Harm Reduction Programming Research Articles

A scoping review on barriers and facilitators to harm reduction care among youth in British Columbia, Canada

BackgroundProgressive harm reduction policies have been implemented in British Columbia, Canada. However, youth who use drugs face barriers to receiving harm reduction care, resulting in increasing opioid-related hospitalizations and drug toxicity deaths. This scoping review collates peer-reviewed evidence to understand the barriers and facilitators faced by youth who use drugs when accessing harm reduction programming in British Columbia, Canada.MethodsThis scoping review entailed conducting a systematic search of relevant databases to identify relevant articles. Articles were included if they: (i) contained youth falling between the ages of 12 and 26 years old; (ii) explored accessibility, barriers, and/or facilitators to harm reduction care or related topics; (iii) were empirical research articles using primary data (i.e., reviews, grey literature, theoretical or conceptual papers, books, etc. were excluded); and (iv) were available in the English language, given the geographic focus on British Columbia.ResultsA total of 398 sources were identified and ultimately, data from 13 sources were charted and extracted. When investigating barriers to harm reduction care among youth, four themes emerged: self-stigma, service navigation, service delivery, and negative provider interactions. Furthermore, in exploring factors that facilitate harm reduction care for youth, four themes surfaced: ability to meet basic needs, positive provider interactions, social networks, and risk mitigation guidance.ConclusionsThe expansion of harm reduction services in 2016 did not fully address accessibility challenges faced by youth who use drugs. Barriers continue to hinder harm reduction engagement, while supportive networks, positive provider interactions, and the ability to meet basic needs facilitated sustained access. Tailored policy interventions rooted in equity are crucial to improving access to harm reduction services for youth who use drugs.

What Would Equitable Harm Reduction Look Like?

Structural determinants of health frameworks must express antiracism to be effective, but racial and ethnic inequities are widely documented, even in harm reduction programs that focus on person-centered interventions. Harm reduction strategies should express social justice and health equity, resist stigma and discrimination, and mitigate marginalization experiences among people who use drugs (PWUD). To do so, government and organizational policies that promote harm reduction must acknowledge historical and ongoing patterns of racializing drug use. This article gives examples of such racialization and offers recommendations about how harm reduction programming can most easily and effectively motivate equitable, antiracist care for PWUD.

Factors Associated With Self-Reported Overdose Reversals Using Naloxone in Little Rock, Arkansas: Implications for Harm Reduction Service Delivery in the US South

Background. The Central Arkansas Harm Reduction Project (CAHR) is located in Little Rock, Arkansas, and is the only harm reduction service provider in the city. This quality improvement study was conducted to inform harm reduction programming decisions. Methods. We used CAHR data among clients who reported methamphetamine and/or opioid use (2021-2022; N = 459). We used an explanatory mixed methods design to identify factors associated with self-reported overdose reversals using naloxone. Results. The average number of reversals was 3.27. Nearly all clients (95%) reported methamphetamine use. The use of both methamphetamine and opioids (vs. opioids only; [Formula: see text] = 0.26, p = .04) was positively associated with a higher number of reversals. Our qualitative analysis provided additional context around methamphetamine and overdose, including leveraging community members connected to large networks of people who use drugs. Conclusion. Future CAHR initiatives will focus on expanding public health education around naloxone and fentanyl for a population increasingly using methamphetamine.

“When people who use drugs can’t differentiate between medical care and cops, it’s a problem.” Compounding risks of law Enforcement Harassment & Punitive Healthcare Policies

