are ambivalent or ‘don't know enough to say’. Plain language information about SIFs and their potential benefits, targeted to those who are ambivalent/’don't know’ may further increase public support.
The aim of this research was to explore how the concept of harm is constituted in case law judicial decisions pertaining to the importation, production, possession, and trafficking of drugs in Canada using critical discourse analysis methodology. The research was designed to uncover taken-for-granted assumptions about drugs and associated harms. The data source for this study is judicial decisions. These are published texts where judge(s) summarize details about the factors considered, provide a reasoned interpretation of sentencing principles relevant to the judicial decision, and explain the rationale for their decision. Initially, codes were identified deductively, using words related to drugs and harm. Codes were added when incidents of moralization language were observed to be high. Moralization language was defined as “the usage of language cues referencing moral values”. The selection process resulted in n = 129 judicial decisions meeting the inclusion criteria. Discourse analysis was guided by four tools described by Gee’s study: the significance tool, the why this way and not that way tool, the connections tool, and the intertextuality tool. Emergent themes are: (1) trafficking as an immoral enterprise; (2) scourge to society, (3) fentanyl and harm, and (4) constructing gravity. This study uncovers discursive practices in many judicial decisions that convey the (re)production of institutionalized stigma. High reliance on legal tropes about drug harms, harm of trafficking, moral culpability associated with distribution of some drugs, by some people, in some ways, and a lack of contextual awareness of social inequities that influence the lives of Canadians perpetuates legal interpretations that support rationales for sentence predicated on denunciation and deterrence.
We investigate how issue fields with increasing levels of contestation can develop into fields characterized by echo chambers. Studying the introduction of a controversial new approach to addiction services – harm reduction – we explain how proponents’ and opponents’ rhetorical arguments changed over time, transitioning the issue field through different configurations. Our findings reveal how field actors were initially differentiated by moral convictions, and as their expression of moral emotions became more intense, the two groups became increasingly divided and polarized in their views, leading to an issue field characterized by echo chambers. Through our analysis of archival materials and interview data, we explicate this process by identifying three phases of issue field transition: (1) Creating a moral emotional divide; (2) Intensifying antagonization; (3) Insulating against the other side. We contribute to the literature by presenting a model of change explaining how emotional rhetoric, together with different types of triggering events, can fuel increasing levels of contestation and drive the field toward developing echo chambers. Second, by taking a discursive view of issue fields with particular attention to rhetorical arguments, we provide foundational work for an institutional perspective on echo chamber – that echo chambers result from ongoing social processes where people encapsulate themselves based on a sense of right and wrong, in contrast to the predominant view of becoming trapped in an enclosed space. Third, through our focus on the role of moral emotions and how they can escalate in situations of contestation, we advance knowledge regarding the importance of emotions in field dynamics.
Objective
This study assessed the quality of campus alcohol policies against best practice to assist campus decision-makers in strengthening their campus alcohol policies and reducing student alcohol use and harm.
Methods
Drawing on empirical literature and expert opinion, we developed an evidence-based scoring rubric to assess the quality of campus alcohol policies across 10 alcohol policy domains. Campus alcohol policy data were collected from 12 Atlantic Canadian universities. All extracted data were verified by the institutions and then scored.
Results
On average, post-secondary institutions are implementing only a third of the evidence-based alcohol policies captured by the 10 domains assessed. The average campus policy score was 33% (range 15‒49%). Of the 10 domains examined, only enforcement achieved an average score above 50%, followed closely by leadership and surveillance at 48%. The two heaviest-weighted domains—availability and access, and advertising and sponsorship—had average scores of 27% and 24%, respectively. However, if post-secondary campuses adopted the highest scoring policies from across all 12 campuses, they could achieve a score of 74%, indicating improvement is possible.
Conclusion
Atlantic Canadian universities are collectively achieving less than half their potential to reduce student alcohol-related harm. However, this study identifies opportunities where policies can be enhanced or modified. The fact that most policies are present at one or more campuses highlights that policy recommendations are an achievable goal for campuses. Campuses are encouraged to look to each other as models for improving their own policies.
Background
This targeted and comprehensive policy scan examined how different levels of governments in Australia and Canada responded to the financial crisis brought on by the COVID-19 pandemic. We mapped the types of early policy responses addressing financial strain and promoting financial wellbeing. We also examined their equity considerations.
Methods
Through a systematic search, snowballing, and manual search, we identified Canadian and Australian policies at all government levels related to financial strain or financial wellbeing enacted or amended in 2019–2020. Using a deductive-inductive approach, policies were categorized by jurisdiction level, focal areas, and target population groups.
Results
In total, 213 and 97 policies in Canada and Australia, respectively, were included. Comparisons between Canadian and Australian policies indicated a more diversified and equity-targeted policy landscape in Canada. In both countries, most policies focused on individual and family finances, followed by housing and employment areas.
Conclusions
The policy scan identified gaps and missed opportunities in the early policies related to financial strain and financial wellbeing. While fast, temporary actions addressed individuals’ immediate needs, we recommend governments develop a longer-term action plan to tackle the root causes of financial strain and poor financial wellbeing for better health and non-health crisis preparedness.
Statement on Ethics and Informed Consent
This research reported in this paper did not require ethical clearance or patient informed consent as the data sources were published policy documents. This study did not involve data collection with humans (or animals), nor any secondary datasets involving data provided by humans (or from animal studies).
As opioid fatalities rise in North America, the need to improve the supports available to those who are dependent on opioids and pregnant has become more urgent. This paper discusses the social organisation of drug treatment supports for those who are pregnant, using Canadian clinical practice guidelines (CPGs) for methadone maintenance treatment (MMT) as a case study. Pregnant patients are a priority population for MMT, both in Canada and internationally; the regulatory bodies that oversee MMT in Canada are the provincial Colleges of Physician and Surgeons and Health Canada. The paper analyses MMT CPGs published by these agencies, comparing their general recommendations to those specific to pregnant patients. We demonstrate that the guidelines address few treatment considerations for pregnant patients, other than improved birth outcomes and child welfare, despite acknowledging their more complex needs. Drawing on social science studies of gender and drugs, we argue that MMT CPGs therefore perpetuate the intensified surveillance and foetal prioritisation that have long generated barriers to care for opiate‐dependent pregnant patients. We also discuss how and why the CPGs ultimately only reinforced these current limitations in the drug treatment sector.
