Women who use drugs: engagement in practices of harm reduction care.

BACKGROUND: Harm reduction services that employ or are operated by people who use drugs are an effective means of mitigating overdose risks and other drug-related harms. However, stereotypes portraying people who use criminalized drugs as incapable caregivers persist. This is especially true for women who use drugs, and to a greater extent racialized women, who are characterized as having diverged from traditional ideals of womanhood as a result of drug-user stigma and the intersections of gender- and class-based and racist stereotypes. In an effort to identify and understand how women who use drugs practise care through harm reduction, we explored the experiences of women accessing a low-threshold supervised consumption site exclusively for women (transgender and non-binary inclusive) in Vancouver, Canada. METHODS: Data were drawn from research conducted from May 2017 to June 2018 exploring women's experiences accessing the supervised consumption site during an overdose crisis. Data included forty-five semistructured interviews with women recruited from the site, analysed thematically to explore practices of care through harm reduction. FINDINGS: Participants reported engaging in both formal and informal care. Acts of care included interventions that both aligned with and deviated from conventional understandings of care practices, including overdose reversal and education, overdose supervision/care, and assisted injection. CONCLUSION: The boundary between formal and informal harm reduction care is fluid. Women who use drugs engage in harm reduction across these borders with acts of care that align with or fill the gaps in current harm reduction services in order to meet the needs of drug-using communities, challenging negative stereotypes of women who use drugs. However, these caregiving practices can increase risks to care providers' physical, mental, and emotional health and wellness. Increased financial, social, and institutional supports, including safer supply, assisted injection, and community resources, are needed to better support women as they continue to engage in harm reduction care.

Mothers Who Use Drugs: Closing the Gaps in Harm Reduction Response Amidst the Dual Epidemics of Overdose and Violence in a Canadian Urban Setting.

Objectives. To identify key gaps in overdose prevention interventions for mothers who use drugs and the paradoxical impact of institutional practices that can increase overdose risk in the context of punitive drug policies and a toxic drug supply. Methods. Semistructured interviews were conducted with 40 women accessing 2 women-only, low-barrier supervised consumption sites in Greater Vancouver, British Columbia, Canada, between 2017 and 2019. Our analysis drew on intersectional understandings of structural, everyday, and symbolic violence. Results. Participants' substance use and overdose risk (e.g., injecting alone) was shaped by fear of institutional and partner scrutiny and loss (or feared loss) of child custody or reunification. Findings indicate that punitive policies and institutional practices that frame women who use drugs as unfit parents continue to negatively shape the lives of women, most significantly among Indigenous participants. Conclusions. Nonpunitive policies, including access to safe, nontoxic drug supplies, are critical first steps to decreasing women's overdose risk alongside gender-specific and culturally informed harm-reduction responses, including community-based, peer-led initiatives to maintain parent-child relationships. (Am J Public Health. 2022;112(S2):S191-S198. https://doi.org/10.2105/AJPH.2022.306776).

Negotiating sex work and client interactions in the context of a fentanyl-related overdose epidemic.

Despite awareness of the role of drug use in shaping sex worker/client interactions, these dynamics remain poorly understood in the context of illicit fentanyl-driven overdose epidemics. This study examined sex workers' experiences negotiating client interactions amidst a toxic drug supply in Vancouver, Canada. Findings draw from two ethnographic studies. The first, conducted between December 2016 and May 2017, examined the rapid implementation of several low-threshold supervised consumption sites. The second investigated experiences of women accessing a women-only site from May 2017 to June 2018. Data included 200 hours of fieldwork and in-depth semi-structured interviews with 34 street-based sex workers who use illicit drugs. Data were analysed thematically with attention to the risk environment. Participants described providing harm reduction services to clients as a means to reduce overdose-related risks, thus increasing sex workers' hidden labour. Participants, comments regarding criminalisation and stigma surrounding drug use and sex work indicated a reticence to report overdoses, thereby potentially increasing the risks of overdose-related harms, including death. There is an urgent need for sex worker-led overdose prevention strategies that prioritise health and safety of sex workers and their clients with specific attention to how the criminalisation of particular drugs, practices and people contributes to overdose-related risks.

