Harm Reduction in BC: We set the pace, but can we keep it up?

The harm reduction series on CARBC’s Matters of Substance blog has spent the past three months examining the scope of harm reduction as an approach to reducing harms of drug and alcohol use. These posts explore harm reduction as we know it today by going beyond evidence of injection drug users engaged in HIV prevention programs; rather, we establish that harm reduction now includes a wide range of user-informed, user-specific initiatives. For instance, some of the blog contributions include introductions to crack kit distribution, safe consumption services, syringe access for prisoners, opioid substitution treatment, managed alcohol programs, Housing First programs, and even e-cigarettes. Such initiatives have shaped a public health landscape in BC that focuses not on drug and alcohol use itself, but instead on the determinants of health which influence safer substance use environments.

This blog series has shown that harm reduction works – and as a pragmatic approach to public health, it is only appropriate that we highlight some more recent research taking place in the harm reduction field. The post by Ashraf Amlani and Dr. Jane Buxton reveals that B.C.’s Take Home Naloxone Program has saved an overwhelming 55 lives from 600 naloxone kits distributed since 2012. Among the over 30 research studies conducted at Insite, we learn that supervised consumption sites increase access to drug treatment, decrease drug use and disease transmission, and eliminate on-site overdose deaths – collectively, a social benefit worth approximately $6 million per year. We also learn that such approaches work across populations, with crack pipe distribution decreasing crack cocaine use and disease transmission in Vancouver.

These examples and other evidence have helped change both the political and public health climate in British Columbia. Harm reduction expert Dr. Carol Strike used such evidence to develop best practices, setting a higher precedence for public health practices across the country. Perhaps one of the main themes in these best practices, and our blog series overall, is user-informed, user-involved public health practice and policy. Actively engaging the people who are affected by drug and alcohol use not only makes sense and provides insight, but also creates a trusting environment, increases legitimacy and contributes to the self-worth of the community itself – a “win-win-win” situation.

An early post in the harm reduction blog series reveals that over three-quarters of British Columbians support harm reduction. Exciting, right? But even after 10 years of passionate debate, evidence building and community organizing, all of our guest bloggers acknowledge that there is still a lot of work to do.

Donald MacPherson, the Director of the Canadian Drug Policy Coalition, points out that one of the biggest hurdles we face is advancing public health policy in the face of criminalization of drug use. As such, MacPherson argues, we must continue to urge the government to eliminate criminalization of drug use in an effort to maximize a more comprehensive approach to drug problems. Without action, we risk perpetuating more harm being caused by these policies.

And although the public is becoming more comfortable with needle exchanges (over 72 percent of British Columbians are in support), they are still warming up to supervised injection sites across the country. One reason for this may be a more limited public perception and understanding of sometimes counterintuitive, non-traditional approaches to substance use, such as managed alcohol use programs and a Housing First model.

So what’s next? The fact remains that while we have gained momentum in public health, there is still a lot of work to do. Over the next couple years, we have the opportunity to translate evidence and public opinion into policy and connect it to a more comprehensive approach to public health. We’ll get there by raising our voices, continuing to present evidence and working to inform best practices. We certainly look forward to continuing the conversation.

AG

Author: Alissa Greer, Centre for Addictions Research of BC

*Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC

Should We Ban Drinking at Home?

So, what does the small print at the bottom of your rental agreement say? What if it specified that you could not use alcohol or any substances as a condition of renting? Would you sign anyway, knowing there are not a lot of places you can afford to rent? Maybe that doesn’t matter because you don’t use drugs and alcohol at all, not even a drink now and then. But what if you have friends over — could they have a beer or glass of wine? Very few of us are expected to be abstinent in the privacy of our own homes; rather, we are expected to pay our rent (or mortgage) and respect our neighbours.

