International Journal of Drug Policy - 2014

Volume 25 Issue 3 May 2014

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Page 145 of 153

646 C. Strike et al. / International Journal of Drug Policy 25 (2014) 640–649 Hospital regulations and risk Casey House Hospital is subject to the Ontario Public Hos- pitals Act (Government of Ontario, R.S.O., 1990, Chapter P.40) and despite its harm reduction policy cannot permit smoking of tobacco, marijuana or other substances within the house. Unlike managed alcohol programs or supervised consumption facilities, clients wishing to consume substances that were not prescribed to them and/or to smoke any substance, including those prescribed (e.g., medical marijuana) were required to do so off site. While a hospital admission may have reduced the harms from untreated medical problems, for active drug using clients, an inpatient stay, interrupted drug use practices and created new spaces for danger for those previously unaccustomed to using outdoors. However, for those who had previously used drugs outdoors, the hospital admis- sion did not alter this pattern, and reproduced outdoor drug using risks. This participant reflected on the difficulties of using when he was not feeling well and a time before regulations governing indoor tobacco smoking came into force: To use your marijuana. . . you have to go outside. That's the challenge. . . If I'm really nauseous in the middle of the night. . . there's no where I can go in the house. . . although, I was here at a time when there was a smoke room downstairs. This excerpt reflects the informal acceptance of marijuana smoking before tobacco control regulations led to the prohibition of indoor tobacco smoking, the closure of indoor smoking rooms and forced all smokers outdoors. These next participants offered descriptions of becoming targets of harassment, exploitation, and violence. Also, these descriptions and the photo in Fig. 1 highlighted the production of hierarchies of users with some perhaps more entitled to use in safe places than others: Like I'd be sitting on the bench, people are coming in to buy crack next door, or here even. . . they look at you a little different right? You'd be the prey. *** And behind here is the building right here, where everybody goes and they're all screwed up on crystal and crack and every- thing in there too. So, it's a very shifty place to be sitting with these people behind you at night, when you're smoking a joint. *** Because there was a guy in the wheelchair smoking crack out front all the time, and people were taking his money to go get it and they wouldn't come back. So they were robbing him. They'd come by here to rob 'the idiot' in the chair. Right? Poor guy, he could have got hurt at one of those times. . . but it is kind of dangerous if you're sick and you can't defend yourself. Our results have been bracketed with a discussion of Casey House Hospital as a drug using space at the beginning and as a non-drug using space at the end, with different relationships to place throughout. In our discussion we try to make sense of this duality and the opportunities and challenges that emerge within this shifting context. Discussion Important critiques have been levied against harm reduction claiming that while it is certainly preferable to current drug poli- cies, it nevertheless promotes techniques for governing drug users (P. Miller, 2001). We appreciate that harm reduction interven- tions, can and do, serve to discipline drug users and make them more docile and governable (Bourgois, 2000). However, at Casey House Hospital the power exerted through such programming and interventions was regularly challenged to produce a constant nego- tiation and boundary pushing between clients, and between clients and clinicians and staff. Our analyses surfaced how the imple- mentation of harm reduction is shaped by space and contested understanding of place and health. In particular, the organisation of space, bodies and practices creates and recreates both safer and more dangerous places to be ill for people who use and do not use drugs. At Casey House Hospital this resulted in partic- ular ways of being for drug 'users/non-user' (with related codes and practices), and the demarcation of space in and around the facility. These constraints posed barriers to effectively addressing the needs of drug-users and caused tension between users and non-users who are temporarily housed together to receive medical care. While investigation and exploration of harm reduction in hos- pitals is generally lacking within the literature, the few examples that do exist tend not to consider the struggles over space within these settings. At Casey House Hospital the introduction of a harm reduction policy brought drug use to the forefront and enabled more open discussions of drug use and reduced the shame expe- rienced by some clients. However, the introduction of the policy combined with the proximity of diverse patients within this small setting led to interpersonal conflict between supposed users and non-users, which for some made it an inhospitable environment. While we agree with Lianping and Kerr (2013) that hospitals have a role to play in harm reduction, including through the integration of safe consumption rooms, there needs to be a broader discus- sion about what to do beyond preventing drug users from leaving against medical advice. Setting up a formal consumption site, or even allowing the informal use of a bench behind a building, has broader effects when people who use drugs have extended hospital stays. Our analyses highlight what can transpire when people who use drugs are encouraged to stay but their use brings them into con- flict with other clients. Specifically, we observed the ways in which space and place are not neutral but become highly politicised and contested within a hospital setting where 'people should be get- ting better.' Despite organisational support for the harm reduction policy, clients, including current and former users, took issue with the encroachment of other 'disruptive' and openly using clients in the facility. This created a situation in which marginalised individ- uals started engaging in a dual process of governing themselves and others. This entailed demarcating certain spaces as safe and unsafe, certain people as users or non-users, and modifying their behaviour, including drug use patterns, to fit within the new culture or to resist it. A limitation of our study is the lack of perspectives from users who were more actively drug using–the clients who leave their beds empty for days at a time, who disrupt a movie night by chang- ing the channels, and who wander into other people's rooms in the middle of the night. These clients were not easily recruited but we would have liked to know more about their experience of re- entering the space after having to leave to use. How would they describe their interpersonal encounters and the way hospital regu- lations shape their substance using practices? Within the narratives of mostly self-described 'non-users,' we heard how hospital regu- lations limited spaces where drugs can be consumed and forced other clients to use in adjacent communal, outdoor spaces. This put some clients at personal risk and even exposed the organisation to unwelcome attention within the area it is located. Casey House Hospital represents a micro-risk environment comprised of physi- cal, social, economic, and policy related risks for drug users (Rhodes, 2009). This does not mean that harm reduction is not appropriate for hospital settings, but that introducing it within existing environ- ments may produce new risks and exasperate existing ones. Thus harm reduction in a hospital setting represents both an important

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