How Peer Education can make Festivals Safer

With the recent deaths at Toronto’s VELD festival or the Boonstock Festival in Penticton, BC, many people are now scrambling to come up with explanations for the tragedies. Toronto Police are blaming bad drugs. Many media outlets are taking the opportunity to blame youth culture. Whatever story we tell, the fact is that people are doing drugs at parties.

How can we encourage people to party more safely? (image courtesy of the Trip! Project)

That’s where The Trip! Project comes in. We go where the party is. We hit up bars, festivals, frosh events, concerts, bathhouses, raves, after hours clubs – wherever folks are getting down. Here at Trip! we neither condemn nor condone drug use. Trip! is a harm reduction outreach group based in Toronto. We offer peer support, tripsitting (supporting someone through a psychedelic crisis) and give out tons of information about how to party safer.

The Trip! Project is run by peers, youth who party themselves and are active in the scene. Peer education is an invaluable tool in harm reduction. When we set up a Trip! booth, we are able to engage with people who party on a different level than other drug educators. As peers, we are able to meet people where they are at, have honest and frank discussions about substances and create a sense of trust. When we do rounds at a party, we’re checking in on people who are suspicious of security and medics but tend to be in situations outside of their experiences. We are able to offer on the spot support, answer basic questions, suggest ways to reduce harm, and spot signs of medical distress. Peers are trusted because they operate outside of formal institutions associated with one-sided information linked to an abstinence-based, prohibition model.

At parties, we set up Trip! booths, which have all kinds of non-judgemental and helpful information on different substances, safer use and safer sex. We give out condoms and lube as well as different coloured straws, so that if folks are snorting with friends they can keep track of their straw and reduce the risk of spreading Hepatitis C.

Our outreach workers also liaise with venues and promoters to help them make their parties safer. We advocate for free water. We encourage clubs and venues to allow ins and outs so that people can cool down and suggest other simple measures to help create a safer nightlife. At festivals, we encourage organizers to keep police away from medic tents unless absolutely necessary. This stops people in need of medical attention from avoiding medics because of fear of criminalization. Most importantly, we try to help organizers acknowledge drug use at their events and allow us to help make it safer.

Festivals can be safer. Nobody has to die at a party. But we need a harm reduction approach that gives people the information and resources they need to stay safe.

Contact us at: info@tripproject.ca and like us on Facebook!

Author: Steff Pinch, harm reduction outreach worker at the Trip! Project

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

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.

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

“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.

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

Needles in Prison: Where is Public Health Behind Bars?

“Our government has a zero-tolerance policy for drugs in our institutions.”  This comment comes from Canada’s Public Security Minister Vic Toews, responding the 2012 Federal lawsuit filed by four HIV groups and a former Canadian Correction inmate seeking a supervisory injunction – a court order that would force Ottawa to establish Canadian prison-based syringe access programs (PSAPs).

You may be asking yourself: “Drugs are illegal and prisons are drug-free, so why would we give inmates needles to commit a crime?”

The reality is prisons are not drug-free and needle-free; never have been, never will be.

Contrary to the assumption that prisons are a highly restricted, secure environment, virtually no prison in the world has been able to keep drugs completely out. Needles are easily smuggled in or can be made from various items already in prisons (see example here). These needles are shared, often for a fee, between anywhere from 10 to 20 inmates.

Roughly 80 percent of inmates arrive with substance use problems and incarceration has absolutely no effect on reducing injection drug use.  The Correctional Service of Canada itself admitted that 17 percent of male and 14 percent of female inmates reported injecting drugs while in prison – 60 percent of the time with a used syringe.

The danger here is that our prisons have become hot spots for HIV and hepatitis C virus (HCV) transmission. To begin with, HIV and HCV prevalence rates in prisons are at least 10 and 30 times higher than the population as a whole. A Vancouver study estimated 21 percent of all HIV infections among people in Vancouver who inject drugs were acquired in prison.

In the face of our government’s “zero tolerance” policies, Canada has acknowledged that drug use does exist in its institutions. Currently, bleach kits, which inmates can use to sterilize syringes, are available upon request. Advocates for PSAPs see bleach kit programs as a step in the right direction. But these programs have also come under scrutiny. Research shows inmates report limited access to such programs, particularly because they come with increased surveillance and stigmatization from correctional officers.

In addition to principles based on prohibition, the reason the Correctional Service of Canada has not moved forward with PSAPs is because of the concern that inmates may turn syringes on officers and use them as weapons. What is the evidence behind this?

