Revisioning women and drug use: gender sensitivity, embodiment and reducing harm

The purpose of this paper is ‘to revision’ our approach to women's use of drugs – which means to let go of how we have seen in order to construct new perceptions. Women use a variety of substances for a range of reasons, including pleasure. Yet, women who experience problems are left feeling stigmatised, marginalised and demoralised. The paper includes three inter-related discussions. First, two co-existing approaches to drug use, the classical and the postmodern, are explained. Second, after demonstrating how the postmodern approach is more valuable for the development of a gender-sensitive perspective, I will, with special reference to drug use, explain the complexities of two contemporary concepts, gender and embodiment. Here, I attempt to generate a deeper appreciation of these concepts in the postmodern approach. Third, I ask, ‘How can we develop a gender-sensitive, harm reduction approach’? The contention is that while harm reduction philosophies are admirable, these need to be gender-sensitive in order to be effective. A multi-levelled, ‘gender-sensitive’ view of harm reduction is put forward, as harm reduction is examined at the subjective, treatment, relationship, occupational and leisure levels.     

Casting light on harm reduction: Introducing two instruments for analysing contradictions between harm reduction and ‘non-harm reduction’

Background: Harm reduction is commonly regarded as complementary to other drug problem responses—as the fourth tier. Yet even core examples of harm reduction such as the provision of injection equipment and methadone treatment have over and over encountered considerable opposition, and harm reduction in its more comprehensive forms continuously stirs up controversy. In spite of this the notion of complementarity is commonly upheld leaving opposition to harm reduction inexplicable and non-researchable. Methods: Teaching experience in multiple settings in which opposing views have surfaced and a review of relevant literature on contradictions involved in drug policy debates have been utilized to analyse and summarize policy contradictions involved implicitly or explicitly in disagreements on harm reduction. Results: Analysing contradictions is a difficult endeavour, but many opposing views appear if you approach the task systematically. For this purpose two instruments have been constructed: ‘The Harm Reduction Inventory’ (25 items) and ‘The Drug Policy Propensity Index’ (11 items). These tentative instruments are presented in full and their potentials are discussed. Conclusion: Harm reduction may in fact represent goals, methods, priorities and understandings which are to a considerable extent at odds with the opposite of harm reduction – here termed ‘non-harm reduction’. This insight may be overlooked if assuming complementarity. To describe and analyse harm reduction by way of juxtaposing opposites seems a feasible and illuminative approach. The instruments provided could perhaps facilitate better understanding of conflicts of vision and contribute towards illuminating policy barriers.     

Drug use, risk and urban order: examining supervised injection sites (SISs) as ‘governmentality’

This paper problematises the emergence and functioning of the recent phenomenon of ‘supervised injection sites’ (SISs) as a case study of post-welfarist governmentality. We propose that SISs arose as an unprecedented intervention in the late 20th century to deal with the increasing challenge of ‘urban drug scenes’ towards public order interests ‘entrepreneurial city’. Under predominant discourses of ‘public health’ and ‘harm reduction’, SISs became possible within a wide variety of political interests as a technology for purifying public spaces of ‘disorderly’ drug users to present the ‘new city’ as an attractive consumption space. Thus, SISs can be meaningfully understood as one element of socio-spatial ‘exclusion’ of marginalised populations from urban cores to ghettoised, peripheral spaces, even as they more benignly seek to better meet the unique needs of drug user populations. Further, the inner workings of SISs illustrate these facilities as powerful surveillance and discipline sites, defining the drug user as an agent of omnipresent risk being responsibilized in the care of the self and body, but also multiple aspects of behaviour and lifestyle reaching beyond drug use; thus construing the drug user as a ‘normalised’ citizen/consumer. We suggest that pressures to answer to powerful interests promoting ‘order’ are concretised as practices of ‘risk management’ ‘on the shop floor’, raising serious questions about the extent to which the ability to meet user needs is compromised in the interest of social control, surveillance, ‘management’, ‘education’, and ‘rehabilitation’, particularly in the current socio-political context (characterised as it is by a persistence, and indeed concomitant hardening, of repressive measures ‘on the street’).     

Drug use as a ‘practice of the self’: is there any place for an ‘ethics of moderation’ in contemporary drug policy?

