Harm reduction in name, but not substance: a comparative analysis of current Canadian provincial and territorial policy frameworks.

BACKGROUND: In Canada, funding, administration, and delivery of health services-including those targeting people who use drugs-are primarily the responsibility of the provinces and territories. Access to harm reduction services varies across jurisdictions, possibly reflecting differences in provincial and territorial policy commitments. We examined the quality of current provincial and territorial harm reduction policies in Canada, relative to how well official documents reflect internationally recognized principles and attributes of a harm reduction approach. METHODS: We employed an iterative search and screening process to generate a corpus of 54 provincial and territorial harm reduction policy documents that were current to the end of 2015. Documents were content-analyzed using a deductive coding framework comprised of 17 indicators that assessed the quality of policies relative to how well they described key population and program aspects of a harm reduction approach. RESULTS: Only two jurisdictions had current provincial-level, stand-alone harm reduction policies; all other documents were focused on either substance use, addiction and/or mental health, or sexually transmitted and/or blood-borne infections. Policies rarely named specific harm reduction interventions and more frequently referred to generic harm reduction programs or services. Only one document met all 17 indicators. Very few documents acknowledged that stigma and discrimination are issues faced by people who use drugs, that not all substance use is problematic, or that people who use drugs are legitimate participants in policymaking. A minority of documents recognized that abstaining from substance use is not required to receive services. Just over a quarter addressed the risk of drug overdose, and even fewer acknowledged the need to apply harm reduction approaches to an array of drugs and modes of use. CONCLUSIONS: Current provincial and territorial policies offer few robust characterizations of harm reduction or go beyond rhetorical or generic support for the approach. By endorsing harm reduction in name, but not in substance, provincial and territorial policies may communicate to diverse stakeholders a general lack of support for key aspects of the approach, potentially challenging efforts to expand harm reduction services.

Canada moving backwards on illegal drugs.

Internationally, illegal drug use remains a major public health problem. In response, many countries have begun to shift their illegal drug policies away from enforcement and towards public health objectives. Recently, both the Global Commission on Drug Policy and the Supreme Court of Canada have endorsed this change in direction, supporting empirically sound illegal drug policies that reduce criminalization and stigmatization of drug users and bolster treatment and harm reduction efforts. Until recently, Canada was a participant in this growing movement towards rational drug policy. Unfortunately, in recent years, policy changes have made Canada one of the few remaining advocates of a "war-on-drugs" approach. Indeed, the current government has implemented a number of new illegal drug policies that contradict well-established scientific evidence from public health, criminology and other fields. As such, their approach is expected to do little to reduce the harms associated with substance use in Canada. The authors call on the current government to heed the recommendations of the Global Commission's report and learn from the many countries that are innovating in illegal drug policy by prioritizing evidence, human rights and public health.

Legislative and policy analysis of HIV prevention, treatment and care for people who use drugs and incarcerated people in Central Asia and Azerbaijan.

In January 2011, the Regional Office for Central Asia of the UN Office on Drugs and Crime (UNODC) and the Canadian HIV/AIDS Legal Network released an extensive report assessing the legislative and policy environment affecting the response to HIV in six countries of the Commonwealth of Independent States (CIS). The report, which draws in part upon the work of a national expert group in each country, puts forward dozens of recommendations for legislative and policy reform, including recommendations for specific reform tailored to the situation in each of the participating countries, with a particular focus on addressing the fast-growing HIV epidemic linked to injection drug use and in prisons.

Panel: emerging issues in Canada's drug policy--implications for HIV prevention and health promotion for people who use drugs.

This article contains summaries of the three presentations made during this panel. Carol Strike discusses various strategies that have been used to prevent HIV transmission among people who use drugs. Richard Elliott reviews the implications of the 2008 judgment by the British Columbia Supreme Court on Insite, the supervised injection facility in Vancouver. Finally, Senator Claude Nolin provides some observations on legislating in the area of drug law.

Depression in primary care.

Depression is common in primary care settings, affecting at least 10% of primary care patients. It carries medical and psychiatric comorbidity, increasing the risk of cardiovascular disease, diabetes, hypertension, stroke, medically unexplained (functional) symptoms, chronic pain, anxiety disorders, and substance abuse. Diagnosis and treatment are straightforward for many patients. The greatest current challenge is to recognize and relieve symptoms of treatment-resistant depression. This article reviews current approaches to diagnosing and treating depression, especially treatment-resistant forms of depression.

Drug treatment courts in Canada: an evidence-based review.

