Harm Reduction

Needle exchange and the HIV epidemic in Vancouver: Lessons learned from 15 years of research

by Elaine Hyshka

Hyshka, E., Strathdee, S., Wood, E., Kerr, T.

During the mid-1990s, Vancouver experienced a well characterized HIV outbreak among injection drug users (IDU) and... more During the mid-1990s, Vancouver experienced a well characterized HIV outbreak among injection drug users (IDU) and many questioned how this could occur in the presence of a high volume needle exchange program (NEP). Specific concerns were fuelled by early research demonstrating that frequent needle exchange program attendees were more likely to be HIV positive than those who attended the NEP less frequently. Since then, some have misinterpreted this finding as evidence that NEPs are ineffective or potentially harmful. In light of continuing questions about the Vancouver HIV epidemic, we review 15 years of peer-reviewed research on Vancouver's NEP to describe what has been learned through this work. Our review demonstrates that: (1) NEP attendance is not causally associated with HIV infection, (2) frequent attendees of Vancouver's NEP have higher risk profiles which explain their increased risk of HIV seroconversion, and (3) a number of policy concerns, as well as the high prevalence of cocaine injecting contributed to the failure of the NEP to prevent the outbreak. Additionally, we highlight several improvements to Vancouver's NEP that contributed to declines in syringe sharing and HIV incidence. Vancouver's experience provides a number of important lessons regarding NEP. Keys to success include refocusing the NEP away from an emphasis on public order objectives by separating distribution and collection functions, removing syringe distribution limits and decentralizing and diversifying NEP services. Additionally, our review highlights the importance of context when implementing NEPs, as well as ongoing evaluation to identify factors that constrain or improve access to sterile syringes.

How a devolved Scotland inteprets UK national drugs policy

by iain mcphee

This chapter examines empirical data on contraventions of the Misuse of Drugs Act 1971. In particular we examine why... more This chapter examines empirical data on contraventions of the Misuse of Drugs Act 1971. In particular we examine why Scotland prosecutes twice as many people for drug dealing than England and Wales. We explore cultural, procedural and political differences in Scotland that may help explain the differences in the number of prosecutions for dealing. Firstly we examine the addiction concept which is underpinned by several cultural beliefs which can be traced to temperance ideology; we then address procedural changes in Scottish policing, and finally examine the impact of Scotland’s political decision to increase its commitment to prohibition by deciding to emulate the USA Drugs Enforcement Administration.

Canada moving backwards on illegal drugs

by Elaine Hyshka

Hyshka, E., Butler-McPhee, J., Elliott, R., Wood, E. & Kerr, T. (2012). Canada moving backwards on illegal drugs. Canadian Journal of Public Health, 103(2), 125-127.

Seeking out 'easy targets'? Tobacco companies, health inequalities, and public policy

by David Clifford

Nicotine control: e-cigarettes, smoking and addiction

by Kirsten Bell

Co-authored with Helen Keane and published in International Journal of Drug Policy

Over the past year or so, electronic cigarettes, more commonly known as 'e-cigarettes', have achieved widespread... more Over the past year or so, electronic cigarettes, more commonly known as 'e-cigarettes', have achieved widespread visibility and growing popularity. These products, which deliver nicotine via an inhaled mist, have caused no small amount of controversy in public health circles, and their rise has been accompanied by energetic debate about their potential harms and benefits. Interspersed with an analysis of current media coverage on e-cigarettes and the response of mainstream tobacco control and public health to these devices, this article examines the emergence of nicotine as both as an 'addiction' and a treatment for addiction. We argue that by delivering nicotine in way that resembles the visual spectacle and bodily pleasures of smoking, but without the harms of combustible tobacco, e-cigarettes highlight the complex status of nicotine as both a poison and remedy in contemporary public health and tobacco control. In consequence, they jeopardize the carefully drawn distinctions between 'good' and bad' forms of nicotine.

Successful Risk Assessment May Not Always Lead To Successful Risk Control: A Systematic Literature Review of Risk Control after Root Cause Analysis

by Alan Card

Alan J. Card, James Ward, P. John Clarkson. Successful Risk Assessment May Not Always Lead To Successful Risk Control: A Systematic Literature Review of Risk Control after Root Cause Analysis. Journal of Healthcare Risk Management. 2012;31(3):6-12.

