More-than-harm reduction: Engaging with alternative ontologies of 'movement' in UK drug services

"In Sweden you are worthless. In Denmark you get an identity again" - on being perceived and received as a person who uses drugs in different drug policy settings

BACKGROUND

Policies to address substance use differ greatly between settings, where goals may range from zero-tolerance to harm reduction. Different approaches impact formats of care, policing, and even interpersonal interactions, and may play a role in the labelling and stigmatization of people who use drugs (PWUD). Where Sweden has a more restrictive policy, aiming to have a society free from drugs, Denmark has embraced harm reduction principles. The aim of this study was to explore PWUDs' experiences of interpersonal interactions, policing, and service formats in the two countries.

METHODS

The data consists of 17 qualitative semi-structured interviews with Swedish PWUD who have been in both Sweden and Denmark. Recruitment took place at harm reduction sites in both countries, and through snowball sampling.

RESULTS

Participants reflected on how they were perceived by those in public spaces, and received by care systems and personnel. In public settings in Sweden, participants felt they were ignored, rendered invisible, and lost their humanity. In Denmark, they were perceived and acknowledged, valued as people. This was simultaneously linked to being embodied by the availability of differing service offerings and policing practices, which solidified their "right to be out" in public. Reflecting on their reception in the treatment system, strict formatting in Sweden caused participants to feel that an identity was projected upon them, limiting their opportunities or growth of new facets of identity. Care relations in Denmark fostered more opportunity for autonomy and trust.

CONCLUSION

A zero-tolerance policy and associated public discourses could solidify and universalize stigmatizing categorizations as a central feature of PWUD identity and reception from those around them, exacerbating social exclusion. Conversely, harm reduction-centered policies fostered positive interactions between individuals with care providers, public, and police, which may promote inclusion, empowerment, and wellbeing.

The effectiveness of abstinence-based and harm reduction-based interventions in reducing problematic substance use in adults who are experiencing homelessness in high income countries: A systematic review and meta-analysis: A systematic review

Background

Homelessness is a traumatic experience, and can have a devastating effect on those experiencing it. People who are homeless often face significant barriers when accessing public services, and have often experienced adverse childhood events, extreme social disadvantage, physical, emotional and sexual abuse, neglect, low self-esteem, poor physical and mental health, and much lower life expectancy compared to the general population. Rates of problematic substance use are disproportionately high, with many using drugs and alcohol to deal with the stress of living on the street, to keep warm, or to block out memories of previous abuse or trauma. Substance dependency can also create barriers to successful transition to stable housing.

Objectives

To understand the effectiveness of different substance use interventions for adults experiencing homelessness.

Search Methods

The primary source of studies for was the 4th edition of the Homelessness Effectiveness Studies Evidence and Gaps Maps (EGM). Searches for the EGM were completed in September 2021. Other potential studies were identified through a call for grey evidence, hand-searching key journals, and unpacking relevant systematic reviews.

Selection Criteria

Eligible studies were impact evaluations that involved some comparison group. We included studies that tested the effectiveness of substance use interventions, and measured substance use outcomes, for adults experiencing homelessness in high income countries.

Data Collection and Analysis

Descriptive characteristics and statistical information in included studies were coded and checked by at least two members of the review team. Studies selected for the review were assessed for confidence in the findings. Standardised effect sizes were calculated and, if a study did not provide sufficient raw data for the calculation of an effect size, author(s) were contacted to obtain these data. We used random-effects meta-analysis and robust-variance estimation procedures to synthesise effect sizes. If a study included multiple effects, we carried out a critical assessment to determine (even if only theoretically) whether the effects are likely to be dependent. Where dependent effects were identified, we used robust variance estimation to determine whether we can account for these. Where effect sizes were converted from a binary to continuous measure (or vice versa), we undertook a sensitivity analysis by running an additional analysis with these studies omitted. We also assessed the sensitivity of results to inclusion of non-randomised studies and studies classified as low confidence in findings. All included an assessment of statistical heterogeneity. Finally, we undertook analysis to assess whether publication bias was likely to be a factor in our findings. For those studies that we were unable to include in meta-analysis, we have provided a narrative synthesis of the study and its findings.

