March 2014 – Matters of Substance

So, what does the small print at the bottom of your rental agreement say? What if it specified that you could not use alcohol or any substances as a condition of renting? Would you sign anyway, knowing there are not a lot of places you can afford to rent? Maybe that doesn’t matter because you don’t use drugs and alcohol at all, not even a drink now and then. But what if you have friends over — could they have a beer or glass of wine? Very few of us are expected to be abstinent in the privacy of our own homes; rather, we are expected to pay our rent (or mortgage) and respect our neighbours.

We would guess that few rental agreements would have such fine print. However, it is common for social housing programs to only accept people if they are abstinent. While this was the norm for a long time, the Housing First policy is now challenging that thinking. Housing First supports housing as a right and promotes the provision of housing that does not require or expect abstinence. This policy combines the provision of housing with a philosophy of harm reduction. There is a lot of evidence to support harm reduction strategies. There is also considerable evidence that a harm reduction approach to housing (Housing First) is effective in helping people who have been homeless to maintain their housing, maintain supports and access services according to their needs without causing harm to others1.

What does this look like? In Seattle, at 1811 Eastlake, men who were previously homeless with severe alcohol dependency were provided with housing and allowed to drink in their rooms. People living in regular rental units may access harm reduction services in the community to reduce and prevent harms from alcohol or other drug use. For those in social housing complexes, harm reduction services might be provided onsite. For example, managed alcohol programs located in housing programs provide people who are dependent on alcohol with regulated doses of alcohol. (A MAP program evaluation report for Thunder Bay MAP can be found at www.carbc.ca). The Dr. Peter Centre in Vancouver provides harm reduction supplies, onsite supervised injection services and housing for people who are HIV positive.

What does a community need to move housing programs towards a Housing First model that incorporates harm reduction? First, there has to be an available and adequate supply of affordable housing; that is the foundation. Second, an important principle of harm reduction is to actively engage people who are affected by substance use and homelessness in planning housing programs. Third, the public, housing agencies and healthcare providers need to know about and have access to harm reduction education. Lastly, Housing First and other housing programs need clearly developed harm reduction policies so that everyone is clear on the organization’s approach.

So, does every housing program need to incorporate harm reduction? Probably not, but everyone has the right to live by the same rules. Most of us already live in housing where we decide whether or not we consume substances in our home. So why not grant everyone the same choices and rights? Housing First shows us it can be done without endangering the rights of others.

Authors: Dr. Bernie Pauly, CARBC Scientist and Associate Professor, School of Nursing; Dan Reist, CARBC Assistant Director, Knowledge Exchange; and Lynne Belle-Isle, CARBC Graduate Student.

1. Pauly, B., et al., Housing and harm reduction: What is the role of harm reduction in addressing homelessness? International Journal of Drug Policy, 2013. 24(4): p. 284-290.

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC

Calls for supervised consumption services (SCS) are gaining momentum and popularity. Here in Victoria, B.C., the YES2SCS campaign advocates for the establishment of supervised consumption services in the city within five years. SCS have been heralded for their ability to provide safer spaces for people to use drugs — spaces free from criminalization, stigmatization and violence.

In arguing for the benefits of SCS, proponents (myself included) seek to move conversations into the mainstream by focusing on the medicalized and supervised aspect of the service (clean and sanitary spaces with nurse supervision, access to detox and treatment, etc.). While these are meaningful and significant aspects of SCS, we tend to focus less on another crucial aspect of these services: peer support.

The value of peer leadership, peer support and peer-delivered services has been extensively documented. A report called Harm Reduction at Work summarizes the benefits and highlights best practices for hiring people who use drugs in harm-reduction services. The benefits include, but are in no way limited to:

Providing public-health information about safer use and harm-reduction supplies in a way that makes sense to people accessing the service
Providing insight to the organization to inform program design and delivery (e.g., drug use trends, what’s happening on the street, etc.)
Creating a trusting and culturally safe environment for those accessing services
Increasing the legitimacy of the hiring organization and sending a message to the community that the organization sees people who use drugs as knowledgeable and valuable
Contributing to self worth, feelings of accomplishment and participation of people who use drugs

In short, meaningful inclusion of people who use drugs in harm-reduction services is a win-win-win that benefits the people who use the service, the employing organization and the people with experiential knowledge who fill these roles.

People who use drugs have profoundly negative experiences accessing healthcare. Experiences of stigmatization, criminalization and violence in the healthcare system compound and impact all future interactions with healthcare workers. When a person accesses health services and realizes they are speaking with a person who has “been there; done that,” the power shift is evident and recognizable.

In my experience,* the presence of people who use drugs shifts the usual service provider/client power dynamic. It forces workers in an organization to speak differently about their “clients” and creates new norms and complicates the typical “us/them” dynamic. Workers without drug-use experience are privileged to learn how their practice may impact people who use the service. For instance, they can be immediately informed when they are not making sense or are practicing in a way that is inaccessible, paternalistic or just plain using incorrect information. Most importantly, it keeps things “real;” street reality is brought into the organization practice, encouraging a radical element in the organization with constant reminders that this work is about love, family, life and death.

Meaningful inclusion of people who have “been there; done that” is imperative to the success of SCS and harm-reduction services.

Author: Ashley Mollison, Graduate Student, Centre for Addictions Research of B.C.

* I write on this topic not as someone who identifies as a “peer,” a person who currently or formerly uses illicit drugs, but as someone who has seen peer support in action. I have witnessed the value of peer leadership and support in my work with Society of Living Illicit Drug Users (SOLID) and AIDS Vancouver Island. SOLID is a harm-reduction organization run by and for people who use(d) drugs and AVI has recently hired people specifically for their experiential knowledge of drug use, street and prison culture in their harm-reduction program.

**Please note that the material presented here does not necessarily imply endorsement or agreement by individuals at the Centre for Addictions Research of BC

Month: March 2014

Should We Ban Drinking at Home?

“Been There; Done That:” the Necessity of Embedding Peer Leadership and Support in Supervised Consumption and Harm-Reduction Services