Understanding policy persistence—The case of police drug detection dog policy in NSW,Australia

BackgroundSignificant research attention has been given to understanding the processes of drug policy reform. However, there has been surprisingly little analysis of the persistence of policy in the face of opposition and evidence of ineffectiveness. In this article we analysed just such a case – police drug detection dog policy in NSW, Australia. We sought to identify factors which may account for the continuation of this policy, in spite of counter-evidence and concerted advocacy.MethodsThe analysis was conducted using the Advocacy Coalition Framework (ACF). We collated documents relating to NSW drug detection dog policy from 1995 to 2016, including parliamentary records (NSW Parliament Hansard), government and institutional reports, legislation, police procedures, books, media, and academic publications. Texts were then read, coded and classified against the core dimensions of the ACF, including subsystem actors and coalitions, their belief systems and resources and venues employed for policy debate.ResultsThree coalitions were identified as competing in the policy subsystem: security/law and order, civil liberties and harm reduction. Factors that aided policy stability were the continued dominance of the security/law and order coalition since they introduced the drug dog policy; a power imbalance enabling the ruling coalition to limit when and where the policy was discussed; and a highly adversarial policy subsystem. In this context even technical knowledge that dogs infringed civil liberties and increased risks of overdose were readily downplayed, leading to only incremental changes in implementation rather than policy cessation or wholesale revision.ConclusionThe analysis provides new insights into why the accumulation of new evidence and advocacy efforts can be insufficient to drive significant policy change. It poses a challenge for the evidence-based paradigm suggesting that in highly adversarial policy subsystems new evidence is unlikely to generate policy change without broader subsystem change, such as reducing the adversarial nature and/or providing new avenues for cross-coalition learning.     

Canadian harm reduction policies: A comparative content analysis of provincial and territorial documents, 2000–2015

BackgroundAccess 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.MethodsSystematic 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.ResultsNationally, 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.ConclusionCanada 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.     

Peer,professional, and public: An analysis of the drugs policy advocacy community in Europe

BackgroundIn recent decades a range of advocacy organisations have emerged on the drugs policy landscape seeking to shape the development of policy at national and international levels. This development has been facilitated by the expansion of ‘democratic spaces’ for civil society participation in governance fora at national and supranational level. However, little is known about these policy actors – their aims, scope, organisational structure, or the purpose of their engagement.MethodsDrug policy advocacy organisations were defined as organisations with a clearly stated aim to influence policy and which were based in Europe. Data on these organisations was collected through a systematic tri-lingual (English, French and Spanish) Internet search, supplemented by information provided by national agencies in the 28 EU member states, Norway and Turkey. In order to differentiate between the diverse range of activities, strategies and standpoints of these groups, information from the websites was used to categorise the organisations by their scope of operation, advocacy tools and policy constituencies; and by three key typologies – the type of advocacy they engaged in, their organisational type, and their advocacy objectives and orientation.ResultsThe study identified over two hundred EU-based advocacy organisations (N = 218) which included civil society associations, NGOs, and large-scale alliances and coalitions, operating at local, national and European levels. Three forms of advocacy emerged from the data analysis – peer, professional and public policy. These groups focused their campaigns on practice development (harm reduction or abstinence) and legislative reform (reducing or strengthening drug controls).ConclusionThe findings from this study provide a nuanced profile of civil society advocacy as a policy community in the drugs field; their legitimacy to represent cases, causes, social values and ideals; and their focus on both insider and outsider strategies to achieve their goals. The level of convergence and divergence in Europe in relation to policy positions on service provision ethos and drug control regulation is indicated.     

The role of public health advocacy in preventing and reducing gambling related harm: challenges,facilitators, and opportunities for change

Background: Public health advocacy is important in preventing harm and promoting health in communities. There has been little research into public health advocacy strategies which address gambling related harms. This study aimed to identify the role of advocacy in gambling reform, challenges to gambling advocacy implementation, and strategies that could facilitate change.

Methods: Semi-structured qualitative interviews were conducted with a sample of 50 stakeholders with backgrounds in gambling policy, research, health promotion, and advocacy. Participants were asked about how advocacy could be used to address gambling harm, and the range of barriers and facilitators for effective advocacy responses. A constant comparative method of analysis was used on the data.

Results: While participants perceived that there was a role for advocacy in preventing and reducing gambling related harm, they discussed a range of challenges. These included restrictions associated with funding of research and services, the power of the gambling industry, and the role of stigma in preventing people with lived experience of gambling from speaking about their experiences. Participants also described a range of facilitators of public health advocacy approaches, including independent funding sources, reframing the ‘responsibility’ debate, developing opportunities and capacity for people with lived experience of harm, and developing broadly based coalitions to enable cohesive and consistent advocacy responses to gambling harm.

