“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.

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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

21st century drinking in BC: more convenience, more government revenue and reduced harms?

On Friday January 31, 2014 the BC government endorsed all 73 recommendations contained in John Yap’s landmark review of liquor laws with the stated goal of modernizing BC’s approach to managing alcohol. Modern drinking in British Columbia will mean consumers are able to purchase and consume more types of alcohol and in more places. Bars, nightclubs and restaurants will be able to compete aggressively on price by offering happy hours; Canucks fans will be able to consume hard liquor while watching a game; festivalgoers will be able to purchase alcohol and wander freely as they drink it; shoppers will be able to buy alcohol with their groceries and parents will be allowed to bring their children into pubs.

The government heralds these and other measures as a way to free businesses and charities from cumbersome, out of date regulations. Interestingly, the media release is relatively silent on an encouraging swathe of other recommendations in the report that, while less politically appealing, make BC’s approach to alcohol also more responsive to health concerns. Mr Yap clearly heard the messages delivered during the review by individuals and groups concerned with health and safety, including those summarised in the CARBC submission.

We congratulate Mr Yap on his acknowledgement that alcohol is a major health issue and not just a matter for the economy, for tourism and government revenue. His very first recommendations concern the need to communicate the serious health effects of alcohol more effectively to British Columbians along with active promotion of the national drinking guidelines. The report even mentions the word “cancer”. This is critically important: at the present time the BC Liquor Distribution Branch has absolutely no mandate to acknowledge, address or monitor the health and safety consequences of the product it so efficiently distributes across our province. It will now be required to collaborate with health experts to design educational materials and, more importantly, consider how to price the many thousands of its alcoholic products so that: a) they are not too cheap and b) their price reflects their degree of potential harmfulness i.e. alcoholic strength.

Perhaps wisely, the government press release has not trumpeted the recommendations on alcohol pricing. It has used only cautious language stating rather timidly that the BC Liquor Distribution Branch should “consider” setting minimum prices according to the ethanol content of drinks and whether they are at “an appropriate level”. Such policies, while possibly the most effective available to government to reduce alcohol-related harm, are undoubtedly not quite as popular as the introduction of happy hours and less red tape for small business.

For the past eight years CARBC has been collecting and reporting indicators of alcohol consumption and related harms across 89 local areas of the province as part of the Alcohol and Other Drug (AOD) Monitoring Project. When Mr Yap’s report asserts that in 2011 there were 20,542 alcohol-related hospital admissions and 1191 alcohol-related deaths, those estimates were calculated by the AOD project team. They were also the basis of research published in the American Journal of Public Health identifying the significant positive impacts of minimum alcohol prices on BC hospital admissions. This same paper also identified negative but smaller impacts on hospital admissions from the increased availability of alcohol associated with the large increase in private liquor outlets that occurred between 2002 and 2006.

On the basis both of local and international research, if the government proceeds with only the more popular recommendations in the report, the net effect will be upward pressure on levels of alcohol consumption and increased harms. If the key recommendations for higher minimum prices based on ethanol content are fully implemented, the net effect will be reduced alcohol-related harms and increased government revenues. Maybe this is what 21st century drinking should be: more choices, more responsibility, more convenience and more financial incentives to produce, promote and consume less harmful products. Perhaps also more funds for treatment and prevention. We at CARBC will continue to watch and hope that the easier and popular policy changes will not be implemented in advance of those which are less popular but more effective in terms of protecting health and safety. Either way, we will observe and report the outcomes as they unfold.

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Authors (left to right): Tim Stockwell, Dan Reist, Kara Thompson, Gerald Thomas, & Kate Vallance

Why does providing crack pipes to people who smoke crack matter?

Imagine ordering your favourite alcoholic beverage at your favourite establishment and being served this beverage in a chipped, dirty, unwashed glass. Now imagine taking a sip, your lips brushing the jagged rim, oily fingerprints, an unusual taste. Is that a spot of blood on the glass rim? Or maybe just a bit of food, left there by the previous user? Thankfully, regulations and regular public health inspections prevent this kind of scenario by ensuring establishments provide customers with utensils that are clean and safe to use. 

This is a basic tenet of harm reduction. A simple measure of public health.           

Unfortunately, this public heath measure does not extend to all forms of psychoactive substance use. If consumption of the most widely used substance in Canada (i.e., alcohol) is regulated to ensure that we safely consume it, shouldn’t people who use other substances be offered the same basic health measures?

Although the continued establishment of programs like needle exchange and supervised injection sites is a sign that harm reduction principles are increasingly accepted, not all is fair and equal in the world of harm reduction. People who smoke crack cocaine, for example, are not accorded the same public health measures – like being given safer drug use equipment – as people who inject their drugs. One of the more controversial harm reduction programs recently implemented in just a few cities in Canada is the distribution of pipes to people who smoke crack.

I’m often asked: “But why would we want to give pipes to people who smoke crack?”

Here is why:

  • Without access to clean pipes, people smoke with unsafe objects, which can cause cuts and burns to their lips and mouth.
  • Without access to clean pipes, people tend to share these unsafe pipes.
  • Crucially, sharing pipes has been associated with the transmission of illness and disease like hepatitis C, pneumonia, and tuberculosis.

Providing clean pipes to people who smoke crack is the same as providing clean needles to people who inject drugs. Risk of disease transmission decreases. Outreach workers have increased contact with drug users. People start to believe we care about them, and stop thinking (and this is something I’ve heard numerous times), “I’m not as important because I’m a crack smoker.” Not providing pipes to people who smoke crack is kind of like saying, “Your experiences of inequality, while detrimental to your well being, are not as important because you don’t inject drugs.”

I’m also often asked: “Doesn’t handing out crack pipes encourage crack use?”

It was recently found in Vancouver that crack use declined once crack pipes started being distributed. Not only does providing pipes not encourage crack use, but now people are less frequently cutting and burning their lips/mouths, and pipe sharing has been reduced, thus reducing the risk of disease transmission (and subsequent costs of related medical visits and care).

I’m often told: “Alcohol is legal, crack is not.”

Legality of drugs is subjective. Health is not.

 

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

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Author: Andrew Ivsins, PhD candidate in Sociology at the University of Victoria/Centre for Addictions Research of BC.