Elaine Hyshka

Turning failure into success: what does the case of Western Australia tell us about Canadian cannabis policy-making?

Cannabis policy in Canada is a puzzling affair. Since the 1960s and as recently as 2006, several policy windows have opened promising evidence-based cannabis law reform only to be slammed shut before achieving meaningful change. This ‘saga of promise, hesitation, and retreat’ has motivated Canadian cannabis researchers to investigate the reasons behind this policy inertia. These single-jurisdiction analyses have resulted in interesting yet necessarily tenuous findings. Fischers (1999) Policy Studies article suggests the need for an analysis of Canadian cannabis policy in comparative context and offers Australia as a point of departure. This article addresses this analytic task by examining two recent case studies in cannabis policy. Specifically, borrowing Kingdons (1995) concept of a policy window, it contrasts Canadas failure to decriminalise minor cannabis offences between 2001 and 2006 with Western Australias successful decriminalisation of cannabis possession and production for personal use between 2001 and 2004. In particular, it appears that a lack of support from law enforcement and cannabis users, conflicting evidence and risk associated with a lack of an evaluation plan all combined with a weakened electoral mandate for the government to contribute to a perception that cannabis decriminalisation was not politically feasible. Additional variables worthy of further inquiry are also discussed.

Applying a social determinants of health perspective to early adolescent cannabis use--an overview

Cannabis is the most widely used illicit drug in the world. Although the risk of problematic cannabis use is relatively low, the lifetime prevalence of dependence is greater than for all other illicit drugs. As such, the population burden of problematic cannabis use warrants attention. Many health and psychosocial risks associated with cannabis use are exacerbated or predicted by initiation of cannabis use in early adolescence and early adolescent users are more vulnerable to negative developmental outcomes, longer cannabis use trajectories, earlier transitions to heavier use and dependence. This suggests a need for effective prevention interventions targeting this age group. Unfortunately, most prevention efforts focus on individual-level risk factors and evidence indicates that they are not particularly effective for deterring use. This overview outlines a more effective approach for preventing cannabis-related harm. Using a social determinants of health perspective, it highlights peer networks and family structure and quality as the main risk factors associated with early adolescent cannabis use. This article suggests that interventions that targeting these determinants can be effective for preventing cannabis use. It concludes by suggesting complementary harm reduction programmes for older adolescents as a means to further reduce cannabis-related harm.

Consent and Coercion in Addiction Treatment

Publisher Summary This chapter discusses how people experiencing addictions are incapable of making treatment decisions, explaining how treatment provided under mandates is effective. Addiction treatment programs have traditionally adopted the view that clients are sufficiently impaired and concerned by their problems to seek help voluntarily. However, the case-mix has shifted over time, and mandatory treatment pathways are becoming increasingly entrenched in addiction treatment programs and policies around the world. Evidence indicates that at treatment entry, mandated clients often differ from self-referred clients with respect to age, problem severity, personal characteristics, criminality, employment, and motivation for treatment. It is incumbent upon advocates of mandated treatment to address whether treatment under legal, formal, and informal mandates is better than exposure to no treatment at all. Thus, policy makers and treatment providers must take into account the sizeable body of research that has accumulated documenting remission of addictive behaviors without treatment intervention. Additional research is needed to explore how neurocognitive impairments vary in relation to phenotypic heterogeneity with respect to context of drug use, addiction history, treatment history, and time. It will also be important to investigate the shift to a more process-oriented approach of competency assessment and evaluate what impact such an approach might have on the development of client–counselor rapport and client outcomes in treatment.

Implementing managed alcohol programs in hospital settings: A review of academic and grey literature: Managed alcohol programs in hospital

ISSUES People with severe alcohol use disorders are at increased risk of poor acute-care outcomes, in part due to difficulties maintaining abstinence from alcohol while hospitalised. Managed alcohol programs (MAP), which administer controlled doses of beverage alcohol to prevent withdrawal and stabilise drinking patterns, are one strategy for increasing adherence to treatment, and improving health outcomes for hospital inpatients with severe alcohol use disorders. APPROACH Minimal research has examined the implementation of MAPs in hospital settings. We conducted a scoping review to describe extant literature on MAPs in community settings, as well as the therapeutic provision of alcohol to hospital inpatients, to assess the feasibility of implementing formal MAPs in hospital settings and identify knowledge gaps requiring further study. Four academic and 10 grey literature databases were searched. Evidence was synthesised using quantitative and qualitative approaches. KEY FINDINGS Forty-two studies met review inclusion criteria. Twenty-eight examined the administration of alcohol to hospital inpatients, with most reporting positive outcomes related to prevention or treatment of alcohol withdrawal. Fourteen studies examined MAPs in the community and reported that they help stabilise drinking patterns, reduce alcohol-related harms and facilitate non-judgemental health and social care. IMPLICATIONS/CONCLUSIONS MAPs in the community have been well described and research has documented effective provision of alcohol in hospital settings for addressing withdrawal. Implementing MAPs as a harm reduction approach in hospital settings is potentially feasible. However, there remains a need to build off extant literature and develop and evaluate standardised MAP protocols tailored to acute-care settings.