We would guess that few rental agreements would have such fine print. However, it is common for social housing programs to only accept people if they are abstinent. While this was the norm for a long time, the Housing First policy is now challenging that thinking. Housing First supports housing as a right and promotes the provision of housing that does not require or expect abstinence. This policy combines the provision of housing with a philosophy of harm reduction. There is a lot of evidence to support harm reduction strategies. There is also considerable evidence that a harm reduction approach to housing (Housing First) is effective in helping people who have been homeless to maintain their housing, maintain supports and access services according to their needs without causing harm to others1.

What does this look like? In Seattle, at 1811 Eastlake, men who were previously homeless with severe alcohol dependency were provided with housing and allowed to drink in their rooms. People living in regular rental units may access harm reduction services in the community to reduce and prevent harms from alcohol or other drug use. For those in social housing complexes, harm reduction services might be provided onsite. For example, managed alcohol programs located in housing programs provide people who are dependent on alcohol with regulated doses of alcohol. (A MAP program evaluation report for Thunder Bay MAP can be found at http://www.carbc.ca). The Dr. Peter Centre in Vancouver provides harm reduction supplies, onsite supervised injection services and housing for people who are HIV positive.

What does a community need to move housing programs towards a Housing First model that incorporates harm reduction? First, there has to be an available and adequate supply of affordable housing; that is the foundation. Second, an important principle of harm reduction is to actively engage people who are affected by substance use and homelessness in planning housing programs. Third, the public, housing agencies and healthcare providers need to know about and have access to harm reduction education. Lastly, Housing First and other housing programs need clearly developed harm reduction policies so that everyone is clear on the organization’s approach.

So, does every housing program need to incorporate harm reduction? Probably not, but everyone has the right to live by the same rules. Most of us already live in housing where we decide whether or not we consume substances in our home. So why not grant everyone the same choices and rights? Housing First shows us it can be done without endangering the rights of others.

Pauly Bernie-#4 Dan Reist Preferredhead shot Lynne

 

 

 

 

Authors: Dr. Bernie Pauly, CARBC Scientist and Associate Professor, School of Nursing; Dan Reist, CARBC Assistant Director, Knowledge Exchange; and Lynne Belle-Isle, CARBC Graduate Student.

1. Pauly, B., et al., Housing and harm reduction: What is the role of harm reduction in addressing homelessness? International Journal of Drug Policy, 2013. 24(4): p. 284-290.

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC

 

“Been There; Done That:” the Necessity of Embedding Peer Leadership and Support in Supervised Consumption and Harm-Reduction Services

Calls for supervised consumption services (SCS) are gaining momentum and popularity.  Here in Victoria, B.C., the YES2SCS campaign advocates for the establishment of supervised consumption services in the city within five years. SCS have been heralded for their ability to provide safer spaces for people to use drugs — spaces free from criminalization, stigmatization and violence.

In arguing for the benefits of SCS, proponents (myself included) seek to move conversations into the mainstream by focusing on the medicalized and supervised aspect of the service (clean and sanitary spaces with nurse supervision, access to detox and treatment, etc.). While these are meaningful and significant aspects of SCS, we tend to focus less on another crucial aspect of these services: peer support.

The value of peer leadership, peer support and peer-delivered services has been extensively documented. A report called Harm Reduction at Work summarizes the benefits and highlights best practices for hiring people who use drugs in harm-reduction services. The benefits include, but are in no way limited to:

  • Providing public-health information about safer use and harm-reduction supplies in a way that makes sense to people accessing the service
  • Providing insight to the organization to inform program design and delivery (e.g., drug use trends, what’s happening on the street, etc.)
  • Creating a trusting and culturally safe environment for those accessing services
  • Increasing the legitimacy of the hiring organization and sending a message to the community that the organization sees people who use drugs as knowledgeable and valuable
  • Contributing to self worth, feelings of accomplishment and participation of people who use drugs

In short, meaningful inclusion of people who use drugs in harm-reduction services is a win-win-win that benefits the people who use the service, the employing organization and the people with experiential knowledge who fill these roles.