In the 60 PSAPs across 12 countries introduced since 1992, there have been no reports of needles from PSAPs being used as weapons. Rather, evidence shows:

• Reduced needle sharing
• Reduced needle pricks
• Decreased HIV and HCV transmission (also safer for officers if they do get pricked)
• No increase in drug use or injecting
• Reduced drug overdoses
• Increased referrals to drug treatment programs
• Effectiveness in a wide range of institutions

Despite this compelling evidence, PSAPs remain a tough sell in Canada. One possible reason why prison health has not been prioritized by the public may be due to a misconception that people stay in prison forever. But prisoners (including those who have contracted HIV and HCV) do not stay behind bars forever. Over 95 percent of people are eventually released back into the community. They are our brothers and sisters, mothers and fathers, sons and daughters. They are part of our communities – making prison health a vital component of public health.

Ignoring this fact not only harms public health more broadly, but, by definition, also violates human rights. HIV advocacy groups argue many rights are violated by refusing PSAPs, including the right to the highest attainable standard of health.

If not evidence, what will it take to introduce true public health and human right standards for Canadians behind bars?

Author: Alissa Greer, Research Project Coordinator at Rocky Mountain Poison and Drug Center

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

What is harm reduction?

One could argue that the best way to reduce and prevent harms from substance use is for everyone to stop using psychoactive substances. Similarly, one could argue that the best way to eliminate traffic fatalities and injuries is for everyone to stop driving. Rather, we adopt harm reduction strategies like seat belts, encourage people to obey road signs and not to drink and drive. When I ride my bike, I wear a helmet as that has been shown to prevent injuries. Shouldn’t everyone have access to evidence based strategies that reduce harms related to licit and illicit substance use?  The Supreme Court of Canada definitely thinks so. In 2011 they granted Insite, North America’s first and only supervised injection site, an immediate exemption from federal drug laws, upholding BC Supreme Court decision that supervised injection is a health care service.

Harm reduction is a respectful nonjudgmental approach to reducing harms of drug and alcohol use that meets people “where they are at,” in relation to substance use without the expectation of eliminating or reducing use. The goal is to reduce harm, both for the individual using a substance and for those influenced by other people’s use.  Harm reduction philosophy and principles stem from a pragmatic understanding that substance use is a feature of human existence – it is a part of our world and we can work to minimize its harmful effects rather than simply ignore or condemn them (see www.ihra.net). Participation and social inclusion of people who use substances in harm reduction responses are important  principles of harm reduction.  Within an overall philosophy of harm reduction, there is a wide range of evidence based harm reductions strategies that reduce the harms of alcohol, tobacco and illicit drugs such as heroin, cocaine and crack. 

Much of the focus in harm reduction has been on reducing the harms of illicit drug use such as blood borne diseases, overdoses, public disorder and crime.  For example, strategies like the provision of clean injection supplies or safer crack use kits, supervised injection, naloxone, methadone maintenance, and heroin prescription programs have been shown to reduce these harms especially among disadvantaged populations .  Street based harm reduction services often emphasize the importance of a trusting relationship with clients to reduce stigma and to increase referrals and access to other health, housing and social services.

We sometimes hear the argument that restricting or prohibiting the establishment of harm reduction services will reduce harm to the community and is therefore harm reduction. But this is often based on fear or misinformation rather than evidence.   Harm reduction services reduce harms by their presence not their absence.  Illicit drug use is often feared and highly stigmatized with incarceration as a response; treating substance use as a criminal rather than health issue. This is why many are calling for drug policy reform and the decriminalization of currently illegal drugs..

Providing information and education about safer use of drugs and alcohol is also part of a harm reduction approach (e.g. safe use of prescription drugs, safer drinking guidelines or safer injection techniques). Harm reduction strategies are part of public health, substance use and treatment services complementing withdrawal and abstinence based approaches.  So why are some harm reduction strategies seen as more controversial than others even though there is a strong evidence base?   Societal understanding of harm reduction is expanding and more work is being done on alcohol harm reduction and harm reduction approaches tailored to youth and women. Get ready for future blogs that address these and other issues.

Author: Bernie Pauly RN, Ph.D, Associate Professor, School of Nursing, Scientist, Centre for Addictions Research of BC, bpauly@uvic.ca

Nuts and Bolts of Cannabis Regulation in Canada

At the Canadian Drug Policy Coalition (CDPC) one of things we’ve noticed is that any blog we publish on cannabis regulation attracts more attention than any other topic. This is because there’s widespread interest in discussion of changes to the laws that govern cannabis. Unfortunately when it comes to the nuts and bolts of cannabis regulation – in other words – the how of regulation, interest tends to drop off. This is because regulation is actually rather tedious. This is borne out by the length of the proposed regulations for legal recreational cannabis markets in the U.S. states of Washington (43 pages) and Colorado (72 pages). That’s why I’m making a special plea to you our dear readers to stay with me as I say a few words about what regulation might actually entail.