Harm reduction in name, but not substance: a comparative analysis of current Canadian provincial and territorial policy frameworks

BackgroundIn Canada, funding, administration, and delivery of health services—including those targeting people who use drugs—are primarily the responsibility of the provinces and territories. Access to harm reduction services varies across jurisdictions, possibly reflecting differences in provincial and territorial policy commitments. We examined the quality of current provincial and territorial harm reduction policies in Canada, relative to how well official documents reflect internationally recognized principles and attributes of a harm reduction approach.MethodsWe employed an iterative search and screening process to generate a corpus of 54 provincial and territorial harm reduction policy documents that were current to the end of 2015. Documents were content-analyzed using a deductive coding framework comprised of 17 indicators that assessed the quality of policies relative to how well they described key population and program aspects of a harm reduction approach.ResultsOnly two jurisdictions had current provincial-level, stand-alone harm reduction policies; all other documents were focused on either substance use, addiction and/or mental health, or sexually transmitted and/or blood-borne infections. Policies rarely named specific harm reduction interventions and more frequently referred to generic harm reduction programs or services. Only one document met all 17 indicators. Very few documents acknowledged that stigma and discrimination are issues faced by people who use drugs, that not all substance use is problematic, or that people who use drugs are legitimate participants in policymaking. A minority of documents recognized that abstaining from substance use is not required to receive services. Just over a quarter addressed the risk of drug overdose, and even fewer acknowledged the need to apply harm reduction approaches to an array of drugs and modes of use.ConclusionsCurrent provincial and territorial policies offer few robust characterizations of harm reduction or go beyond rhetorical or generic support for the approach. By endorsing harm reduction in name, but not in substance, provincial and territorial policies may communicate to diverse stakeholders a general lack of support for key aspects of the approach, potentially challenging efforts to expand harm reduction services.

The role of consumer perspectives in estimating population need for substance use services: a scoping review

BackgroundA growing body of research assesses population need for substance use services. However, the extent to which survey research incorporates expert versus consumer perspectives on service need is unknown. We conducted a large, international review to (1) describe extant research on population need for substance use services, and the extent to which it incorporates expert and consumer perspectives on service need, (2) critically assess methodological and measurement approaches used to study consumer-defined need, and (3) examine the potential for existing research that prioritizes consumer perspectives to inform substance use service system planning.MethodsSystematic searches of seven databases identified 1930 peer-reviewed articles addressing population need for substance use services between January 1980 and May 2015. Empirical studies (n = 1887) were categorized according to source(s) of data used to derive population estimates of service need (administrative records, biological samples, qualitative data, and/or quantitative surveys). Quantitative survey studies (n = 1594) were categorized as to whether service need was assessed from an expert and/or consumer perspective; studies employing consumer-defined need measures (n = 217) received further in-depth quantitative coding to describe study designs and measurement strategies.ResultsAlmost all survey studies (96%; n = 1534) used diagnostically-oriented measures derived from an expert perspective to assess service need. Of the small number (14%, n = 217) of survey studies that assessed consumer’s perspectives, most (77%) measured perceived need for generic services (i.e. ‘treatment’), with fewer (42%) examining self-assessed barriers to service use, or informal help-seeking from family and friends (10%). Unstandardized measures were commonly used, and very little research was longitudinal or tested hypotheses. Only one study used a consumer-defined need measure to estimate required service system capacity.ConclusionsRhetorical calls for including consumer perspectives in substance use service system planning are belied by the empirical literature, which is dominated by expert-driven approaches to measuring population need. Studies addressing consumer-defined need for substance use services are conceptually underdeveloped, and exhibit methodological and measurement weaknesses. Further scholarship is needed to integrate multidisciplinary perspectives in this literature, and fully realize the promise of incorporating consumer perspectives into substance use service system planning.

Perceived unmet need and barriers to care amongst street-involved people who use illicit drugs.

INTRODUCTION AND AIMS Research on perceived unmet need for care for mental health and substance use problems focuses on general populations to the detriment of hidden populations. This study describes prevalence and correlates of perceived unmet need for care in a community-based sample of street-involved people who use illicit drugs and identifies barriers to care. DESIGN AND METHODS A sample of 320 street-involved people who use drugs participated in a structured, interviewer-assisted survey in Edmonton, Canada. The survey included the Perceived Need for Care Questionnaire, which assessed unmet need for care for mental health and substance use problems across seven service types. Logistic regression examined the associations between perceived unmet need, extent of socioeconomic marginalisation and problem severity. Barriers underlying unmet service needs were also examined. RESULTS Most (82%) participants reported unmet need for one or more services during the past year. Odds of reporting one or more unmet needs were elevated amongst participants reporting substantial housing instability (adjusted odds ratio = 2.37; 95% confidence interval 1.19-4.28) and amongst participants meeting criteria for drug dependence (adjusted odds ratio = 1.22; 95% confidence interval 1.03-1.50), even after adjustment for sociodemographic covariates. Structural, rather than motivational barriers were the most commonly reported reasons underlying unmet service needs. DISCUSSION AND CONCLUSION Street-involved people who use drugs experience very high rates of perceived unmet need for care for mental health and substance use problems. General population studies on perceived unmet need are insufficient for understanding needs and barriers to care in hidden populations.[Hyshka E, Anderson JT, Wild TC. Perceived unmet need and barriers to care amongst street-involved people who use illicit drugs. Drug Alcohol Rev 2017;36:295-304].