People who use drugs have profoundly negative experiences accessing healthcare. Experiences of stigmatization, criminalization and violence in the healthcare system compound and impact all future interactions with healthcare workers. When a person accesses health services and realizes they are speaking with a person who has “been there; done that,” the power shift is evident and recognizable.

In my experience,* the presence of people who use drugs shifts the usual service provider/client power dynamic. It forces workers in an organization to speak differently about their “clients” and creates new norms and complicates the typical “us/them” dynamic. Workers without drug-use experience are privileged to learn how their practice may impact people who use the service. For instance, they can be immediately informed when they are not making sense or are practicing in a way that is inaccessible, paternalistic or just plain using incorrect information. Most importantly, it keeps things “real;” street reality is brought into the organization practice, encouraging a radical element in the organization with constant reminders that this work is about love, family, life and death.

Meaningful inclusion of people who have “been there; done that” is imperative to the success of SCS and harm-reduction services.

ashley mollison

Author: Ashley Mollison, Graduate Student, Centre for Addictions Research of B.C.

* I write on this topic not as someone who identifies as a “peer,” a person who currently or formerly uses illicit drugs, but as someone who has seen peer support in action. I have witnessed the value of peer leadership and support in my work with Society of Living Illicit Drug Users (SOLID) and AIDS Vancouver Island. SOLID is a harm-reduction organization run by and for people who use(d) drugs and AVI has recently hired people specifically for their experiential knowledge of drug use, street and prison culture in their harm-reduction program.

 

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC

Victoria’s YES2SCS Campaign: From Evidence to Action

Ten years ago, community meetings held in Victoria on the subject of “what to do” about drug use in our community were typically loud, sometimes hostile, and certainly full of impassioned energy. Those of us who saw the lack of housing, absence of accessible washrooms, and dearth of health and social supports for people living on the streets spoke out about safety concerns, risk of disease transmission, and exposure of our children to some of the more devastating of human experiences. Those of us who worked with people who use illicit drugs, or perhaps admired the work that was being done just across the water in Vancouver at Insite and the Dr Peter Centre, spoke out about the need for increased access to health care services grounded in scientific evidence and compassionate care. The voices we never heard were those of people who were living on the streets, being crushed by the everyday weight of poverty, trauma, and addiction, and never considered part of the community to begin with.

ImageThe evidence showing the positive impact and efficacy that harm-reduction approaches to illicit drug use have on the health and well-being of local communities continued to accumulate as we debated in our town hall meetings and forums.  Victoria is home to some of the brightest minds engaged in drug-policy reform, nursing care, direct support services, and addictions research, all whom have contributed to the stacks of reportsarticles and blogs that support the need to increase access to harm-reduction services. The evidence has been in for a long time, but we apparently were not yet ready for it.

Since then, conversations have continued, broadened, and are no less impassioned when it comes to drug use in Victoria. Ten years of debate, evidence, community organizing and a slow-but-steady opening of our collective hearts and minds has brought us to a place where perspectives are not so divided. Ten years ago, I would not have believed my ears had I heard the conversations taking place today. Those of us who lashed out with anger and fear for the safety of our children now speak about how supervised injection services could be part of our community response to drug use and reducing risks for all. We talk about how we can share information, educate ourselves, listen to experiential knowledge, and work together to meet  those moments where the impacts of poverty, trauma and addiction collide with pragmatic and empathic responses.  Those of us who use illicit drugs speak out with wisdom and courage of our pain and our struggle—and, increasingly, we are being heard.

Harm-reduction services are a critically important part of how we respond to the reality of illicit drug use in our society. They are not a panacea for addiction, but they are proven to save lives, engage and support people who we typically despise and isolate, and increase the capacity of communities to reduce risk and improve overall health. Victoria is finally ready to put evidence into action.