You just have to have other models, our DNA is different: the experiences of indigenous people who use illicit drugs and/or alcohol accessing substance use treatment.

OBJECTIVES: In Canada, and elsewhere, indigenous peoples who use illicit drugs and/or alcohol (IPWUID/A) commonly experience vulnerability and a disproportionate burden of harm related to substance use. In Vancouver, Canada, there are concerns that inequitable access, retention, and post treatment care within substance use treatment programs may exacerbate these harms. This study sought to understand the policies and practices with the potential to produce inequities and vulnerabilities for IPWUID/A in substance use treatment, situate the vulnerabilities of IPWUID/A in substance use treatment within the context of wider structural vulnerability of IPWUID/A, and generate recommendations for culturally safe treatment options. METHODS: This research employed a qualitative indigenous-led community-based approach using the indigenous methodology of talking circles to explore experiences with substance use treatment. Under the participatory research framework, community researchers led the study design, data collection, and analysis. Talking circles elicited peers' experiences of substance use treatment and were audio-recorded and transcribed. RESULTS: The talking circles identified three key themes that illustrated the experiences of IPWUID/A when accessing substance use treatment: (a) barriers to accessing detox and substance use treatment; (b) incompatible and culturally inappropriate structure, policies, and procedures within treatment programs, such as forced Christianity within treatment settings; and (c) the importance of culturally relevant, peer-led substance use treatment programming. DISCUSSION: Our work demonstrates that some IPWUID/A have limited access to or retention in mainstream treatment due to excessive waiting times, strict rules, and lack of cultural appropriate care while in treatment. However, IPWUID/A narratives revealed strategies that can improve IPWUID/A access and experiences, including those informed by the diverse perspectives of IPWUID/A and those that include trauma-informed and culturally safe practices.

Interest in receiving psychedelic-assisted therapy among marginalized women: Implications and findings from a community-based study in Canada.

Background: Psychedelic-assisted therapies are receiving mounting attention for their therapeutic potential. However, little is known about interest among women who experience elevated risk of mental health and substance use disorders. This study examined interest in receiving psychedelic-assisted therapy and socio-structural factors associated with interest among marginalized women. Methods: Data (2016-2017) were drawn from two community-based, prospective open cohorts of >1000 marginalized women in Metro Vancouver, Canada. Bivariate and multivariable logistic regression examined associations with interest in receiving psychedelic-assisted therapy. Among women who used psychedelics, additional data were collected to describe ratings of personal meaningfulness, sense of wellbeing, and spiritual significance. Results: Of 486 eligible participants (aged 20-67 years), 43% (n = 211) were interested in receiving psychedelic-assisted therapy. Over half identified as Indigenous (First Nations, Métis or Inuit). Factors independently associated with interest in psychedelic-assisted therapy in multivariable analysis included: daily crystal methamphetamine use in the last six months (Adjusted Odds Ratio [AOR] 3.02; 95%Confidence Interval (CI) 1.37-6.65), lifetime mental health conditions (depression, anxiety, post-traumatic stress disorder) (AOR 2.13; 95%CI 1.27-3.59), childhood abuse (AOR 1.99; 95%CI 1.02-3.88), lifetime psychedelic use (AOR 1.97; 95%CI 1.14-3.38), and younger age (AOR 0.97 per year older; 95%CI 0.95-0.99). Conclusions: Several mental health and substance use-related variables that have been demonstrated to be amenable to psychedelic-assisted therapy were associated with interest in receiving psychedelic-assisted therapy among women in this setting. As access to psychedelic-assisted therapies continues to expand, any future approaches to extend psychedelic medicine to marginalized women should integrate trauma-informed care and broader socio-structural supports.

"People need them or else they're going to take fentanyl and die": A qualitative study examining the 'problem' of prescription opioid diversion during an overdose epidemic.