Main Results

We included 48 individual papers covering 34 unique studies. The studies covered 15, 255 participants, with all but one of the studies being from the United States and Canada. Most papers were rated as low confidence (n = 25, or 52%). By far the most common reason for studies being rated as low confidence was high rates of attrition and/or differential attrition of study participants, that fell below the What Works Clearinghouse liberal attrition standard. Eleven of the included studies were rated as medium confidence and 12 studies as high confidence. The interventions included in our analysis were more effective in reducing substance use than treatment as usual, with an overall effect size of -0.11 SD (95% confidence interval [CI], -0.27, 0.05). There was substantial heterogeneity across studies, and the results were sensitive to the removal of low confidence studies (-0.21 SD, 95% CI [-0.59, 0.17] - 6 studies, 17 effect sizes), the removal of quasi-experimental studies (-0.14 SD, 95% CI [-0.30, 0.02] - 14 studies, 41 effect sizes) and the removal of studies where an effect size had been converted from a binary to a continuous outcome (-0.08 SD, 95% CI [-0.31, 0.15] - 10 studies, 31 effect sizes). This suggests that the findings are sensitive to the inclusion of lower quality studies, although unusually the average effect increases when we removed low confidence studies. The average effect for abstinence-based interventions compared to treatment-as-usual (TAU) service provision was -0.28 SD (95% CI, -0.65, 0.09) (6 studies, 15 effect sizes), and for harm reduction interventions compared to a TAU service provision is close to 0 at 0.03 SD (95% CI, -0.08, 0.14) (9 studies, 30 effect sizes). The confidence intervals for both estimates are wide and crossing zero. For both, the comparison groups are primarily abstinence-based, with the exception of two studies where the comparison group condition was unclear. We found that both Assertative Community Treatment and Intensive Case Management were no better than treatment as usual, with average effect on substance use of 0.03 SD, 95% CI [-0.07, 0.13] and -0.47 SD, 95% CI [-0.72, -0.21] 0.05 SD, 95% CI [-0.28, 0.39] respectively. These findings are consistent with wider research, and it is important to note that we only examined the effect on substance use outcomes (these interventions can be effective in terms of other outcomes). We found that CM interventions can be effective in reducing substance use compared to treatment as usual, with an average effect of -0.47 SD, 95% CI (-0.72, -0.21). All of these results need to be considered in light of the quality of the underlying evidence. There were six further interventions where we undertook narrative synthesis. These syntheses suggest that Group Work, Harm Reduction Psychotherapy, and Therapeutic Communities are effective in reducing substance use, with mixed results found for Motivational Interviewing and Talking Therapies (including Cognitive Behavioural Therapy). The narrative synthesis suggested that Residential Rehabilitation was no better than treatment as usual in terms of reducing substance use for our population of interest.

Authors' Conclusions

Although our analysis of harm reduction versus treatment as usual, abstinence versus treatment as usual, and harm reduction versus abstinence suggests that these different approaches make little real difference to the outcomes achieved in comparison to treatment as usual. The findings suggest that some individual interventions are more effective than others. The overall low quality of the primary studies suggests that further primary impact research could be beneficial.

Tinkering with care: Implementing extended-release buprenorphine depot treatment for opioid dependence

We examine how extended-release buprenorphine depot (BUP-XR) is put to use and made to work in implementation practices, attending to how care practices are challenged and adapted as a long-acting technology is introduced into service in opioid agonist treatment (OAT) in Australia. Our approach is informed by ideas in science and technology studies (STS) emphasising the irreducible entanglement of care practices and technology, and in particular the concept of 'tinkering' as a practice of adaptation. To make our analysis, we draw on qualitative interview accounts (n = 19) of service providers involved in BUP-XR implementation across five sites. Our analysis considers the disruptive novelty of BUP-XR. Tinkering to make a novel technology work in practice slows down the expectation of implementation in relation to transformative innovation, despite the promise of dramatic or rapid change. Tinkering allowed for more open relations, for new care practices that departed from the routine and familiar, opening potential for how BUP-XR could be put to use and made to work in its new situation, and as its situation evolved along-with its implementation. Flexibility and openness of altering relations was, however, at times, held in tension with inflexibility and closure. This analysis identifies a concern for what is made present and what is made absent in the altered care network affected by BUP-XR, with the multiple effects of supervised daily dosing practices thrown into relief as they become absented. Tinkering to implement BUP-XR locally connects with a broader assemblage of trial and movement in the constitution of treatment. The introduction of long-acting technologies prompts new questions about embedded implementation practices, including supervised dosing, urinalysis, the time and place of psychosocial support, and how other social aspects of care might be recalibrated in drug treatment.

