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.     

Contested space in the pharmacy: Public attitudes to pharmacy harm reduction services in the West of Scotland

BackgroundInternationally, community pharmacies have become increasingly involved in providing harm reduction services and health advice to people who use illicit drugs.ObjectiveThis paper considers public opinion of community pharmacy services. It discusses attitudes to harm reduction services in the context of stigmatization of addiction and people who use drugs.MethodsThis exploratory study involved twenty-six purposively sampled members of the public, from the West of Scotland, participating in one of 5 focus groups. The groups were composed to represent known groups of users and non-users of community pharmacy, none of whom were problem drug users.ResultsThree thematic categories were identified: methadone service users in community pharmacies; attitudes to harm reduction policies; contested space. Harm reduction service expansion has resulted in a high volume of drug users in and around some Scottish pharmacies. Even if harm reduction services are provided discretely users' behavior can differentiate them from other pharmacy users. Drug users' behavior in this setting is commonly perceived to be unacceptable and can deter other consumers from using pharmacy services. The results of this study infer that negative public opinion is highly suggestive of stereotyping and stigmatization of people who use drugs. Participants considered that (1) community pharmacies were unsuitable environments for harm reduction service provision, as they are used by older people and those with children; (2) current drug policy is perceived as ineffective, as abstinence is seldom achieved and methadone was reported to be re-sold; (3) people who use drugs were avoided where possible in community pharmacies.ConclusionsCommunity pharmacy harm reduction services increasingly bring together the public and drug users. Study participants were reluctant to share pharmacy facilities with drug users. This paper concludes by suggesting mechanisms to minimize stigmatization.     

The Global Fund's leadership on harm reduction: 2002–2009

Injecting drug use is a major driver of the HIV epidemic globally. Whilst robust evidence points to the effectiveness of harm reduction programmes to halt and reverse injecting drug use driven epidemics, uptake of these programmes in developing and transitional countries has been slow. In part, this slow uptake stems from inadequate financial resources for harm reduction; legal, socio-cultural and medical barriers leading to stigmatisation; and weak health systems unequipped to manage marginalized groups.The Global Fund to Fight AIDS, Tuberculosis and Malaria, established in 2002, has become the major multilateral source of external funding for harm reduction programmes in countries experiencing concentrated HIV epidemics driven by injecting drug use. Between 2004 to end of 2008, the Global Fund invested around US$180 million in harm reduction programmes in 42 countries. This funding has helped to initiate and scale up harm reduction programmes in settings where domestic funding was lacking.In addition to financing harm reduction programmes globally, the Global Fund has stimulated a strong dialogue between vulnerable groups and governments. Furthermore, the Global Fund has engaged in a dialogue with countries to encourage an evidence-based approach to policy-making that recognizes the immense value of harm reduction in HIV prevention and control.     

From responsible users to recalcitrant dope fiends: Mapping modes of engagement with harm reduction

This article considers individuals' diverse modes of engagement with an increasingly medicalised strain of harm reduction that emphasises individual accountability for personal health and welfare. Drawing upon 1 year of ethnographic research at a New York City-based syringe exchange (“NYC Harm Reduction”, a pseudonym), I describe how drug users themselves made sense of harm reduction, negotiated its discourses of risk and responsibility, and incorporated its behavioural directives into their own body projects – or did not. While suggesting some participants' apparent absorption of risk reduction into a dominant, and enabling identity, I focus mainly upon individuals' “on-stage” performances and apparent depth of service use and acceptance while at NYC Harm Reduction. Building upon recent critiques of contemporary harm reduction's de-contextualised neoliberal subject, I discuss the crucial roles of public housing assistance and peer worker employment in incentivising participants' uptake of pro-risk reduction attitudes, and (presumably) practices. Ultimately, participants' multiplicity of approaches to harm reduction hinged upon differences in not only personality or stage of drug use, but also current living circumstances; moreover, individuals' differential engagement with NYC Harm Reduction reflected the ways in which the organisation and its government funders prioritised the material investment of certain “risky” bodies – namely, HIV-positive drug users.     