Objectives
Canada continues to battle an opioid overdose crisis marked by an increasingly toxic drug supply and a lack of access to substance use services. Withdrawal management (WM) programs serve as a frontline response for the treatment and support of Opioid Use Disorders (OUD). To gain a better understanding of WM programs in Canada and their involvement with individuals with OUD, we conducted a national environmental scan toward improving and standardizing the evidence base for best WM practices in Canada.
Methods
Between July 2019 and March 2020, we distributed a cross-sectional self-report online questionnaire to program representatives of WM programs across the country. The questionnaire was comprised of both quantitative and open-ended questions, focusing on operational information of programs, as well as admission, treatment, and discharge activities related to OUD and the impacts of the opioid overdose crisis. Data were analyzed for basic frequency distributions and cross-tabulations.
Results
A total of 85 WM programs were included in the final analyses. An estimated 14,171 opioid-related admissions occurred among participating WM programs, and the majority (71/82; 85.7%) of programs reported offering services for clients with problematic opioid use as either a primary or secondary presenting problem. The approaches to opioid-specific withdrawal and opioid agonist therapy (OAT) provision varied considerably. Most 66/78 (84.6%) of respondents indicated that they induct clients on OAT either in-house or refer them to another program within their organization. The respondents also identified significant barriers to facilitating OAT for their clients, such as a lack of capacity and knowledge or ability to prescribe OAT. Many programs discussed the impact of the opioid overdose crisis.
Conclusions
Findings indicate a lack of capacity for OAT delivery, as well as significant discrepancies in the operation of WM programs in Canada and how they support clients with OUD. The results underscore a need to standardize clinical guidelines outlining evidence-based service delivery and care for the management for OUD in a variety of treatment settings and jurisdictions in Canada.
Objectifs
Le Canada continue de lutter contre une crise de surdose d’opioïdes, marquée par un approvisionnement en drogues de plus en plus toxiques et un manque d’accès aux services liés à la consommation de substances. Les programmes de gestion du sevrage (GS) constituent une réponse de première ligne pour le traitement et le support des troubles liés à la consommation d’opioïdes (TCO). Afin de mieux comprendre les programmes de GS au Canada et leur implication auprès des personnes souffrant de TCO, nous avons mené une analyse environnementale nationale visant à améliorer et à normaliser la base de données probantes des meilleures pratiques de GS au Canada.
Méthodes
Entre juillet 2019 et mars 2020, nous avons distribué un questionnaire transversal d’auto-évaluation en ligne aux représentants des programmes de GS à travers le pays. Le questionnaire était composé de questions quantitatives et ouvertes, axées sur les informations opérationnelles des programmes, ainsi que sur les activités d’admission, de traitement et de sortie liées au TCO et aux impacts de la crise des surdoses d’opioïdes. Les données ont été analysées pour des distributions de fréquence de base et des tabulations croisées.
Résultats
Un total de 85 programmes de GS a été inclus dans les analyses finales. On estime à 14 171 le nombre d’admissions liées aux opioïdes parmi les programmes de GS participants, et la majorité (71/82 ; 85,7%) des programmes ont déclaré offrir des services aux clients ayant un usage problématique d’opioïdes comme problème principal ou secondaire. Les approches du sevrage spécifique aux opiacés et de l’offre du programme pour les TCO variaient considérablement. La plupart des 66/78 (84,6%) répondants ont indiqué qu’ils initiaient les clients au programme pour les TCO soit à l’interne, soit en les orientant vers un autre programme au sein de leur organisation. Les répondants ont également identifié des obstacles importants à la facilitation d’accès au programme pour les TCO pour leurs clients, tels que le manque de capacité et de connaissances ou la capacité de prescrire le programme pour les TCO. De nombreux programmes ont évoqué l’impact de la crise des surdoses d’opioïdes.
Conclusion
Les résultats indiquent un manque de capacité pour la mise en œuvre du programme pour les TCO, ainsi que des écarts importants dans le fonctionnement des programmes de GS au Canada et dans la façon dont ils soutiennent les clients souffrant de TCO. Les résultats soulignent la nécessité d’uniformiser les lignes directrices cliniques décrivant la prestation de services et de soins fondés sur des données probantes pour la prise en charge des TCO dans une variété de milieux de traitement et de juridictions au Canada.
Sexualized drug use, also known as Party and Play (PnP, chemsex) is a phenomenon that is increasingly pervasive among 2SGBTQ+ communities in Canada and has been epidemiologically linked to increased risk of HIV and other sexually transmitted and blood‐borne illnesses (STBBI). The phenomenon is highly stigmatized even within 2SGBTQ+ communities, perpetuating discrimination against individuals who PnP. Consequently, such individuals often remain invisible to formal care systems. Even as public health efforts seek to reduce the harms associated with PnP, narrowly epidemiological understandings of the phenomenon without understanding it from the perspectives of those with living experience of it, and—without attention to how historical, socio‐structural, and cultural factors shape the phenomenon—contribute to the stigmatization, disempowerment, and marginalization of people who PnP from healthcare access. In this chapter, we describe how an evaluation‐driven program design process grounded in the transformative evaluation paradigm and the principles of LGBTQ+ evaluation supported a paradigm shift for one public health agency in how they re‐conceptualized a more empowering approach for engaging people who PnP in dignified, meaningful care.
In 2016 British Columbia (BC), Canada declared an overdose crisis due to the increasing adulteration of fentanyl – an opioid approximately 40 times stronger than heroin – into the heroin drug market, leading to a sharp increase in overdoses. In response, several new harm reduction programs have been implemented, including drug checking. Drug checking broadly refers to any number of techniques that test the contents of illegal drugs. Over the last decades, Canadian harm reduction workers serving nightlife and festival communities of people who use drugs have struggled to implement more advanced forms of drug checking. Before 2017, only reagent drug checking was available. Reagents worked like a litmus test for drugs: drop a liquid onto the drug in question and a colour change occurs. The colour change is then matched to a chart of known interactions between that chemical and drug. In 2017, the first Fourier-Transform Infrared Spectrometer (FTIR) began to be used – with a machine worth thousands of dollars, a small sample, and infrared light, the knowledge required to drug check changed.