Root cause analysis is perhaps the most widely used tool in healthcare risk management, but does it actually lead to... more Root cause analysis is perhaps the most widely used tool in healthcare risk management, but does it actually lead to successful risk control? Are there categories of risk control that are more likely to be effective? And do healthcare risk managers have the tools they need to support the risk control process? This systematic review examines how the healthcare sector translates risk analysis to risk control action plans and examines how to do better. It suggests that the hierarchy of risk controls should inform risk control action planning and that new tools should be developed to improve the risk control process.

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Wiley's copyright policies do not allow me to post the published version of the paper, but they do allow me to send out individual copies. So if you don't have access to the Journal of Healthcare Risk Management and would like a copy of this article, please email me at:
alan [dot] j [dot] card [at] gmail [dot] com

Venous access and care: Harnessing pragmatics in harm reduction for people who inject drugs

by Magdalena Harris

Addiction, 2012, co-authored with Tim Rhodes

Aim: To explore the facilitators of long-term hepatitis C avoidance among people who inject drugs.
Design: We... more Aim: To explore the facilitators of long-term hepatitis C avoidance among people who inject drugs.
Design: We employed a qualitative life history design. Two interviews were conducted with each participant, with the second interview incorporating reference to a computer constructed
life history time line. Interview accounts were audio-recorded, transcribed verbatim and analysed thematically.
Setting: Recruitment took place through low threshold drug services and drug user networks in South East and North London. Participants were interviewed at the recruitment services or in their homes.
Participants: The sample comprised 35 people who inject drugs, 20 of whom were hepatitis C antibody negative. Participants’ average injecting trajectory was 19 years (6 – 33), with 66%
primarily injecting heroin, and 34% a crack and heroin mix. Nine (26%) of the sample were female and the average age was 39 years (23 – 53).
Findings: Hepatitis C risk awareness was recent and de-prioritised by the majority of participants. The facilitation of venous access and care was an initial and enduring rationale
for safe injecting practices. Difficult venous access resulted in increased contamination of injecting environments and transitions to femoral injecting. Participants expressed an unmet
desire for non-judgemental venous access information and advice.
Conclusions: Harm reduction interventions which attend to the immediate priorities of people who inject drugs, such as venous access and care, have the potential to re-engage individuals
who are jaded or confused by hepatitis C prevention messages.

Harm reduction and the medicalisation of tobacco use

by Catriona Rooke

Sociology of Health and Illness. Forthcoming.

In tobacco control the focus has, for some time, been on abstinence from all types of tobacco use as the only solution... more In tobacco control the focus has, for some time, been on abstinence from all types of tobacco use as the only solution to the problem of smoking, and harm reduction approaches are controversial. The most recent English tobacco strategy has incorporated harm reduction approaches in the form of new ‘routes’ to quitting smoking that encourage those who cannot quit to use safer sources of nicotine. This move away from a focus on abstinence can be seen as the result of gradual shifts over the past fifty years in the way that that the problem of smoking is understood and the solutions that are offered. These shifts have involved increasingly seeing tobacco use as a medical problem. This paper uses conceptual tools from science and technology studies to examine developments over the last decade in England, primarily the increasing importance of the idea of harm reduction. Drawing on twenty semi-structured qualitative interviews with key stakeholders and documentary analysis, I suggest that the shape harm reduction has taken in English tobacco control policy has been another shift towards the medicalisation of tobacco use, but that this process has occurred in ways that provide a contrast to commonly outlined ‘drivers’ of medicalisation.

Raise Shit: Social Action Saving Lives (review)

by Elaine Hyshka

Hyshka, E. (2010). Review of “Raise Shit: Social Action Saving Lives” by Susan Boyd, Donald MacPherson and Bud Osborn. Labour/Le Travail, 66, 249.

obesity, autonomy and the harm principle

by Monique Jonas

Addiction, Gender, and the Limits of Public Health Solutions to IV Drug Use in Ukraine