‘It's too much,I'm getting really tired of it’: Overdose response and structural vulnerabilities among harm reduction workers in community settings

BackgroundIn response to the devastating overdose epidemic across Canada, overdose education and naloxone distribution programs (OEND) targeted at people who use drugs have been scaled-up. The ways in which people who use drugs (PWUD) – who experience social and structural vulnerabilities due to their drug use – enact advice from these health education campaigns remains underexplored. This study examines structural vulnerabilities that constrain PWUD as they attempt to implement OEND program advice.MethodsData were drawn from an ethnographic study of “Satellite Sites”, a program where PWUD are employed by a community health center to operate satellite harm reduction programs within their homes. Data collection included participant observation within the Satellite Sites, complemented by semi-structured interviews and a focus group with Satellite Site workers. Thematic analysis was used to explore impacts of responding to overdose.ResultsOEND advice includes not injecting alone, carrying naloxone, and calling 911 if overdose occurs. The ability of Satellite Site workers to respond according to public health guidelines is complicated by contextual and structural factors, including a lack of supervised injection services, vulnerability to eviction, and continued criminalization of drug use. Participants described how responding to increasing numbers of overdoses was stressful, with stress compounded by their close relationships with those who were overdosing. These factors were impacting the willingness of Satellite Site workers to continue to supervise drug use.ConclusionOEND programs are essential and effective; however, they are a response to a crisis within a policy and legal environment framed by the criminalization of drug use. Efforts to expand access to complementary interventions, such as supervised injection services, safer supply interventions, and protection against evictions, are necessary to complement OEND programs and address multiple contextual factors within the risk environment for overdose. Additionally, criminalization will continue to impede and constrain the public health response to drug use.     

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.     

Expanding the accessibility of harm reduction services in the United States: Measuring the impact of an automated harm reduction dispensing machine

BackgroundIn 2021, approximately 107,622 Americans died from drug overdose in the United States. With overdose deaths rising rapidly, it is imperative that prevention efforts focus on expanding proven, evidence-based strategies to curb overdose death rates such as targeted naloxone distribution and syringe service programs (SSPs). The COVID-19 pandemic placed additional strain on SSPs, increasing the need for programs that minimize direct contact and potential COVID-19 exposure. The purpose of this study is to evaluate the impact of an automated harm reduction dispensing machine on the local accessibility of harm reduction services.ObjectivesThe primary outcome of the study is the number of harm reduction supplies distributed to the community by the dispensing machine in its first year compared to the number of supplies distributed by the same organization in the previous year. Secondary outcomes include the countywide incidence of fatal drug overdose and human immunodeficiency virus (HIV) compared to previous years.MethodsThe machine is located outside, in the same location as a once weekly, in-person SSP. Clients register with the program over the phone with a harm reduction coordinator. Each client is connected to products and services such as naloxone, sharps containers, safer injection/smoking kits, pregnancy tests, HIV tests, substance use disorder treatment, and more.ResultsSince installation, 637 individuals registered with the program, 12% of whom had never reportedly used harm reduction services before. Within its first year of use, the machine dispensed 3360 naloxone doses and 10,155 fentanyl test strips, more than any other SSP in the county.ConclusionThe implementation of an automated harm reduction dispensing machine led to an increased accessibility of harm reduction products and services and was associated with a lower countywide incidence of unintentional overdose death and HIV. The association with decreased overdose death and HIV incidence should be further investigated to assess causality.     

Polytobacco use and risk perceptions among young adults: The potential role of habituation to risk

IntroductionPolytobacco use and experimentation is common among young adults. Additional research is needed to determine how these patterns of use impact perceptions of tobacco-related harm and risk. The current study examined whether a relationship exists between an increased number of tobacco products used and decreases in perceptions of harmfulness and health risk.MethodParticipants (N = 792) completed a survey assessing current/lifetime tobacco use, perceived absolute harmfulness of tobacco/nicotine products and perceived health risk of smoking. For some analyses, participants were grouped by polytobacco use status.ResultsAmong participants who ever tried a tobacco product, a greater number of products tried was associated with lower perceptions of harm (all p < .05). For e-cigarettes and hookah, nonusers rated tobacco products as more harmful compared to single product, dual, and poly users (all p < .05). Number of products tried predicted perceived harmfulness above and beyond demographic characteristics and polytobacco use status across all products. Similarly, number of products tried predicted perceived health risk above and beyond demographic characteristics and polytobacco use status for both lung cancer and heart disease risk.DiscussionTrying a greater number of tobacco products is associated with lower perceived harmfulness of tobacco products. Prospective studies are needed to determine if experimentation with more tobacco products leads to reductions in perceived risk of tobacco use and subsequent sustained use of tobacco.     

Assembling the dominant accounts of youth drug use in Australian harm reduction drug education

Education programs are a central element of Australian harm reduction drug policy. Considered less judgmental and more effective than the punitive policies of Australia's past, harm reduction drug education is premised on the goal of reducing ‘risks’ and harms associated with illicit drug use rather than an elimination of use per se. In this article I analyse two sets of key texts designed to reduce drug related harm in Australia: harm reduction teaching resources designed for classroom use and social marketing campaigns that are targeted to a more general audience. I identify two significant accounts of young people's drug use present in Australian harm reduction drug education: ‘damaged mental health’ and ‘distress’. I then draw on some of Deleuze and Guattari's key concepts to consider the harm reducing potential these accounts may have for young people's drug using experiences. To demonstrate the potential limitations of current drug education, I refer to an established body of work examining young people's experiences of chroming. From here, I argue that the accounts of ‘damaged mental health’ and ‘distress’ may work to limit the capacity of young drug users to practice safer drug use. In sum, current Australian harm reduction drug education and social marketing may be producing rather than reducing drug related harm.     