BackgroundCommunity-based harm reduction programming is widely recognized as an effective strategy for reducing the increased risks for and spread of HIV, HCV, and for reducing the growing rate of overdose deaths among people who use drugs (PWUD). PWUD in the United States (US) are a highly justice-involved population, also at increased risk for law enforcement interaction, arrest, and incarceration. These risks compound and interact in the context of criminalization and law enforcement surveillance. Justice involvement increases risks for overdose and for riskier injecting behavior among PWUD, in turn increasing HCV and HIV risks. In Central and Southern Appalachia specifically, PWUD have identified fear of law enforcement harassment and arrest as a barrier to engaging in harm reduction behavior, and a deterrent to seeking help at the scene of an overdose. Moreover, stigmatizing and punitive treatment in healthcare settings can deter PWUD from seeking care, with life or death consequences. This evaluation research study assessing the successes and impacts of a grant-funded project to increase access to safer drug consumption supplies and overdose prevention education for PWUD, including justice-involved participants of a syringe access program (SAP), in public housing and beyond in a South-Central Appalachian setting used key informant and opportunistic sampling. Mixed-methods data were compiled and collected including secondary program data; primary interview and participant-observation data.ResultsThe evaluation research identified that grant deliverables were largely achieved, despite challenges presented by the COVID-19 pandemic. In addition, SAP participants and staff reported larger themes surrounding grant-funded activities, in which they perceived that widespread local law enforcement harassment of PWUD increased participants’ risks for overdose death and infectious disease risks and that punitive local healthcare settings and policies acted as deterrents to care-seeking for many PWUD.ConclusionsOverall, the evaluation research found that participants’ experiences with and perceptions of local law enforcement harassment combined with their understandings and experiences of local punitive healthcare settings and policies; together compounding and increasing overdose risks and negative health consequences for local justice-involved PWUD.

Updates on syringe coverage and service uptake among needle and syringe programs in the United States, 2019–2020

BackgroundAs injection drug use has increased in the US, so too has the prevalence of receptive syringe sharing. Since the 1980s, Needle and Syringe Programs (NSPs) have been an important source of clean injection equipment and disposal of used syringes. This study reports national syringe coverage and examines the impact of program attributes on organizational-level service uptake, defined as number of syringes distributed per participant contact per year. MethodsIn 2019 and 2020, we administered an annual cross-sectional survey to NSPs operating in the US (n = 260). A national estimate of coverage was calculated by dividing the total number of syringes distributed by the 2019 and 2020 population estimate of people who inject drugs (PWID). Frequency distributions and percentages were calculated for categorical variables (e.g., funding, census region, distribution policy/modality), and median and interquartile ranges (IQR) were calculated for continuous variables (e.g., participant contacts, syringes distributed). Bivariate and multivariable mixed effects logistic regression models were used to estimate the odds ratio associated with organizational characteristics on increasing service uptake at the NSP level. ResultsFrom 2019 to 2020, the total number of participant contacts by NSPs increased from 871,976 to 898,891, and the number of syringes distributed increased from 92,648,529 to 113,071,748. The national coverage estimate increased from 29.5 (95 % CI = 15.0, 58.2) to 35.8 (95 % CI = 18.2, 70.6) syringes per PWID. Fifty-eight percent of NSPs increased service uptake in 2020 as compared to the previous year. NSPs that received government funding and NSPs that changed to a less restrictive syringe distribution policy were more likely to increase service uptake (aOR 1.80, 95 % CI = 1.01, 3.22 and aOR 3.33, 95 % CI = 1.11, 9.94, respectively). Syringe distribution modalities also diversified, with more NSPs reaching participants via backpacking/outreach, fixed site pop-ups, mobile delivery, mail-based delivery, leaving supplies out, and secondary distribution. ConclusionBoth governmental investment in harm reduction programming and needs-based distribution of syringes increased service uptake and thus should be expanded and sustained to reduce harms associated with injection drug use.

“It’s starting to weigh on me”: Exploring the Experiences and Support Needs of Harm Reduction Staff in Connecticut using the Social-Ecological Model

BackgroundThe experiences and perceived support needs of harm reduction workers in the USA have been understudied. While previous research has explored staff burnout and role-related stress, there is a research gap around potential supports for staff wellbeing and individual longevity in their roles. This is especially critical given the growing overdose crisis and the need for sustainable harm reduction programming. Thus, we sought to describe the experiences of harm reduction staff and identify the perceived support that could empower harm reduction staff to successfully navigate their roles.MethodsPurposive sampling methods were used to recruit harm reduction staff working in Connecticut. Seventeen semi-structured, one-on-one interviews were conducted between December 2022 and March 2023. Participants were asked about their experiences with role-related stressors and supports. Informed by the Social-Ecological Model, transcripts were coded using both inductive and deductive codes, and themes were developed using thematic analysis approaches.ResultsStudy participants described their experiences working in harm reduction and the numerous ways they already are or could be receiving support in their roles. These experiences were organized into eight themes according to the levels of the Social-Ecological Model. At the individual level, participants explained that support could help them navigate the variability of the physical environment, boundary setting, and self-care. Relationships between clients and co-workers were both identified as means of support at the interpersonal level, helping participants navigate difficult situations and feelings of stress. At the organizational level, study participants explained how they look to their organization to provide sufficient support by way of training, staffing, compensation, and benefits. Additionally, participants stressed the importance of having supervisors who valued their work and provided emotional support. Lastly, at the community level, participants discussed how support was needed to help them navigate complex systems while working with a stigmatized population in an often-stigmatized field.ConclusionsTo best support harm reduction staff in their day-to-day roles, our findings underscore the need for support on multiple levels. Future research could explore how the provision of support to harm reduction staff impacts not only staff perceptions of support but also the success of clients accessing harm reduction services.