Drug checking in BC began to professionalize. Before the FTIR, those involved in drug checking were not expected to have a formal education. Now that the FTIR has replaced reagent drug checking, actors who come from backgrounds such as pharmacology and chemistry obtain a new position based on their expertise. This thesis has three fundamental research questions: 1) What distinguishes the analytic chemist from their non-chemistry counterparts? When new forms of knowledge become necessary for drug checking, can people lacking a formal chemistry background still operate the FTIR?”2) What kind of knowledge is required to operate the FTIR? 3) Can the arrival of new drug checking technologies do more than just provide people who use drugs with information about their substances? Can these new technologies create opportunities for people who use drugs who want to learn to operate the FTIR?
This thesis is informed by my harm reduction work in BC (2014-2016) before the arrival of the FTIR. It contains two distinct qualitative studies that explore different drug using communities where FTIR drug checking is practiced. The first study follows festival harm reduction workers. By observing and interviewing activists and drug checkers, the thesis examines how new ways of thinking and different skills become valued in drug checking when professionalization occurs. In the second study, as a research assistant for the BC Centre on Substance Use, a public health research organization, I conducted 26 interviews with people who use drugs and who went to an Overdose Prevention Site (a low-barrier clinic for people to inject drugs while under supervision). These interviews focused on how people understand the FTIR and why they use it, examining an early peer-FTIR training program at the Overdose Prevention Site.
Those with a chemistry background have an extensive knowledge of the spectra the FTIR produces. They see the patterns in the FTIR’s output and can determine which of the drugs identified by the FTIR are most likely in a sample. Yet, those without a background in analytical chemistry can also learn to use the FTIR effectively. I develop a new theoretical framework to explain how peers come to know how the FTIR works. I make a case for why peers can be involved in drug checking within their own communities. Drug checking has the potential to provide new opportunities to people who use drugs that they may not have had otherwise due to systemic oppression.
In 2018, the government of Canada legalized cannabis for non-medical use. In addition to safeguarding public health, the main objective was to divert profits from the illicit market and restricting its availability to youth. This dramatic shift in policy direction introduces new challenges for the criminal justice system due to the persistence of unlawful distribution among persons who refuse to abide by the new law. Continuing unlawful distribution is foreseeable, in part, because of stringent measures to reduce availability by targeting participants in the illegal market. Recognizing that the most heavy, frequent, users account for the majority of cannabis consumed—and are the group most likely to keep purchasing from dealers because of lower costs and easy access—the illegal market will continue to provide a substantial (albeit unknown) proportion of the total volume. The recent change in policy in Canada provides new opportunities for research to assess how legalization of cannabis affects its use and distribution patterns. The National Cannabis Survey (NCS), administered at three-month intervals, allows for multi-wave comparison of prevalence statistics and point of purchase information before and after legalization. Drawing on the NCS, this article examines the extent to which the primary supply source has changed across the provinces, controlling for other factors and consumer characteristics. Findings are interpreted with reference to studies of cannabis law reform in North America informing research and policy observers in these and other jurisdictions, undergoing or considering, similar reforms.
People who use substances (PWUS), and specifically individuals who use injection drugs and/or smoke crack cocaine, experience risks which harm reduction programmes can help reduce. Prior to implementing harm reduction programmes, however, it is critical to understand how programme users and others in the community perceive the programmes as their perceptions may influence implementation. A mixed-methods study asked PWUS and key informants about their perceptions of implementing five harm reduction programmes in their communities, including perceptions of the advantages of the programmes, where best to locate them, and community support. Questionnaires were administered to 160 PWUS, and qualitative interviews were conducted with 11 purposefully sampled key informants. Data were collected in one medium-size and one small-size community/municipality in Nova Scotia, Canada, during 2017–2018. SPSS was used to generate descriptive statistics and means from the quantitative data, and the qualitative data were analysed for key themes using thematic analysis. Both PWUS and key informants perceived numerous advantages of the harm reduction programmes, but some key informants suggested that there might be potential opposition to the implementation of additional needle distribution and disposal programmes in some locations and potential opposition to safer consumption sites. Further research is needed to understand why these programmes were viewed as potentially generating opposition, but findings suggest that a key factor is the association of the programmes with ‘danger’ because the programmes are directly linked with criminalized drug use. In contrast, the three other programmes are linked to ‘safety’ because naloxone saves lives, peer navigation programmes support access to existing programmes and detoxification programmes are associated with safety through the reduction/elimination of drug use. Legalization/decriminalization of drugs might help to change the association of some programmes with ‘danger’ and therefore help support the implementation of harm reduction programmes that appear to be perceived by some as linked to danger.
Background:
In the past five years, we have seen a rapid expansion of harm reduction approaches, programs, and policies in Canada. To keep up with the changing policy landscape, a number of Canadian researchers have undertaken projects that seek to analyze policy documents published by provincial and territorial governments. Building on this important body of work, we undertook a similar analysis using documents published by nursing organizations.
Purpose:
To present key findings and propose ways that nursing organizations can strengthen their position on harm reduction.
Methods:
We conducted an environmental scan with a two-part analysis. To complete the first part, we used the 17 quality indicators. To complete the second part, we analyzed the documents for specific harm reduction interventions.
Results:
A total of 39 documents were collected across 76 nursing organizations. The majority of the documents were press or public statements (n = 22), and the most frequently mentioned intervention was supervised injection services (n = 31). On average, documents met 5.6 quality indicators. Documents scored highest on indicator 12 (discuss low-threshold approaches to service provision) and lowest on indicator 3 (acknowledge that not all substance use is problematic).
Conclusions:
Six areas were identified to strengthen nursing organizations' position on harm reduction.
Background:
Harm reduction interventions reduce mortality and morbidity for people who use drugs (PWUD), but are contentious and haphazardly implemented. This study describes volume and content of Canadian newspaper coverage of harm reduction produced from 2000 to 2016.
Methods:
Searches of 54 English-language newspapers identified 5681 texts, coded for type (news reports, opinion pieces), tone (positive, negative, or neutral/balanced coverage), topic (health, crime, social welfare, and political perspectives on harm reduction), and seven harm reduction interventions.
Results:
Volume of coverage doubled in 2008 (after removal of harm reduction from federal drug policy and legal challenges to Vancouver's supervised consumption program) and quadrupled in 2016 (tracking Canada's opioid emergency). Health perspectives on harm reduction were most common (39% of texts) while criminal perspectives were rare (3%). Negative coverage was over 10 times more common in opinion pieces (31%) compared to news reports (3%); this trend was more pronounced in British Columbia and Alberta, a region particularly affected by Canada's opioid emergency. Supervised drug consumption accounted for 49% of all newspaper coverage.