Drug treatment courts (DTCs), which are judicially mandated treatment alternatives to the incarceration of illicit drug offenders, were introduced in Canada in late 1998. Recent announcements from the federal government suggest that the drug treatment court model will continue to operate and expand in a number of Canadian jurisdictions. Two major evaluations of these programs--in Vancouver and Toronto--have been conducted. In this article, D. Werb et al. analyze the results of these evaluations. Their analysis reveals that, despite the evaluations, little is known regarding the success of DTCs in contributing to the long-term reduction of drug use and recidivism among their participants; and that the cost-effectiveness of these programs requires further study. The authors conclude that further funding for DTCs in Canada should be dependent on the implementation of randomized controlled trials that measure the success of these programs in reducing drug use and recidivism in the long term; that measure the impact of DTCs on societal end-points such as rates of crime and incarceration of injection drug users; and that include components to measure the cost-effectiveness of DTCs compared with other interventions aimed at reducing the negative effects of problematic drug use and drug-related crime.

Canadian harm reduction policies: A comparative content analysis of provincial and territorial documents, 2000-2015.

BACKGROUND: Access to harm reduction interventions among substance users across Canada is highly variable, and largely within the policy jurisdiction of the provinces and territories. This study systematically described variation in policy frameworks guiding harm reduction services among Canadian provinces and territories as part of the first national multimethod case study of harm reduction policy. METHODS: Systematic and purposive searches identified publicly-accessible policy texts guiding planning and organization of one or more of seven targeted harm reduction services: needle distribution, naloxone, supervised injection/consumption, low-threshold opioid substitution (or maintenance) treatment, buprenorphine/naloxone (suboxone), drug checking, and safer inhalation kits. A corpus of 101 documents written or commissioned by provincial/territorial governments or their regional health authorities from 2000 to 2015 were identified and verified for relevance by a National Reference Committee. Texts were content analyzed using an a priori governance framework assessing managerial roles and functions, structures, interventions endorsed, client characteristics, and environmental variables. RESULTS: Nationally, few (12%) of the documents were written to expressly guide harm reduction services or resources as their primary named purpose; most documents included harm reduction as a component of broader addiction and/or mental health strategies (43%) or blood-borne pathogen strategies (43%). Most documents (72%) identified roles and responsibilities of health service providers, but fewer declared how services would be funded (56%), specified a policy timeline (38%), referenced supporting legislation (26%), or received endorsement from elected members of government (16%). Nonspecific references to 'harm reduction' appeared an average of 12.8 times per document-far more frequently than references to specific harm reduction interventions (needle distribution=4.6 times/document; supervised injection service=1.4 times/document). Low-threshold opioid substitution, safer inhalation kits, drug checking, and buprenorphine/naloxone were virtually unmentioned. Two cases (Quebec and BC) produced about half of all policy documents, while 6 cases - covering parts of Atlantic and Northern Canada - each produced three or fewer. CONCLUSION: Canada exhibited wide regional variation in policies guiding the planning and organization of Canadian harm reduction services, with some areas of the country producing few or no policies. Despite a wealth of effectiveness and health economic research demonstrating the value of specific harm reduction interventions, policies guiding Canada from 2000 to 2015 did not stake out harm reduction interventions as a distinct, legitimate health service domain.

Harm reduction, HIV/AIDS, and the human rights challenge to global drug control policy.

The global HIV/AIDS pandemic, and the role of unsafe drug injection as one of its principal drivers, have added to the list of harms associated with unsafe drug use. HIV/AIDS has highlighted ways in which prohibitionist drug policy causes or contributes to such harms and focused attention on the international regime of illicit drug control. At the same time, HIV/AIDS has catalyzed the "health and human rights movement" to articulate legal and policy responses that both represent sound public health policy and fulfill human rights obligations recognized in international law; this necessarily includes scrutinizing the interpretation and implementation of the UN drug control conventions. This article brings together public health evidence and legal analysis as a contribution toward changing the global drug control regime to a more health-friendly, human rights-based system.

Ex utero intrapartum treatment procedure for management of congenital high airway obstruction syndrome in a vertex/breech twin gestation.

Congenital high airway obstruction syndrome (CHAOS) is one indication for the ex utero intrapartum treatment (EXIT), which is used to secure the fetal airway, while fetal oxygenation is maintained by uteroplacental circulation. We report a successful EXIT procedure in a twin gestation in which one child had CHAOS while the other was a healthy child without any congenital abnormalities. After version of Twin B to allow for delivery of Twin A, Twin B underwent airway evaluation and tracheostomy for laryngeal atresia prior to delivery.

