This thesis was undertaken to assess the characteristics of individuals who smoke crack cocaine and to examine the health-related risks and healthcare needs of this population. A literature review of 147 published articles was conducted to synthesize evidence regarding behaviours associated with crack use and to assess the risks of disease transmission through crack smoking behaviours. Qualitative interviews were subsequently conducted with thirty Ottawa residents who smoke crack to learn about their experiences with healthcare and harm reduction services. Results identified barriers related to accessing primary healthcare and drug treatment programming among people who smoke crack and gaps within existing harm reduction services. Individuals who smoke crack represent a marginalized population who are often missed through traditional health promotion and harm reduction programming. There is a need for increased coverage of current programming and a reduction of factors which currently hinder the delivery and effectiveness of crack-specific harm reduction programs.

The reduction of intentional exposure to ultraviolet (UV) radiation is an important area of skin cancer prevention. Hillhouse et al. (Cancer 113:3257-3266, 2008) have developed an appearance-focused intervention with evidence of efficacy in lowering indoor tanning UV exposure in young women. In the current study, a subgroup approach was used to determine moderators of intervention efficacy. Undergraduate females in two regions of the United States (n = 362) were randomized into an intervention or control condition. Latent profile analysis was used to identify subgroups of indoor tanners based on patterns of indoor tanning motives. Intervention efficacy was examined within each subgroup. We found evidence for 4 subgroups of tanners: knowledgeable-appearance tanners, low-knowledge tanners, low-knowledge, relaxation tanners, and knowledgeable, low-appearance and lowrelaxation tanners. The intervention significantly reduced indoor tanning for the low-knowledge subgroup (34% of the sample). The utility of the subgroup approach in developing targeted behavioral skin cancer interventions is discussed.

Background: One approach to increasing the reach of syringe programs in rural areas could be through provision of syringes at community pharmacies. This study evaluated relationships between state-specific syringe policies, pharmacy, and pharmacist characteristics and pharmacists’ nonprescription syringe dispensing behaviors in a 3- state Appalachian region at high risk for HIV and HCV transmission. Methods: We conducted a telephone census of community pharmacies in the Appalachian counties of North Carolina, Tennessee, and Virginia from April–June 2018. Behaviors studied included having ever sold syringes without a prescription, quantity of individuals to whom nonprescription syringes were dispensed in the past 30 days, having ever denied a request for nonprescription syringes, and past 30-day denial of nonprescription syringe requests. Behavioral intention and perceptions of legality were elicited. Results: A response rate of 52.3 % was achieved (N = 391). North Carolina pharmacists reported increased past 30-day dispensing, less denial of nonprescription syringe requests, and decreased justification for syringe dispensing (proof of medical need) as compared to Tennessee and Virginia pharmacists. Behavioral intention to dispense did not vary by state but did vary by political affiliation. Perceptions of syringe dispensing legality in NC were significantly different from those in TN and VA. Conclusions: Significant differences in pharmacists’ perceptions and behaviors were noted across state lines with North Carolina pharmacists reporting more engagement in syringe dispensing as compared to pharmacists in Tennessee and Virginia. Policy allowing pharmacists to dispense syringes to people who inject drugs appears to foster some but not all pharmacist engagement in this harm reduction intervention.