Opioid Use Disorder Stigma and Support for Harm Reduction in Rural Counties

Background: The opioid crisis is a public health emergency in the United States, particularly in rural Pennsylvania. Stigma in rural communities is a treatment barrier and impacts harm reduction programming availability. Objectives: The current study utilized an observational, cross-sectional design to examine latent subgroups of stigma and differences in support for harm reduction strategies (i.e., safe injection facilities, syringe services programs, fentanyl test strips, Naloxone distribution). Participants included rural Pennsylvanians (n = 252), taken from a statewide survey of opioid use disorder (OUD) stigma. Participants reported OUD public stigma (i.e., attitudes/perceptions about OUD, willingness to engage with individuals with OUD) and support for harm reduction strategies. Results: Latent class analysis identified 4 stigma classes: 1) high stigma (HS), 2) high judgment/low stigmatizing behavior (HJ/LB), 3) high stigmatizing behavior/low stigmatizing attitude (HB/LA), and 4) low stigma (LS). ANCOVAs identified subgroup differences in harm reduction support. The HS group indicated less support for safe injection sites, syringe services programs, and fentanyl test strips, compared to the HB/LA and LS groups. The HS group indicated less support for Naloxone distribution compared to the HJ/LB, HB/LA, and LS groups. Lastly, the HJ/LB group indicated less support for each program compared to the LS group. Conclusions/Importance: Findings highlight that OUD stigma profiles differ across rural Pennsylvania and are associated with varying support for harm reduction strategies. Individuals with less stigma report more support for harm reduction strategies. Interventions to implement harm reduction strategies should consider varying levels of stigma and use a targeted approach to inform implementation and messaging strategies.

Commentary on Rosen et al.: Attending to the unique needs of pregnant and parenting women at risk for overdose.

Women experience unique determinants of overdose risk, including fears concerning child protective services involvement and child custody loss. When addressing the risk for opioid overdose, harm reduction services must account for the needs of pregnant and parenting people. Decades of research has examined the unique social, structural and policy drivers of drug-related harms among women who use drugs (WWUD). Much of this research has been concerned with the social dynamics of drug use and how women's intimate relationships influence harm through patterns of drug use initiation, control over drug use and sexual and injection-related risk for HIV and HCV acquisition [1-6]. Rosen et al. [7] bring this scholarship into the current era by addressing the nature of and reasons for solitary drug use (a risk factor for overdose death [8]) among WWUD. They identify three motivations for solitary drug use among women in their sample: (i) the need to alleviate opioid withdrawal symptoms, (ii) a desire to avoid anticipated and experienced substance use stigma and (iii) an attempt to reduce vulnerability to violence while intoxicated. An important additional consideration emerging in our research is the fear of child protective services (CPS) involvement among pregnant and parenting WWUD 1 and how that fear influences solitary drug use and other overdose risk factors. Some have argued that families are ground zero for the US drug war [9], and WWUD and their children (especially in communities of color) have been subjected to increased harms. In the United States, 53% of Black children will have CPS involvement by their 18th birthday [10], and parental substance use was a condition of removal for nearly 40% of all children placed in foster care in 2019 [11]. We have found that fear of CPS involvement weighs heavily upon women's decisions about when, where and with whom to use drugs. In our unpublished but forthcoming study on the acceptability of overdose prevention sites (a harm reduction strategy recommended by Rosen et al. to address the concerns in their study), women who had children living at home (or were care-givers to family members) found themselves in need of a safe space to use drugs that was both (i) outside the home and (ii) supervised in case of overdose. In the absence of such a site, some respondents describe using opioids alone, out of sight of children and other family members. Providing a supervised environment for parents while also reducing children's exposure to parental substance use and the trauma of a parent's overdose is a potential benefit of overdose prevention sites. We have also found that fear of CPS influences decisions to seek emergency medical assistance for an overdose by calling 911 [12]. It is well established that people who use drugs fear calling 911 because of the risk of law enforcement involvement [13] In our state, Nevada, where a 911 Good Samaritan Law protects 911 callers from some charges, involvement with CPS is not specifically protected under the law, leading to more risk to parenting women and heightened fear related to summoning help for overdose response. To our knowledge, this protection is not included in any state's 911 Good Samaritan Law. Similar to our findings in the later years of the HIV epidemic [6], in which we identified a host of competing priorities that challenged women's ability to negotiate HIV prevention behavior, Rosen et al.'s research [7] highlights issues that challenge women's ability to reduce their risk for fatal overdose. Harris et al. [14], too, recently found that women worry much more about their personal safety and care-giving responsibilities than the ‘inevitability’ of overdose. They conclude that gender-responsive harm reduction programming is needed to explicitly address women's concerns, including provision of child-care, women-only programs and women-focused mental health programming. We argue that other important additions to these gender-responsive approaches include explicit protections for pregnant and parenting people that keep parents safe from harm and guard against state surveillance that can result in family separation. None. L.L. is a staff member of the Washoe County Human Services Agency, in the CQI unit of Children's Services. Karla D. Wagner: Conceptualization; writing—original draft; writing—review and editing. Lisa Lee: Conceptualization; writing—original draft; writing—review and editing. None.