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.     

Reducing harms through interactions: Workers orienting to unpredictable frames in a low-threshold project for people injecting drugs

BackgroundPeople using injection drugs and living in complex, vulnerable and stigmatised life situations can face many kinds of barriers when accessing social and healthcare services. Thus, they are often encountered in easily reachable low-threshold services aimed at harm reduction. However, little is known about how clients’ multiple drug-related needs are actually encountered in the everyday practices of harm reduction work.MethodsThis ethnomethodologically oriented interaction analysis examines harm reduction work in a Finnish low-threshold project, the aim of which is to support clients broadly in their drug-related life situations. The data consist of 12 audio-recorded client-worker meetings observed in 2017 by utilising mobile ethnography. In this context, workers are expected to react to clients’ needs in situ; they must take different kinds of orientations within the interactional frames that the clients have set for the meetings. This study asks: 1) In what kinds of frames are client-worker conversations conducted in the project? 2) How do the workers orient to these frames?ResultsThe results point out that participants orient to various frames – practical, therapeutic, educational and casual – during the meetings. The workers respect the frames set by the clients and maintain them by taking variable interactional orientations. By doing so, they are able to respond to the clients’ individual and acute needs, and they conduct a client-centred harm reduction approach through interactions.ConclusionsThe study highlights that when workers utilise situationally reactive interactional approaches, they conduct client-centred harm reduction work through interactions. When people using injection drugs are given much interactional freedom, they can be powerful actors in institutional contexts. Thus, harm reduction is not merely about reducing the concrete risks of drug use; it is also about social interactions that show respect for the interests of the people visiting the service.     

The lure and the loss of harm reduction in UK drug policy and practice

Since the late 1980s drug policy and practice within UK has been heavily influenced by the idea of reducing drug related harm. The paradigm of harm reduction, which has shaped drug treatment services grew out of the fear that HIV may spread rapidly and widely amongst injecting drug users. This article looks at the extent to which drug use or HIV have had the greater impact on individual and public health within UK and the extent to which it has been possible to reduce drug related harm in the face of continuing drug use. The article concludes that in the face of the growth in the prevalence of problem drug use over the last 10 years and the persistence of an array of drug related harms including: the extent of Hepatitis-C amongst injecting drug users, the extent of drug related crime and the impact of drugs on communities and families that it may be appropriate now to make drug prevention, rather than harm reduction, the key aim of drug policy and practice.     

Transition to injection amongst opioid users in Iran: implications for harm reduction

Driven by opioid use, HIV prevalence is high (15-27%) amongst injection drug users (IDU) in Iran. Harm reduction programmes are associated with a reduction in high risk injecting behaviours; however, Iran has a large number of non-injecting opioid users not immediately targeted by harm reduction programmes. The vast majority of heroin injectors tend to have a history of several years of smoking opium or heroin before transitioning to injection, and a small fraction may even start their drug career by injection of opioids, behaviours that can undermine the effectiveness of the harm reduction programmes. In this study, we have reviewed evidence on the HIV epidemic, extent and pattern of opioid use, and correlates of the transition to injection in Iran. We have concluded that harm reduction policies should also emphasize prevention of the transition to injection amongst high-risk non-injecting opioid users as an additional strategy against the spread of HIV infection in Iran.     

Struggling to achieve a ‘normal life’: A qualitative study of Vietnamese methadone patients

Background:Methadone maintenance treatment, initially introduced in Vietnam for HIV harm reduction, has marked a significant switch in the country’s drug policy – from addiction as a moral issue to addiction as a brain disease. After the some initial outstanding achievements, the programme is facing a high dropout rate that threatens both goals of HIV prevention and drug treatment. This sociological study, as part of an HIV intervention research project, explores the challenges and opportunities that individuals who use drugs are faced with in relation to addiction treatment.Methods:A qualitative study among drug users with and without methadone maintenance treatment experiences recruited by peer outreach workers. We conducted 58 in-depth interviews and 2 focus groups between 2016 and 2017.Results:The start of treatment brought about significant feelings of success as heroin use was no longer compulsive. However, being in treatment programmes is also challenging with respect to continuing the recovery process. Barriers to retention include a popular fear of methadone as another harmful drug, a feeling of dependence related to the current practices of methadone treatment programmes and a poor therapeutic relationship. In the face of such challenges, the two major motivations that keep patients in care come from the desire to completely break up with heroin and the pursuit of family happiness.Conclusion:The current practices of methadone programmes pose challenges to patients’ recovery efforts from addiction and threaten treatment retention. Prompt interventions are needed to help Vietnam attain its objective of providing better care for larger vulnerable populations.     