Conclusion: There is a clear role for public health advocacy approaches aimed at preventing and reducing gambling harm. Future research could identify how advocacy strategies may be implemented as a part of a comprehensive public health approach to gambling reform.     

Critical studies of harm reduction: Overdose response in uncertain political times

North America continues to witness escalating rates of opioid overdose deaths. Scale-up of existing and innovative life-saving services – such as overdose prevention sites (OPS) as well as sanctioned and unsanctioned supervised consumption sites – is urgently needed. Is there a place for critical theory-informed studies of harm reduction during times of drug policy failures and overdose crisis? There are different approaches to consider from the critical literature, such as those that, for example, interrogate the basic principles of harm reduction or those that critique the lack of pleasure in the discourses surrounding drug use. Influenced by such work, we examine the development of OPS in Canada, with a focus on recent experiences from the province of Ontario, as an important example of the impacts associated with moving from grassroots harm reduction to institutionalised policy and practice. Services appear to be most innovative, dynamic, and inclusive when people with lived experience, allies, and service providers are directly responding to fast-changing drug use patterns and crises on the ground, before services become formally bureaucratised. We suggest a continuing need to both critically theorise harm reduction and to build strong community relationships in harm reduction work, in efforts to overcome political moves that impede collaboration with and inclusiveness of people who use drugs.     

Syringe exchange in community pharmacies--The Portuguese experience

BackgroundSince 1993 the participation of Portuguese pharmacies to the national Syringe Exchange Programme (SEP) has remained high. However, no national guidelines or standard procedures are available regarding the provision of this service. We aimed to describe practices and attitudes toward syringe dispensing and other harm reduction strategies in Portuguese pharmacies.MethodsA cross-sectional survey was conducted using an anonymous self-administered questionnaire. All pharmacies in Portugal (n = 2775) were invited to participate. The questionnaire addressed SEP ever involvement and discontinuation; injection equipment policies; problems and needs in service provision.ResultsParticipation rates were 69.6% among pharmacies involved in SEP and 42.7% in those not involved in the programme. Among current providers, 64.3% followed a strict “one-for-one” policy and 21.6% established limits on the number of syringes distributed. Syringe selling was reported by 76.2%. One-tenth of pharmacies supervised methadone consumption Problems in service provision were experienced by 12.8% of respondents. Need for increased training and improvement of referral pathways were frequently reported.ConclusionsPharmacy-based harm reduction interventions in Portugal have tended to follow strict policies favouring conservative approaches. Training and feedback adaptation seem indispensable to avoid service discontinuation and boost an activity with an essential humanitarian dimension.     

Implementing harm reduction in non-urban communities affected by opioids and polysubstance use: A qualitative study exploring challenges and mitigating strategies

BackgroundHarm reduction services, which typically provide overdose education and prevention with distribution of naloxone and other supplies related to safer drug use, help reduce opioid-related overdose and infectious disease transmission. However, structural stigma and the ongoing criminalization of drug use have limited the expansion of harm reduction services into many non-urban communities in the United States that have been increasingly affected by the health consequences of opioid and polysubstance use.MethodsWe conducted qualitative interviews with 22 professionals working with people who use drugs in cities and towns across Rhode Island and Massachusetts to understand challenges and strategies for engaging communities in accepting harm reduction perspectives and services.ResultsOur thematic analysis identified several interrelated challenges to implementing harm reduction services in non-urban communities, including: (1) limited understandings of harm reduction practice and preferential focus on substance use treatment and primary prevention, (2) community-level stigma against people who use drugs as well as the agencies supporting them, (3) data reporting and aggregating leading to inaccurate perceptions about local patterns of substance use and related health consequences, and (4) a “prosecutorial mindset” against drug use and harm reduction. From key informants’ narratives, we also identified specific strategies that communities could use to address these challenges, including: (1) identifying local champions to advocate for harm reduction strategies, (2) proactively educating communities about harm reduction approaches before they are implemented, (3) improving the visibility of harm reduction services within communities, and (4) obtaining “buy-in” from a wide range of local stakeholders including law enforcement and local government.ConclusionThese findings carry important implications for expanding harm reduction services, including syringe service programs and safe injection sites, into non-urban communities that have a demonstrated need for evidence-based interventions to reduce drug-related overdose and infectious disease transmission.     

