International Journal of Drug Policy - 2014

Volume 25 Issue 3 May 2014

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Page 142 of 153

C. Strike et al. / International Journal of Drug Policy 25 (2014) 640–649 643 Fig. 1. Photo of bench taken by participant through a haze of smoke. use interview/discussion transcripts alone to answer the research questions. We used 'situational analysis' described by Clarke (2005) to locate our empirical findings in relation to Foucault's theoretical writings. Using situational analysis, we explored the data to iden- tify all human and non-human elements of concern in the situation. Of the data we asked: "What and who are in this situation? Who and what matters in this situation? What elements make a difference?" (Clarke, 2005, p. 561). Within the larger project we conceptually 'mapped' the discourses and debates that matter in this situation. Using this method, situational analysis allows for a theoretically informed analysis of the governing effects of the medical apparatus (including various discourses about health, addiction, and regula- tory policies) but with an attention to the relational, embodied, and spatial aspects of drug use which produce conflict and discon- tinuities in a hospital setting. We used the theoretical literature to sensitise us to potential patterns in the data. Next we used memoing techniques to analyze linkages and relations between the elements within the situational analyses. Analyses centre on moments in our data when the relational dynamics between space, place, actors (patients, clinicians, and staff) and objects (benches, mobility devices, and drugs) simultaneously affirms and negates the need for harm reduction in a hospital. Results Our results are presented with an attention to the ways a par- ticular context is created through the contestation of space and place and the discordance between harm reduction and hospi- tal regulatory policy. Central to shaping notions of whether Casey House Hospital is a "safe place" and for whom, are the relation- ship between using and non-using clients, clients higher and lower on the drug hierarchy, and interactions with clinicians. As clini- cal space becomes place for one group, place is reduced to space for another who no longer feel safe. Rather than de-stigmatising drug use at Casey House Hospital, the adoption of the harm reduction policy sparked inter-client conflict, reproduced domi- nant discourses about health and drug users, and highlights the challenges of sharing space when drug use is involved. Casey House Hospital as a drug using space For those familiar with problematic drug use, positioning hos- pital settings as spaces where people use illicit substances may not seem as jarring as when presented to those who are unfamiliar with illicit substance use. People with highly problematic drug use patterns, including physical dependence, will desire to, and do, use in these settings (Rachlis, Kerr, Montaner, & Wood, 2009). However, as set out above, these same people are likely to be ill-treated when accessing care. Casey House Hospital set itself the goal of changing this experience for their clients by introducing a harm reduction policy. The harm reduction policy recognises that: . . .clients served may present with substance use and mental health issues and behaviours. It is recognized that these issues and behaviours have both biological and psycho-social com- ponents. In partnership with the client, the interdisciplinary team will establish a set of goals that reflects desired substance use and mental health outcomes within the broader context of HIV/AIDS care (Casey House, 2008, p. 5) While "using, sharing, trading and dealing illicit/illegal drugs on the premises at Casey House Hospital is prohibited" the organisa- tion remains committed to "utiliz[ing] a range of practical strategies which are relevant to harm reduction, including: motivational interviewing, application of trans-theoretical model of change, counseling, relapse prevention, education to maximize safety for clients, staff and environments of care, needle exchange, distri- bution of condom packages, methadone bridging therapy, opiate replacement therapy, smoking (nicotine) reduction and connect clients to community programs that offer distribution of safer crack kits, needle exchange and narcan kits." Overall, the approach espoused is holistic and inclusive, and attempts to recognise the roles and respective needs of all stakeholders: clients, clinicians, management and volunteers. Participants described how the harm reduction policy made it an acceptable place to discuss drug use openly at Casey House Hospital. In describing a past experience of leaving Casey House Hospital "AWOL" to use a combination of "uppers, downers, side- ways," for a special occasion this participant described the shame he experienced when returning to Casey House Hospital, but: People were using substances and they were pretending they weren't using. Or if you've used, you felt bad about coming back to Casey House Hospital because you were inebriated. And what they did is they opened the door and they acknowledged the fact that you had used. . . [Casey House Hospital is] giving us the opportunities to be open and not pretend that we're not using. He explained the policy started informally to allow that after using: You were to go to your room and close the door, not interact with anyone else until you felt safe or until other people felt safe. So they, that's how it originally started in my mind and recollection. Because then before, if you were hiding, you didn't want to come into the house. In a very notable way, the harm reduction policy changed the practice of disclosure and opportunities for a dialogue between clinicians and clients were opened. In doing so, the framing of substance use within the organisation changed. Clinicians could now discuss substance use in relation to specific medical (e.g., drug interactions) and personal (e.g., preparing for discharge) needs. Elsewhere, making drug use visible through such interventions as safe injection sites has been critiqued as a strategy for governing drug use by imposing conceptions of order and proper citizenship (Fischer et al., 2004). However, as we discuss below, the shift to more open discussions of substance use at Casey House Hospital produced the opposite effect, introducing an element of disruption and disorder.

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