From prescribing dilemma to knowledge in practice: The ontological politics of benzodiazepines and Z-drugs

The discrepancy between official guidelines and clinical practice is hardly more pronounced than in the case of benzodiazepines and Z-drugs, also known as benzodiazepine receptor agonists (BZRA). Using social-constructionist positioning theory, we unravel how health care professionals deal with the dilemma of prescribing this medication. Our results reveal a prescribing spectrum that is discursively organised around four different storylines used by professionals. The storylines are organised along three axes that are related to a) prescribers' opinions on prescribing and the negotiation of the related risks, b) the power dynamics between provider and patient in the prescribing process and c) the rhetorical use of arguments. The discerned storylines allow us to explore the emotional and moral side of prescribing and demarcate clinical mindlines -internalised tacit guidelines-that professionals adhere to when they prescribe. By relying on Annemarie Mol's conceptualisation of ontological politics, we explain how these storylines enact multiple versions of this class of medication and justify seemingly contradictory prescribing practices.

The fluid hospital: On the making of care environments in COVID-19

This paper explores the boundary-making practices enacted by the hospital. Taking a hospital in Sydney, Australia, as our case, we investigate how the hospital holds together as a care environment through the coordinating movements of many materials, spaces, bodies, technologies, and affects. Drawing on interviews with hospital healthcare workers involved in care, research, and management related to COVID-19, we examine the multiplying effects of these movements to trace the ways in which the hospital is (re)made in relation with pandemic assemblages. We accentuate the material affordances of care environments and how care is adapted through the reshaping of the spaces and flows of the hospital. Through this, we highlight how care providers can work with the fluidity of the hospital, including through reorganizing routines and spaces of care, engaging with communication technologies to enact care at many scales, and remaking mundane materials as medical objects in the evolving care environment.

Implementing buprenorphine prolonged-release injection using a health at the margins approach for transactional sex-workers

Background

Access to prescribed interventions and retention in treatment services are associated with improved health outcomes and reduced premature mortality rates for people living with opioid use disorder (OUD). In Leeds, transactional sex-workers frequently cycled in and out of treatment for OUD such that they never reached a level of engagement that permitted opportunities to meet their healthcare or housing needs. Barriers to accessing care provision include an itinerant lifestyle, difficulties with travel at unpredictable hours, impacting upon adherence to medication regimens including daily supervised consumption.

Objectives

To use a co-produced, "health at the margins" approach, to reach the sex-working population in Leeds, and support informed choices about the potential to receive buprenorphine prolonged-release injection (BPRI) as a treatment option for OUD.

Methods

BPRI was introduced using a theory of change model and improvements in sex-worker care delivery was reviewed. Strategies included buprenorphine micro-induction, shared decision-making, collaborative multi-agency working and supporting a strengths-based and trauma-informed approach.

Results

Benefits of BPRI included removal of the need for daily pharmacy visits, reducing the risk of diversion, improved medication adherence, stability and engagement with treatment and supportive services.

Conclusion

BPRI may offer an additional option for pharmacological interventions for people with OUD where there may be increased barriers to accessing treatment for example due to sex-working. Strategies for effective BPRI include micro-induction, shared decision-making, collaborative multi-agency working and supporting a strengths-based approach.

'This is hardcore': a qualitative study exploring service users' experiences of Heroin-Assisted Treatment (HAT) in Middlesbrough, England

BACKGROUND

Heroin-Assisted Treatment (HAT) is well evidenced internationally to improve health and social outcomes for people dependent on opioids who have not been helped by traditional treatment options. Despite this evidence base, England has been slow to implement HAT. The first service outside of a trial setting opened in 2019, providing twice-daily supervised injections of medical-grade heroin (diamorphine) to a select sample of high-risk heroin users in Middlesbrough. This paper explores their experiences, including the negotiation of the strict regularly controls required of a novel intervention in the UK context.

METHODS

We conducted in-depth interviews with service providers and users of the Middlesbrough HAT service between September and November 2021. Data from each group were thematically analysed and reported separately. This paper details the experiences of the twelve heroin dependent men and women accessing HAT.

RESULTS

Participants' accounts of HAT treatment evidenced a tension between the regulatory constraints and uncertainty of treatment provision, and the positive outcomes experienced through supportive service provision and an injectable treatment option. Limited confidence was held in treatment efficacy, longevity of funding, and personal capacity for treatment success. This was counteracted by a strong motivation to cease engagement with the illicit drug market. While attendance requirements placed restrictions on daily activities, participants also experienced benefits from strong, supportive bonds built with the service providers through their continued engagement.