Conclusions:
Although federal policy support for harm reduction waxed and waned over 17 years, Canadian newspapers independently shaped public discourse, frequently characterizing harm reduction positively/neutrally and from a health perspective. However, issue framing and agenda setting was also evident: supervised drug consumption offered in a single Canadian city crowded out coverage of all other harm reduction services, except for naloxone. This narrow sense of 'newsworthiness' obscured public discourse on the full spectrum of evidence-based harm reduction services that could benefit PWUD.
This paper explores the social inclusion of the illicit drug user. It does this through a comparative examination of policy orientations to the social inclusion of people who use drugs. Six policy documents from Canada and Scotland produced in the years 2000 and 2001 were systematically sampled from 42 known documents. A poststructural content analysis adapted from the work of Maarten Hajer and mapped onto an analytic frame derived from Nikolas Rose's Governing the Soul: The Shaping of the Private Self is conducted. Within the years considered, drug policy texts from Scotland signaled a more punitive approach to drug use and a less socially inclusive approach to people who used drugs than drug policy texts from Canada. The differences in policy directions identified were in keeping with a priori interpretations of each country's broad approach to illicit drug use and to the social inclusion of the illicit drug user, if not to social inclusion itself. Methodologically, combining the approaches of Hajer and Rose proved complimentary and useful as well as promising for future application to the content analysis of public discourse.
Background:
Drug-related overdoses were declared a public health emergency in British Columbia, Canada in April, 2016 facilitating the scale-up of responses including rapid sanctioning and implementation of overdose prevention sites (OPSs). OPSs are a health service providing supervised injection and immediate overdose response. In BC, OPSs were operational within weeks of sanctioning. In the first year of operation over 20 OPSs were established with approximately 550,000 visits and no overdose deaths at any site. In this paper, we examine the implementation of OPSs as a novel and nimble response to prevent overdose deaths as a result of injection drug use.
Methods:
A multiple case study design was used with the Consolidated Framework for Implementation (CFIR) informing the analysis. Three sites in a single city were included with each site constituting a case. In this paper, we focus on qualitative interviews with 15 staff and their perceptions of the implementation of the OPSs as well as provincial and local documents.
Results:
The legislative process to implement OPSs was unprecedented as it sanctioned supervised injection services as an extraordinary measure under a declared public health emergency. Innovative and inclusionary practices were possible within state-sanctioned OPSs, as the sites were government-directed yet community-developed, with PWUD centred in service design, implementation and delivery. OPSs lack permanency and may be limited to the duration of the public health emergency.
Conclusion:
The rapid implementation of OPSs provides an international example of an alternative to lengthy and often onerous sanctioning processes for supervised consumption services (SCSs). Overdose prevention sites provide an example of a novel service design and nimble implementation process that combines the benefits of state-sanctioned injection services with community-driven implementation. Such evidence questions the continued acceptability of governments' restrictive sanctioning processes, which have limited expansion of SCSs internationally and the implementation of services that are not necessarily aligned with the needs of PWUD.
Background
The worldwide economic, health, and social consequences of drug use disorders are devastating. Injection drug use is now a major factor contributing to hepatitis C virus (HCV) transmission globally, and it is an important public health concern.
Methods
This article presents a narrative review of scientific evidence on public health strategies for HCV prevention among people who inject drugs (PWID) in Canada.
Results
A combination of public health strategies including timely HCV detection and harm reduction (mostly needle and syringe programmes and opioid substitution therapy) have helped to reduce HCV transmission among PWID. The rising prevalence of pharmaceutical opioid and methamphetamine use and associated HCV risk in several Canadian settings has prompted further innovation in harm reduction, including supervised injection facilities and low-threshold opioid substitution therapies. Further significant decreases in HCV incidence and prevalence, and in corresponding disease burden, can only be accomplished by reducing transmission among high-risk persons and enhancing access to HCV treatment for those at the greatest risk of disease progression or viral transmission. Highly effective and tolerable direct-acting antiviral therapies have transformed the landscape for HCV-infected patients and are a valuable addition to the prevention toolkit. Curing HCV-infected persons, and thus eliminating new infections, is now a real possibility.
Conclusions
Prevention strategies have not yet ended HCV transmission, and sharing of injecting equipment among PWID continues to challenge the World Health Organization goal of eliminating HCV as a global public health threat by 2030. Future needs for research, intervention implementation, and uptake in Canada are discussed.
Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field [1],[2], and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research [3], and some health care journals are moving in this direction [4]. As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews.
Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in four leading medical journals in 1985 and 1986 and found that none met all eight explicit scientific criteria, such as a quality assessment of included studies [5]. In 1987, Sacks and colleagues [6] evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in six domains. Reporting was generally poor; between one and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement [7].
In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials [8]. In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1).
Box 1: Conceptual Issues in the Evolution from QUOROM to PRISMA
Completing a Systematic Review Is an Iterative Process
The conduct of a systematic review depends heavily on the scope and quality of included studies: thus systematic reviewers may need to modify their original review protocol during its conduct. Any systematic review reporting guideline should recommend that such changes can be reported and explained without suggesting that they are inappropriate. The PRISMA Statement (Items 5, 11, 16, and 23) acknowledges this iterative process. Aside from Cochrane reviews, all of which should have a protocol, only about 10% of systematic reviewers report working from a protocol [22]. Without a protocol that is publicly accessible, it is difficult to judge between appropriate and inappropriate modifications.
Many legal scholars well recognize that, in some instances, support for a law or policy may be primarily because of its expressive
function, i.e. the statements it makes about underlying values. In these cases, the expressive content of a law or policy
may actually overshadow its central purpose. Examples of this phenomenon, according to Cass Sunstein, include, for example,
regulations against hate speech in the USA. He suggests that achieving the consequence (prohibiting hateful speech against
certain groups) may not be the real focus (central purpose) of the law. Rather, the real focus is on the social meaning of
these regulations—that bigotry is unacceptable in a liberal society. In this way, a particular law or policy can operate on
many levels—while aiming to achieve a particular objective or behavior, it can also be a valuable tool for achieving other
important social goals through its expressive function. This article applies this insight to the realm of public health policy,
with particular attention to the case of pandemic planning, and suggests that public health policy and its overall goals may
be well-served by deliberate regard for, and appropriate utilization of, the expressive function.