This paper offers a series of critical interrogations of the principles and practice of harm minimisation. This critique draws from Michel Foucault's account of ethics, pleasure and moderation in pointing to some significant gaps and conceptual problems within Australia's National Drug Strategy. I argue that this strategy has had only indirect impacts upon the ways in which illicit drugs are consumed in Australia, and on the behaviour of individual users. Part of this problem lies in the ways in which the cultures and the contexts of illicit drug use have been conceptualised within contemporary drug policy. Following Foucault, I argue that drug use ought to be conceptualised as a distinctive ‘practice of the self’. I argue further that Foucault's work on pleasure and ethics offers important new ways of understanding the changing nature of drug use for young people, as well as providing new conceptual bases for the design and delivery of harm minimisation strategies within those settings and contexts in which drug use takes place.     

Living with addiction: The perspectives of drug using and non-using individuals about sharing space in a hospital setting

Hospitals seem to be places where harm reduction approaches could have great benefit but few have responded to the needs of people who use drugs. Drawing on recent theoretical contributions to harm reduction from health geography, we examine how the implementation of harm reduction is shaped by space and contested understandings of place and health. We examine how drug use and harm reduction approaches pose challenges and offer opportunities in hospital-based care using interview data from people living with HIV and who were or had recently been admitted to a hospital with an innovative harm reduction policy. Our data reveal the contested spatial arrangements (and the related practices and corporeal relations) that occur due to the discordance between harm reduction and hospital regulatory policy. Rather than de-stigmatising drug use at Casey House Hospital, the adoption of the harm reduction policy sparked inter-client conflict, reproduced dominant discourses about health and drug users, and highlights the challenges of sharing space when drug use is involved. The hospital setting produces particular ways of being for people who use and those who do not use drugs and the demarcation of space in a drug using context. Moving forward, harm reduction practice and research needs to consider more than just interactions between drug users and healthcare providers, or the role of administrative policies; it needs to position ethics at the forefront of understanding the collisions between people, drug use, place, and space. We raise questions about the relationship between subjectivity and spatial arrangements in mediating the success of harm reduction.     

Self and community based opioid substitution among opioid dependent populations in the Indian sub-continent

The phenomena of ‘traditional’ drug use in Asia has been well documented since the presence of the British in the region. Substances such as cannabinoids and opioids have found their way to Western markets at substantial profit margins and this resulted in international pressure for supply reduction and crop eradication measures. In Asia traditional forms of opioids gave way to the manufacture of heroin in the Golden Triangle and the Golden Crescent regions. The purity of the heroin manufactured in the SE Asian region, as well as the reduced availability of opium products resulted in the switch to a more cost effective mode of use. Hong Kong (1950s) first saw a shift, (Crofts, 1995), from smoking to injecting of heroin with Thailand (1960s), Laos (1970s) and North East India (1980s) following suit. The cruder products from the Golden Crescent region were more suited to ingestion through inhalation and by the mid 1980’s, cheap and abundant supplies of brown sugar flooded the Indian markets.     

Anxiety and containment in the risk society: theorising young people and drug prevention policy

This paper sets out to make sense of government responses to young people and drug use through an application of some central concepts arising from the work of Ulrich Beck and risk society theory. It is primarily concerned with recent universal and targeted drug prevention initiatives in the UK. With regard to universal educational and health promotion, it is argued that initiatives have struggled to define their communicative rationality in the context of young people's changing social encounter with drugs. Policy-based initiatives have also become increasingly expansive in nature as they seek to contain a complex and contested social risk environment. Yet, in so doing they encounter operational difficulties associated with ‘manufactured risks’. Meanwhile, targeted drug prevention has become increasingly driven by the science of risk and vulnerability. However, rather than managing hazards, both ‘risk science’ associated policy-based interventions encounter definitional problems and system-generated risks associated with their praxis. Government agencies have, in turn, responded through introducing formalized systems for co-ordination and the responsibilisation of an increasing range of actors. Notwithstanding some difficulties, it is suggested therefore that risk society theory elucidates some of the conflicts and instabilities that underlie contemporary young people and drug prevention policy.     