Still “at risk”: An examination of how street-involved young people understand,experience, and engage with “harm reduction” in Vancouver’s inner city

BackgroundVancouver is an international leader in implementing interventions to reduce harms related to drug use. However, street-involved young people who use drugs continue to be vulnerable to overdose death, hepatitis C (HCV) infection, and high rates of syringe sharing. To better understand this in the context of the intensive public health response, we examined how young people, who are involved in the ‘street drug scene’, understood, experienced and engaged with harm reduction.MethodsTwelve semi-structured interviews were conducted in 2013 with 13 young people (ages 17–28) recruited from the At-Risk Youth Study, a prospective cohort of street-involved and drug-using young people. These interviews were embedded within a larger, eight-year program of ethnographic research and explored participants’ understandings of harm reduction, their use of specific services, and their ideas about improving their day-to-day lives. Interviews were transcribed verbatim and a thematic analysis was performed.ResultsYoung peoples’ ideas about harm reduction were diverse and expansive. They articulated the limitations of existing programs, indicating that while they are positioned to reduce the risk of HIV and HCV transmission, they offer little meaningful support to improve young peoples’ broader life chances. Young people described strategies to mitigate risk and harm in their own lives, including transitioning to drugs deemed less harmful and attempting to gain access to drug treatment. Finally, young people indicated that spatial considerations (e.g., distance from Vancouver's Downtown Eastside) strongly determined access to services.ConclusionsIn Vancouver, a large, well established harm reduction infrastructure seeks to reduce HIV and HCV transmission among street-involved young people. However, young peoples’ multiple understandings, experiences and engagements with harm reduction in this setting illustrate the limitations of the existing infrastructure in improving their broader life chances.     

Injecting drug users: a stigmatised and stigmatising population

BackgroundThis paper considers the way that social stigma impacts both on injecting drug user (IDU) populations and operates within them and the consequences this has for prevention and harm reduction amongst IDUs.MethodsThe research from which this paper is drawn was a city case study, itself part of a larger national study to evaluate the efficacy of needle exchanges throughout England and Wales. Not initially part of the issues being explored, the interviews consistently pointed to concerns of stigma, and in this sense the theme was emergent from the qualitative process itself.ResultsThe primary findings relating to this issue were: IDUs concern for being recognised or ‘seen’ as IDUs affected service uptake and/or their interaction with services; ‘normal’ IDUs moreover tended to stigmatise those IDUs they believed to be ‘worse’ than them – primarily the homeless – despite the fact that their own behaviour was often less than ‘responsible’ itself. In these ways ‘stigma’, whether being accepted or expressed by these different groups militated against the ‘harm reductive’ goals of Safer Injecting Services.ConclusionIt is concluded that much can be done to reduce stigma related to IDU and drug use in general and that this may result in improved service efficacy and a reduction in associated drug related harms. It is also concluded that many IDUs seek to enhance their own self-esteem and reinforce their own sense as ‘responsible members of society’ rather than the outsiders they often feel themselves to be by attributing stigmatised behaviours on other ‘lesser’ IDUs. This practice may also contribute to them militating against their own guilt regarding their own risky behaviours, however in so doing the goal of harm reduction may be further undermined.     

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.     

A multi criteria decision analysis (MCDA) for evaluating and appraising government policy responses to non medical heroin use

BackgroundGlobally, non-medical heroin use is generating significant public health and social harms, and drug policy about heroin is a controversial field that encompasses many complex issues. Policy responses to illegal heroin markets have varied from militarized eradication of the opium poppy and harsh punishment of users, to more tolerant harm reduction approaches with decriminalized possession and use.MethodsThis paper reports the outcomes of a multi-criteria decision analysis (MCDA) on four generic regulatory regimes of heroin: prohibition, decriminalisation, state control and free market. Invited experts on drug harms, addiction, criminology and drug policy developed a comprehensive set of 27 policy outcome criteria against which these drug policy regimes were assessed.ResultsState control of heroin was identified as the preferred policy option although other policy regimes scored better on specific outcome criteria. The free market model scored better than decriminalisation, with absolute prohibition scoring worst on every criterium. The ranking of the regimes was robust to variations in the criterion-specific weights.ConclusionThe implications of these findings for the development of future policy responses to heroin and opioids generally are discussed in detail. Despite increasing overdose deaths and an opioid epidemic in North America, prohibition remains the predominant policy approach to heroin regulation at present. It is hoped that the current paper adds to the discussion of finding a valid regulatory alternative.