ImageThe YES2SCS campaign (Yes to Supervised Consumption Services) has been created to harness the impassioned momentum that is continuing to move our community forward. The campaign includes healthcare professionals, people who use(d) illicit drugs, researchers, community activists, social workers, and individuals committed to social justice and public health.  YES2SCS exists to unite the many Greater Victoria residents who know we can set the ground for supervised consumption services in our community. It’s time to harness this renewed energy and readiness to try new and effective strategies for caring for one another. We invite you to join us in asserting our capacity to create a healthier community for everyone!

To learn more about YES2SCS and to support the campaign through letter writing, petition signing, event organizing, and creating opportunities for dialogue, please connect with us:

yes2scs@gmail.com

www.yes2scs.ca

www.facebook.com/yes2scs‎

www.twitter.com/Yes2SCS

Image

Author: Heather Hobbs, Coordinator of Harm Reduction Services for the South Island at AIDS Vancouver Island.

“Nothing About Us, Without Us”: the inclusion of people with lived experience in harm reduction decisions

The slogan “Nothing About Us, Without Us” has been a daily mantra and practice in harm-reduction work for some time now. It has become much more commonplace to include people with lived experience of drug use and harm-reduction services in decisions that affect their lives. Navigating the intricacies of their inclusion has been both awkward and rewarding. But why include people with lived experience? How is this done? And most importantly, what’s in it for them? In this blog, I address these questions and share the life-altering impacts I have witnessed and personally experienced.

So who are “people with lived experience”? In the context of harm-reduction work, they are people who use or have used illegal drugs or pharmaceutical drugs non-medically, usually by injection or smoking. But it’s not that simple. I am not talking about the Toronto Bay Street stock broker who enjoys a bit of cocaine on the weekend. I am referring to people who are marginalized because of a complex mix of drug use and other factors and life conditions. These may include factors related to their age, gender, sexual orientation, race, ethnicity, socioeconomic status, housing and homelessness status, life experiences of trauma and violence, or health conditions such as HIV and hepatitis C.

Our current drug laws have greatly exacerbated their exclusion from society. We criminalize people who use drugs, which fosters an anti-drug-user attitude and drives people away from services and social supports they may need. It also makes it difficult for service providers to reach them. We undervalue services for people who use drugs and poorly fund their care, treatment and support. We are reluctant to educate people about safer drug-use practices and to provide sterile drug use equipment, especially in prison.

Engaging People with Lived ExperiencePolicy makers, service providers and researchers are experimenting with creative and innovative ways to include people with lived experience in decisions that affect their lives. The idea is that by bringing them into decision-making structures (committees, boards of directors, service delivery and research teams, etc.), we become allies by sharing the decision-making power, all the while striving to relate to each other in non-discriminatory, non-stigmatizing ways.

Research shows that including people with lived experiences has kept their priorities and needs in focus and resulted in better adapted services, the reduction of drug-use risk behaviours, and has played a role in improving life conditions, health and wellbeing. It has also provided people with lived experience with opportunities to reclaim their capacity to lead a self-determining life, something many of us more privileged people take for granted.

By working together, we learn about each other, bring our various strengths to the table, challenge our assumptions about each other, and reflect on how we interact, which leads to reduced stigma and improved rapport. People with lived experience come to view themselves more positively, inspire their peers, get meaning and a sense of purpose to help others and gain valuable life skills. The bottom line is we are all transformed by this experience.

Don’t get me wrong. Changing our societal ways and decision-making power structures is challenging. There are few models on how to include people with lived experience well and meaningfully. There are still barriers to their participation such as economic inequities, stigma and discrimination, limited resources and diverging agendas between various people at the table. People with lived experience often face health, financial and life priorities that make their participation challenging.

I am currently partnering with both the Drug Users Advocacy League and the Society of Living Illicit Drug Users for my PhD research to examine how decision-making power is shared in such committees. We aim to come up with some insights and helpful practice guidelines to assist all of us in better including people with lived experience.