If supply-oriented drug policy is broken, can harm reduction help fix it? Melding disciplines and methods to advance international drug-control policy

Critics of the international drug-control regime contend that supply-oriented policy interventions are not just ineffective, but, in focusing almost exclusively on supply reduction, they also produce unintended adverse consequences. Evidence from the world heroin market supports their claims. The balance of the effects of policy is yet unknown, but the prospect of adverse consequences underlies a central paradox of contemporary supply-oriented policy. In this paper, we evaluate whether harm reduction, a subject of intense debate in the demand-oriented drug-policy community, can provide a unifying foundation for supply-oriented drug policy and speak more directly to policy goals. Our analysis rests on an extensive review of the literature on harm reduction and draws insight from other policy communities’ disciplines and methods. First, we explore the paradoxes of supply-oriented policy that initially motivated our interest in harm reduction; second, we consider the conceptual and technical challenges that have contributed to the debate on harm reduction and assess their relevance to a supply-oriented application; third, we examine responses to those challenges, i.e., various tools (taxonomies, models, and measurement strategies), that can be used to identify, categorize, and assess harms. Despite substantial conceptual and technical challenges, we find that harm reduction can provide a basis for assessing the net consequences of supply-oriented drug policy, choosing more rigorously amongst policy options, and identifying new options. In addition, we outline a practical path forward for assessing harms and policy options. On the basis of our analysis, we suggest pursuing a harm-based approach and making a clearer distinction between supply-oriented and supply-reduction policy.     

The relationship of illicit drug use to HIV-infection among commercial sex workers in the city of Santos, São Paulo, Brazil

Objective: To assess the role of illicit drug use as a risk factor of HIV infection among female commercial sex workers (CSWs) in the city of Santos, Brazil. Design: Cross-sectional survey of 697 chain-referred CSWs. Methodology: The study included information on social-demographic characteristics, sexual practices and use of illicit drugs. Blood samples were tested for HIV. Associations between the response variable and drug-related variables, controlling for potential confounders, were assessed through multiple logistic regression procedures. Results: The univariate analyses for all drug-related variables evidenced that ‘use of injecting drugs’ (odds-ratios (OR)=10.9) and ‘use of crack in the previous month’ (OR=9.0), were the two variables most highly associated to the outcome. The multivariate analysis emphasized the role of crack use, the first variable included in the stepwise procedure (adjusted OR=5.3, P=0.0001). Other relevant predictors were ‘educational level’ (P=0.0003), ‘practice of anal intercourse with customers’ (P=0.0031), ‘use of injecting drugs’ (adjusted OR=3.1, P=0.0647), ‘age at first intercourse’ (P=0.0188) and ‘age’ (P=0.0175). Additional multivariate results showed that crack-users tend to use other drugs simultaneously, to agree more frequently to have unprotected sex and to earn a significantly smaller payment per sexual encounter than crack non-users. Conclusions: The analysis showed the vulnerability of CSWs in relation to drug use, lack of education and unprotected sex. These findings highlight the need for preventive programs focused on the general use of drugs in this population as well as efforts to help CSWs to acquire educational and professional skills.     

‘We realised we needed a new approach’: Government and law enforcement perspectives on the implementation and future of the drug decriminalisation policy in vietnam

In 2009, Vietnam officially decriminalised drug use through amendments to the criminal law. The amendments outlined explicitly that illicit drug use would be seen as an administrative violation, but not a criminal offence. This legal transition has not been without implementation challenges, and police particularly have struggled to find a balance between drug law enforcement and decriminalisation. Despite being a health-orientated drug policy amendment, in practice it allows police to send suspected drug users to compulsory treatment centres without judicial oversight and people who use drugs continue to face challenges in their interface with law enforcement which can negatively impact access to harm reduction and community-based treatment programs. Using policy desk research combined with indepth interviews with 14 key informants from people representing a range of relevant Vietnamese government (n = 10) and non-government agencies (n = 4), this paper explores some insights and considerations into how decriminalisation of drug use in the amended law was implemented. We explore key informant perspectives into how the decriminalisation amendment could be implemented more effectively in order to improve health outcomes for people who use drugs in Vietnam through re-envisioned police protocols and practices. Findings show that while decriminalising drug use in Vietnam was designed as a progressive and health-orientated drug policy, the ongoing disconnect between the health intent of the policy and the police-led oversight of its implementation in the community persists. Part of this disconnect is explained by the lack of training and clear protocols that would enhance the police in their ability to contribute to the health intent of the policy rather than continue to view drug use through a drug law enforcement only lens. The paper calls for further collaboration across policing and the health and community-based organisations delivering services for people who use drugs. We suggest that through developing a deeper understanding of the interplay between policing and the implementation of harm reduction policy and programs, decriminalisation can co-exist within a broader and deeply entrenched drug control strategy in Vietnam.     