"At the Root of COVID Grew a More Complicated Situation": A Qualitative Analysis of the Guatemalan Gender-Based Violence Prevention and Response System during the COVID-19 Pandemic.

A growing body of literature has documented an increased risk of gender-based violence (GBV) within the context of COVID-19 and service providers’ reduced capacity to address this vulnerability. Less examined are the system-level impacts of the pandemic on the GBV sector in low- and middle-income countries. Drawing on the perspectives of 18 service providers working across various GBV-related sectors in Guatemala, we explored how the Guatemalan GBV prevention and response system operated during the COVID-19 pandemic. Findings highlight that the pandemic reinforced survivors’ existing adversities (inadequate transportation access, food insecurity, digital divides), which subsequently reduced access to reporting, justice, and support. Consequently, the GBV prevention and response system had to absorb the responsibility of securing survivors’ essential social determinants of health, further limiting already inflexible budgets. The pandemic also imposed new challenges, such as service gridlocks, that negatively affected survivors’ system navigation and impaired service providers’ abilities to efficiently receive reports and mobilize harm reduction and prevention programming. The findings underscore the systemic challenges faced by GBV service providers and the need to incorporate gender mainstreaming across public service sectors—namely, transportation and information/communication—to improve lifesaving GBV service delivery for Guatemalan survivors, particularly survivors in rural/remote regions.

Sexual Violence Among Sorority Women: Victimization Experiences, Contexts, and Disclosure.

The purpose of this study was to examine and compare sexual violence (SV) victimization among sorority women and unaffiliated counterparts. Results showed sorority women were more likely than unaffiliated women to report experiencing some types of SV, consuming alcohol prior to victimization, and to identify their perpetrator as a hookup/casual partner. More women, regardless of affiliation, informally disclosed their victimization compared to formally reporting; many did not tell anyone because they did not think it was serious enough. The findings point to implications for harm reduction, bystander intervention, and primary prevention programming, as well as institutional policy to address SV.

The challenges, opportunities and strategies of engaging young people who use drugs in harm reduction: insights from young people with lived and living experience

The meaningful inclusion of young people who use or have used drugs is a fundamental aspect of harm reduction, including in program design, research, service provision, and advocacy efforts. However, there are very few examples of meaningful and equitable engagement of young people who use drugs in harm reduction, globally. Youth continue to be excluded from harm reduction programming and policymaking; when they are included, they often face tokenistic efforts that lack clear expectations, equitable work conditions, and are rarely afforded agency and autonomy over decision-making. In this commentary, we identify and discuss issues in youth engagement, and offer recommendations for the future of harm reduction.