The morality policy framework is a lens for understanding the unique characteristics of policies that attempt to regulate personal morals and behaviors. Needle exchange, a controversial intervention for reducing the transmission of HIV in injection drug users, shares many of the hallmark characteristics of morality policies. Analyz-ing needle exchange from a morality policy perspective, focusing on the 21-year ban on federal funding for needle exchange, reveals how value-based arguments have been used in the needle exchange debate and explains why the issue is likely to remain controversial in the United States. This analysis adds to the understanding of moral and political aspects of U.S. HIV/AIDS prevention and care policies. Injection drug use is one of the main HIV transmission routes in the United States, contributing directly or indirectly to more than a third of new HIV infections since the beginning of the epidemic. It has been a key factor in the rising HIV preva-lence in women, with 58% of HIV positive women contracting the disease through injection drug use or sexual intercourse with drug users (Centers for Disease Control and Prevention, 2005). Early in the epidemic, needle exchange emerged as a solution for reducing the spread of AIDS and other diseases in injection drug users, based on the simple concept of providing participants with free, clean needles to use for every injection.
This contribution examines morality policies from the perspective of the comparative public policy literature. We analyse which concepts, theories and explanatory factors are useful given the peculiarities of this policy field. We answer the question to what extent morality policies are different by analysing these central aspects from a policy change perspective. In view of the identified problems in morality policy research, we suggest an alternative concept of measurement. It is based on the assumption that the constitutive cleavage underlying morality policies refers to a single dimension on which changes occur, namely, the degree of restrictiveness of a given regulatory provision. As such, this paper contributes to the emerging field of morality policy research by outlining future venues of research along with an overview of the different existing approaches.
Using the concepts of stigma, NIMBY and place, this paper examines the difficulties of finding a place for needle exchange programs (NEPs). Data were drawn from semi-structured interviews with NEP staff (Ontario, Canada) that focused on operational policies and routines. An iterative, inductive analytic process was used. NEPs, their staff and clients are not always welcome additions to organizations or communities because of concerns about the 'dangerousness' of clients and the potential contamination of communities and workplaces by stigmatized individuals and their artefacts (e.g. contaminated injection equipment). Public parks where a lot of drug 'action' takes place are good destinations for outreach workers but these places are contentious sites for NEP activities, particularly when residents do not perceive a need for the program and/or want to redefine their neighbourhoods. Issues of 'place' are further complicated when service delivery is mobile. Finding a place within organizations is difficult for NEPs because of concerns about the diversion of limited financial and spatial resources to 'non-core' activities and 'undesirable' clients. Workers respond to these challenges by contesting the social and spatial boundaries of who is an acceptable client or neighbour and refuting the perceived 'differentness' of injection drug users. Implementation of an unpopular service involves a delicate balancing act of interests, understanding of the dynamics of particular communities and a willingness to reinvent and redefine programs. The sociospatial stigmatization of injection drug use has had a negative impact on NEPs, and perhaps limits HIV prevention efforts.
The North American Opiate Medication Initiative (NAOMI) is a randomized controlled trial evaluating the feasibility and effectiveness
of heroin-assisted treatment (HAT) in the Canadian context. Our objective is to analyze the profile of the NAOMI participant
cohort in the context of illicit opioid use in Canada and to evaluate its comparability with patient profiles of European
HAT studies. Recruitment began in February 2005 and ended in March 2007. Inclusion criteria included opioid dependence, 5
or more years of opioid use, regular opioid injection, and at least two previous opiate addiction treatment attempts. Standardized
assessment instruments such as the European Addiction Severity Index and the Maudsley Addiction Profile were employed. A total
of 251 individuals were randomized from Vancouver, BC (192, 76.5%), and Montreal, Quebec (59, 23.5%); 38.5% were female, the
mean age was 39.7years (SD:8.6), and participants had injected drugs for 16.5years (SD:9.9), on average. In the prior month,
heroin was used a mean of 26.5days (SD:7.4) and cocaine 16days (SD;12.6). Vancouver had significantly more patients residing
in unstable housing (88.5 vs. 22%; p < 0.001) and higher use of smoked crack cocaine (16.9days vs. 2.3days in the prior month; p < 0.001), while a significantly higher proportion of Montreal participants reported needle sharing in the prior 6months
(25% vs. 3.7%; p < 0.001). In many respects, the patient cohort was similar to the European trials; however, NAOMI had a higher proportion
of female participants and participants residing in unstable housing. This study suggests that the NAOMI study successfully
recruited participants with a profile indicated for HAT. It also raises concern about the high levels of crack cocaine use
and social marginalization.
Debates about which policy initiatives can prevent or reduce the damage that illicit drugs cause to the public good are rarely informed by scientific evidence. Fortunately, evidence-based interventions are increasingly being identified that are capable of making drugs less available, reducing violence in drug markets, lessening misuse of legal pharmaceuticals, preventing drug use initiation in young people, and reducing drug use and its consequences in established drug users. We review relevant evidence and outline the likely effects of fuller implementation of existing interventions. The reasoning behind the final decisions for action might be of a non-scientific nature, focused more on what the public and policy-makers deem of value. Nevertheless, important opportunities exist for science to inform these deliberations and guide the selection of policies that maximise the public good.
Awareness of drug use in rural communities and small towns has been growing, but we know relatively little about the challenges injection drug users (IDUs) living in such places face in accessing harm reduction services. Semi-structured interviews were conducted with 115 IDUs in urban and non-urban areas of Atlantic Canada. In many instances, geographic distance to a needle exchange program (NEP) meant that individuals living outside of urban areas and who were not provided services through an NEP's outreach program were at a disadvantage in terms of an array of supports offered through many NEPs. These include access to free clean injecting equipment, and such ancillary services as clothing, food, referrals, information and social support. The integration of the services and approaches provided by NEPs into mainstream health services in non-urban places is one possible model for improving such access.