CONCLUSIONS

The Middlesbrough HAT programme provided benefits to a high-risk population of opioid dependent people who were unable or disinclined to participate in conventional opioid substitution treatments. The findings in this paper highlight the potential for service modifications to further enhance engagement. The closure of this programme in 2022 prohibits this opportunity for the Middlesbrough community, but holds potential to inform advocacy and innovation for future HAT interventions in England.

Precarious Lives, Precarious Treatments: Making Drug Treatment Work in Northern Myanmar

We explore how precarious livelihoods intersect with precarious treatments for heroin dependency in a setting affected by longstanding conflicts and an illicit drug economy as well as by recent events of pandemic and political change. Working with 33 qualitative interviews with people who inject drugs in Kachin State, northern Myanmar, we explore how drug dependency treatment, especially methadone substitution, is made to work in efforts to sustain everyday livelihoods. Our analysis attends to the work that is done to enable therapeutic trajectories to emerge as "generous constraints" in precarity. We trace methadone substitution as an emergent intervention of livelihood survival.

Chemical species: the art and politics of living with(out) drugs after addiction

We live within and are made up of ever-changing chemical flows. Witnessing a "chemical turn" in the social sciences, this article asks what a chemical reading of drugs and bodies can offer an understanding of drug dependency and recovery. Where chemicals render bodies "molecular" (Deleuze and Guattari, 1987), they open them up to more intimate forms of connection that extend our understanding of drug-body relationships beyond limiting categories such as addiction. Rather than a chemical drug entering a biological body, there are chemical interactions that expand the boundaries of where one ends and the other begins. While chemicals have long been a preoccupation in neurological models of addiction, they are seldom taken up in sociological studies of these concerns. Drawing on a series of body-mapping workshops with people in drug recovery/treatment in London, UK, to track these chemical bodies, this article explores the art of living a chemically transformed life. This is an art that thinks with Isabelle Stengers' (in Stengers and Savransky, 2018) notion of the word to include "not paying attention" as a mode of "paying attention to what may lurk" in living with the ongoing effects of drugs in unequally entangled worlds.

PROTOCOL: The effectiveness of abstinence-based and harm reduction-based interventions in reducing problematic substance use in adults who are experiencing severe and multiple disadvantage homelessness: A systematic review and meta-analysis

Background

Homelessness is a major social and public health concern. It is a traumatic experience, and can have a devastating effect on those experiencing it. People who are homeless often face significant barriers when accessing public services, and those experiencing more visible and extreme forms of homelessness have often faced adverse childhood events, extreme social disadvantage, physical, emotional and sexual abuse, neglect, low self-esteem, poor physical and mental health, and much lower life expectancy compared to the general population. Problematic substance use is disproportionately high amongst people experiencing homelessness, with many using drugs and alcohol to deal with the stress of living on the street, to keep warm, or to block out memories of previous abuse or trauma. Drug overdose is a major cause of death for people experiencing street homelessness. Substance dependency can also create barriers to successful transition to stable housing. There is ongoing policy interest in the effectiveness of different interventions that aim to stop, reduce or prevent problematic substance use, and there is specific interest in the relative effectiveness of interventions that adopt harm reduction or abstinence-based approaches.

Objectives

The objective of this review is to understand the effectiveness of different substance use interventions. The review will consider the effectiveness of harm reduction-based interventions, and abstinence-based interventions, for adults experiencing homelessness. The focus of the review is on high-income countries.

Search Methods

The primary source of studies for potential inclusion in this review is the Homelessness Effectiveness Studies Evidence and Gaps Maps (EGM). The first of these was published in 2018, with updates published in 2019 and 2020. A further update is due to be published in the summer of 2022. It is this update that provides the final list of studies from which this review will draw. The search for this update (EGM 4th edition) was completed in September 2021. Other potential studies will be identified through a call for grey evidence and hand-searching key journals.

Selection Criteria

Eligible studies will be impact evaluations with designs at levels, 3, 4 and 5 of the Maryland Scientific Methods scale. This therefore includes all studies categorised as either 'Randomised Controlled Trials' or 'nonexperimental designs with a comparison group' from the studies which form the basis of the Homelessness Effectiveness Studies Evidence and Gap Maps (EGM) created by CHI and the Campbell Collaboration. We are interested in studies that examine the effect of interventions on substance use outcomes. Studies to be excluded are those with designs at levels 1 and 2 of the Maryland Scientific Methods scale, for example, studies without a control or comparison group, 'before vs. after' designs (without an untreated comparison group), and cross-sectional regressions.