‘This is what's going to heal our kids’: bringing the Sexy Health Carnival into Indigenous cultural gatherings

The Sexy Health Carnival is a peer-developed Indigenous health initiative designed to provide culturally-relevant health information for Indigenous youth. The Carnival takes a strengths-based, holistic approach to address topics in fun and interactive ways. As part of the study described here, the Carnival was taken to 6 First Nations, 3 Métis, and 2 Inuit cultural gatherings in Canada. Due to complex histories of colonialism, bringing sexual health and harm reduction programming to cultural gatherings remains controversial. Interviews were conducted with 10 Carnival leaders. Transcripts were transcribed verbatim and inductively coded using NVivo. There was strong support for bringing the Carnival into cultural spaces because (a) teachings on health, sexuality, and reproduction are sacred and belong in cultural spaces, (b) doing so was requested by the communities themselves, (c) the Carnival holds potential to challenge harmful stigma, and (d) the Carnival supported a peer-led initiative. Facilitators also described several challenges encountered including (a) resistance to discussing stigmatised subjects, (b) issues of safety and (c) the intensive physical and emotional demands of the Carnival’s implementation. The Carnival aids in re-imagining what culturally safe health promotion can look like when it is led by and for Indigenous youth. While the Carnival contributes to Indigenous cultural resilience and resurgence, further support is needed to enhance sustainably.

Capacity for sustainment of recently established syringe service programs in Appalachian Kentucky: The central role of staff champions.

Ensuring adequate harm reduction infrastructure in rural areas is imperative, as drug-related epidemics expand into them. Here, we explore the capacity for sustainment of syringe service programs (SSP) in Appalachian Kentucky. We interviewed all staff (n= 16) of all SSPs (n= 7) in two Kentucky health districts in 2018-2019 using semi-structured one-on-one qualitative interviews; local departments of health (DOH) operated the SSPs. Interview domains encompassed: (i) SSP establishment; (ii) day-to-day operations, participation and health impacts; (iii) perceived prospects for sustainment; and (iv) perceived influences on #i-#iii. We analysed verbatim transcripts using thematic analytic methods; Schell's 'capacity for sustainment' constructs were treated as sensitising concepts during the analysis. Most community members, law enforcement and DOH staff opposed SSPs before they opened, because of stigma and concerns about enabling and needlestick injuries; DOH staff also opposed SSPs because they believed they lacked the capacity to operate them. Training, technical assistance, visible evidence of the programs' public health impact and contact with SSP participants transformed DOH staff into program champions. As champions, SSP staff developed programs that had strong capacity for sustainment, as defined by Schell (e.g. visible public health impact, stable funding, political support). Staff reported that the SSPs had high prospects for sustainment. As in SSPs that opened in cities decades ago, staff in emerging SSPs in these rural areas appear to have become crucial champions for these controversial programs, and may serve as vital resources for expanding harm reduction programming more broadly in these underserved areas.

The Impact of COVID-19 on Drug Use and Harm Reduction Programming in the Middle East and North Africa (MENA) Region: a Regional Consultation of Stakeholders and People Who Use Drugs

The Middle East and North Africa (MENA) region has witnessed a slow but steady increase in the harm reduction response since 2016. It is likely that such gains are threatened by the impact of COVID-19. Very little is known about the health response and situation of people who use drugs (PWUD) during the pandemic in the region. A mixed method study was conducted by the MENA Harm Reduction Association (MENAHRA) to assess the situation of PWUD and impacts on harm reduction services during COVID-19. Twelve countries and two regional viewpoints responded to the survey. A virtual focus group was held with the MENA Network of People who Use Drugs (MENANPUD) focal points (n = 11). The study highlights how COVID-19 aggravated existing marginalization and stigmatization of PWUD and other key populations in the MENA region, with government level resourcing severely impacted by COVID-19. It further illustrates the commitment by harm reduction non-governmental organizations (NGOs) in diversifying their response, particularly through mobile outreach to drug hot spots, and the reliance of technology to support awareness raising, telemedicine, and medicine supplies. Positive shifts are observed in harm reduction policy by governments in some MENA countries and the continued commitment to support PWUD communities by existing harm reduction NGOs. Continued advocacy for and implementation of harm reduction responses at the domestic and regional levels should be underpinned by inclusion in state health emergency planning and disease control efforts, awareness raising around innovation and telemedicine to support health and NGO support systems and medicine supply chains, resourcing of NGOs, and provision of economic support for PWUD, disease surveillance, and research.