There is growing recognition, particularly in the areas of illicit drug policy and HIV prevention, that policy-makers are in many instances implementing suboptimal programs and services because they are not basing their decisions on the best available scientific evidence. One notable example where a policy-making body has failed to use scientific evidence to inform policy is the Canadian federal government's opposition to Vancouver's supervised injection facility despite a large body of scientific evidence indicating that the program is associated with a range of health and social benefits. Two of the key strategies that have been used to try to shift drug policy toward an evidence-based approach and maintain the operation of this evidence-based health facility are knowledge translation and legal actions. We provide an overview of these two strategies and hope it will offer lessons for the implementation of evidence-based approaches in other controversial areas of public policy.
In 2008, one of the oldest fixed site needle exchanges in a large urban city in Canada was closed due to community pressure. This service had been in existence for over 20 years.
This case study focuses on the consequences of the switch to mobile needle exchange services immediately after the closure and examines the impact of the closure on changes in risk behavior related to drug use, needle distribution and access to services The context surrounding the closure was also examined.
After the closure of the fixed site exchange, access to needle exchange services decreased as evidenced by the sharp decline in numbers of clients reached, and the numbers of needles distributed and collected monthly. Reports related to needle reuse and selling of syringes suggest changes in risk behaviors. Thousands of needles remain unaccounted for in the community. To date, a new fixed site has not been found.
Closing the fixed site needle exchange had an adverse effect on already vulnerable clients and reduced access to comprehensive harm reduction services. While official public policy supports a fixed site, politicization of the issue has meant a significant setback for harm reduction with reduced potential to meet public health targets related to reducing the spread of blood borne diseases. This situation is unacceptable from a public health perspective.
The United States is in the midst of a prolonged and growing epidemic of accidental and preventable deaths associated with overdoses of licit and illicit opioids. For more than 3 decades, naloxone has been used by emergency medical personnel to pharmacologically reverse overdoses. The peers or family members of overdose victims, however, are most often the actual first responders and are best positioned to intervene within an hour of the onset of overdose symptoms.
Data from recent pilot programs demonstrate that lay persons are consistently successful in safely administering naloxone and reversing opioid overdose. Current evidence supports the extensive scaleup of access to naloxone. We present advantages and limitations associated with a range of possible policy and program responses.
North America's first medically supervised safer injecting facility for illicit injection drug users was opened in Vancouver on Sept. 22, 2003. Although similar facilities exist in a number of European cities and in Sydney, Australia, no standardized evaluations of their impact have been presented in the scientific literature.
Using a standardized prospective data collection protocol, we measured injection-related public order problems during the 6 weeks before and the 12 weeks after the opening of the safer injecting facility in Vancouver. We measured changes in the number of drug users injecting in public, publicly discarded syringes and injection-related litter. We used Poisson log-linear regression models to evaluate changes in these public order indicators while considering potential confounding variables such as police presence and rainfall.
In stratified linear regression models, the 12-week period after the facility's opening was independently associated with reductions in the number of drug users injecting in public (p < 0.001), publicly discarded syringes (p < 0.001) and injection-related litter (p < 0.001). The predicted mean daily number of drug users injecting in public was 4.3 (95% confidence interval [CI] 3.5-5.4) during the period before the facility's opening and 2.4 (95% CI 1.9-3.0) after the opening; the corresponding predicted mean daily numbers of publicly discarded syringes were 11.5 (95% CI 10.0-13.2) and 5.4 (95% CI 4.7-6.2). Externally compiled statistics from the city of Vancouver on the number of syringes discarded in outdoor safe disposal boxes were consistent with our findings.
The opening of the safer injecting facility was independently associated with improvements in several measures of public order, including reduced public injection drug use and public syringe disposal.
North America's first government sanctioned medically supervised injection facility (SIF) was opened during September 2003 in Vancouver, Canada. This was in response to a large open public drug scene, high rates of HIV and hepatitis C transmission, fatal drug overdoses, and poor health outcomes among the city's injection drug users. Between December 2003 and April 2005, a representative sample of 1,035 SIF participants were enrolled in a prospective cohort that required completing an interviewer-administered questionnaire and providing a blood sample for HIV testing. HIV infection was detected in 170/1007 (17%) participants and was associated with Aboriginal ethnicity (adjusted Odds Ratio [aOR], 2.70, 95% Confidence Interval [95% CI], 1.84-3.97), a history of borrowing used needles/syringes (aOR, 2.0, 95% CI, 1.37-2.93), previous incarceration (aOR, 1.87, 95% CI, 1.11-3.14), and daily injection cocaine use (aOR, 1.42, 95% CI, 1.00-2.03). The SIF has attracted a large number of marginalized injection drug users and presents an excellent opportunity to enhance HIV prevention through education, the provision of sterile injecting equipment, and a supervised environment to self-inject. In addition, the SIF is an important point of contact for HIV positive individuals who may not be participating in HIV care and treatment.
Community activism can be important in shaping public health policies. For example, political pressure and direct action from grassroots activists have been central to the formation of syringe exchange programs (SEPs) in the United States.
We explored why SEPs are present in some localities but not others, hypothesizing that programs are unevenly distributed across geographic areas as a result of political, socioeconomic, and organizational characteristics of localities, including needs, resources, and local opposition. We examined the effects of these factors on whether SEPs were present in different US metropolitan statistical areas in 2000.
Predictors of the presence of an SEP included percentage of the population with a college education, the existence of local AIDS Coalition to Unleash Power (ACT UP) chapters, and the percentage of men who have sex with men in the population. Need was not a predictor.
It's about integrating individual clinical expertise and the best external evidenceEvidence based medicine, whose philosophical origins extend back to mid-19th century Paris and earlier, remains a hot topic for clinicians, public health practitioners, purchasers, planners, and the public. There are now frequent workshops in how to practice and teach it (one sponsored by the BMJ will be held in London on 24 April); undergraduate1 and postgraduate2 training programmes are incorporating it3 (or pondering how to do so); British centres for evidence based practice have been established or planned in adult medicine, child health, surgery, pathology, pharmacotherapy, nursing, general practice, and dentistry; the Cochrane Collaboration and Britain's Centre for Review and Dissemination in York are providing systematic reviews of the effects of health care; new evidence based practice journals are being launched; and it has become a common topic in the lay media. But enthusiasm has been mixed with some negative reaction.4 5 6 Criticism has ranged from evidence based medicine being old hat to it being a dangerous innovation, perpetrated by the arrogant to serve cost cutters and suppress clinical freedom. As evidence based medicine continues to evolve and adapt, now is a useful time to refine the discussion of what it is and what it is not.Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The …
Although considerable research has been conducted to identify the behavioural characteristics that predispose individuals to inject drugs or become infected with HIV via injection drug use, much less research has been conducted on structural and policy determinants, cultural norms, stigma, and ecological factors which may affect drug use risk behaviour, users' networks and HIV rates associated with drug use across geographic areas. For programme planners, whether official or grassroots, an understanding of place-based characteristics can help better identify risk environments to injection drug use-related HIV, and determine how to facilitate actions regarding public policy and harm reduction to aid in the reduction of risk. As such, we consider in this commentary the importance of geographic place and the socio-spatial and political processes related to place that may help determine where IDU-related HIV risk environments occur.