I think it’s fair to suggest that both the CDPC and the Centre for Addictions Research of BC favour a model of regulation that draws on the best evidence from public health regulation of alcohol and tobacco. But when it comes to cannabis regulation the devil really is in the details. There’s no magic bullet that will make all the current problems with cannabis prohibition disappear. But thanks to the Health Officer’s Council of BC, some of the heavy lifting when it comes to creating models for drug regulation has been done. If you’re curious, check out their 2011 report. As you can see from the diagram drawn from that report, regulations for cannabis should not be so loose that they create a free and unregulated market for cannabis; nor should regulations be so overly restrictive that we end up reproducing the negative aspects of the current underground economy (control by organized crime, etc.). 

At the same time we need to be clear about the goals we hope to achieve with a legal regulated market for cannabis. Ideally our regulations will help protect and improve public health, reduce drug related crime, protect the young and vulnerable, protect human rights and provide good value for money. So what are some of the things we’ll need to consider? How about we start with the basics.

Presumably legalization would entail the removal of cannabis from Schedule 2 of the federal Controlled Drugs and Substances Act, followed by its inclusion in the Food and Drug Act. It seems like the next logical thing to do would be to turn over the regulation of cannabis to the provinces, in the same way that alcohol is currently regulated. We would want to ensure that there is at least some consistency across the provinces so that means somebody at the federal level will have to oversee the regulations as they emerge. That’s the easy part because legalization would ALSO entail consideration of at least the following issues: production, product, packaging, vendor and outlet controls, marketing controls, creation of a system of regulators and inspectors as well as on-going research and monitoring.

For this blog post, I want to focus on production and product controls. Future blog posts may consider the other items on the long list noted above. My comments meant to stimulate discussion of regulation rather than to propose firm rules for how a legal recreational cannabis market might operate.

In Canada, marijuana is currently produced in one of two ways – under existing legal medical marijuana guidelines or in illegal circumstances. Growing marijuana takes places in a vast array of situations ranging from a few plants grown for personal use all the way to large-scale industrial size operations with 100’s of plants.

Thus regulating the growth of marijuana for a legal recreational market will not be simple. Many people are very attached to their small-scale gardens, and it would be difficult to impossible (as well as undesirable) to eliminate growing marijuana for personal use. And it’s important not to turn the whole thing over to heavily capitalized large scale commercial producers who main motivation is profit, especially since the range of available strains of marijuana has been the result of innovation by many small-scale growers. Thus, we need to ensure that the best practices in indoor, outdoor, personal, commercial production are preserved while ensuring that cannabis is produced in safe and clean facilities.  We will also need to decide who is the appropriate authority for regulating growing operations: municipalities or provinces or some combination of both. Neither seems overly keen on this role so they will require some convincing.

Okay if your head doesn’t hurt yet lets turn our attention to product controls. Product controls include issues like price, age limits, potency, permissible preparations (edibles, tinctures, etc.), quality control, and labeling and packaging requirements. Price is a key issue when it comes to meeting public health goals. Price can help shape sales and thus use of cannabis, so we want to ensure that pricing reflects what we’ve learned from alcohol – namely that alcohol consumption is sensitive to price and that price must in some way be related to potency. Related to price is taxation – at what point in the chain from seed to sale will cannabis be taxed and at what rate? And what preparations will cannabis regulations allow? Plant materials, tinctures and oils, edibles? Right now Canada’s medical marijuana access program only allows for the distribution of plant material. Clearly this is a very limited approach given that the medical cannabis dispensaries have created a range of edible and other products that eliminate the necessity of smoking cannabis. We will also need to decide where we stand on potency: in other words will we put limits on how potent products can be, and given that there are over 100 cannabinoids, how will we decide which ones we want to measure and regulate? 

Okay so I haven’t covered other essential issues like vendor controls, marketing and evaluation and monitoring but I think you get the picture. Regulation is by no means a simple matter, but it can be done. In fact, experience from legal recreational markets in Washington and Colorado will provide valuable insights that can inform Canada’s approach. And regulation has the potential to create conditions where cannabis production and use is a whole lot safer than the current prohibition approach.

 

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

Connie Carter, Senior Policy Analyst, Canadian Drug Policy Coalition