Changes in cannabis use modes among Canadian youth across recreational cannabis legalization: Data from the COMPASS prospective cohort study

IntroductionCanadian youth consume cannabis in multiple ways, including by smoking, vaping, and eating or drinking. Existing evidence suggests that these behaviours may change after law liberalization, though data regarding youth are scarce. We investigated changes in cannabis modes of use and associated factors across the federal legalization of recreational cannabis use for adults in Canada, among a large sample of underage youth before alternative products were made legally available. MethodsData were available from 2953 longitudinally linked Canadian high school students who reported on their cannabis use during the 2017/2018 and 2018/2019 school years. We explored whether students maintained a single or multiple cannabis use mode(s), contracted, or expanded the number of modes used. We then used generalized estimating equations to analyse associations of baseline characteristics with use mode trajectory. ResultsExpansion of cannabis use modes (42.3%) was more common than maintenance of a single mode (31.3%), maintenance of multiple modes (14.3%), or reduction (12.1%). Students who maintained multiple modes were significantly more likely to have high amounts of weekly spending money (AOR 1.68), to binge drink (AOR 2.25) or vape (AOR 1.99), to use cannabis regularly (AOR 2.67), and to endorse more symptoms of depression (AOR 1.06). School support for quitting tobacco, drug, or alcohol use appeared to have no effect. ConclusionsMulti-modal cannabis use increased among Canadian youth in our sample. Its association with other substance use and depressive symptoms may indicate clustering of additional harms. Screening for this use pattern may assist in identifying high-risk substance use and should be considered in the design of harm reduction programming.

Public and semi-public injection drug use in Thunder Bay, Ontario: the case for supervised injection services

Although public injecting has been studied in large urban centres, little is known about the factors that drive public injecting in remote communities. This study sought to explore public and semi-public injection in Thunder Bay, a remote and mid-sized city in Northwestern Ontario. Peer researchers completed surveys with people who inject drugs. Multivariable logistic regression was used to examine sociodemographic characteristics and behavioural patterns associated with injecting in public or semi-public settings. Among 200 people who inject drugs, 128 (64%) individuals reported engaging in public injection. In multivariable analyses, public injecting was positively associated with age (Adjusted Odds Ratio [AOR], 0.97, 95% Confidence Interval [CI]: 0.97–1.00; p = 0.05), homelessness (AOR 2.34, 95% CI: 1.10–5.02; p = 0.02), sex work (AOR 4.62, 95% CI: 1.37–21.61; p = 0.02), injecting alone (AOR 2.66, 95% CI: 1.19–6.02; p = 0.01), opioid injecting (AOR 3.64, 95% CI: 1.48–9.41; p = 0.05) and cocaine injecting (AOR 4.35, 95% CI: 2.11–9.44). The most frequent reasons for public injecting were proximity to where people buy drugs (59.4%), being too far from home (27.3%), and being homeless (25.8%). Our findings suggest that the scale-up of additional harm reduction programming in Thunder Bay, including supervised injection services, may address public injecting and reduce associated harms in this setting.

Combining respondent-driven sampling with a community-based participatory action study of people who smoke drugs in two cities in British Columbia, Canada

BackgroundThe smoking of illicit drugs presents a serious social and economic burden in Canada. People who smoke drugs (PWSD) are at increased risk of contracting multiple infections through risky drug practices. Peer-led harm reduction activities, and the resulting social networks that form around them, can potentially minimize the dangers associated with the smoking illicit drugs.GoalThe goals of this study were to pilot test the combined approaches of respondent driven sampling with community based participatory action research in these settings and compare the attributes and social networks of PWSD in two British Columbia cities with different harm reduction programs.MethodsUsing community-based participatory action research (CBPAR) and respondent-driven sampling (RDS), individuals with lived drug experiences were employed from communities in Abbotsford and Vancouver as peer researchers to interview ten contacts from their social networks. Contacts completed a questionnaire about their harm reduction behaviours and interactions.ResultsWe found that PWSD residing in Abbotsford were more likely to report engaging in harm-promoting behaviours, such as sharing, reusing, or borrowing crack pipes. However, PWSD in the Downtown East side Community of Vancouver were more likely to report engaging in harm-reducing activities, such as being trained in naloxone use and CPR. We found no differences in network sizes between the two communities, despite the population differences and harm reduction programsConclusionThe high participation rates and interactions between researchers, and peer researchers enriched the study implementation and successfully informed our results. The fact that there were no differences in network size suggests that people have similar support in Vancouver as in Abbotsford, and that drug use practices differ mainly due to availability of harm reduction programming and resources.