Covering a wide range of issues, the 22 cases included in Case Studies in Canadian Health Policy and Management constitute an exceptional resource for bringing real-life policy questions into the classroom. Based on actual events, the cases have been developed with input from mid-career professionals with strong field experience and extensively tested in Raisa B. Deber’s graduate case study seminar at the University of Toronto. Each case features both a substantive health policy issue and a selection of key concepts and methods appropriate to examining public policy, public health, and health care management issues. In each case, the authors provide a summary of the case and the related policy issues, a description of events, suggested questions for discussion, supporting information, and both works cited and further reading. Suitable for graduate and undergraduate classrooms in programs in a variety of fields, Case Studies in Canadian Health Policy and Management is an exceptional educational resource. This second edition features all new cases, as well as adding an introductory chapter that provides a framework and tools for health policy analysis in Canada.
Drug overdose death rates have increased steadily in the United States since 1979. In 2008, a total of 36,450 drug overdose deaths (i.e., unintentional, intentional [suicide or homicide], or undetermined intent) were reported, with prescription opioid analgesics (e.g., oxycodone, hydrocodone, and methadone), cocaine, and heroin the drugs most commonly involved . Since the mid-1990s, community-based programs have offered opioid overdose prevention services to persons who use drugs, their families and friends, and service providers. Since 1996, an increasing number of these programs have provided the opioid antagonist naloxone hydrochloride, the treatment of choice to reverse the potentially fatal respiratory depression caused by overdose of heroin and other opioids. Naloxone has no effect on non-opioid overdoses (e.g., cocaine, benzodiazepines, or alcohol) . In October 2010, the Harm Reduction Coalition, a national advocacy and capacity-building organization, surveyed 50 programs known to distribute naloxone in the United States, to collect data on local program locations, naloxone distribution, and overdose reversals. This report summarizes the findings for the 48 programs that completed the survey and the 188 local programs represented by the responses. Since the first opioid overdose prevention program began distributing naloxone in 1996, the respondent programs reported training and distributing naloxone to 53,032 persons and receiving reports of 10,171 overdose reversals. Providing opioid overdose education and naloxone to persons who use drugs and to persons who might be present at an opioid overdose can help reduce opioid overdose mortality, a rapidly growing public health concern.
Objectives: This study was designed to gather data on the implementation of community-based naloxone delivery for opioid overdose in a Canadian setting. Participants: A convenience sample of 50 clients accessing a needle exchange program for harm reduction supplies. Setting: This program took place in an urban Canadian city and was based out of a needle exchange program. Intervention: After written, informed consent was obtained, all participants were trained in overdose recognition, artificial respiration, naloxone administration and emergency medical services (EMS) activation. Outcomes: Most participants were male (30, 60%) and the average age was 45.1 years (±8.6 years). The majority (40, 80%) used opioids either daily (36, 72%) or weekly (4, 8%). Most (39, 78%) had experienced an overdose themselves and the vast majority (46, 92%) had witnessed someone else overdose. Over the 20-month study period, naloxone use was reported nine times. It was most often administered in a private residence (4, 44%). It was administered to another individual in eight cases; one person self-administered naloxone. Artificial respiration was provided in four cases, and a clean needle and syringe were used in all cases; EMS was activated in only one case. No adverse reactions and no deaths after naloxone use were reported. Conclusions: Community-based naloxone programs can be implemented in a Canadian setting and have the potential to reduce the morbidity and mortality associated with opioid overdose. Significant barriers to activating EMS still exist in this setting.
Drug consumption and gambling are regarded as morality policies, especially in the American literature. Both are perceived as sinful and treated accordingly. This highly generalized assessment is rarely analysed systematically in a non-American context. Therefore, we investigate whether these policies are indeed framed morally and if this framing is stable over time in two European countries. Next, we analyse whether shifts in morality framing have consequences for regulation. In this way,we contribute to the literature on morality policies, particularly the ways in which these policies are defined and empirically identified. We identify morality policies based on how actors frame issues rather than by policies' substantive content. We show that the morality framing was once prominent but has lost its importance over time, and we find a close connection between frame shifts and policy output, although this is not a uniform development and does not characterize all cases.
Despite the 2010 repeal of the ban on spending federal monies to fund syringe exchange programs (SEPs) in the U.S.A., these interventions--and specifically SEP site locations--remain controversial. To further inform discussions about the location of SEP sites, this longitudinal multilevel study investigates the relationship between spatial access to sterile syringes distributed by SEPs in New York City (NYC) United Hospital Fund (UHF) districts and injecting with an unsterile syringe among injectors over time (1995-2006). Annual measures of spatial access to syringes in each UHF district (N = 42) were created using data on SEP site locations and site-specific syringe distribution data. Individual-level data on unsterile injecting among injectors (N = 4,067) living in these districts, and on individual-level covariates, were drawn from the Risk Factors study, an ongoing cross-sectional study of NYC drug users. We used multilevel models to explore the relationship of district-level access to syringes to the odds of injecting with an unsterile syringe in >75% of injection events in the past 6 months, and to test whether this relationship varied by district-level arrest rates (per 1,000 residents) for drug and drug paraphernalia possession. The relationship between district-level access to syringes and the odds of injecting with an unsterile syringe depended on district-level arrest rates. In districts with low baseline arrest rates, better syringe access was associated with a decline in the odds of frequently injecting with an unsterile syringe (AOR, 0.95). In districts with no baseline syringe access, higher arrest rates were associated with increased odds of frequently injecting with an unsterile syringe (AOR, 1.02) When both interventions were present, arrest rates eroded the protective effects of spatial access to syringes. Spatial access to syringes in small geographic areas appears to reduce the odds of injecting with an unsterile syringe among local injectors, and arrest rates elevate these odds. Policies and practices that curtail syringe flow in geographic areas (e.g., restrictions on SEP locations or syringe distribution) or that make it difficult for injectors to use the sterile syringes they have acquired may damage local injectors' efforts to reduce HIV transmission and other injection-related harms.