Update to international guidelines on HIV/AIDS and human rights.

On 10 September 2002, the Office of the UN High Commissioner for Human Rights (OHCHR) and the Joint UN Programme on HIV/AIDS (UNAIDS) released a revised international guideline on "Access to prevention, treatment, care and support." The update to Guideline 6 of HIV/AIDS and Human Rights: International Guidelines reflects significant therapeutic, political, and legal developments in this area since the 12 guidelines were originally published in 1998. The new Guideline 6 significantly expands the guidance given to governments on what international human rights norms require of them in relation to HIV/AIDS prevention, treatment, care and support.

South Africa: TAC, COSATU and allies file complaint of excessive pricing.

On 19 September 2002, the Treatment Action Campaign (TAC), the Council of South African Trade Unions (COSATU), the Chemical, Energy, Paper, Printing, Wood and Allied Workers' Union (CEPPWA), and eight individuals (health-care workers and people living with HIV/AIDS) launched a complaint with the country's Competition Commission against two major transnational pharmaceutical companies. TAC and its allies allege that GlaxoSmithKline (GSK) has engaged in excessive pricing for its antiretroviral drugs Retrovir (zidovudine or AZT), 3TC (lamivudine), and Combivir (AZT/lamivudine), and that Boeringer Ingelheim (BI) has engaged in excessive pricing of its antiretroviral drug Viramune (nevirapine).

WTO ministerial conference adopts declaration on TRIPS and public health.

In November 2001, the 4th Ministerial Conference of the World Trade Organization adopted a Ministerial Declaration on public health and the WTO's Agreement on Trade-Related Aspects of Intellectual Property Rights (the "TRIPS Agreement"). The declaration represents a modest advance in addressing concerns that strict patent laws, and threats of trade sanctions, will be a barrier to most of the world's people with HIV/AIDS accessing affordable medicines. The full significance of the declaration remains to be seen, as it depends on what political impact it has at the WTO and on its member countries, and what legal impact it will have in the interpretation of the TRIPS Agreement.

South Africa: Treatment Action Campaign steps up pressure.

In December 2002, in its ongoing efforts to secure access to affordable HIV/AIDS treatment for all South Africans, the grassroots organization Treatment Action Campaign (TAC) initiated two new proceedings over governmental failure to act to prevent mother-to-child transmission of HIV. In March 2003, it launched a national civil disobedience campaign to pressure government into implementing a national treatment and prevention plan, including taking measures to ensure access to affordable medicines.

Establishing safe injection facilities in Canada: legal and ethical issues.

In the face of an ongoing and escalating health crisis among injection drug users in Canada, calls are coming from many quarters to initiate safe injection facilities as a way to reduce overdoses, the spread of bloodborne diseases, and other health and community problems associated with injection drug use. This article summarizes a paper on safe injection facilities released in early 2002 by the Canadian HIV/AIDS Legal Network. The paper contributes to the policy discussion in Canada and sets out why and how the law should support the introduction of safe injection facilities.

Barcelona 2002: law, ethics, and human rights. Using the law to improve access to treatments.

The XIII International AIDS Conference in Durban, South Africa in July 2000 focused worldwide attention on the problem of accessing treatments in developing countries. In the interim, thanks to the work of activists - from demonstrations to court cases, and from acts of public courage by people living with HIV/AIDS to ongoing lobbying of politicians and trade negotiators - some very significant developments have occurred. But the reality is that the vast majority of people living with HIV/AIDS still lack access to affordable, quality medicines. This article, a summary of a paper presented at "Putting Third First: Vaccines, Access to Treatments and the Law," a satellite meeting held at Barcelona on 5 July 2002 and organized by the Canadian HIV/AIDS Legal Network, the AIDS Law Project, South Africa, and the Lawyers Collective HIV/AIDS Unit, India, explores three approaches for improving access. In the first part, Richard Elliott provides an overview of the state of the right to health as embodied in international human rights law; comments on the experience to date in litigating claims to the right to health; and identifies potential strategies activists can adopt to advance recognition of the right to health. In the second part, Sharan Parmar and Vivek Divan describe price-control and drug-financing mechanisms used by industrialized countries to increase the affordability of medicines; and discuss how some of these mechanisms could be adapted for use in developing countries. Finally, Jonathan Berger describes the use of litigation in the courts by the Treatment Action Campaign in South Africa.