The practice of prescription opioid (PO) diversion remains highly controversial and has been characterized as a source of significant drug-related harm by physicians and public health officials. We critically analyze the "problem" of diversion through an examination of the perspectives of people who divert POs during an overdose epidemic to better understand the practice, including benefits and challenges, as well as how diversion is shaped by structural contexts. Qualitative semi-structured interviews were conducted with 21 participants recruited from ongoing cohort studies involving people who use drugs in Vancouver, Canada. Prohibitive prescribing policies made accessing POs difficult, leading some to smuggle drugs out of clinics. Others would buy POs in bulk or do trades to acquire them. Participants risked having their prescriptions terminated, but rationalized this risk as a protective measure that allows them to provide safer drugs to others (e.g., to prevent overdose or treat withdrawal). Poverty also framed diversion, with some participants diverting their POs to generate income to pay for expenses including food and sometimes illicit fentanyl (perceived as a stronger alternative). However, diversion was shaped by other constraints, including criminalization, negative health impacts from not consistently consuming POs, and supplies running out, which led some participants to rely on other illegal means to generate income. This study highlights the intricate means by which POs are acquired and diverted and how environmental contexts frame how participants negotiated risk and rationalized diversion. Our study provides an alternative perspective on the "problem" of diversion and demonstrate a positive effect in providing a safer drug supply to others during an overdose crisis. Given that drug policy, criminalization, and poverty created challenges, our findings demonstrate the need for strategies that engender greater safety, reduce harm, and alleviate the effects of these constraints, including through policies promoting safer drug supplies, decriminalization, and employment.

"Bed Bugs and Beyond": An ethnographic analysis of North America's first women-only supervised drug consumption site.

BACKGROUND: Attention to how women are differentially impacted within harm reduction environments is salient amidst North America's overdose crisis. Harm reduction interventions are typically 'gender-neutral', thus failing to address the systemic and everyday racialized and gendered discrimination, stigma, and violence extending into service settings and limiting some women's access. Such dynamics highlight the significance of North America's first low-threshold supervised consumption site exclusively for women (transgender and non-binary inclusive), SisterSpace, in Vancouver, Canada. This study explores women's lived experiences of this unique harm reduction intervention. METHODS: Ethnographic research was conducted from May 2017 to June 2018 to explore women's experiences with SisterSpace in Vancouver's Downtown Eastside, an epicenter of Canada's overdose crisis. Data include more than 100 hours of ethnographic fieldwork, including unstructured conversations with structurally vulnerable women who use illegal drugs, and in-depth interviews with 45 women recruited from this site. Data were analyzed in NVivo by drawing on deductive and inductive approaches. FINDINGS: The setting (non-institutional), operational policies (no men; inclusive), and environment (diversity of structurally vulnerable women who use illegal drugs), constituted a space affording participants a temporary reprieve from some forms of stigma and discrimination, gendered and social violence and drug-related harms, including overdose. SisterSpace fostered a sense of safety and subjective autonomy (though structurally constrained) among those often defined as 'deviant' and 'victims', enabling knowledge-sharing of experiences through a gendered lens. CONCLUSION: SisterSpace demonstrates the value and effectiveness of initiatives that engage with socio-structural factors beyond the often narrow focus of overdose prevention and that account for the complex social relations that constitute such initiatives. In the context of structural inequities, criminalization, and an overdose crisis, SisterSpace represents an innovative approach to harm reduction that accounts for situations of gender inequality not being met by mixed-gender services, with relevance to other settings.

A missed opportunity? Cannabis legalization and reparations in Canada.

As Canada moves towards the legalization of cannabis, the Cannabis Act itself remains void of any complementary social justice measures. Decades of criminalization for the possession, production, and sale of cannabis will remain unscathed under this ostensibly new approach, leaving intact laws that have disproportionately and prejudicially impacted Indigenous people and people of colour. This includes the overpolicing and criminalization of these communities, furthering criminal justice disparities, and the lack of meaningful initiatives to aid communities of colour and Indigenous communities in participating in the legal cannabis industry. Despite the continuing impacts, the Government of Canada has made no commitment to tandem initiatives that address the issues of reparation for those who have been most heavily targeted under cannabis prohibition. Public health implications are discussed.