Understanding post 9/11 drug control policy and politics in Central Asia

This paper exposes contemporary drug policy challenges in Central Asia by focusing on a single point in the history of drug control, in a single region of the global war against drugs and terrorism, and on one agency whose mission is to help make the world safer from crime, drugs and terrorism. By looking closely at the post 9/11 security-oriented donor priorities, I conclude that, in Central Asia, the rhetoric of the taking a more ‘balanced approach’ to drug policy is bankrupt. When enacted by the national law enforcement agencies in the Central Asian republics, the ‘Drug Free’ aspirational goal is driving the HIV epidemic among IDUs. The face-saving ‘containment’ thesis does not reflect the drug situation in this region but rather the failure to adopt an evidence-based approach. The harm reduction agenda continues to face many challenges including resistance to substitution treatment, the harm from drug treatment, from poorly designed drug prevention programmes and from repressive counter-narcotics policies and practices.     

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’).     

Harm reduction: Come as you are

The purpose of this paper is to describe what harm reduction is, how it developed, how it works, and why it is becoming a major approach in the addictive behaviors field. Based on principles of public health, harm reduction offers a pragmatic yet compassionate set of strategies designed to reduce the harmful consequences of addictive behavior for both drug consumers and the communities in which they live. To illustrate how harm reduction has been applied to both the prevention and treatment of addiction problems, highlights of a national conference on harm reduction are presented. The historical roots of harm reduction programs in Europe (Netherlands and the United Kingdom) are described. The paper concludes with a discussion of four basic assumptions central to harm reduction: (a) harm reduction is a public health alternative to the moral/criminal and disease models of drug use and addiction; (b) it recognizes abstinence as an ideal outcome but accepts alternatives that reduce harm; (c) it has emerged primarily as a “bottom-up” approach based on addict advocacy, rather than a “topdown” policy established by addiction professionals; and (d) it promotes low threshold access to services as an alternative to traditional high threshold approaches.     

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.     

Perceived risk and risk reduction among ecstasy users: the role of drug, set, and setting

In order to provide information on, and to identify factors associated with, risk-taking behaviours and adverse experience among ecstasy users, data were collected by way of focus groups involving 42 participants, all of whom had used ecstasy. While participants described a range of adverse experiences resulting from ecstasy use, they reported few major harmful outcomes from these experiences. Participants described a range of coping strategies for dealing with such experiences, which partly derived from an appreciation of the relative importance of drug, set, and setting, and the interaction between these factors. Social support networks were described as being particularly important in this respect. These strategies were applied not only during an unpleasant drug-taking episode, but also when preparing for using ecstasy, and also for ‘winding down' after taking ecstasy. Participants' awareness of harm reduction principles in relation to ecstasy use was encouraging, but more worrying was the limited impact of possible long-term neurological damage on the group’s behaviour and perceptions of risk. The risk reduction strategies of this group are discussed in the more general context of risk discourse, specifically to highlight participants’ different subjective assessments of short- and long-term risk.     

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.     

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.     

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.     

Studying illicit drug markets: Disciplinary contributions

This paper provides a reflective account of the different disciplinary approaches to studying illicit drug markets. The term ‘drug market’ is used widely in illicit drug research, and means different things to different researchers. An economist may have a very specific view of what is meant by a drug market, and that will differ from one held by an ethnographer. The paper endeavours to describe and explain five different disciplinary approaches to studying drug markets—ethnographic and qualitative approaches; economic approaches; behavioural and psychological research; population-based and survey research; criminology and law enforcement evaluation. Each discipline has strengths and limitations. I do not argue for the supremacy of one approach, but that we need to appreciate the different approaches and develop better multi-disciplinary models.     