Insights in the application of research-grade diagnostic kits for biomarker assessments in support of clinical drug development: bioanalysis of circulating concentrations of soluble receptor activator of nuclear factor kappaB ligand

Application of research-grade diagnostic kits in clinical drug development has grown commensurate with the increased interest in utilization of biomarkers as drug development tools. Since novel biomarkers are frequently macromolecular, immunoassay methodology comprises the ‘technology-of-choice’ for biomarker quantification. In particular, commercial research-grade immunoassay kits are appealing for use in biomarker quantification during clinical phase drug development because of their ready availability, ease of operation and perceived convenience. However, bioanalytical validation issues arise often during the application of commercial kits, as GLP regulatory-compliant application places greater demands on kit design and performance. In this review, we have used the receptor activator of nuclear factor κB ligand (RANKL) as a model system to offer some insights into the challenges that can be encountered in the application of ‘research-grade’ diagnostic kits in support of clinical drug development.Currently only a few assays are available commercially for the determination of circulating concentrations of sRANKL. Of these, two immunoassay designs have been most often. The first design employs human osteoprotegerin to capture unbound sRANKL from serum and, thereby, provides a measure of circulating free concentrations. In contrast, the other common assay design first involves preincubation of serum samples with human osteoprotegerin to convert the free fraction of sRANKL to the osteoprotegerin-bound complex. The bound fraction is subsequently captured by an anti-osteoprotegerin antibody. In both immunoassay designs, detection is accomplished with an anti-sRANKL enzyme conjugation system. In this report we review these sRANKL immunoassay designs critically from the perspective of their potential suitability as drug development biomarker tools. In addition, analytical challenges relevant to the application of these ‘research-grade’ diagnostic kits for regulatory-compliant determination of sRANKL concentrations are discussed.     

Young people and drugs: Next generation of harm reduction

Globally, young people under 25 accounted for an estimated 45% of all new HIV infections in 2007. Across the Eastern Europe and Central Asia region as many as 25% of injecting drug users (IDUs) are younger than 20. The Eurasian Harm Reduction assessment of young peoples’ (under 25) drug use, risk behaviours and service availability and accessibility confirms, young people at risk of injecting, or those already experimenting with injecting drugs, find themselves isolated from health and prevention services, which increases the risks for health and social harms, while the approach towards young peoples’ use rely heavily on law enforcement. Denying young drug users’ access to life-saving drug treatment and other harm reduction services contributes to the risk environment surrounding their use and violates their right to health and well-being as identified in the Convention on the Rights of the Child. Governments, health care providers and harm reduction services should work together to create an environment in which young people can access needed services, including non-judgmental and low-threshold approaches offered by harm reduction programs.     

‘An Irish solution to an Irish problem’: Harm reduction and ambiguity in the drug policy of the Republic of Ireland

While policy makers in the Republic of Ireland had been concerned with illicit drug use since the late-1960s, it was only from 1980 onwards that the emergence of a culture of intravenous heroin use in areas of generalised social deprivation in Dublin gave urgency to this policy process. This paper traces the gradual introduction, on public health grounds, of harm reduction practices and services – such as methadone maintenance, needle exchange and the creation of outreach and locally-based services – following the identification in the mid-1980s of needle-sharing amongst injecting drug users as one of the key routes for the transmission of HIV in this country. It is argued that harm reduction in the Republic of Ireland has been largely implicit, in the sense that political leaders have generally not encouraged or participated in explicit public debate on this topic, nor have they ever publicly announced that this concept now underpins much of the healthcare system's responses to illicit drug use. It is also argued that this covert style of policy making has persisted, despite the more recent proliferation of formal policy-making structures and the dominance of a rhetoric which emphasises strategic management and the allegedly transparent and evidence-based nature of drug policy. This tactic of shrouding drug policy in ambiguity is discussed in the context of the wider tendency within Irish political culture to manage sensitive and potentially divisive social issues in such a manner. It is concluded that the ambiguity which surrounds harm reduction in Ireland has been functional in that it has confused and frustrated ideological opponents of this concept, but dysfunctional in that it has not facilitated the emergence of more tolerant or respectful attitudes towards drug users and may have delayed the introduction of a wider range of harm reduction practices.     

