Drug related harm, risks and protective environments

A session on drug use, stigma and public health requires consideration of drug related harms. What does drug related harms mean to you ? How do you think they are produced ? These are important questions, as our understanding of harm influence how we intervene. For example, if harm is viewed as inherent to the drug itself, as caused by the pharmacological properties acting on the brain (As in a ‘brain disease model’ with harms related to dependence, compulsion, reduction of inhibition, etc.)

Then, interventions are likely to focus on : reducing availability and supply (through prohibition for example) and reducing demand, often through educational and behavioural change interventions. So what I hope to do in this short talk is to provide a broader perspective, one which considers the role of social environments and structures in acting to both produce and alleviate harms related to drug use and how this broader perspective can inform innovative community-acceptable responses.

So here the concept of “drug, set and setting” is useful to think with. This emerged in the field of 1960s psychedelic drug research where drug effects were considered not only to be related to the pharmacology of a particular drug, but also the mindset of the user and the setting in which the drug use took place. So here, “set” refers to anything related to the internal state of the person, (personality, preparation, expectation, and their intention around taking the drug) And “setting” is anything related to the physical, social and cultural environment in which the experience takes place. Now while this concept arose in the field of psychedelics, it has been extended by

So, for example, in a 1972 study of American service men returning from Vietnam, Robbins and Al found that nearly half had used heroin or opium in Vietnam and just over half of these displayed signs of dependence. So 20 percent of the total could be said to be addicted. In a 12 month follow up however, despite widespread availability of heroin, only 10 percent reported heroin use and only 1 percent were considered to be dependent. Around the same time in Canada, Bruce Alexander conducted a series of studies called Rat Park, finding that rats living in a social environment were much less likely to self administer morphine than those who were isolated.

How might this then help us think about harm reduction interventions differently ? Is it better, perhaps, to think about changing the cage rather than the rat? So Tim Rhodes’ work on risk environments provides a useful framework for thinking about how macro or large scale environmental structures can impact to produce harm at an individual or micro level. For example, The policy environment criminalises drug use, this sanctions social stigma and acts to produce harms related to secrecy and shame. Using alone, for example, increases overdose risk. Gender norms can exacerbate harms for women who often avoid seeking help, including for injecting related health harms for fear that their children will be taken away.

The most marginalized are also the most visible. They are often seen in the public eye as the example of problem drug use. However, the harms we see here are more often socially produced rather than pharmacological or psychological.

So I’m going to provide an example from my current research with People Who Inject Drugs in London. We generated survey data with 455 participants and qualitative interviews with 36. Now, most of the sample reported a lifetime history of street homelessness and nearly all had experience of injecting in public places. This is a risk environment for injecting. People have to hurry, for fear of being seen by others of the police and ability to practice hygienic preparation practices is often compromised. The current policy and environment in the UK increases the environmental risk. Restrictions on public spending have heavily impacted drug services in many pharmacies and no longer providing sterile water and injection preparation packs.

At the same time, public toilets are closing and security increasing in cafes so that washrooms are more difficult to access. This means that for people living on the street, access to clean water to prepare and injection wells can be very difficult. Participants described to me preparing injections with alcohol, Coca-Cola, puddle water, and in some cases their own saliva. This is incredibly dangerous given the large amount of bacteria in saliva, with one person hospitalised for three months as a result. So here you can see the immediate harms posed by policy and physical environment in which people are living.

Also, how harm reduction materials that enjoin people to always wash their hands and use sterile water can be alienating and shaming for those with the least resources to do so.

Structural problems require structural solutions. And messages tailored to the everyday realities of people living and constrained circumstances. In relation to this example I have worked with a social enterprise, providing injecting equipment to revise their water risks poster. So that it steps people through a hierarchy of safe practices. If you can’t access sterile water, what’s the next best option ? We’re also campaigning to get water for injection provided for the homeless through pharmacy services, as the costs of this are far outweighed by the costs of inaction. An ideal structural intervention would be the provision of safe injecting rooms. The health harms, both immediate and long term, prevented by this action would be profound.

We can see this also in relation to the current COVID crisis. A very important initiative to house street homeless people in hostels would have been ideally supported by the provision of a communal safe space where people could inject while socially distanced. Placed in sole occupancy rooms, people are more likely to inject alone, increasing overdose risk, and many were evicted due to zero tolerance drug use policies. In providing these examples, I hope to encourage you to think more broadly about how we can act to reduce drug related harms to the most marginalized, and also to question

wich constrain the actions of those who chose to use drugs other than alcohol. As with alcohol, for many, the use of other drugs may not in itself be problematic. They can have pleasurable, indeed, productive effects, but harms caused by the policy, social and physical environments can be profound. This understanding can help us to inform structural interventions than in alleviating the constraints for people who use drugs can also, importantly, reduce the harms related to shame and stigma.