by Jennifer Carroll

This paper explores emergent discourses of drug addiction within civil society and the NGO-driven sphere of HIV... more This paper explores emergent discourses of drug addiction within civil society and the NGO-driven sphere of HIV prevention in Ukraine. More specifically, it examines the ways in which popular understandings of gender and gender roles shape the medicalization of drug addiction in the context of harm reduction and substitution therapy. As the implementation of and advocacy for substitution therapy continues to grow in Ukraine, narcotics addiction becomes increasingly framed as a physical and psychological disease in Western biomedical terms. Recent ethnographic fieldwork has revealed a tendency for public health professionals and advocates to frame men’s addiction in this way—as a biomedical disease, which has potential for successful medical treatment and recovery. Women’s addiction, on the other hand, does not always become fully medicalized. It is sometimes perceived by these same actors to be evidence of a personal failing that lies beyond the scope of medical help. It can be easy, then, to write off female drug users as statistical outliers or as fundamentally different from male narcotics addicts due to perceived social and psychological differences in the underlying causes and patterns of their drug use. This can limit women’s access to public health responses to addiction by undercutting the classification of their drug use behavior as a medical disease.
This analysis is based on preliminary research that began in Ukraine during the summer of 2010. The overall goal of this ethnographic research was to start examining the work of HIV prevention NGOs in southern and central Ukraine by focusing on the social consequences of operating them and the political economies of being a client. Open-ended interviews were conducted with public health professionals who work in regional harm reduction organizations for drug users, with program coordinators who manage treatment and prevention services for intravenous drug users at the national level, and with narcologists who operate Ukraine’s new substitution therapy programs. This paper addresses these insights achieved during this research period and cautiously suggests that current public health approaches to drug addiction in Ukraine might be doing some Ukrainians – namely women – more harm than good.

Prohibitory Prostitution Laws and the Human Right to Health

by Wendy Lyon

LLM dissertation

This paper demonstrated that laws that criminalise sex work or aspects thereof are associated with negative outcomes... more This paper demonstrated that laws that criminalise sex work or aspects thereof are associated with negative outcomes for sex workers’ right to health under international law. It also showed that the right to health is an underused mechanism in judicial challenges to these laws.

The objective was to analyse, at practical and judicial levels, the relationship between prohibitory prostitution laws and the right to health. International treaties were examined to establish the relevant content of the right. Studies of the health-related effects of these laws, in various jurisdictions, were reviewed. Existing research into the effects of legalising prostitution under specified circumstances, and the effects of decriminalisation, was also examined. Case law was reviewed of judicial challenges to prostitution laws, and health-related aspects of relevant cases were discussed. The reasons that each court did or did not reach a decision protecting sex workers’ right to health were also considered.

The dissertation found that prohibitory laws lead to negative consequences for sex workers’ health by increasing their risk of violence and sexually-transmitted infections; adversely affecting their mental health, through these risks and through stigmatisation; denying them occupational health and safety; and excluding them from the process by which health-affecting decisions are made. It found positive health outcomes from removal of these laws, although excessive regulation of legal prostitution can have negative effects. It also found insufficient justification for health-based arguments in favour of prohibitory laws.

It showed that only a small number of challenges to these laws have highlighted their relationship to health, and the basis of these challenges has not been the right to health itself, although a breach of a derivative right has sometimes been asserted. Health has also, at times, served as a defence to these laws.
It concluded that sex workers’ right to health can best be protected through a legal framework that decriminalises consensual commercial sex and explicitly protects their occupational health and safety rights. This must be accompanied by efforts to ameliorate stigmatisation. Judicial action can play a role, although it may require the assertion of a derivative right rather than the right to health.

Barriers to Recovery: Stigma and Discrimination

by Julian Buchanan

Presented at the 2011 New Zealand Drug Policy Symposium 'Through the Maze"

The presentation explores our understanding of, and reactions to problematic drug use. Populist punitive discourse... more The presentation explores our understanding of, and reactions to problematic drug use. Populist punitive discourse perceives physiological and psychological dependence upon drugs as key drivers that perpetuate ongoing ‘addiction’ that threatens society. instead I explore the links between the war on drugs, the social construction of 'drugs' and the social barriers faced by problem drug users.

It is featured on YouTube if you prefer to see and hear the paper:


http://youtu.be/scoqktXn52Q

Staying Safe From Hepatitis C: Engaging With Multiple Priorities

by Magdalena Harris

Qualitative Health Research, 2011

Hepatitis C virus (HCV) infection is a significant global public health problem. In developed countries, 90% of new... more Hepatitis C virus (HCV) infection is a significant global public health problem. In developed countries, 90% of new infections occur among people who inject drugs (PWID), with seroprevalence increasing rapidly among new injectors. Staying Safe is an international, qualitative, social research project, the aim of which is to draw on the experiences of longterm PWID to inform a new generation of HCV prevention strategies. The Sydney project team employed life history interviews and computer-generated timelines to elicit detailed data about unexposed participants’ (n =13) injecting practices, circumstances, and social networks over time. The motivations and strategies that enabled participants to avoid risk situations, and which might have helped them to “stay safe,” appeared not to be directly related to harm reduction messages or HCV avoidance. These included the ability and inclination to maintain social and structural resources, to mainly inject alone, to manage withdrawal, and to avoid injecting-related scars. These findings point to the multiple priorities that facilitate viral avoidance among PWID and the potential efficacy of nonspecific HCV harm reduction interventions for HCV prevention.