People with lived experience are part of our communities. “Nothing About Us, Without Us” includes ALL of us.

head shot Lynne

Author: Lynne Belle-Isle is a PhD candidate in the Social Dimensions of Health Program at the Centre for Addictions Research of BC at the University of Victoria. She is a National Programs Consultant with the Canadian AIDS Society and the Chair of the Canadian Drug Policy Coalition.

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC

Why give alcohol to alcoholics?

Three people sit around a kitchen table; they chat, share a meal and enjoy warmth from the stove on a cold Ontario winter day. As they visit, someone approaches the group to remind them: it’s time for their dose of alcohol.

A year ago these three people would have lived outside in sub-zero temperatures, moved in and out of emergency shelters, and repeatedly be picked up by the police or emergency medical services. They were homeless and dependent on alcohol, often drinking heavily over a short time and consuming “non-beverage” alcohol like mouthwash, rubbing alcohol and hair spray. Today they have a place to call home and alcohol harm reduction support as participants in the Kwae Kii Win Managed Alcohol Program.

Kwae Kii Win, Thunder Bay, CA

Kwae Kii Win, Thunder Bay, CA

For the last few years, I’ve been part of a team studying Canadian Managed Alcohol Programs and their impacts on participants and communities. Most discussions about harm reduction focus on health measures for people who inject or smoke illicit drugs, but we can use the same harm-reduction principles to help people addicted to alcohol. Many emergency shelters do not allow people to drink or have alcohol with them, so for those addicted to alcohol and without housing, the only option may be to stay outside. Managed Alcohol Programs provide housing and small regular doses of “beverage” alcohol (usually white wine). This is enough alcohol so that people do not go into withdrawal, but not so much that they are intoxicated. The wine also replaces more harmful kinds of alcohol like rubbing alcohol. The primary goal is to improve the welfare of participants, but some programs also try to reduce emergency health and policing costs by reducing need for these services among participants.

When I first heard about Managed Alcohol Programs, I wondered, “Why would anyone give alcohol to alcoholics?”

Actually, the idea is not to give people more alcohol, but to change how they consume alcohol so that it’s consumed in safer ways. The intention is to replace the existing unsafe drinking (in public, in the cold, large amounts at a time, unsafe kinds of alcohol) with safer drinking (inside in their own homes, under medical supervision, much smaller amounts at a time), and not to increase the overall amount of alcohol.

You may be wondering, “If drinking is so bad for you, why can’t people just stop drinking?”

People in Managed Alcohol Programs have all tried, repeatedly and without success, to stop drinking, sometimes undergoing many rounds of detox and treatment. Many times, it seems, people are drinking to cope with traumatic events in their lives, and while that pain remains, drinking seems like the best option. Also, anyone who drinks a lot cannot stop suddenly without suffering significant medical problems like seizures. Managed Alcohol Programs, like other harm-reduction measures, provide a link to health services and can be a first step towards drinking less or quitting altogether if the participant decides that’s what they want.

Most significantly, though, Managed Alcohol Programs provide a safer place for people who are otherwise left without protection from the often gendered and racialized violence and trauma that characterize many people’s experiences of homelessness. As one Managed Alcohol Program participant put it, her family members know where to find her now and don’t have to wonder, when they read of the death of an Aboriginal woman in the paper, if that is her.

For more information about Managed Alcohol Programs, take a look at these links:

This new report highlights significant reductions in hospital admissions and time in police custody for participants once they start the program, as well as other benefits.

MAP Shelter House – Thunder Bay “The Value of Harm Reduction” http://www.youtube.com/watch?v=exaIP5TUZNw&feature=youtu.be

The Current interview: http://www.cbc.ca/thecurrent/episode/2014/01/06/harm-reduction-vs-abstinence-is-it-ok-to-give-an-alcoholic-a-drink/

Kathleen

Author: Kathleen Perkin, Research Manager, National Evaluation of Managed Alcohol Programs in Canada, Centre for Addictions Research of BC

Harm Reduction Comes of Age in Canada, or Does It?