Advocacy for harm reduction in China: A new era dawns

BackgroundChina's initial response to drug use and HIV was largely ineffective but has improved with recent government endorsement of harm reduction interventions. This paper examines the views of senior key informants inside China who articulated core needs and objectives for the development of a harm reduction advocacy strategy.MethodsThirty-nine key informants (KI) were interviewed, representing 19 stakeholder bodies selected from the Chinese government public health sector, public security sector, international agencies such as WHO, UNODC and UNAIDS, and international non-government organisations.ResultsThe concept of harm reduction is widely understood and considered valid. Support for harm reduction is increasing, but KIs perceived an imbalance between the rapid expansion of methadone maintenance treatment programs over needle and syringe programs and other interventions. Challenges for harm reduction identified by KIs included: policy inconsistencies; lack of skilled resources, training programs and technical capacity; poor coverage of interventions; and gaps in the sharing of information. KIs suggested numerous ways to strengthen the capacity of the government and communities to reduce drug related harm.DiscussionIncreased acceptance of harm reduction in China, particularly among public security, implies a new level of optimism towards addressing the HIV epidemic among drug users, and parallels an impressive expansion of harm reduction interventions. Nevertheless, scaling up a response to the ongoing dual epidemic of drug use and HIV remains an enormous challenge. With appropriate technical education and training, ongoing advocacy, and a cohesive, coordinated multi-sectoral effort, the capacity of the government and community to adopt, support and promote measures to reduce HIV and other drug related harm would be markedly strengthened.     

Assessing support for supervised injection services among community stakeholders in London,Canada

ObjectivesFew qualitative studies have examined support for supervised injection services (SIS), and these have been restricted to large cities. This study aimed to assess support for SIS among a diverse representation of community stakeholders in London, a mid-sized city in southwestern Ontario, Canada.MethodsThis qualitative study was undertaken as part of the Ontario Integrated Supervised Injection Services Feasibility Study. We used purposive sampling methods to recruit a diversity of key informants (n = 20) from five sectors: healthcare; social services; government and municipal services; police and emergency services; and the business and community sector. Interview data, collected via one-to-one semi structured interviews, were coded and analyzed using thematic analyses through NVivo 10 software.ResultsInterview participants unanimously supported the implementation of SIS in London. However, participant support for SIS was met with some implementation-related preferences and/or conditions. These included centralization or decentralization of SIS; accessibility of SIS for people who inject drugs; proximity of SIS to interview participants; and other services and strategies offered alongside SIS.DiscussionThe results of this study challenge the assumptions that smaller cities like London may be unlikely to support SIS. Community stakeholders were supportive of the implementation of SIS with some preferences or conditions. Interview participants had differing perspectives, but ultimately supported similar end goals of accessibility and reducing community harms associated with injection drug use. Future research and SIS programming should consider these factors when determining optimal service delivery in ways that increase support from a diversity of community stakeholders.     

Exploring stakeholder perceptions of acceptability and feasibility of needle exchange programmes, syringe vending machines and safer injection facilities in Tijuana, Mexico

BackgroundInjection drug use is a growing public health crisis along the U.S.–Mexican border and rising rates of blood-borne infections highlight the pressing need for harm reduction interventions. We explored the acceptability and feasibility of such interventions in Tijuana, a city adjacent to San Diego, California.MethodsUsing in-depth qualitative interviews conducted from August 2006–March 2007 with 40 key stakeholders – pharmacists, legal professionals, health officials, religious officials, drug treatment providers, and law enforcement personnel – we explored the acceptability and feasibility of interventions to reduce drug-related harm in Tijuana, Mexico. Interviews were taped with consent, transcribed verbatim, and translated. Content analysis was conducted to identify themes which included barriers, structural limitations, and suggestions for implementation.ResultsTopics included acceptance and feasibility of needle exchange programmes (NEPs), syringe vending machines, and safer injection facilities (SIFs), structural barriers and suggestions for implementation. Of these interventions, NEPs were deemed the most acceptable (75%); however, only half believed these could be feasibly implemented, citing barriers involving religion, police, and lack of political will, public awareness, and funding.ConclusionsIncreasing HIV infection rates among injection drug users in Tijuana have prompted interest in public health responses. Our results may assist policy strategists in implementing social-structural interventions that will help create enabling environments that facilitate the scale-up and implementation of harm reduction in Tijuana.     