Harm reduction programmes in the Asia--Pacific Region

INTRODUCTION AND AIMS: This paper reports on the public health intervention of harm reduction to address drug use issues in the Asia-Pacific region. DESIGN AND METHODS: It is based on the report 'Situational analysis of illicit drug issues and responses in Asia and the Pacific', commissioned by the Australian National Council on Drugs Asia Pacific Drug Issues Committee. A comprehensive desk-based review based on published and unpublished literature and key informant data. RESULTS: Drug use in the Asia--Pacific region is widespread, resulting in serious adverse health consequences. Needle and syringe programmes are found in some parts of Asia, but not in the six Pacific Island countries reviewed. Outreach and peer education programmes are implemented, but overall appear minor in size and scope. Substitution therapy programmes appear to be entering a new era of acceptance in some parts of Asia. Primary health care specifically for drug users overall is limited. DISCUSSION AND CONCLUSIONS: Harm reduction programmes in the Asia--Pacific region are either small in scale or do not exist. Most programmes lack the technical capacity, human resources and a limited scope of operations to respond effectively to the needs of drug users. Governments in this region should be encouraged to endorse evidence-based harm reduction programmes.     

江苏省某胸部专科医院肺癌治疗的原研药与仿制药利用分析

目的：在加速仿制药替代的背景下,提出促进仿制药使用的政策建议。方法：选取江苏省某胸部专科医院治疗肺癌的8种既有原研药也有仿制药的品种,按季度分析2018年1月至2020年6月原研药和仿制药使用量占比、使用金额占比、价格比,以及2019年6月至2020年6月执行集中采购前后仿制药替代潜在的费用节省率。结果：2018年第1季度至2020年第2季度,原研药、仿制药使用数量占比分别由22.38%下降至14.26%、77.62%上升至85.87%,使用金额占比分别由39.43％下降至21.56％、60.57％上升至78.44％,仿制药与原研药价格比从2.08上升至2.75。在执行集中采购后,仿制药替代原研药潜在可节约费用1 061 254.51元,费用节省率为55.93％。结论：随着仿制药相关政策的推进,仿制药使用数量和金额占比都在上升,仿制药替代确有降低药品费用支出的作用。因此,加快仿制药一致性评价,同时配合仿制药政策的宣传,着力提高医患对仿制药的认同,再通过集中采购政策,可以促进仿制药利用以节约医疗资源。     

A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs

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. [Ritter A, Cameron J. A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs. Drug Alcohol Rev 2006;25:611 - 624]     

Defining harm reduction

Harm reduction attempts to reduce the adverse consequences of drug use among persons who continue to use drugs. It developed in response to the excesses of a “zero tolerance approach”. Harm reduction emphasizes practical rather than idealized goals. It has been expanded from illicit drugs to legal drugs and is grounded in the evolving public health and advocacy movements. Harm reduction has proved to be effective and it has gained increasing official acceptance; for example, it is now the basis of Canada's Drug Strategy. However, the concept is still poorly defined, as virtually any drug policy or programme, even abstinence-oriented programmes, attempt to reduce drug-related harm. The principle feature of harm reduction is the acceptance of the fact that some drug users cannot be expected to cease their drug use at the present time. Harm reduction is neutral about the long term goals of intervention while according a high priority to short-term realizable goals. Harm reduction should be neutral about legalization. The essence of the concept is to ameliorate adverse consequences of drug use while, at least in the short term, drug use continues.     

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.     

KEYNOTE ADDRESS FROM THE 7TH INTERNATIONAL CONFERENCE ON THE REDUCTION OF DRUG-RELATED HARM:Harm reduction and social policy: should addicts be paid?

Harm reduction principles have not been applied to social policy programs that affect drug users. This paper considers whether income supports for the drug-dependent poor might be harm reducing, given that a principal harm related to drug dependence is crime committed to finance drug use. We examine the political fate of the principal income support program in the United States that targeted the drug dependent. Revelations that the money was being used in part for the purchase of drugs has led to a scaling back and tightening of the program. We suggest that the program might have been more effectively defended if attention had been paid to community harms rather than only to drug consumption by recipients. European and Australian governments provide income support which is no doubt also used for drug consumption, but in the context of universalist income support programs they do not require a harm reduction defense. We conclude that great potential for reducing drug-related harm may fall well outside the domain of targeted drug policy, whether of the supply reduction, demand reduction or harm reduction variety.