In February 2017, Tanzanian President John Magufuli publicly declared a war on drugs, an unexpected change in policy in a country previously leading the way in harm reduction in Sub-Saharan Africa. The war on drugs, a set of policies aimed at reducing drug supply and use through the punishment, forced treatment and criminalization of drug users, is a part of Magufuli’s strategy to ‘clean up’ Tanzanian society. Prior to his election, the Tanzanian government largely ignored treatment and drug policy, and foreign NGOs, in partnership with local activists, funded and implemented harm reduction interventions. This thesis seeks to understand a puzzling reversal from harm reduction to repression, posing the questions: 1) How did the Tanzanian government implement a war on drugs that went against the goals of a number of powerful foreign actors funding services for drug users? 2) What have been the outcomes for drug users in Tanzania as a result of the drug policies and programming implemented since the election of Magufuli? 3) How does Tanzania’s war on drugs shape international and domestic approaches to drug use and drug policy in the country? In the fall of 2018, I interviewed foreign and local NGO workers, officials from major international organizations and former drug users and activists in Dar es Salaam, Tanzania. Using interviews and observations during this fieldwork, I explore the realities on the ground underlying both the drug policy changes towards drug users implemented over 2016/17, and the more public crackdown on drug use in 2017. I rely on a constructivist methodology to challenge and interrogate the narratives being produced by the Tanzanian government, which echoed harsh, war on drugs ideology but also boasted about comprehensive harm reduction programming, a contradictory position I also explore in this thesis. In answer to my first research question, I argue that the Tanzanian government evaded donor pressure or interference in pursuing an anti-drug user agenda through strategies of appeasement, intimidation and the exploitation of a neglected policy area. The Tanzanian government touted its harm reduction program at the international level to produce a narrative of continued support for drug users, appeasing donors and foreign agencies while, in reality, narrowing the scope of treatment to the detriment of people who use drugs. The government also used intimidation tactics, threatening the work of foreign NGOs working with vulnerable population, which chose to stay and provide limited services rather than risk being kicked out of the country. The Tanzanian government, with limited resources, took advantage of donors’ focus on HIV/AIDS and lack of commitment to drug users, to maneuver and achieve a repressive policy agenda without interference. I build on this argument using the evidence I gathered during fieldwork to answer to my second research question. I argue that the outcomes of the Tanzanian drug war agenda were increased police harassment, higher drug prices and fear of punishment among drug users which led to riskier drug use, greater difficulty in accessing services and greater economic vulnerability. Drug users had to go farther, spend more money on drugs and face harassment as they tried to avoid dopesickness. Policy changes resulted in the closure of harm reduction centres frequented by drug users, limited access to needle exchange and limited the outreach efforts of local and international NGOs, making life much more difficult for people who use drugs. During my research, I found that, contrary to some of the literature I read which posited the war on drugs as a Western strategy of political control, the Tanzanian government was actually producing war on drugs narratives, and using these narratives to justify its repressive policies. This finding supports the answer to my third research question. I argue that the Tanzanian government produced narratives of drugs hindering development, causing corruption and threatening national unity. I also argue that donors such as the United Kingdom, and foreign agencies working in HIV/AIDS, are reproducing these narratives and are following an agenda, set by the Tanzanian government, that does not meet the needs of drug users and supports the centralization and repression of the Magufuli regime. Foreign agencies shifted from supporting drug users, to instead following an agenda that does not meet their goals in reaching drug users. Donors did not notice or prioritize the increased abuse of drug users’ human rights at all, accepting the provision of methadone as evidence of support for drug users and continuing to provide general budget support to the Tanzanian government and even providing specific funding to limit drug supply in the country. The effectiveness of Tanzania producing such narratives, and enacting the repressive policies war on drugs narratives justify, reveals global antipathy towards actually supporting people who use drugs and advancing the rights of people who use drugs. In upholding old war on drugs narratives and implementing policies that attack people who use drugs, Tanzania is contributing to an international consensus that the war on drugs is justified as long as basic treatment is provided. This thesis, using the voices of activists and advocates on the ground, deconstructs the Tanzanian war on drugs. I argue for the inclusion of those with lived experiences in shaping and changing the repressive drug policies and epistemologies that are being produced by the Tanzanian state and are being accepted by the international community.

Fatal opioid overdoses in Massachusetts, U.S.A. increased by 311% from 2000 to 2019 and claim the lives of nearly 2,000 residents every year. Research suggests that the public is growing critical of traditional punitive approaches to opioid use disorder. In this study, a political feasibility study of passing non-arrest policies for opioid addiction was conducted. Semi-structured interviews with 32 experts from law enforcement, program administration, addiction treatment, policymaking, and policy advocacy were completed. The political feasibility of three policy proposals across six criteria (effect, relevance, support, opposition, enabling factors, and inhibiting factors) was examined. Media and document review augmented and affirmed interview data. Study participants reported a growth in the number of opioid-addicted young adult White residents and a concomitant shift in increased public support for treatment over incarceration. Data suggest that communities of color are disproportionately impacted by limited access to treatment. Study participants caution that strained relationships between people of color and the police could impede the positive effects of non-arrest programs among diverse populations. Results suggest that it may be politically feasible to scale non-arrest programs, but that it is not currently feasible to pass policies that decriminalize drugs or prohibit judges from requiring individuals to remain drug-free as a condition of probation. To ensure that policies benefit diverse populations, lawmakers must invest in treatment programs and pass legislation that accounts for the different relationships that Black and Hispanic residents have with the police. / 2022-09-26T00:00:00Z

Drug overdose death rates in the United States have more than tripled since 1990 with more than 36,000 dying in 2008. In 2007 the estimated cost of drug use to U.S. society due to lost productivity, increased health care, and criminal justice costs was over $193 billion. Previous researchers have found that harm reduction is a viable treatment option within the field of addiction. The guiding premise in the harm reduction approach is that all people can achieve improved psychological and physiological health even if they are unable to be substance-free. However, there remains an important gap in the current literature regarding factors that may influence substance abuse counselors' use of the harm reduction model. Specific individual counselor independent variables (recovery status, education level, age, length of time in the field, and understanding of substance abuse conceptualizations) may play a role in counselors' acceptance of the harm reduction approach as a viable treatment for substance abuse. Therefore, the purpose of this quantitative study was to investigate which variables played a role in counselors' acceptance of the harm reduction model. This research sampled 100 professional substance abuse counselors selected from the American Counseling Association (ACA) database. Multiple regression analyses were utilized to examine study research questions. Findings of this study indicated that disease and eclectic orientation conceptualizations were significant predictors of harm reduction acceptance, suggesting training targets for increasing acceptance of the harm reduction model among counselors. This is an important contribution to the existing literature and enhances social change initiatives by expanding the use of effective substance abuse treatment options.