The politics of harm reduction in federal prisons

BackgroundWe need to understand better the political barriers to prison-based harm reduction programs. In this paper, I examine the situation in the Correctional Service of Canada (CSC), a federal prison agency with a zero-tolerance drug policy and general opposition to prison needle and syringe programs (PNSPs) and safer tattooing initiatives.MethodsThis study draws on 16 interviews with former CSC senior officials, former frontline staff, and external stakeholders; CSC policy and practice documents; and testimony from a House of Commons Standing Committee public study. Thematic coding and comparison of texts were used to examine emergent themes of interest.ResultsFour interrelated issues were central for understanding the political barriers: a narrower definition of harm reduction used in corrections, both in principle and practice; the Conservative government's tough-on-crime agenda; strong union opposition; and stakeholder perceptions that political constraints will likely persist, including the view that litigation may offer the only way to introduce PNSPs.ConclusionThe system is at an impasse and key questions remain about the importability of harm reduction services into federal prisons. Despite a highly challenging policy environment, moving forward will demand asking new, critical questions and devising more strategic ways of entering the political-operational dialogue that opposes evidence-based programs.     

A clash of policy approaches: The rise (and fall?) of Dutch harm reduction policies towards ecstasy consumption

This paper describes the origins and evolution of Dutch harm reduction policies towards ecstasy. It is argued that the national government has allowed and supported local stakeholders to experiment with harm reduction measures. In the mid-1990s, the national government officially stated that the harm reduction practices developed on a local level represented the best possible solution to prevent harm. However, recently, harm reduction policy has come under pressure due to a variety of developments. The paper argues that the bottom-up approach of the Dutch government is no longer pursued because international pressure helps law enforcement agencies as well as conservative political parties to restructure ecstasy policy in a top-down and law enforcement direction. This process is underway but it has not yet fully eroded the structures that have instantiated harm reduction policies in the last decade.     

‘It's our safe sanctuary’: Experiences of using an unsanctioned overdose prevention site in Toronto,Ontario

BackgroundOverdose prevention sites (OPSs) are spaces where people can consume drugs under the supervision of trained volunteers or staff and receive help in the event of an overdose. Unsanctioned OPSs are a grassroots response to the current opioid crisis in Canada.MethodsWe used rapid evaluation methods to study the experiences of 30 individuals accessing the smoking and injection services at the first unsanctioned OPS in Toronto, Ontario using semi-structured interviews. Data were analyzed using an applied thematic analysis approach to identify emergent themes related to service user experiences, characteristics of the risk environment, and recommended changes to the service model.ResultsThe OPS represented a safe sanctuary and brought a sense of belonging to a community that often experiences discrimination. Valued aspects included: shelter; protection from violence; safety from overdoses; free equipment; information about health and social services; food and beverages; and socializing and connecting with others. Integrating peer workers in the design and delivery of services encouraged service users to visit the site. The OPS changed the risk environment by: providing access to the first supervised smoking service in Toronto; having few explicit rules and a communal approach to making new rules; allowing assisted injection, and negotiating with police to allow people to access the site with minimal contact. Service users noted the need to ensure a safe space for women and recommended extended hours of operation and moving to a more permanent space with heat and lighting for both smoking and injecting drugs.ConclusionThe unsanctioned OPS in Toronto served an important role in defining new, community-led, flexible responses to opioid overdose-related deaths at a time of markedly increasing mortality. Providing harm reduction services in diverse settings and expanding services to include smoking and assisted injection may increase access for marginalized people who use drugs.     

“Like being put on an ice floe and shoved away”: A qualitative study of the impacts of opioid-related policy changes on people who take opioids

AimsTo characterize the impacts of policies intended to improve opioid prescribing and prevent opioid-related overdose and death on individuals who take opioids.MethodsWe conducted a qualitative study using focus groups with 48 adults aged 18 years and over who had experience taking opioids. Participants were recruited from across Ontario, Canada, and separate focus groups were held for individuals taking opioids for chronic pain and individuals taking opioids for other reasons. We drew upon stigma theory to interpret participants’ accounts.ResultsFollowing analysis and interpretation, we generated three themes describing the impacts of recently implemented opioid-related policies and harm reduction interventions on people who take opioids: ‘propagating stigma: addict as dominant status’, ‘loss of autonomy’ and ‘producing/reproducing structural vulnerabilities’. Specifically, participants characterize an environment in which ‘addict’ has become the dominant social identity ascribed to people who take opioids, and where relationships with providers have become strained as participants perceive themselves to be powerless when decisions regarding opioid use and pain management are made. These shifts in identity and relationships had negative repercussions when help-seeking and exposed larger vulnerabilities related to poverty and criminalization.ConclusionsThe introduction of opioid-related policies had unintended consequences for people who take opioids. Potential measures for mitigating these consequences include ensuring that people who take opioids are involved in all facets of policy development and implementation, integrating peer workers into the care of these individuals, and respecting patient agency when decisions about pain management and opioid use are made.     

