Dynamics of drug overdose in the 20th and 21st centuries: The exponential curve was not inevitable, and continued increases are preventable.

Abstract

While much has been written about the positive individual and collective effects of Supervised injection services (SIS), notably on health and drug-related harm, little research focuses on their operational context and constraints. Building on Lascoumes and Le Gales's “public policy instrument and instrumentation” framework (2007), this article analyzes the implementation of Montreal SIS and discusses how the organizational aspects of SIS produce the contexts for drug injection.Using an ethnographic approach, this article draws on three types of data: 10 months of participant observation in a SIS (700 h); 19 semi-structured interviews with staff members (social workers, peers, heads of staff, management); and analysis of organizational documents (protocols, staff notebooks).First, this article examines how political context and advocacy coalitions produced Montreal SIS as a public policy instrument, affecting both the philosophy and the implementation of the service. It shows that Montreal SIS were developed under a health care network blueprint rather than a community organization harm reduction framework. Then, it analyzes how SIS as a policy instrument defines what constitutes appropriate injection practices, trying to supervise injection as an individual and technical act, rather than a broader social practice composed of pleasure, rituals, routines, and group dynamics.Montreal SIS were conceptualized under a “health banner” and through alliances between regional public health administration and local well-known community organizations. They were then developed mostly under a health care administration blueprint, although operated at a ground-level by local community organizations. It created tensions between the logics of “zero risk” and “harm reduction”, and ambiguity about how injection should be supervised and what parts of drug use could be managed.