"That original tension". Negotiating abstinence in clinicians' accounts of harm reduction in nonresidential treatment of heroin withdrawal

The aim of this article is to examine how drug and alcohol clinicians, guided by a policy of harm reduction, approach their withdrawal work in their encounter with injecting heroin users seeking nonmethadone withdrawal treatment. The study, qualitative in design, involved detailed interviews with all seven clinicians who worked in the nonmethadone withdrawal program of a nonresidential drug and alcohol center in Melbourne, Australia. I draw attention to the difficulties that these clinicians have in their withdrawal work, especially concerning the place of abstinence in withdrawal and in harm reduction. Abstinence is a legitimate goal of harm reduction. Yet, how harm-reduction knowledge is practiced and reproduced in the clinical encounter is underpinned by dominant and taken-for-granted assumptions about abstinence as 'other' to harm reduction. The ideal of abstinence in drug and alcohol treatment and its decentering within the concept of harm reduction, make introducing harm-reduction strategies in the clinical encounter precarious. The work of withdrawal is compromised with an unresolved tension brought about through the paradox of legitimating illicit drug use in one context (the medical) when it is not legitimate in another context (the sociopolitical).     

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.     

The unintended consequences of emphasising blood-borne virus in research on,and services for,people who inject image and performance enhancing drugs: A commentary based on enhanced bodybuilder perspectives

Blood-borne viruses (BBVs) are an established focus of drug research and harm reduction. While a focus on BBVs has been applied to people who inject image and performance enhancing drugs (IPEDs), research has demonstrated that there are significant differences between this group and people who inject other drugs. Furthermore, the literature on BBVs and IPED use has been misrepresented by the media and harm reduction programs, with significant consequences for how some people who inject IPEDs view academic research and health services. It seems time to ask, is our current approach to the issue of BBV among people who inject IPEDs the most appropriate, and are there ways that it could be improved to ensure that there are no unintended consequences? In this commentary I suggest ways research and harm reduction efforts could tackle the issue of BBV without exacerbating existing divides between people who inject IPEDs and the health and academic communities. These suggestions are based on the views of the enhanced bodybuilders with whom I am privileged to work.     

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.     

Drug use and sex in abstentionist treatment programs

Many organisations with treatment programs for drug users based on abstinence principles rule that sexual intercourse is forbidden while drug users are still under treatment. Most of these people suffer due to the lack of hard institutional regulations when they return to their social environment. Thus, working with preventive issues, especially safer sexual practices, as a harm reduction strategy, is very important before treatment ends. This is because sex will probably be one of the social interactions most promptly recuperated. Workshops oriented to diffuse preventive information related to safer sexual practices were developed in some of those organisations. It’s main objectives were: make condom use familiar; work with social representations and beliefs regarding a change of attitude towards condom use; give information about contraceptive methods, their uses and effectiveness to prevent HIV transmission and other STDs. For drug users in treatment programs, those workshops offered the possibility of acquiring information and analysing their social representations related to safer sexual practices. Results were presented to the staff of treatment programs and made it possible to discuss their social representations related to one of the most rooted stereotypes which states that “drug users are incapable of taking care of themselves or of others in their sexual practices”.     

Optimal timing of use reduction vs. harm reduction in a drug epidemic model

BackgroundOpponents of harm reduction fear that reducing harmfulness might increase use, and opponents of use reduction fear that efforts to reduce use can increase harmfulness. We raise the possibility that both strategies have a role but at different points in a drug “epidemic”.MethodsWe present a stylized two-state, one-control policy simulation model of the use vs. harm reduction choice when initiation stems from susceptible non-users interacting with current users.ResultsWithin this model, whether harm reduction is a good strategy can depend on the particular drug and/or country, the social cost structure, and the stage of the epidemic. The dynamic solutions also involve indifference curves, consisting of points where the decision maker is indifferent between two transients that will approach the same steady state in the long run. Depending on how overall prevalence feeds back to affect the likelihood a susceptible non-user will initiate after interacting with a current user, the model can have tipping points where small shocks can have amplified long-run effects. For most epidemic states, harm reduction reduces the present value of future social costs, but not near such tipping points.ConclusionTo the extent that drug use patterns involve feedback effects, any shock to initiation – from harm reduction or any other source – can produce changes in use that are more than proportional, or less than proportional, to the shock. Hence, advocates in the use vs. harm reduction debate may wish to explain why their preferred policy is particularly appropriate at the current stage of a country's drug use trajectory, rather than arguing for universal applicability of their preferred programme.