Framing and scientific uncertainty in nicotine vaping product regulation: An examination of competing narratives among health and medical organisations in the UK,Australia and New Zealand

AimsTo compare the policy positions of health and medical organisations across Australia, New Zealand, and the UK as they relate to sale and supply of nicotine vaping products (NVPs) and evaluate factors that have informed the differences in policy recommendations among these countries.MethodsWe used mixed methods to analyse data from position or policy statements published by health and medical organisations regarding NVPs (n = 30) and consultation documents submitted to government committees regarding policy options for the regulation of NVPs (n = 26). Quality assessment of included documents was conducted using the six-item Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Text and Opinion Papers, and findings were presented narratively. Qualitative data were coded using NVivo 12 software and analysed using thematic analysis.ResultsAn overwhelming majority of health bodies, charities and government agencies in the UK and New Zealand portrayed NVPs as a life-saving harm reduction tool. In contrast, concerns about addicting non-smoking youth to nicotine, a perceived lack of clear and convincing evidence of safety and efficacy and the potential to undermine tobacco control progress continues to define attitudes and recommendations towards NVPs among Australian health and medical organisations. Although the profoundly divided views among stakeholders seem to arise from empirical uncertainties and disagreements over the level and credibility of evidence, the source of most of these disagreements can be traced back to the fundamental and irreconcilable differences in the framing of the NVP debate, and varied tolerability of risk trade-offs associated with NVPs.ConclusionProgress in resolving the controversy surrounding NVP policy requires stakeholders to be frame-reflective and engage in a meaningful dialogue of risk trade-offs, as well as both intended and unintended consequences of proposed policies.     

Extra-legal policing strategies and HIV risk environment: accounts of people who inject drugs in Nigeria

Abstract

This article reports on an exploratory qualitative study investigating extra-legal policing practices and HIV vulnerability among injecting drug users. It draws upon thematic analysis of interview accounts of 29 street-involved PWID, recruited through snowball sampling in Uyo, Nigeria. The data emphasized that policing is a structural mechanism perpetuating drug-related harms and social suffering in the lives of PWID. Policing strategies, including searches, violence and confiscation of sterile needles and syringes, reproduce an environment of fear that undermines risk reduction and contributes to HIV risk via injecting in risky settings and receptive syringe sharing. Accounts highlighted humiliations, labeling and other expressions of contempt as forms of ‘moral policing’, which reinforce stigma and sanction human rights violations. Extra-legal policing practices, including violence, extortion and sexual harassments, adversely affect health and well-being. This raises questions about the effectiveness and legitimacy of policing and highlights a social justice perspective that may contribute to the reduction of health inequalities for PWID. It also provides a social justice and human rights rationale for advocacy for policy reforms, safe injection sites, needle and syringe distribution, oral drug substitution programs and rights-based, public health-oriented policing that enable access to harm reduction services for PWID.     

Police Perceptions of Supervised Consumption Sites (SCSs): A Qualitative Study

Police are key stakeholders in cities considering supervised consumption site (SCS) implementation. We examine police perceptions of SCSs using data collected between 2008 and 2010. Data from interviews and focus groups conducted with police officers of varied ranks (n = 18) in Ottawa and Toronto, Canada, were analyzed using thematic analyses. Participants opposed SCS implementation in their respective cities. The police views we heard invoke values and perspectives on evidence that differ from those used in research. Whether these divergent frameworks are reconcilable is a question for future research. Study limitations are noted. The Ontario HIV Treatment Network funded the study.     

Experience of harm from others’ drinking and support for stricter alcohol policies: Analysis of the Australian National Drug Strategy Household Survey

BackgroundPrevious research indicates that those who have experienced alcohol-related harm from others are more likely to support stricter alcohol control policies. This study investigates the association between types of harm experienced because of others’ drinking and support for stricter alcohol control policies.MethodsData from 20,570 Australians aged 18 and over who completed the 2013 National Drug Strategy Household Survey was used. Questions about experience of alcohol-related harm from others – being put in fear and abuse (verbal or physical) – were asked. Support for stricter alcohol control policies was quantified by a mean policy support score across 18 alcohol policy questions.ResultsTwenty seven percent of respondents reported harm from someone’s drinking. Respondents who were put in fear had a higher level of support for stricter alcohol control policies than respondents who were not harmed (p < 0.001), regardless of whether they were abused or not. Conversely, respondents who experienced abuse but were not put in fear did not significantly differ in their support for stricter policies from those who experienced no harm.ConclusionIt is the apprehension of harm (i.e. having been put in fear), and not the experience of harm itself (i.e. abuse), which is related to people’s support for stricter alcohol policies. These findings suggest that perceiving others’ intoxication as dangerous to oneself may motivate support for stricter alcohol policies.