School of Public Health, University of Alberta, Canada.
School of Nursing and Centre for Addictions Research of BC, University of Victoria, Canada.
Int J Drug Policy. 2017 Jul;45:9-17. doi: 10.1016/j.drugpo.2017.03.014. Epub 2017 Apr 25.
Access to harm reduction interventions among substance users across Canada is highly variable, and largely within the policy jurisdiction of the provinces and territories. This study systematically described variation in policy frameworks guiding harm reduction services among Canadian provinces and territories as part of the first national multimethod case study of harm reduction policy.
Systematic and purposive searches identified publicly-accessible policy texts guiding planning and organization of one or more of seven targeted harm reduction services: needle distribution, naloxone, supervised injection/consumption, low-threshold opioid substitution (or maintenance) treatment, buprenorphine/naloxone (suboxone), drug checking, and safer inhalation kits. A corpus of 101 documents written or commissioned by provincial/territorial governments or their regional health authorities from 2000 to 2015 were identified and verified for relevance by a National Reference Committee. Texts were content analyzed using an a priori governance framework assessing managerial roles and functions, structures, interventions endorsed, client characteristics, and environmental variables.
Nationally, few (12%) of the documents were written to expressly guide harm reduction services or resources as their primary named purpose; most documents included harm reduction as a component of broader addiction and/or mental health strategies (43%) or blood-borne pathogen strategies (43%). Most documents (72%) identified roles and responsibilities of health service providers, but fewer declared how services would be funded (56%), specified a policy timeline (38%), referenced supporting legislation (26%), or received endorsement from elected members of government (16%). Nonspecific references to 'harm reduction' appeared an average of 12.8 times per document-far more frequently than references to specific harm reduction interventions (needle distribution=4.6 times/document; supervised injection service=1.4 times/document). Low-threshold opioid substitution, safer inhalation kits, drug checking, and buprenorphine/naloxone were virtually unmentioned. Two cases (Quebec and BC) produced about half of all policy documents, while 6 cases - covering parts of Atlantic and Northern Canada - each produced three or fewer.
Canada exhibited wide regional variation in policies guiding the planning and organization of Canadian harm reduction services, with some areas of the country producing few or no policies. Despite a wealth of effectiveness and health economic research demonstrating the value of specific harm reduction interventions, policies guiding Canada from 2000 to 2015 did not stake out harm reduction interventions as a distinct, legitimate health service domain.
加拿大各地的物质使用者获得减少伤害干预措施的机会差异很大，而且主要在各省和地区的政策管辖范围内。本研究系统地描述了加拿大各省和地区指导减少伤害服务的政策框架的变化，这是首次对减少伤害政策进行全国多方法案例研究的一部分。
系统和有针对性的搜索确定了可公开获取的政策文本，这些文本指导着一项或多项有针对性的减少伤害服务的规划和组织：针具分发、纳洛酮、监督注射/消费、低门槛阿片类物质替代（或维持）治疗、丁丙诺啡/纳洛酮（丁丙诺啡）、药物检测和更安全的吸入套件。从 2000 年到 2015 年，国家参考委员会通过省级/地区政府或其区域卫生当局编写或委托编写的 101 份文件被确定并经核实具有相关性。使用预先确定的治理框架对文本进行内容分析，该框架评估管理角色和职能、结构、认可的干预措施、客户特征和环境变量。
在全国范围内，只有少数（12%）文件明确将指导减少伤害服务或资源作为其主要目的；大多数文件将减少伤害作为更广泛的成瘾和/或心理健康战略（43%）或血源性病原体战略（43%）的一部分。大多数文件（72%）确定了卫生服务提供者的角色和责任，但较少的文件规定了服务将如何供资（56%）、指定政策时间表（38%）、参考支持立法（26%）或得到政府当选成员的认可（16%）。非特定的“减少伤害”引用在每份文件中平均出现 12.8 次-远远超过对特定减少伤害干预措施的引用（针具分发=每份文件 4.6 次；监督注射服务=每份文件 1.4 次）。低门槛阿片类物质替代、更安全的吸入套件、药物检测和丁丙诺啡/纳洛酮几乎没有提及。两个案例（魁北克和不列颠哥伦比亚省）产生了大约一半的所有政策文件，而 6 个案例-涵盖了大西洋和加拿大北部的部分地区-每个案例都产生了三个或更少的政策文件。
加拿大在指导加拿大减少伤害服务规划和组织的政策方面表现出广泛的区域差异，该国的一些地区制定的政策很少或根本没有。尽管有大量的有效性和健康经济学研究证明了特定减少伤害干预措施的价值，但从 2000 年到 2015 年指导加拿大的政策并没有将减少伤害干预措施作为一个独特的、合法的卫生服务领域。