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This paper explores the discourse surrounding the introduction of supervised injection facilities (SIF) in New York City following their recent introduction in November 2021.  The contemporary debate surrounding SIF in New York is more diverse than may be assumed, even within a seemingly liberal city in the United States, as there are many competing perspectives which make broad categorizations of the discourse difficult. Nevertheless, supporters of SIF have continued to emphasize the efficacy of this program and its potential to prevent overdoses in a largely uniform manner.  In contrast, critics of SIF in NYC have demonstrated a multiplicity of oppositional narratives, which take the forms of traditional abstinence perspectives, localism/not in my backyard rhetoric, law and order beliefs, and social justice evaluations that question the equality of such programs. Nearly all sentiments regarding SIF are founded in the individual perceptions of addiction, specifically whether the individual views it as a disease or a moral failing.        The United States is slowly continuing to adopt more dynamic approaches to substance abuse and move away from the punitive policies established through the War on Drugs strategies advanced throughout the previous decade.  This pilot program can be viewed as a continuation of existing harm reduction policies such as syringe exchange programs.  While the introduction of SIF signifies a substantial evolution of the existing harm reduction policies and provides the basis for national expansion of the program, the current socio-political environment does not prove conducive to its evolution.  Overall, this study explores the diverse range of narratives surrounding SIF, their informing ideology, and attempts to situate these opinions within their broader sociological and historical backgrounds, providing the basis for further research regarding this subject.

Opioid overdose deaths in the United States have been steadily increasing for decades. Initially, these deaths were driven by overdoses from prescription opioids. Strict limits were placed on opioid prescriptions to decrease the supply of available opioids. Instead, this prompted a shift toward the illicit opioid market, causing an increase in heroin-related overdoses. Fentanyl, a synthetic opioid that is more potent than heroin, has become commonplace in the illicit supply of opioids. The illicit opioid market is unregulated and unpredictable, and there is no way to know exactly what is in a bag sold as heroin or “dope”. Illicit drug use has been historically dealt with as a crime rather than a public health issue in the United States. Recently, harm reduction has been offered as an alternative to this punitive approach. Harm reduction is a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Naloxone distribution and syringe service programs are examples of currently utilized harm reduction strategies in the United States. While these programs are necessary to improve the quality of life of people who use illicit drugs, the rates of death from overdose are continuing to increase. These strategies do not protect people from the toxic and unpredictable drug supply. Safe supply is a relatively new concept, but there have been some small-scale implementations of this practice in Canada. Safe supply refers to a legal and regulated supply of drugs with mind and body-altering properties that traditionally have been accessible only through the illicit drug market. This is a necessary strategy to combat the alarming rise in overdose mortality. In this paper, I will analyze the ethics of this strategy using a principalism approach. This analysis concludes that safe supply is ethically sound, and it should be a part of our approach to the overdose epidemic. Safe supply promotes autonomy, prevents harms, advances well-being, and upholds justice for people who use drugs. / Urban Bioethics

Introduction: The entire United States has felt the effects of the overdose epidemic, but rural Appalachia has experienced disproportionate overdose deaths. This variation in overdose mortality can be attributed to the risk environment for overdose in rural Appalachia. Overdose prevention behaviors are individual level behaviors that people who inject drugs can implement that may have the potential to reduce their risk of overdose, however limited research exists regarding the utilization of those behaviors. It is important to consider how the risk environment can influence the utilization of overdose prevention behaviors among people who inject drugs. Therefore, the purpose of this research was to identify overdose prevention behaviors among people who inject drugs in rural Appalachia and better understand the relationship between those behaviors and the rural risk environment for overdose. Methods: This research was conducted using a mixed methods approach, including a scoping review, qualitative, and quantitative study. A scoping review was used to identify overdose prevention strategies and behaviors in rural America. Semi-structured interviews were used to identify overdose prevention behaviors among people who inject drugs in rural Appalachia. A quantitative survey was used to examine the relationship between risk environment determinants and overdose prevention behaviors utilization among people who inject drugs in rural Appalachia. Results: Results of primary data collection showed that people who inject drugs in rural Appalachia do utilize overdose prevention behaviors, including several drug checking methods and safe use behaviors. However, environmental barriers and disparities among people who inject drugs in rural Appalachia were highlighted in this research. Potential relationships exist between environmental determinants and the utilization of some overdose prevention behaviors. Conclusion: This research found the need for several policy and community program implications which all stem from the War on Drugs. Results highlighted the need for systems level change regarding the care for people who inject drugs, which includes the necessity for policy makers to consider harm reduction methods to reduce overdose mortality among people who live in rural Appalachia.