This paper aims to clarify the meaning, and explain the utility, of the case study method, a method j often practiced but little understood. A "case study," I argue, is best defined as an intensive study of a single unit with an aim to generalize across a larger set of units. Case studies rely on the same sort of covariational evidence utilized in non-case study research. Thus, the case study method is correctly understood as a particular way of defining cases, not a way of analyzing cases or a way of modeling causal relations. I show that this understanding of the subject illuminates some of the persistent ambiguities of case study work, ambiguities that are, to some extent, intrinsic to the enterprise. The travails of the case study within the discipline of political science are also rooted in an insufficient appreciation of the methodological tradeoffs that this method calls forth. This paper presents the familiar contrast between case study and non-case study work as a series of characteristic strengths and weaknesses - affinities -rather than as antagonistic approaches to the empirical world. In the end, the perceived hostility between case study and non-case study research is largely unjustified and, perhaps, deserves to be regarded as a misconception. Indeed, the strongest conclusion to arise from this methodological examination concerns the complementarity of single-unit and cross-unit research designs.
Drug addiction is a major public health problem, one that is most acutely felt in major cities around the globe. Harm reduction and safe injection sites are an attempt to address this problem and are at the cutting edge of public health policy and practice. One of the most studied safe injection sites is INSITE located in Vancouver, British Columbia. Using INSITE as a case study, this paper argues that knowledge translation offers a limited framework for understanding the development of public health policy. This paper also argues that the experience of INSITE suggests that science and social justice, the meta-ideas that lie at the core of the public health enterprise, are an inadequate basis for a theory of public health policy making. However, on a more positive note, INSITE also shows the value of concepts drawn from the ways in which political science analyzes the policy process.
This article provides a historical perspective on the development of syringe exchange in Canada, the Canadian legal and policy context, evaluation and monitoring strategies, and current challenges facing HIV prevention efforts among injecting drug users. Despite the fact that it is legal to sell, exchange, or provide an IDU with a syringe and there are no laws in Canada requiring a physician's prescription to justify possession of a syringe, policy development and programming have not been adequate to hold HIV at bay in several cities across the country. Although there have been concerted efforts by syringe and needle exchange programs to increase the supply of injecting equipment, HIV prevalence continues to rise, provoking a rethinking of the role of syringe exchange. In a coordinated strategy for HIV prevention among drug users in Canada, needle and syringe exchange is not itself in question; however, ghettoization and needle quota systems may have had an adverse impact on prevention programming. A national action plan has been developed which aims to decentralize both methadone maintenance and syringe and needle exchange programs, increase access to detoxification and treatment modalities, and advocate for changes in the criminal justice system and law enforcement practices.
After a decade of steady diffusion in the drugs field, the harm reduction movement, posing pragmatic public health solutions based on empirical analysis, is still hindered by dissension and general confusion as to its underlying ideals. Despite having short-term political advantages, its 'value-neutral' style of discourse undercuts deeper moral foundations by attempts to forge the common ground in drug debates. Drawing on key statements in the literature and insights from interviews with leading Canadian drug policy observers, this commentary looks at rhetorical shortcomings that may act to encumber longer term harm reduction adoption and promotion.
Medical practices, clinical practice guidelines, clinical performance measures and measurements, and a variety of health care-related administrative decisions, such as insurance coverage decisions, are claiming to be "evidence based" with increasing frequency. In this paper we examine the "evidence based" label; discuss how evidence ought to have been assembled, evaluated, and synthesized; and when evidence is sufficient for the "evidence-based" moniker to rightfully apply. We also highlight several considerations other than the strength of evidence that are relevant to several common types of health care-related administrative decisions and that influence the extent to which the resulting decisions are truly evidence based.
Harm reduction is both a policy approach and used to describe a specific set of interventions. These interventions aim to reduce the harms associated with drug use. Employing a strict definition of harm reduction, evidence for the efficacy and effectiveness of alcohol, tobacco and illicit drug harm reduction interventions were reviewed. Systematic searches of the published literature were undertaken. Studies were included if they provided evaluation data (pre-post, or control group comparisons). More than 650 articles were included in the review. The majority of the literature concerned illicit drugs. For alcohol, harm reduction interventions to reduce road trauma are well-founded in evidence. Otherwise, there is limited research to support the efficacy and effectiveness of other alcohol harm reduction interventions. For tobacco, the area is controversial but promising new products that reduce the harms associated with smoking are being developed. In the area of illicit drugs there is solid efficacy, effectiveness and economic data to support needle syringe programmes and outreach programmes. There is limited published evidence to date for other harm reduction interventions such as non-injecting routes of administration, brief interventions and emerging positive evidence for supervised injecting facilities. There is sufficient evidence to support the wide-spread adoption of harm reduction interventions and to use harm reduction as an overarching policy approach in relation to illicit drugs. The same cannot be concluded for alcohol or tobacco. Research at a broad policy level is required, especially in light of the failure by many policy makers to adopt cost-effective harm reduction interventions.
North America's first official safe injection facility has begun to generate substantial evidence attesting to the harm reduction benefits of supervised injection. Reductions in morbidity, mortality, and crime rates have strengthened the resolve of local advocates and even influenced the views of some original detractors. Many status quo defenders are unwavering, however, in their condemnation of initiatives like InSite. The term 'drug den' has been used in right-wing media and some opponents of the programme say the evidence is biased. In their view, harm reduction advocates are really 'legalisers' in the guise of scientists and public health professionals. Providing services for people with drug problems sends the message that some use of drugs is normal, rather than affirming that drug use is the problem. Abstinence, prevention, and enforcement are the only acceptable and morally legitimate solutions. Harm reduction's muted stance on morals, rights and values prevents proponents from engaging criticisms of this nature in terms other than the evidence or science. The case of InSite in Vancouver, however, the authors argue, demonstrates the value of asserting human rights claims that do not rest on evidence per se. Scientific arguments are insufficient in themselves to move beyond the status quo on drugs. Rights-based moral warrants in support of harm reduction require far more extensive and explicit cultivation if they are to be discursively established and maintained.
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