Data Collection and Analysis

Descriptive characteristics and statistical information in included studies will be coded and checked by at least two members of the review team. Studies selected for the review will be assessed for confidence in the findings using a critical appraisal tool for determining confidence in primary studies. Standardised effect sizes will be calculated and, if a study does not provide sufficient raw data for the calculation of an effect size, we will attempt to contact the author(s) to obtain this data. We will aim to use random-effects meta-analysis and robust-variance estimation procedures to synthesise effect sizes. If a study includes multiple effects, we will carry out a critical assessment to determine (even if only theoretically) whether the effects are likely to be dependent. Where we suspect dependent effects, we will determine whether we can account for these by robust variance estimation. We will explore the moderating influence of participant and study characteristics, such as gender, race, substances targeted and length of follow-up. Where effect sizes are converted from a binary to continuous measure (or vice versa), we will undertake a sensitivity analysis to investigate the effect of the inclusion of studies with a converted effect size in the meta-analysis by running an additional analysis with these studies omitted. We will also assess the sensitivity of results to inclusion of non-randomised studies and studies classified as low confidence in findings. All analyses will include an assessment of statistical heterogeneity. Finally, we will undertake analysis to assess whether publication bias is likely to be a factor in our findings.

Holding 'new recovery' together: Organising relations and forms of coordination in professional sociomaterial practices of addiction recovery

Questions about what addiction recovery is and the mechanisms by which people 'recover' have long animated alcohol and other drug research and policy. These debates became even more intense following the advent, and increasing influence in some quarters, of the 'new recovery'. Starting from the position that recovery is ontologically multiple (Mol & Law, 2002), we trace how alcohol and other drug professionals attempted to make sense of 'new recovery' as a concept and set of professional practices during a period of Australian drug treatment system reform. Drawing on Annemarie Mol's (2002) account of organising relations and forms of coordination (addition, translation and distribution), we explore how the new recovery was enacted and coordinated in alcohol and other drug professionals' sociomaterial practices, and highlight the ontological work involved in holding such an unstable object together. First, we argue that the addition of multiple enactments of addiction and recovery contributed to the formation of a singular and serviceable problem (that was simultaneously heterogeneous and complex), making the 'disease-to-be-treated' amenable to diverse treatment approaches, including new recovery. Second, we analyse the role of metaphor in translating authoritative logics and obligations into an enactment of new recovery suitable for application in clinical settings. Lastly, we track how incompatible enactments of recovery, both new and old, were kept apart through distribution. Although new recovery ultimately failed to gain policy traction in the Australian context, we focus on the ontological work undertaken by professionals in response to its introduction as such case studies can be useful for analysing other powerfully governing policy objects and their operations.

Ontological journeys: The lifeworld of opium across the Afghan-Iranian border in/out of the pharmacy

How can we conceive alternative policy models that embrace the empirical potentialities emerging from the lifeworld of drugs? The article reflects on this question, concluding that to reassess and to reinvent current policies on drugs, we need to think with a political ontology. Incidentally, the article also responds to the critique dismissing ontological inquiries as obstructing - or, at best, not informing - alternative drug policies. In an archaeological approach inspired by the work of Giorgio Agamben, the article unearths the case study of opium maintenance programme in Iran (1969-79), a forgotten policy experiment in an understudied and yet crucial geo-cultural environment for the global study of drugs. Mobilising the conceptual framework of ontological journeys, the article recomposes the lifeworld of opium within the horizons of transformative cultural practices, international borders, policy regimes and public ethics. Here, the materiality of drug consumption under the maintenance policy links with the changes in opium's transnational political economy and with shifting regimes of health and bioethical orthodoxy. Ontological journeys, hence, develop in a fluid space and time, making it possible to illuminate the lifeworld of drugs in places and times hitherto deserted by global policy studies. In building theoretical reflections upon a non-Western case, the article also incites the possibility of theory beyond Eurocentric knowledge and Euromerican cases. In this way, the article's purpose is to analyse the be-coming of opium beyond 'good' or 'evil', as a 'medicine' or a 'drug' and its real or perceived classification as 'licit' or 'illicit' across the Afghan-Iranian border. In conclusion, the article reflects upon the significance of this forgotten policy experiment, understood as an ontological journey, for contemporary drug policy and drug studies, but also for reinventing notions of care, welfare and health.

WITHDRAWN: A Geology of Drug Morals

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