HeART space: Curating community grief from overdose

This article details the transformation of an empty store into a gallery honouring youth and others who have passed away from overdoses, and the creation of extensive harm reduction and grief support programming that accompanied the display of artwork. The outpouring of community interest, participation, and emotion that surfaced around heART space clearly shows how art, exhibitions and creative programming can help foster communities of care during times of crisis. Drawing from research into practices of care from harm reduction work, grief studies and participatory arts and curatorial studies, the authors explore how heART space comforted youth and others with direct experiences with overdose and disenfranchised grief while creating dialogues with visitors about the stigma of drug use and homelessness. The authors argue curating heART space produced an opportunity for community healing while nuancing and humanizing the way we see people who use drugs. As such, this youth-driven community project created a safe space to share stories, collaborate, honour trauma and transform grief into action.

Stigmatize the use, not the user? Attitudes on opioid use, drug injection, treatment, and overdose prevention in rural communities.

Stigma is a known barrier to treating substance use disorders and dramatically diminishes the quality of life of people who use drugs (PWUD) nonmedically. Stigma against PWUD may be especially pronounced in rural areas due to their decreased anonymity and residents' limited access, or resistance, to "neutralizing" information on factors associated with drug use. Stigma often manifests in the attitudes of professionals whom stigmatized individuals regularly interact with and often materially impact. We analyzed interviews conducted between July 2018 and February 2019 with professional stakeholders in rural southern Illinois who interact with PWUD, specifically those who use opioids nonmedically or who inject drugs (n=30). We further analyzed interview data from a complementary PWUD sample (n=22). Interviews addressed perspectives around nonmedical drug use and treatment/harm reduction, with analysis centered around the Framework Integrating Normative Influences on Stigma and its focus on micro, meso and macro level stigmatization processes. Stakeholder participants included professionals from local law enforcement, courts, healthcare organizations, emergency management services, and faith-based and social services organizations. Most stakeholders, particularly law enforcement, negatively perceived PWUD and nonmedical drug use in general, questioned the character, agency and extrinsic value of PWUD, and used labels (e.g. "addict," "abuser," etc.) that may be regarded as stigmatizing. Further, most respondents, including PWUD, characterized their communities as largely unaware or dismissive of the bio-medical and sociocultural explanations for opioid use, drug injection and towards harm reduction services (e.g., syringe exchanges) and naloxone, which were frequently framed as undeserved usages of taxpayer funds. In conclusion, rural stigma against PWUD manifested and was framed as a substantial issue, notably activating at micro, meso and macro levels. Stigma prevention efforts in these communities should aim to improve public knowledge on the intricate factors contributing to opioid use and drug injection and harm reduction programming's moral and fiscal value.

Practices of care among people who buy, use, and sell drugs in community settings

BackgroundPopular perception of people who sell drugs is negative, with drug selling framed as predatory and morally reprehensible. In contrast, people who use drugs (PWUD) often describe positive perceptions of the people who sell them drugs. The “Satellite Sites” program in Toronto, Canada, provides harm reduction services in the community spaces where people gather to buy, use, and sell drugs. This program hires PWUD—who may move into and out of drug selling—as harm reduction workers. In this paper, we examine the integration of people who sell drugs directly into harm reduction service provision, and their practices of care with other PWUD in their community.MethodsData collection included participant observation within the Satellite Sites over a 7-month period in 2016–2017, complemented by 20 semi-structured interviews with Satellite Site workers, clients, and program supervisors. Thematic analysis was used to examine practices of care emerging from the activities of Satellite Site workers, including those circulating around drug selling and sharing behaviors.ResultsSatellite Site workers engage in a variety of practices of care with PWUD accessing their sites. Distribution of harm reduction equipment is more easily visible as a practice of care because it conforms to normative framings of care. Criminalization, coupled with negative framings of drug selling as predatory, contributes to the difficultly in examining acts of mutual aid and care that surround drug selling as practices of care. By taking seriously the importance for PWUD of procuring good quality drugs, a wider variety of practices of care are made visible. These additional practices of care include assistance in buying drugs, information on drug potency, and refusal to sell drugs that are perceived to be too strong.ConclusionOur results suggest a potential for harm reduction programs to incorporate some people who sell drugs into programming. Taking practices of care seriously may remove some barriers to integration of people who sell drugs into harm reduction programming, and assist in the development of more pertinent interventions that understand the key role of drug buying and selling within the lives of PWUD.