The Supreme Court of Canada’s September 2011 decision allowing Vancouver’s supervised injection site, Insite, to keep operating was a critical milestone for harm reduction in Canada. One only has to look at the list of interveners in the case in support of this innovative service to see that it has become a valued and mainstream service in Canada. Canadian health organizations including the Canadian Medical Association, Canadian Nurses Association, Canadian Public Health Association and 11 others saw fit to come before the court to support Insite. But even with this high level of support, scaling up harm-reduction services in Canada remains a challenge.

Harm reduction gained traction as a result of the HIV/AIDS crisis in the early 1980s and played a critical role as a strategy to engage injection-drug users in HIV prevention. Harm reduction’s more recent challenges have elevated the critique of policy-related harms – harm caused by policies that criminalize people who use illegal drugs.

ImageHarm reduction acknowledges that there are significant risks associated with illegal drugs and also attempts to work towards mitigating harms within the criminalized environment where drug use occurs. This often puts the public-health goals of engaging people who use drugs in conflict with traditional public-safety strategies that rely on disruption of illegal drug markets, and in turn disruption of the lives of people who use illegal substances.  Harm-reduction approaches balance these realities and focus on creating safer environments as much as possible within a context of criminalization. Some examples include promoting supervision of consumption or discouraging using drugs while alone, promoting rapid response strategies in the form of peer-delivered naloxone programs and strategies that work towards achieving a kind of détente between health efforts and enforcement practices. Given the context of criminalization, a key goal of harm reduction is to maximize the benefits of public-health interventions and minimize the harm of drug use and the enforcement of drug policy.

So what should Canada be doing to facilitate the development of a more robust harm reduction approach as a part of a comprehensive response to drug use? We urge governments to begin with a review of current drug policies to determine the benefits and harms to individuals and communities that accrue from the criminalization of drugs and the people who use them.

Other countries have done such an analysis and have decided to eliminate criminalization as a response to possession of drugs for personal use in an effort to maximize the benefit of a public-health approach to drug problems. Portugal (2001) and the Czech Republic (2009), are two examples of jurisdictions that have taken this step. Both have decriminalized all drugs that are deemed to be for personal use. Portugal decriminalized drugs as part of a response to an HIV epidemic and high rates of drug overdose. The Czech Republic did the same as a result of an extensive evaluation of the previous policy of criminalization.  Evaluation of the experience in Portugal has shown that results have been positive overall – HIV incidence and overdose deaths have been reduced, police are supportive of the new law as it has given them more meaningful and helpful involvement in steering individuals towards health services, more people are accessing treatment and other health services which were improved as a part of the decriminalization policy. Additionally no negative trends have been seen in terms of increased harms attributed to this policy change.

Achieving a policy shift as significant as decriminalization will take some time. In the meantime, the Canadian Drug Policy Report, Getting to Tomorrow, outlines some possibilities for improving the development of harm reduction in Canada in the short term:

  • Acknowledge that harm reduction is much more than supply distribution and is an essential component of a comprehensive public health response to problematic substance use that offers client-centred strategies with health engagement at their core.
  • Acknowledge that harm reduction values the human rights of people who use drugs and affirms that they are the primary agents of change for reducing the harms of their drug use.
  • Provincial governments can commit to articulating harm reduction strategies across mental health, addictions and infectious disease policy frameworks.
  • Where harm reduction language is present within policy frameworks ensure implementation at the community level.
  • Support innovation at all levels. An ethic of experimentation will help create an environment where new ideas and novel approaches can be developed and explored.
  • Provide leadership to bring health and policing agencies together to get “on the same page” with regard to harm reduction. Opposition by some in the policing community is unfortunate and an unnecessary barrier to scaling up harm reduction programs.

Developing a robust and equitable harm-reduction approach for Canadians will necessitate new thinking about old strategies —thinking that exposes the harms that flow directly from our current policy frameworks and will open the door to new ideas and approaches that are emerging around the world.

Author: Donald Macpherson, Executive Director of the Canadian Drug Policy Coalition

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC