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Critical studies of harm reduction: Overdose response in uncertain political times
International Journal of Drug Policy 76 (2020) 102615
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Commentary
Critical studies of harm reduction: Overdose response in uncertain political times
T
Tara Marie Watsona, , Gillian Kollab,c, Emily van der Meulend, Zoë Doddc ⁎
a
Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Russell Street, 3rd floor Tower, Toronto, Ontario M5S 2S1, Canada Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario M5T 3M7, Canada c Toronto Overdose Prevention Society, Toronto, Ontario, Canada d Department of Criminology Ryerson University 380 Victoria Street Toronto, Ontario, Canada M5B 2K3 b
ARTICLE INFO
ABSTRACT
Keywords: Harm reduction Overdose prevention Opioids Critical theory Canada Ontario
North America continues to witness escalating rates of opioid overdose deaths. Scale-up of existing and innovative life-saving services – such as overdose prevention sites (OPS) as well as sanctioned and unsanctioned supervised consumption sites – is urgently needed. Is there a place for critical theory-informed studies of harm reduction during times of drug policy failures and overdose crisis? There are different approaches to consider from the critical literature, such as those that, for example, interrogate the basic principles of harm reduction or those that critique the lack of pleasure in the discourses surrounding drug use. Influenced by such work, we examine the development of OPS in Canada, with a focus on recent experiences from the province of Ontario, as an important example of the impacts associated with moving from grassroots harm reduction to institutionalised policy and practice. Services appear to be most innovative, dynamic, and inclusive when people with lived experience, allies, and service providers are directly responding to fast-changing drug use patterns and crises on the ground, before services become formally bureaucratised. We suggest a continuing need to both critically theorise harm reduction and to build strong community relationships in harm reduction work, in efforts to overcome political moves that impede collaboration with and inclusiveness of people who use drugs.
Introduction Critical theory-informed studies and commentaries about harm reduction can contribute rich perspectives to the literature and spark lively debates. Does such scholarly work, however, contribute to advances in practice that help to improve the safety and well-being of people who use drugs? If so, in what concrete or meaningful ways? Critical analyses of harm reduction may appear far removed from actual lived experience and essential service delivery, and might seem to be of little practical utility during a public health crisis. As communities across North America are experiencing escalating rates of opioid-related overdose deaths (Hall & Farrell, 2018; Special Advisory Committee on the Epidemic of Opioid Overdoses, 2018), existing and innovative lifesaving programs such as supervised consumption services (SCS) and overdose prevention sites (OPS) are being swiftly expanded in Canada using a range of modalities and operational models, including both sanctioned (i.e., formally authorised through means such as legislation/ regulations or governmental approval) and unsanctioned services (Kerr, Mitra, Kennedy & McNeil, 2017; Scheim & Werb, 2018; Strike &
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Corresponding author. E-mail address: [email protected] (T.M. Watson).
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Watson, 2019). Perhaps this current moment represents a new phase or era of harm reduction altogether (see Erickson, 1999; Stimson & O'Hare, 2010). Although at this time we cannot claim to know with any certainty where this moment will lead, we contend that, even during a devastating overdose crisis, there is a continuing need to critically interrogate harm reduction and, in particular, its relationships with communities, health authorities, policymakers, and other stakeholders. We write this commentary as a group of drug policy/harm reduction researchers and drug user rights activists, with two of the authors (GK and ZD) heavily involved in the development of OPS, as well as various other supports for communities of people who use drugs, in the Canadian province of Ontario. We begin by briefly summarising key critical literature on harm reduction. After this summary, we give an overview of the emergence of OPS, an intervention designed to immediately fill important service gaps in safer drug consumption and overdose prevention. Our focus here is on Canada, with a specific examination of very recent experiences from Ontario. We demonstrate that harm reduction services are often at their most dynamic, inclusive, and innovative when people with lived experience, allies, and service
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providers are together responding to fast-changing drug use realities in their communities. Thus, these programs may be best situated to meet the diverse needs of people who use drugs before they become formally institutionalised, even perhaps before becoming recognised by scholars or policymakers as ‘evidence-based’ (see Lancaster, Seear, Treloar, & Ritter, 2017; Lancaster, Treloar, & Ritter, 2017). Critical studies have played and continue to play a key role in enhancing and building our understanding of such processes.
of ‘pleasure’ in harm reduction discourse and in the design of policies and programs (cf. Dennis, 2017a; Duff, 2004; Duncan, Duff, Sebar & Lee, 2017; Race, 2008). This body of literature leads us to question how a model that emphasises the importance of meeting people who use drugs ‘where they currently are in their lives’ (Harm Reduction International, 2010) adequately fulfills this principle without paying much, if any, attention to pleasure and the beneficial impacts of drug use. Not talking about pleasure serves to erase from research and discourse the important role that it plays (Duff, 2015; Moore, 2008), while also ignoring the full spectrum of drug use experiences, as not all drug use has adverse consequences or reflects dependence, another central tenet of harm reduction (Duff, 2004; Harm Reduction International, 2010). Although an increasing number of scholars and other voices are calling for greater recognition of pleasure in drug policy (see Dennis & Farrugia, 2017; Race, 2017), how these calls are or will become operationalised in practice largely remains to be seen. Another major and diverse stream of harm reduction literature utilises approaches from science and technology studies, post-humanism, and new materialism to explore the importance of relational understandings of concepts such as ‘addiction’ and ‘problematic drug use,’ arguing that these are not stable phenomena but are continually made and remade in practice (Fraser, 2017; Fraser & Moore, 2011, 2014). These studies draw attention to the non-human actors in events of drug consumption and highlight the ways in which a multitude of elements (including subjects, practices, and effects) are assembled in dynamic ways in the drug event (Dennis, 2017b; Dilkes-Frayne, 2014; Duff, 2014, 2016; Duncan et al., 2017; Race, 2011; Rhodes, 2018, 2019). In turn, such frameworks highlight the destigmatising potential of theoretically-informed approaches and programs (Farrugia et al., 2019; Fraser et al., 2014; Pienaar & Dilkes-Frayne, 2017). Situating some of these theoretical approaches in community practice, in the next section we consider the emergence of OPS in Canadian contexts, especially the recent experiences in Ontario. In what follows, we explore how major themes uncovered by critical studies of harm reduction occur on the ground in the development of services for people who use drugs in the context of the overdose crisis.
Critically theorising harm reduction Studies that engage with theory to critique or attempt to reconceptualise harm reduction principles and practices are scant in comparison to standard empirical, including evaluative, research. Indeed, there was enough empirical evidence over a decade ago to convince some drug policy researchers that, at the time, ‘The scientific debate about harm reduction[…]is now over’ (Wodak, 2007, p. 29). Since then, the relevant evidence base continues to grow and is often used to justify the establishment of new programs and adopt harm reduction as a pillar of drug policy (e.g., Strang et al., 2012). This popular narrative about the success of harm reduction is especially convincing when viewed against the long history of criminal justice and drug war failures that is recognised as having contributed to staggering social costs and much drug-related morbidity and mortality (e.g., DeBeck et al., 2017; Jensen, Gerber & Mosher, 2004; Wodak, 2014). Notably, scholars who utilise theory to challenge harm reduction tend not to dismiss the scientific basis behind the model and associated services; instead, these scholars ask critical questions and present alternative narratives that we think can be better harnessed to push for more equitable, inclusive, and innovative policies and practices. Critical studies of harm reduction in the published literature contain multiple theoretical perspectives and opportunities for new ways of thinking. One of the most notable and longstanding bodies of work challenges the ostensibly ‘amoral’ or ‘value-neutral’ principles of harm reduction by drawing on Foucauldian and other governmentality logics regarding surveillance and control mechanisms that produce highly responsibilised, self-governing subjects (cf. Fischer, Turnbull, Poland & Haydon, 2004; Hathaway, 2001; Keane, 2003; Miller, 2001; Moore & Fraser, 2006; Mugford, 1993; O'Malley, 2004; Quirion, 2003; Roe, 2005; Souleymanov & Allman, 2016). This literature includes valuable discussions of reproduced power structures, including perspectives on harm reduction such as the following:
Overdose prevention sites as community-driven responses in a time of crisis The OPS model developed in direct response to the rising number of overdose deaths, combined with relative government inaction and bureaucratic delays in the face of these deaths. OPS emerged in the Canadian provinces of British Columbia (B.C.) in 2016 and Ontario in 2017 as unsanctioned, low-threshold services run by volunteers and community members in makeshift environments, such as tents and trailers (Collins, Bluthenthal, Boyd & McNeil, 2018; Kerr et al., 2017; Lupick, 2017; Wallace, Pagan & Pauly, 2019). When the first unsanctioned OPS was launched in September 2016 in B.C., there were only two state-sanctioned SCS in operation across the country, despite a mechanism in place to allow organisations to seek an exemption from federal drug laws to open new SCS (Kerr et al., 2017). This process, however, was repeatedly criticized as too onerous, prompting the opening of the first unsanctioned OPS. In both B.C. and Ontario, municipal and criminal justice actors did not intervene to shut down the unsanctioned sites while, through different mechanisms, health authorities moved quickly to regularise the status of OPS. The provincial government in B.C. declared a state of public health emergency in relation to the overdose crisis on April 14, 2016; this declaration was used to sanction the opening in December 2016 of additional OPS at organisations already providing frontline services to people who use drugs (Collins et al., 2018; Kerr et al., 2017). In Ontario, the first unsanctioned OPS opened in August 2017; within months, the Ontario government chose to instead obtain a class exemption from federal health authorities to approve OPS within the province and then swiftly moved to develop a program model for OPS (Ministry of Health & Long-Term
This ‘band-aid’ approach is popular because its rhetoric adheres to and further legitimizes those discourses propagated by those institutions in power which act to preserve the population in a governable state. In other words, public health advocates can be accused of leaving unexamined and intact the power relations that these narratives both reproduce and help to sustain. This leads to the conclusion that harm minimization is a safety net, not a strategy, representing a convergence of economic rationalism and social policy. (Miller, 2001, p. 177) Within this stream of literature, investigations of particular services (e.g., SCS, Fischer et al., 2004; methadone maintenance programs, Quirion, 2003) foster understandings of how interventions, once institutionalised and likely bureaucratised, can get diverted from initial program objectives and well-intentioned harm reduction principles (see Harm Reduction International, 2010). Problematic, especially for program clients or service users, is the potential for some interventions to then become exclusionary, focused on security and surveillance, or otherwise more aligned with traditional treatment and rehabilitation goals than those of harm reduction. For instance, Fischer et al. (2004) discuss how SCS ‘house rules’ may deter or exclude some service users, a phenomenon that has since been documented using qualitative research (see also Small et al., 2011). In addition, there are also studies that identify a lack of recognition 2
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Care, 2018a). Crucially, in both B.C. and Ontario, government and public health authorities sought to formalise a program model that had already been functioning as an unsanctioned service by volunteers and community members, with integral input and leadership from people who use drugs. The involvement of people with lived experience in the development of OPS has been documented as a strength of such services, promoting safety and engagement among service users (Boyd et al., 2018; Kennedy et al., 2019). That said, initial efforts from government and public health authorities to formalise an OPS model harken back to critical studies informed by governmentality logics, particularly examples of programs having their operations negotiated away from grassroots-driven origins to more bureaucratic, surveillance-oriented goals (see again Fischer et al., 2004; Quirion, 2003). The Ontario unsanctioned OPS – called the Moss Park Overdose Prevention Site – was opened in a downtown Toronto park in response to a local spike in overdose deaths (Mullin, 2017). The site was established by a collective of people who use drugs, harm reduction workers, and healthcare providers, and originally comprised three tents. While one tent was used to distribute harm reduction equipment and naloxone kits, a second provided supervised consumption of drugs used through injection, nasal inhalation, or oral routes of administration. The third tent was available for people to smoke drugs such as crack cocaine, crystal methamphetamine, and opioids. After four months of daily operation, the Moss Park OPS acquired a heated trailer in November 2017 (Gray, 2017). Operations continued – with injection and distribution services in the trailer and one tent attached outside for smoking/inhalation – until July 2018, when the site received approval under the new provincial OPS program, at which point the services moved into a nearby storefront to become a fully sanctioned and provincially-funded location, complete with paid staff members (Sheldon, 2018). Notably, within eleven months in operation as an unsanctioned site, the Moss Park OPS saw 9062 visits to its injection monitoring service, intervened in 251 overdoses, and had no deaths (Kolla, Dodd, Ko, Boyce & Ovens, 2019). A key strength of the Moss Park model has been that the group of volunteers running the site largely consisted of people with lived experience who have championed low-threshold service delivery with few rules or regulations in place. For example, aligned with known preferences of those who were already using drugs in the park where the site was established, no OPS rules were made or enforced around splitting or sharing drugs, location of injection on the body, or assisted injection (Kolla et al., 2019). Ongoing attempts were made to be responsive to OPS user feedback regarding the manner in which overdose intervention occurs, efforts that took into account more than drug-related effects but also the dynamic practices and experiences that shape and reshape the drug-taking events at the site. In other words, staff and volunteers were continuously attempting to attend to user needs and better situate the OPS intervention within lived experiences and practices at the site. These efforts were made not only to ensure smooth operations, but to also acknowledge the centrality of pleasure within the experience of drug use and the variety of embodied and affective ways in which pleasure could flow in both the consumption and postconsumption spaces (see again Duncan et al., 2017). For example, Moss Park OPS volunteers (including authors GK and ZD) observed people using the service telling others, for instance, to be careful not to go ‘on the nod’ following an opioid injection or they would be ‘naloxoned’ (i.e., administered a dose of the opioid antagonist). While Moss Park OPS volunteers were attempting to respect the desires of people using the service to avoid such an outcome due to the precipitated withdrawal symptoms that many experience following naloxone administration, these volunteers were also attempting to create a space where people who use drugs could have a positive drug consumption experience, including experiencing pleasure from their high (Duncan et al., 2017). These observations led to attempts to ensure that volunteers supervising the injection tent were well trained in overdose recognition
to prevent unnecessary naloxone administration by well-meaning but overly-cautious volunteers. Moreover, those supervising the injection tent were paired up on shift, so that one medical volunteer (i.e., a doctor, nurse, or nurse practitioner) was paired with a volunteer with lived experience of injection drug use, to ensure that overly medicalized perspectives on drug consumption and traditional power relations did not dominate. These two volunteers were together responsible for management of all overdoses in accordance with the medical directive in place for the site. This directive was developed cooperatively by the group of volunteers running the site and used a decision support tool to specify the parameters for responding to overdoses at the OPS. The directive included privileging oxygen administration and stimulation in cases where breathing was still present, only using naloxone in cases where breathing was absent or when stimulation and oxygen administration failed to bring respiration rates up above 10 breaths per minute. The opening of the Moss Park OPS in August 2017, prior to the establishment of SCS or other OPS in Ontario, had an immediate influence on the drug policy environment in the province. Within a year, in August 2018, there were a total of eight SCS or OPS in operation in the city of Toronto, and an additional eight SCS or OPS in other Ontario communities. The OPS model that developed in the province, like the original Moss Park site, was low-threshold, designed to allow organisations providing services to people who use drugs to quickly apply for and receive funding from the provincial Ministry of Health to open a new service, with a response to OPS applications provided within two weeks of application submission (Ministry of Health and Long-Term Care, 2018a). The OPS model that was instituted in January 2018 provided funding for staff only, envisaging that organisations would use existing facilities to open a bare-bones model of supervised drug consumption; it also provided for considerable flexibility in the operationalisation of the model, with a variety of services being accepted for funding, and did not require that a registered healthcare provider (such as a registered nurse) be on site. Significant input from the frontlines of the overdose crisis was incorporated into the OPS model that was developed, through discussions between Moss Park organisers and the provincial Ministry of Health, as well as the presence of Moss Park workers and people with lived experience of drug use on the Opioid Emergency Task Force that designed the OPS model. In practice, and compared to the SCS model in use, this process resulted in an approach that was more strongly shaped by the needs and practices of the people who would be using these sites. The greater flexibility of the model and integration of practices that were not permitted in the SCS model (e.g., assisted injection) was an attempt to create a space that engendered more positive experiences for service users. It also held the potential to open discussion about pleasure and related user practices/experiences, and how these could be operationalised within drug consumption spaces like OPS, even amid a public health crisis. However, the June 2018 election of a Progressive Conservative provincial government dramatically changed the direction of Ontario's evolving drug policy landscape, which had been previously guided by the Liberal Party. Two months later, in August, the new conservative government announced a ‘pause’ on the opening of three previously approved OPS (Russell, 2018). In a move that was widely perceived to be partisan and ideologically driven, the same government announced a review of the evidence on SCS and OPS (e.g., Rushowy, 2018). This review culminated in the October 2018 announcement of a ‘Consumption and Treatment Services’ (CTS) model, which dismantles the previous OPS model, replacing it with an approach that allowed supervised injection services to continue only if they implemented a ‘comprehensive enforcement and audit protocol’ and a ‘new focus on connecting people with treatment and rehabilitation services’ (Ministry of Health and Long-Term Care, 2018b). This new focus is also arguably ideological in nature as there is a lack of evidence for enhanced monitoring and reporting, or for an emphasis on referrals to treatment, as contributing to the effectiveness of SCS or OPS when it 3
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comes to their primary goals of reducing the health risks associated with injection (Ministry of Health and Long-Term Care, 2018c). The new model also includes an arbitrary cap of 21 on the maximum number of sites allowed to function in the province, institutes new proximity requirements that limit site operation within 600 m of each other, and imposes extra community consultation requirements on sites located within 200 m of childcare centres, parks, or schools (including post-secondary institutions; Ministry of Health and Long-Term Care, 2018c). After having completed a burdensome application process for the new CTS model in December 2018, and operating on precarious month-to-month extensions from October 2018 to March 2019, the Ontario government announced on March 29, 2019 that 15 existing OPS/SCS had been approved as CTS, with two OPS (in the city of Toronto) and one SCS (in the city of Ottawa) denied provincial funding (HIV & AIDS Legal Clinic Ontario, 2018; Ministry of Health and LongTerm Care, 2019; Stone, 2019). At the time of writing, the three OPS/ SCS denied funding were still operating under an emergency exemption from the federal government. Again, such moves coming top-down from the provincial government – and much more forceful than the initial attempts to formalise the OPS model – are reminiscent of lessons from the first set of critical studies we summarised above. That is, we see this case study from Ontario as a compelling example of external constraints placed on harm reduction programs to bring them more in line with traditional power structures and control mechanisms (e.g., rehabilitative service goals, location and other restrictions). A wide range of groups have voiced their strong opposition to the Conservative government's CTS model (see Pagliaro, 2018; The Canadian Press, 2018; Weeks & Miller, 2019). We view the move as an effort to dismantle the low-threshold OPS model that had been developed by people who use drugs, with significant input from frontline workers, and replace it with a highly bureaucratic approach. The Ontario experience outlined here thus represents an example of some themes that critical scholarship have helped to reveal. While an initial attempt to formalise a grassroots-led, unsanctioned model first resulted in a low-threshold OPS that was quickly taken up by organisations and activists across the province, it has since been dismantled by a new government in power that is perceived by numerous stakeholders as being motivated by ideology rather than evidence or the expressed needs of people who use drugs. The impacts and results of the new CTS model remain to be seen in view of its recent imposition; however, preliminary feedback has been overwhelmingly negative due to the surveillance and monitoring that is required, and a greater focus on rule adherence, treatment, and rehabilitation-oriented goals (CBC News, 2018; Pagliaro, 2018). The strict standardisation within the new approach – including features such as a more bureaucratic application process, hugely increased reporting requirements, the condition that a registered health professional must always be on site, design standards that are not reflective of the evidence base, and a cap imposed on number of sites – does not provide for flexibility in service provision and seems designed to render service delivery as onerous as possible. Additionally, the rigid metrics within the reporting and evaluation requirements that privilege referrals to treatment conflate any drug use to problematic use. These features further restrict the ability of service providers and site volunteers to change practices to meet service users’ dynamic needs, including in ways that recognise diverse drug-taking experiences and pleasure among people using OPS.
surveillance. Other literature (e.g., Dennis, 2017a; Duff, 2004; Race, 2008) reveals the silencing of pleasure, despite the central role of pleasure in much drug-taking and the stated intention of harm reduction to recognise the realities of drug use (see again Harm Reduction International, 2010). Explorations of the experience of pleasure within supervised consumption spaces have been rare, with Duncan et al. (2017) providing a notable exception. While still other literature (e.g., Fraser, 2017; Fraser & Moore, 2011; Fraser et al., 2014) leads us to question how notions of problematic drug use are made and reshaped in practice. Overall, these bodies of critical work prompt important queries about who has the authority to define harm reduction policies and services, and shed light on how such policies and services are constantly being negotiated by multiple actors including those in political power despite their distance from evolving user-driven practices on the ground. The evolution of OPS we have outlined, especially the recent events in Ontario, illustrates such themes in action. This is not the first example of political shifts that have impeded the establishment or threatened the continuation of harm reduction programs in Canada (e.g., Boyd, 2013; Hathaway & Tousaw, 2008; Kerr et al., 2017). As we have aimed to show, despite an extensive evidence base in support of SCS (Potier, Laprévote, Dubois-Arber, Cottencin & Rolland, 2014) and the continued epidemic of drug-related deaths that ethically and urgently demands response, interventions such as SCS and OPS continue to be questioned by policymakers and others. Times of political uncertainty are nonetheless key moments to critically interrogate the assumptions of harm reduction, while examining the programmatic shifts occurring in response to such political shifts. Critical studies have helped to demonstrate how program development and operation can lose sight of basic harm reduction principles that articulate that services should be inclusive and responsive to the changing needs of people who use drugs. Further, such studies can help reveal for a larger audience what many service providers and service users already know from their own experiences about the ways in which political expediency can sacrifice the needs of people who use drugs and foreclose any attempts to attend to the experience of pleasure within consumption spaces. A noted shortfall of the critical traditions we have outlined is that while they illuminate how harm reduction services can lose sight of the goals of being user-driven and user-centred, the existing scholarship tends not to provide clear guidance on how to rectify this situation. Recommendations for how to preserve the centrality of the needs and pleasures of people who use drugs in harm reduction, and prevent the abovementioned diversion to risk management modalities that can lead to exclusion, still very much require development. Recent directions from work that examines ways in which ontology can be mobilised within health and substance use interventions are promising here, as this work delves into questions of how evidence-making practices contribute to bringing not only drugs and their effects into being, but also policies like the ones that govern harm reduction programs and OPS into being (see Rhodes, Closson, Paparini, Guise & Strathdee, 2016; Rhodes & Lancaster, 2019). The continued vulnerability of harm reduction services to both institutionalisation and political threat (at least in North American contexts) remains pertinent. How can critically theorising harm reduction support the development of resistance to institutionalisation? Can such work also support greater formal recognition and perhaps even integration in practice of experiences of pleasure within supervised consumption spaces like OPS to create more positive experiences for people who use drugs? Would development of novel critical approaches, such as more recent attempts to remake and apply new conceptualisations of ‘addiction’, be useful to advancing such goals? These are important questions as there continues to be a divide between critical scholarship and the dedicated work occurring daily on the ground in a time of crisis; and importantly, we continue to lack methods for achieving a more inclusive and balanced sharing of expertise (Greer et al., 2019; Kennedy et al., 2019). We call attention to this shortfall as it highlights
Looking ahead Critical studies of harm reduction contain valuable lessons that are relevant to events currently unfolding within the opioid overdose crisis. From some of this literature (e.g., Fischer et al., 2004; O'Malley, 2004; Quirion, 2003) we learn how programs, particularly once formalised, can start to reproduce certain power structures and be diverted from their original goals, becoming more focused on security and 4
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the potential for greater connection- and relationship-building between scholars who employ theory and the diverse stakeholders within harm reduction, including people with lived experience and allies who are advocating for, providing, and/or using services such as OPS. Doing such work need not be an ivory-tower endeavour, but can and should include partnerships with community members, especially people who use drugs.
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Conflict of Interest Statement None. References Boyd, J., Collins, A., Mayer, S., Maher, L., Kerr, T., & McNeil, R. (2018). Gendered violence and overdose prevention sites: A rapid ethnographic study during an overdose epidemic in Vancouver, Canada. Addiction, 113(12), 2261–2270. Boyd, N. (2013). Lessons from INSITE, Vancouver's supervised injection facility: 2003–2012. Drugs: Education, Prevention, and Policy, 20(3), 234–240. CBC News. (2018). New provincial guidelines make it difficult for Toronto overdose prevention sites, critics say. Retrieved fromhttp://www.cbc.ca/news/canada/ toronto/provincial-guideline-overdose-prevention-site-1.4893110. Collins, A. B., Bluthenthal, R. N., Boyd, J., & McNeil, R. (2018). Harnessing the language of overdose prevention to advance evidence-based responses to the opioid crisis. International Journal of Drug Policy, 55, 77–79. DeBeck, K., Cheng, T., Montaner, J. S., Beyrer, C., Elliott, R., Sherman, S., et al. (2017). HIV and the criminalisation of drug use among people who inject drugs: A systematic review. The Lancet, 4(8), e357–e374. Dennis, F. (2017a). Conceiving of addicted pleasures: A ‘modern’ paradox. International Journal of Drug Policy, 49, 150–159. Dennis, F. (2017b). The injecting “event”: Harm reduction beyond the human. Critical Public Health, 27(3), 337–349. Dennis, F., & Farrugia, A. (2017). Materialising drugged pleasures: Practice, politics, care. International Journal of Drug Policy, 49, 86–91. Dilkes-Frayne, E. (2014). Tracing the “event” of drug use: ‘Context’ and the coproduction of a night out on MDMA. Contemporary Drug Problems, 41(3), 445–479. Duff, C. (2004). Drug use as a ‘practice of the self’: Is there any place for an ‘ethics of moderation’ in contemporary drug policy. International Journal of Drug Policy, 15, 385–393. Duff, C. (2014). The place and time of drugs. International Journal of Drug Policy, 25(3), 633–639. Duff, C. (2015). Governing drug use otherwise: For an ethics of care. Journal of Sociology, 51(1), 81–96. Duff, C. (2016). Assemblages, territories, contexts. International Journal of Drug Policy, 33, 15–20. Duncan, T., Duff, C., Sebar, B., & Lee, J. (2017). ‘Enjoying the kick’: Locating pleasure within the drug consumption room. International Journal of Drug Policy, 49, 92–101. Erickson, P. G. (1999). Introduction: The three phases of harm reduction. An examination of emerging concepts, methodologies, and critiques. Substance Use and Misuse, 34, 1–7. Farrugia, A., Fraser, S., Dwyer, R., Fomiatti, R., Neale, J., Dietze, P., et al. (2019). Takehome naloxone and the politics of care. Sociology of Health and Illness, 41(2), 427–443. Fischer, B., Turnbull, S., Poland, B., & Haydon, E. (2004). Drug use, risk and urban order: Examining supervised injection sites (SISs) as ‘governmentality’. International Journal of Drug Policy, 15, 357–365. Fraser, S., & Moore, D. (2011). The drug effect: Health, crime and society. Cambridge: Cambridge University Press. Fraser, S. (2017). The future of ‘addiction’: Critique and composition. International Journal of Drug Policy, 44, 130–134. Fraser, S., Moore, D., & Keane, H. (2014). Habits: Remaking addiction. New York: Palgrave Macmillan. Gray, J. (2017). Operators of Moss Park overdose-prevention site defy city, bring in trailer. The globe and mail. Retrieved from http://www.theglobeandmail.com/news/toronto/ operators-of-moss-park-overdose-prevention-site-defy-city-bring-in-trailer/ article37030003/. Greer, A. M., Amlani, A., Burmeister, C., Scott, A., Newman, C., Lampkin, H., et al. (2019). Peer engagement barriers and enablers: Insights from people who use drugs in British Columbia, Canada. Canadian Journal of Public Health, 110(2), 227–235. Hall, W. D., & Farrell, M. (2018). Reducing the opioid overdose death toll in North America. PLoS Medicine, 15, e1002626. https://doi.org/10.1371/journal.pmed. 1002626. Harm Reduction International. (2010). What is harm reduction? A position statement from the international harm reduction association. Retrieved fromhttp://www.hri. global/files/2010/08/10/Briefing_What_is_HR_English.pdf. Hathaway, A. D. (2001). Shortcomings of harm reduction: Toward a morally invested drug reform strategy. International Journal of Drug Policy, 12, 125–137. Hathaway, A. D., & Tousaw, K. I. (2008). Harm reduction headway and continuing resistance: Insights from safe injection in the city of Vancouver. International Journal of Drug Policy, 19(1), 11–16. HIV & AIDS Legal Clinic Ontario. (2018). Ontario's new “Consumption and Treatment
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T.M. Watson, et al. Rhodes, T., & Lancaster, K. (2019). Evidence-making interventions in health: A conceptual framing. Social Science and Medicine, 238, 112488. Roe, G. (2005). Harm reduction as paradigm: Is better than bad good enough? The origins of harm reduction. Critical Public Health, 15, 243–250. Rushowy, K. (2018). Recommendation on safe-injection sites postponed. The Star. Retrieved from http://www.thestar.com/news/queenspark/2018/10/01/recommendation-onsafe-injection-sites-postponed.html. Russell, A. (2018). Ontario's decision to halt new overdose-prevention sites could ‘lead to more death’: Experts. Retrieved from http://globalnews.ca/news/4387312/ontariooverdose-prevention-site-controversy/. Scheim, A., & Werb, D. (2018). Integrating supervised consumption into a continuum of care for people who use drugs. Canadian Medical Association Journal, 190(31), E921–E922. Sheldon, M. (2018). ‘When people come here they feel safe’: Finding sanctuary at the moss park overdose prevention site. Retrieved from http://www.cbc.ca/news/canada/ national-moss-park-overdose-prevention-site-opioids-1.4929844. Small, W., Shoveller, J., Moore, D., Tyndall, M., Wood, E., & Kerr, T. (2011). Injection drug users’ access to a supervised injection facility in Vancouver, Canada: The influence of operating policies and local drug culture. Qualitative Health Research, 21(6), 743–756. Souleymanov, R., & Allman, D. (2016). Articulating connections between the harm-reduction paradigm and the marginalisation of people who use illicit drugs. British Journal of Social Work, 46, 1429–1445. Special Advisory Committee on the Epidemic of Opioid Overdoses. (2018). National report: Apparent opioid-related deaths in Canada (January 2016 to March 2018). Ottawa: Public Health Agency of Canada. Retrieved from http://www.canada.ca/en/public-
health/services/publications/healthy-living/national-report-apparent-opioidrelated-deaths-released-september-2018.html. Stimson, G. V., & O'Hare, P. (2010). Harm reduction: Moving through the third decade. International Journal of Drug Policy, 21, 91–93. Stone, L. (2019, 5). Trudeau says Ford government putting lives at risk by closing supervised drug-use sites. Globe and Mail. Retrieved from http://www.theglobeandmail.com/ canada/article-trudeau-says-ford-government-putting-lives-at-risk-by-closing/. Strang, J., Babor, T., Caulkins, J., Fischer, B., Foxcroft, D., & Humphreys, K. (2012). Drug policy and the public good: Evidence for effective interventions. Lancet, 379(9810), 71–83. Strike, C., & Watson, T.M. (.2019). Losing the uphill battle? Emergent harm reduction interventions and barriers during the opioid overdose crisis in Canada. doi: 10.1016/ j.drugpo.2019.02.005. The Canadian Press. (2018). Health groups urge ontario government to rethink position on overdose prevention sites. Global News. Retrieved from http://globalnews.ca/news/ 4418682/ontario-overdose-prevention-sites-review/. Wallace, B., Pagan, F., & Pauly, B. (2019). The implementation of overdose prevention sites as a novel and nimble response during an illegal drug overdose public health emergency. International Journal of Drug Policy, 66, 64–72. Weeks, C., & Miller, M. (2019). Health advocates urge Ontario to declare state of emergency over opioids. The Globe and Mail. Retrieved from http://www.theglobeandmail.com/ canada/article-health-advocates-urge-ontario-to-declare-state-of-emergency-over/. Wodak, A. M. (2014). The abject failure of drug prohibition. Australian and New Zealand Journal of Criminology, 47(2), 190–201. Wodak, A. (2007). Ethics and drug policy. Psychiatry, 6(2), 59–62.
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International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo
Commentary
Critical studies of harm reduction: Overdose response in uncertain political times
T
Tara Marie Watsona, , Gillian Kollab,c, Emily van der Meulend, Zoë Doddc ⁎
a
Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Russell Street, 3rd floor Tower, Toronto, Ontario M5S 2S1, Canada Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario M5T 3M7, Canada c Toronto Overdose Prevention Society, Toronto, Ontario, Canada d Department of Criminology Ryerson University 380 Victoria Street Toronto, Ontario, Canada M5B 2K3 b
ARTICLE INFO
ABSTRACT
Keywords: Harm reduction Overdose prevention Opioids Critical theory Canada Ontario
North America continues to witness escalating rates of opioid overdose deaths. Scale-up of existing and innovative life-saving services – such as overdose prevention sites (OPS) as well as sanctioned and unsanctioned supervised consumption sites – is urgently needed. Is there a place for critical theory-informed studies of harm reduction during times of drug policy failures and overdose crisis? There are different approaches to consider from the critical literature, such as those that, for example, interrogate the basic principles of harm reduction or those that critique the lack of pleasure in the discourses surrounding drug use. Influenced by such work, we examine the development of OPS in Canada, with a focus on recent experiences from the province of Ontario, as an important example of the impacts associated with moving from grassroots harm reduction to institutionalised policy and practice. Services appear to be most innovative, dynamic, and inclusive when people with lived experience, allies, and service providers are directly responding to fast-changing drug use patterns and crises on the ground, before services become formally bureaucratised. We suggest a continuing need to both critically theorise harm reduction and to build strong community relationships in harm reduction work, in efforts to overcome political moves that impede collaboration with and inclusiveness of people who use drugs.
Introduction Critical theory-informed studies and commentaries about harm reduction can contribute rich perspectives to the literature and spark lively debates. Does such scholarly work, however, contribute to advances in practice that help to improve the safety and well-being of people who use drugs? If so, in what concrete or meaningful ways? Critical analyses of harm reduction may appear far removed from actual lived experience and essential service delivery, and might seem to be of little practical utility during a public health crisis. As communities across North America are experiencing escalating rates of opioid-related overdose deaths (Hall & Farrell, 2018; Special Advisory Committee on the Epidemic of Opioid Overdoses, 2018), existing and innovative lifesaving programs such as supervised consumption services (SCS) and overdose prevention sites (OPS) are being swiftly expanded in Canada using a range of modalities and operational models, including both sanctioned (i.e., formally authorised through means such as legislation/ regulations or governmental approval) and unsanctioned services (Kerr, Mitra, Kennedy & McNeil, 2017; Scheim & Werb, 2018; Strike &
⁎
Corresponding author. E-mail address: [email protected] (T.M. Watson).
https://doi.org/10.1016/j.drugpo.2019.102615
0955-3959/ © 2019 Elsevier B.V. All rights reserved.
Watson, 2019). Perhaps this current moment represents a new phase or era of harm reduction altogether (see Erickson, 1999; Stimson & O'Hare, 2010). Although at this time we cannot claim to know with any certainty where this moment will lead, we contend that, even during a devastating overdose crisis, there is a continuing need to critically interrogate harm reduction and, in particular, its relationships with communities, health authorities, policymakers, and other stakeholders. We write this commentary as a group of drug policy/harm reduction researchers and drug user rights activists, with two of the authors (GK and ZD) heavily involved in the development of OPS, as well as various other supports for communities of people who use drugs, in the Canadian province of Ontario. We begin by briefly summarising key critical literature on harm reduction. After this summary, we give an overview of the emergence of OPS, an intervention designed to immediately fill important service gaps in safer drug consumption and overdose prevention. Our focus here is on Canada, with a specific examination of very recent experiences from Ontario. We demonstrate that harm reduction services are often at their most dynamic, inclusive, and innovative when people with lived experience, allies, and service
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providers are together responding to fast-changing drug use realities in their communities. Thus, these programs may be best situated to meet the diverse needs of people who use drugs before they become formally institutionalised, even perhaps before becoming recognised by scholars or policymakers as ‘evidence-based’ (see Lancaster, Seear, Treloar, & Ritter, 2017; Lancaster, Treloar, & Ritter, 2017). Critical studies have played and continue to play a key role in enhancing and building our understanding of such processes.
of ‘pleasure’ in harm reduction discourse and in the design of policies and programs (cf. Dennis, 2017a; Duff, 2004; Duncan, Duff, Sebar & Lee, 2017; Race, 2008). This body of literature leads us to question how a model that emphasises the importance of meeting people who use drugs ‘where they currently are in their lives’ (Harm Reduction International, 2010) adequately fulfills this principle without paying much, if any, attention to pleasure and the beneficial impacts of drug use. Not talking about pleasure serves to erase from research and discourse the important role that it plays (Duff, 2015; Moore, 2008), while also ignoring the full spectrum of drug use experiences, as not all drug use has adverse consequences or reflects dependence, another central tenet of harm reduction (Duff, 2004; Harm Reduction International, 2010). Although an increasing number of scholars and other voices are calling for greater recognition of pleasure in drug policy (see Dennis & Farrugia, 2017; Race, 2017), how these calls are or will become operationalised in practice largely remains to be seen. Another major and diverse stream of harm reduction literature utilises approaches from science and technology studies, post-humanism, and new materialism to explore the importance of relational understandings of concepts such as ‘addiction’ and ‘problematic drug use,’ arguing that these are not stable phenomena but are continually made and remade in practice (Fraser, 2017; Fraser & Moore, 2011, 2014). These studies draw attention to the non-human actors in events of drug consumption and highlight the ways in which a multitude of elements (including subjects, practices, and effects) are assembled in dynamic ways in the drug event (Dennis, 2017b; Dilkes-Frayne, 2014; Duff, 2014, 2016; Duncan et al., 2017; Race, 2011; Rhodes, 2018, 2019). In turn, such frameworks highlight the destigmatising potential of theoretically-informed approaches and programs (Farrugia et al., 2019; Fraser et al., 2014; Pienaar & Dilkes-Frayne, 2017). Situating some of these theoretical approaches in community practice, in the next section we consider the emergence of OPS in Canadian contexts, especially the recent experiences in Ontario. In what follows, we explore how major themes uncovered by critical studies of harm reduction occur on the ground in the development of services for people who use drugs in the context of the overdose crisis.
Critically theorising harm reduction Studies that engage with theory to critique or attempt to reconceptualise harm reduction principles and practices are scant in comparison to standard empirical, including evaluative, research. Indeed, there was enough empirical evidence over a decade ago to convince some drug policy researchers that, at the time, ‘The scientific debate about harm reduction[…]is now over’ (Wodak, 2007, p. 29). Since then, the relevant evidence base continues to grow and is often used to justify the establishment of new programs and adopt harm reduction as a pillar of drug policy (e.g., Strang et al., 2012). This popular narrative about the success of harm reduction is especially convincing when viewed against the long history of criminal justice and drug war failures that is recognised as having contributed to staggering social costs and much drug-related morbidity and mortality (e.g., DeBeck et al., 2017; Jensen, Gerber & Mosher, 2004; Wodak, 2014). Notably, scholars who utilise theory to challenge harm reduction tend not to dismiss the scientific basis behind the model and associated services; instead, these scholars ask critical questions and present alternative narratives that we think can be better harnessed to push for more equitable, inclusive, and innovative policies and practices. Critical studies of harm reduction in the published literature contain multiple theoretical perspectives and opportunities for new ways of thinking. One of the most notable and longstanding bodies of work challenges the ostensibly ‘amoral’ or ‘value-neutral’ principles of harm reduction by drawing on Foucauldian and other governmentality logics regarding surveillance and control mechanisms that produce highly responsibilised, self-governing subjects (cf. Fischer, Turnbull, Poland & Haydon, 2004; Hathaway, 2001; Keane, 2003; Miller, 2001; Moore & Fraser, 2006; Mugford, 1993; O'Malley, 2004; Quirion, 2003; Roe, 2005; Souleymanov & Allman, 2016). This literature includes valuable discussions of reproduced power structures, including perspectives on harm reduction such as the following:
Overdose prevention sites as community-driven responses in a time of crisis The OPS model developed in direct response to the rising number of overdose deaths, combined with relative government inaction and bureaucratic delays in the face of these deaths. OPS emerged in the Canadian provinces of British Columbia (B.C.) in 2016 and Ontario in 2017 as unsanctioned, low-threshold services run by volunteers and community members in makeshift environments, such as tents and trailers (Collins, Bluthenthal, Boyd & McNeil, 2018; Kerr et al., 2017; Lupick, 2017; Wallace, Pagan & Pauly, 2019). When the first unsanctioned OPS was launched in September 2016 in B.C., there were only two state-sanctioned SCS in operation across the country, despite a mechanism in place to allow organisations to seek an exemption from federal drug laws to open new SCS (Kerr et al., 2017). This process, however, was repeatedly criticized as too onerous, prompting the opening of the first unsanctioned OPS. In both B.C. and Ontario, municipal and criminal justice actors did not intervene to shut down the unsanctioned sites while, through different mechanisms, health authorities moved quickly to regularise the status of OPS. The provincial government in B.C. declared a state of public health emergency in relation to the overdose crisis on April 14, 2016; this declaration was used to sanction the opening in December 2016 of additional OPS at organisations already providing frontline services to people who use drugs (Collins et al., 2018; Kerr et al., 2017). In Ontario, the first unsanctioned OPS opened in August 2017; within months, the Ontario government chose to instead obtain a class exemption from federal health authorities to approve OPS within the province and then swiftly moved to develop a program model for OPS (Ministry of Health & Long-Term
This ‘band-aid’ approach is popular because its rhetoric adheres to and further legitimizes those discourses propagated by those institutions in power which act to preserve the population in a governable state. In other words, public health advocates can be accused of leaving unexamined and intact the power relations that these narratives both reproduce and help to sustain. This leads to the conclusion that harm minimization is a safety net, not a strategy, representing a convergence of economic rationalism and social policy. (Miller, 2001, p. 177) Within this stream of literature, investigations of particular services (e.g., SCS, Fischer et al., 2004; methadone maintenance programs, Quirion, 2003) foster understandings of how interventions, once institutionalised and likely bureaucratised, can get diverted from initial program objectives and well-intentioned harm reduction principles (see Harm Reduction International, 2010). Problematic, especially for program clients or service users, is the potential for some interventions to then become exclusionary, focused on security and surveillance, or otherwise more aligned with traditional treatment and rehabilitation goals than those of harm reduction. For instance, Fischer et al. (2004) discuss how SCS ‘house rules’ may deter or exclude some service users, a phenomenon that has since been documented using qualitative research (see also Small et al., 2011). In addition, there are also studies that identify a lack of recognition 2
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Care, 2018a). Crucially, in both B.C. and Ontario, government and public health authorities sought to formalise a program model that had already been functioning as an unsanctioned service by volunteers and community members, with integral input and leadership from people who use drugs. The involvement of people with lived experience in the development of OPS has been documented as a strength of such services, promoting safety and engagement among service users (Boyd et al., 2018; Kennedy et al., 2019). That said, initial efforts from government and public health authorities to formalise an OPS model harken back to critical studies informed by governmentality logics, particularly examples of programs having their operations negotiated away from grassroots-driven origins to more bureaucratic, surveillance-oriented goals (see again Fischer et al., 2004; Quirion, 2003). The Ontario unsanctioned OPS – called the Moss Park Overdose Prevention Site – was opened in a downtown Toronto park in response to a local spike in overdose deaths (Mullin, 2017). The site was established by a collective of people who use drugs, harm reduction workers, and healthcare providers, and originally comprised three tents. While one tent was used to distribute harm reduction equipment and naloxone kits, a second provided supervised consumption of drugs used through injection, nasal inhalation, or oral routes of administration. The third tent was available for people to smoke drugs such as crack cocaine, crystal methamphetamine, and opioids. After four months of daily operation, the Moss Park OPS acquired a heated trailer in November 2017 (Gray, 2017). Operations continued – with injection and distribution services in the trailer and one tent attached outside for smoking/inhalation – until July 2018, when the site received approval under the new provincial OPS program, at which point the services moved into a nearby storefront to become a fully sanctioned and provincially-funded location, complete with paid staff members (Sheldon, 2018). Notably, within eleven months in operation as an unsanctioned site, the Moss Park OPS saw 9062 visits to its injection monitoring service, intervened in 251 overdoses, and had no deaths (Kolla, Dodd, Ko, Boyce & Ovens, 2019). A key strength of the Moss Park model has been that the group of volunteers running the site largely consisted of people with lived experience who have championed low-threshold service delivery with few rules or regulations in place. For example, aligned with known preferences of those who were already using drugs in the park where the site was established, no OPS rules were made or enforced around splitting or sharing drugs, location of injection on the body, or assisted injection (Kolla et al., 2019). Ongoing attempts were made to be responsive to OPS user feedback regarding the manner in which overdose intervention occurs, efforts that took into account more than drug-related effects but also the dynamic practices and experiences that shape and reshape the drug-taking events at the site. In other words, staff and volunteers were continuously attempting to attend to user needs and better situate the OPS intervention within lived experiences and practices at the site. These efforts were made not only to ensure smooth operations, but to also acknowledge the centrality of pleasure within the experience of drug use and the variety of embodied and affective ways in which pleasure could flow in both the consumption and postconsumption spaces (see again Duncan et al., 2017). For example, Moss Park OPS volunteers (including authors GK and ZD) observed people using the service telling others, for instance, to be careful not to go ‘on the nod’ following an opioid injection or they would be ‘naloxoned’ (i.e., administered a dose of the opioid antagonist). While Moss Park OPS volunteers were attempting to respect the desires of people using the service to avoid such an outcome due to the precipitated withdrawal symptoms that many experience following naloxone administration, these volunteers were also attempting to create a space where people who use drugs could have a positive drug consumption experience, including experiencing pleasure from their high (Duncan et al., 2017). These observations led to attempts to ensure that volunteers supervising the injection tent were well trained in overdose recognition
to prevent unnecessary naloxone administration by well-meaning but overly-cautious volunteers. Moreover, those supervising the injection tent were paired up on shift, so that one medical volunteer (i.e., a doctor, nurse, or nurse practitioner) was paired with a volunteer with lived experience of injection drug use, to ensure that overly medicalized perspectives on drug consumption and traditional power relations did not dominate. These two volunteers were together responsible for management of all overdoses in accordance with the medical directive in place for the site. This directive was developed cooperatively by the group of volunteers running the site and used a decision support tool to specify the parameters for responding to overdoses at the OPS. The directive included privileging oxygen administration and stimulation in cases where breathing was still present, only using naloxone in cases where breathing was absent or when stimulation and oxygen administration failed to bring respiration rates up above 10 breaths per minute. The opening of the Moss Park OPS in August 2017, prior to the establishment of SCS or other OPS in Ontario, had an immediate influence on the drug policy environment in the province. Within a year, in August 2018, there were a total of eight SCS or OPS in operation in the city of Toronto, and an additional eight SCS or OPS in other Ontario communities. The OPS model that developed in the province, like the original Moss Park site, was low-threshold, designed to allow organisations providing services to people who use drugs to quickly apply for and receive funding from the provincial Ministry of Health to open a new service, with a response to OPS applications provided within two weeks of application submission (Ministry of Health and Long-Term Care, 2018a). The OPS model that was instituted in January 2018 provided funding for staff only, envisaging that organisations would use existing facilities to open a bare-bones model of supervised drug consumption; it also provided for considerable flexibility in the operationalisation of the model, with a variety of services being accepted for funding, and did not require that a registered healthcare provider (such as a registered nurse) be on site. Significant input from the frontlines of the overdose crisis was incorporated into the OPS model that was developed, through discussions between Moss Park organisers and the provincial Ministry of Health, as well as the presence of Moss Park workers and people with lived experience of drug use on the Opioid Emergency Task Force that designed the OPS model. In practice, and compared to the SCS model in use, this process resulted in an approach that was more strongly shaped by the needs and practices of the people who would be using these sites. The greater flexibility of the model and integration of practices that were not permitted in the SCS model (e.g., assisted injection) was an attempt to create a space that engendered more positive experiences for service users. It also held the potential to open discussion about pleasure and related user practices/experiences, and how these could be operationalised within drug consumption spaces like OPS, even amid a public health crisis. However, the June 2018 election of a Progressive Conservative provincial government dramatically changed the direction of Ontario's evolving drug policy landscape, which had been previously guided by the Liberal Party. Two months later, in August, the new conservative government announced a ‘pause’ on the opening of three previously approved OPS (Russell, 2018). In a move that was widely perceived to be partisan and ideologically driven, the same government announced a review of the evidence on SCS and OPS (e.g., Rushowy, 2018). This review culminated in the October 2018 announcement of a ‘Consumption and Treatment Services’ (CTS) model, which dismantles the previous OPS model, replacing it with an approach that allowed supervised injection services to continue only if they implemented a ‘comprehensive enforcement and audit protocol’ and a ‘new focus on connecting people with treatment and rehabilitation services’ (Ministry of Health and Long-Term Care, 2018b). This new focus is also arguably ideological in nature as there is a lack of evidence for enhanced monitoring and reporting, or for an emphasis on referrals to treatment, as contributing to the effectiveness of SCS or OPS when it 3
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comes to their primary goals of reducing the health risks associated with injection (Ministry of Health and Long-Term Care, 2018c). The new model also includes an arbitrary cap of 21 on the maximum number of sites allowed to function in the province, institutes new proximity requirements that limit site operation within 600 m of each other, and imposes extra community consultation requirements on sites located within 200 m of childcare centres, parks, or schools (including post-secondary institutions; Ministry of Health and Long-Term Care, 2018c). After having completed a burdensome application process for the new CTS model in December 2018, and operating on precarious month-to-month extensions from October 2018 to March 2019, the Ontario government announced on March 29, 2019 that 15 existing OPS/SCS had been approved as CTS, with two OPS (in the city of Toronto) and one SCS (in the city of Ottawa) denied provincial funding (HIV & AIDS Legal Clinic Ontario, 2018; Ministry of Health and LongTerm Care, 2019; Stone, 2019). At the time of writing, the three OPS/ SCS denied funding were still operating under an emergency exemption from the federal government. Again, such moves coming top-down from the provincial government – and much more forceful than the initial attempts to formalise the OPS model – are reminiscent of lessons from the first set of critical studies we summarised above. That is, we see this case study from Ontario as a compelling example of external constraints placed on harm reduction programs to bring them more in line with traditional power structures and control mechanisms (e.g., rehabilitative service goals, location and other restrictions). A wide range of groups have voiced their strong opposition to the Conservative government's CTS model (see Pagliaro, 2018; The Canadian Press, 2018; Weeks & Miller, 2019). We view the move as an effort to dismantle the low-threshold OPS model that had been developed by people who use drugs, with significant input from frontline workers, and replace it with a highly bureaucratic approach. The Ontario experience outlined here thus represents an example of some themes that critical scholarship have helped to reveal. While an initial attempt to formalise a grassroots-led, unsanctioned model first resulted in a low-threshold OPS that was quickly taken up by organisations and activists across the province, it has since been dismantled by a new government in power that is perceived by numerous stakeholders as being motivated by ideology rather than evidence or the expressed needs of people who use drugs. The impacts and results of the new CTS model remain to be seen in view of its recent imposition; however, preliminary feedback has been overwhelmingly negative due to the surveillance and monitoring that is required, and a greater focus on rule adherence, treatment, and rehabilitation-oriented goals (CBC News, 2018; Pagliaro, 2018). The strict standardisation within the new approach – including features such as a more bureaucratic application process, hugely increased reporting requirements, the condition that a registered health professional must always be on site, design standards that are not reflective of the evidence base, and a cap imposed on number of sites – does not provide for flexibility in service provision and seems designed to render service delivery as onerous as possible. Additionally, the rigid metrics within the reporting and evaluation requirements that privilege referrals to treatment conflate any drug use to problematic use. These features further restrict the ability of service providers and site volunteers to change practices to meet service users’ dynamic needs, including in ways that recognise diverse drug-taking experiences and pleasure among people using OPS.
surveillance. Other literature (e.g., Dennis, 2017a; Duff, 2004; Race, 2008) reveals the silencing of pleasure, despite the central role of pleasure in much drug-taking and the stated intention of harm reduction to recognise the realities of drug use (see again Harm Reduction International, 2010). Explorations of the experience of pleasure within supervised consumption spaces have been rare, with Duncan et al. (2017) providing a notable exception. While still other literature (e.g., Fraser, 2017; Fraser & Moore, 2011; Fraser et al., 2014) leads us to question how notions of problematic drug use are made and reshaped in practice. Overall, these bodies of critical work prompt important queries about who has the authority to define harm reduction policies and services, and shed light on how such policies and services are constantly being negotiated by multiple actors including those in political power despite their distance from evolving user-driven practices on the ground. The evolution of OPS we have outlined, especially the recent events in Ontario, illustrates such themes in action. This is not the first example of political shifts that have impeded the establishment or threatened the continuation of harm reduction programs in Canada (e.g., Boyd, 2013; Hathaway & Tousaw, 2008; Kerr et al., 2017). As we have aimed to show, despite an extensive evidence base in support of SCS (Potier, Laprévote, Dubois-Arber, Cottencin & Rolland, 2014) and the continued epidemic of drug-related deaths that ethically and urgently demands response, interventions such as SCS and OPS continue to be questioned by policymakers and others. Times of political uncertainty are nonetheless key moments to critically interrogate the assumptions of harm reduction, while examining the programmatic shifts occurring in response to such political shifts. Critical studies have helped to demonstrate how program development and operation can lose sight of basic harm reduction principles that articulate that services should be inclusive and responsive to the changing needs of people who use drugs. Further, such studies can help reveal for a larger audience what many service providers and service users already know from their own experiences about the ways in which political expediency can sacrifice the needs of people who use drugs and foreclose any attempts to attend to the experience of pleasure within consumption spaces. A noted shortfall of the critical traditions we have outlined is that while they illuminate how harm reduction services can lose sight of the goals of being user-driven and user-centred, the existing scholarship tends not to provide clear guidance on how to rectify this situation. Recommendations for how to preserve the centrality of the needs and pleasures of people who use drugs in harm reduction, and prevent the abovementioned diversion to risk management modalities that can lead to exclusion, still very much require development. Recent directions from work that examines ways in which ontology can be mobilised within health and substance use interventions are promising here, as this work delves into questions of how evidence-making practices contribute to bringing not only drugs and their effects into being, but also policies like the ones that govern harm reduction programs and OPS into being (see Rhodes, Closson, Paparini, Guise & Strathdee, 2016; Rhodes & Lancaster, 2019). The continued vulnerability of harm reduction services to both institutionalisation and political threat (at least in North American contexts) remains pertinent. How can critically theorising harm reduction support the development of resistance to institutionalisation? Can such work also support greater formal recognition and perhaps even integration in practice of experiences of pleasure within supervised consumption spaces like OPS to create more positive experiences for people who use drugs? Would development of novel critical approaches, such as more recent attempts to remake and apply new conceptualisations of ‘addiction’, be useful to advancing such goals? These are important questions as there continues to be a divide between critical scholarship and the dedicated work occurring daily on the ground in a time of crisis; and importantly, we continue to lack methods for achieving a more inclusive and balanced sharing of expertise (Greer et al., 2019; Kennedy et al., 2019). We call attention to this shortfall as it highlights
Looking ahead Critical studies of harm reduction contain valuable lessons that are relevant to events currently unfolding within the opioid overdose crisis. From some of this literature (e.g., Fischer et al., 2004; O'Malley, 2004; Quirion, 2003) we learn how programs, particularly once formalised, can start to reproduce certain power structures and be diverted from their original goals, becoming more focused on security and 4
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the potential for greater connection- and relationship-building between scholars who employ theory and the diverse stakeholders within harm reduction, including people with lived experience and allies who are advocating for, providing, and/or using services such as OPS. Doing such work need not be an ivory-tower endeavour, but can and should include partnerships with community members, especially people who use drugs.
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