HARM INDUCTION VS HARM REDUCTION: A comparison of American and British Approaches to Drug Use

by katherine van wormer

Addiction treatment: A strengths perspective

by katherine van wormer

Pleasure and Drugs.

by Martin Holt

http://dx.doi.org/doi:10.1016/j.drugpo.2007.12.007

At the risk of sounding clichéd, it gives us great pleasure to introduce this special issue of the International... more At the risk of sounding clichéd, it gives us great pleasure to introduce this special issue of the International Journal of Drug Policy. The genesis of this insightful and at times provocative collection of papers was a plenary session of the 9th Social Research Conference on HIV, Hepatitis C and Related Diseases, StigmaPleasurePractice, held in Sydney, Australia in 2006, entitled ‘Where did the pleasure go?’ The speakers were asked to consider why it appeared difficult to consider pleasure in drug policy and practice, what the consequences of this apparent oversight might be, and how a greater focus on the pleasures of drugs might invigorate harm reduction approaches. We asked contributors to this issue to take up these concerns and develop them in relation to harm reduction theory, research and practice.

‘The Role of Social Networks in Accessing Injecting Equipment and the Implications for Harm Reduction Interventions’

by Lloyd Belcher

Thesis Paper: University of Oxford (2008)

Party Animals: The significance of drug practices in the materialization of urban gay identity

by Kane Race

Forthcoming in S. Fraser and D. Moore (eds.) The Drug Effect: Health, Crime and Society. Cambridge University Press

Understanding the emergence of contemporary gay identity is impossible without considering the history of parties. A... more Understanding the emergence of contemporary gay identity is impossible without considering the history of parties. A party is an event: a provisional and temporary coming together of diverse elements, people and things. A festive mode of social participation. Neither temporally permanent nor spatially fixed, parties nevertheless leave their imprint on cultural memory, urban geography – even political identity. And though party practices are immensely variable and historically diverse, patterns can be traced which reveal much about the shifting relations between sexual minorities, social authorities, and cultural economies. In Pleasure Consuming Medicine, I argued that greater attentiveness to pleasure and its varieties and social dynamics might enable new ways of reflecting on policies and practices of care (Race, 2009). Here I supplement that analysis with a more historically and geographically specific investigation of parties as they have featured in the formation and imagination of urban gay identity, with a particular focus on Sydney and some of the metropolitan histories its gay community draws upon, such as that of New York. My primary claim is that psychostimulant drugs have played a productive part in the materialization of gay political identity in the twentieth century. But figuring the activity of drugs within cultural processes raises the problem of pharmacological determinism. Hence my focus on party practices. Situating drug use as one practice among the many that make up lives and cultures may allow an acknowledgement of their activity in the formation and transformation of spaces of sexual expressivity without reifying drugs as fixed, in terms of their significance or effects.

The use of pleasure in harm reduction: perspectives from The History of Sexuality

by Kane Race

International Journal of Drug Policy (2008) 19, 5: 417-423

The absence of pleasure in harm reduction discourse is more and more frequently noted, but few have considered what,... more The absence of pleasure in harm reduction discourse is more and more frequently noted, but few have considered what, exactly, more attention to pleasure might do. What is the value of pleasure for harm reduction praxis? Central to such an inquiry is the question of how pleasure is grasped, conceptually and methodologically. In this paper I use Foucault’s History of Sexuality to elaborate a perspective on the use of pleasure within harm reduction. I argue that Foucault’s work suggests a distinction between therapeutic and social-pragmatic approaches to pleasure, and that such a distinction is important for harm reduction – to the extent that it seeks to maintain a critical awareness of the relation between stigma and care – in that the latter model raises the possibility of maintaining de-pathologizing modes of care. An appreciation of pleasure in terms of its social pragmatics helps to recognize practices of safety, care and risk that might otherwise go unregistered in the current punitive political environment. It provides a basis for conceiving practical measures that are in touch with given concerns and bodily
practices, and thus have more chance of being taken up. It also enables a more dynamic and responsive approach to the practice of bodies and pleasures.