This rapid response prepared by the Ontario HIV Treatment Network (OHTN) summarizes the available research evidence to inform the following two questions:
1. What are public perceptions and opinions of needle exchange programs, methadone clinics, supervised injection facilities/safe injection sites and other harm reduction interventions?
2. How can negative public perceptions of these interventions be addressed?
Key Take-Home Messages
Public opinion polls and surveys taken between 2003 and 2007 in Ontario, Quebec, British Columbia and nationwide in Canada, have found majority support for harm reduction programs, including heroin-assisted treatment (HAT) and supervised injection facilities (SIFs).
Positive public perception of harm reduction programs often involved an acknowledgement that drug addiction and drug-related issues, such as poverty, disease and crime, requires a pragmatic solution beyond drug enforcement and control.
Negative public perception was usually based on a concern that these programs condone and even promote illegal drug use, attract people who use drugs and bring violence into local communities of program sites, and would do nothing to re-integrate people who use drugs back into society.
There have been several studies and in-depth analyses on successful, and unsuccessful, experiences with addressing and changing negative public perceptions of harm reduction interventions.
Successful strategies often involved: public education about both the immediate goals (save lives and improve public amenity) and long-term goals (cessation of drug use and re-integration); eliciting endorsement from respected public figures and organizations; and remodeling the debate around illegal drug use to one based on morals and public health, rather than on drug policy and enforcement.
Unsuccessful strategies often appeared to be the result of insufficient knowledge transfer in and consultation with communities; negative portrayals and messaging in the media; and non-local and culturally insensitive approaches.
The Issue and Why It’s Important
There has been growing local and international support since the 1990s, particularly from the HIV/AIDS and medical community, for harm reduction programs as a pragmatic approach to minimize the harmful consequences of individual behaviours – even if these behaviours are deemed risky or illegal.(1;2)
Harm reduction interventions are important for preventing HIV and hepatitis B/C for people who use injection drugs because of the high incidence and prevalence rates in this population.(3-5)
According to a national addiction survey in 2006, it is estimated that there are over 4.1 million people in Canada who have injected drugs at some point in their lives, and nearly 270,000 people had reported using injection drugs that year.(6) In Ontario alone, there are approximately 41,000 people who use injection drugs who are at a higher risk of becoming infected with HIV or HCV, and of other drug-related morbidities and mortality, than the general population.
There is a growing body of evidence internationally, particularly in Western countries, confirming the successes of harm reduction interventions in reducing HIV and HCV transmissions, decreasing drug overdoses, increasing access to and enrolment in drug treatment programs, and minimizing public order issues, among others.(2;7-9) However, in order to scale up harm reduction interventions, there needs to be widespread support from the public that stems from a cultural change in attitudes towards drug addiction. Public opinions and perceptions of harm reduction interventions often have a significant impact on political will to establish and sustain these programs. For example, it has been suggested that the continued existence of InSite – prior to the 2011 Supreme Court decision – has largely been due to the measured support of British Columbians and Canadians.(10;11) In contrast, there have been incidences in the United States where public opposition has led to closure of existing needle exchange programs.(12;13)
Although there has been a growing number of needle exchange programs (NEPs) and methadone treatment clinics across Canada, the same has not occurred for SIFs, despite the positive outcomes of InSite in Vancouver, British Columbia, which is the only SIF in North America. The recent decision from the Supreme Court of Canada to allow InSite to continue operations under an exemption from the federal drug control legislation (14) has created an opportunity for the rest of Canada to follow suit. Thus, it is an opportune time to review public opinions in Canada and to develop strategies that could improve the negative perceptions of harm reduction strategies.
What We Found
We found 40 published studies, reviews and commentaries that explored public opinions and perceptions of harm reduction programs, and/or discussed experiences with strategies to change them.
Public opinion and perceptions
Most studies, polls, and surveys on public opinions and perceptions come from Canada, the U.S., the U.K., and Australia.(10;15-23) These surveys have predominantly found a clear majority supporting different harm reduction programs, ranging from NEPs and SIFs, to HAT and methadone clinics. Some repeated polls in the U.S. and Australia have shown a steady increase in support for these programs since the 1990s.(17;18;21)
A 2006 survey of 1,407 Canadians was completed for Canada’s Privy Council Office, commissioned by Prime Minster Stephen Harper’s senior staff, to gauge public support for InSite in Vancouver.
The results of the poll indicated that 56% of Canadians want more supervised injection sites to be created in Canada, and another 68% of Canadians support needle exchange. The support was strongest in British Columbia, where 70% of those polled support needle exchanges and 64% support additional safe injection programs.(10;11) Similar trends were found in separate polls conducted in Ontario and Quebec.(16;23) A recent report released from the Toronto and Ottawa Supervised Consumption Assessment Study (TOSCA) (24) found that 56% of more than 900 Ontarians surveyed in 2009 strongly agreed with the establishment of SIFs “if it can be shown that supervised injection facilities reduce neighbourhood problems related to injection drug use.” However, this slight majority support changed depending on the goal of establishing the SIFs: the proportion fell to 48% if the establishment was based on reducing overdose deaths or infectious disease among people who use drugs, or on increasing their contact with health and social workers; and fell even more to 31% if they were established to encourage safer drug use.
However, it has been shown that poll results can vary greatly depending on who commissioned the study, as well as on the wording and phrasing of the survey questions.(21) For example, a survey conducted in 1997 by the Human Rights Campaign, a gay and lesbian lobbying group, found 55% of those polled supported NEPs, yet, a poll conducted in the same year by the Family Research Council, a conservative lobbying group, found 62% opposition to NEPs.(25) Vernick et al.(21) systematically reviewed all reported U.S. national surveys on syringe exchange programs between 1987 and 2000, and found that support for NEPs ranged from 29% to 66% over this period of time. They found that word choices such as “drug addicts” would decrease support for NEPs, whereas the words “those addicted to illegal drugs” would increase support. They concluded that there is no consensus in the U.S. public regarding support for NEPs due to the malleable nature of public opinion, and that it would be impossible to assess support over time unless polls and surveys were consistent in language and conducted by independent organizations. However, the findings and conclusions from this review should be interpreted with caution given that the data is from more than 10 years ago and based on public perception from the United States where views may, on average, differ from those in Canada.
The literature suggests there are many possible factors contributing to support for harm reduction programs. Most notably, those with higher income and education, who view people who use drugs as ‘ill’ people, and who agree that people who use drugs need public support, are more likely to have positive opinions towards these interventions.(16)
In a more nuanced analysis of public opinion in Quebec, Dubé et al. (23) found that support for harm reduction programs primarily came from individuals who have values based in solidarity, equity, universality and social justice. They concluded that Quebec residents tended to perceive social questions and problems, such as injection drug use, in the broader context of the community and societal wellbeing, irrespective of the traditional prohibitionist attitudes towards illicit drugs.
There were common themes that emerged from analyses of negative opinions and perceptions of harm reduction interventions. The most predominant theme is the perceived immorality of providing harm reduction services to people who use drugs.(13;19;26-29) Common arguments from opponents tend to argue that these programs promote drug use, attract more people who use drugs, and destroy communities.(27;29-31) There is also the ‘not in my back yard’ phenomenon where people might support the idea of harm reduction interventions, as long as they are not in their communities.(31) Those with moderate opposition towards harm reduction may argue these programs do not address broader social issues that cause addiction or incorporate comprehensive strategies to end drug addiction and re-integrate people who use drugs into the community.(31;32) More extreme opponents have suggested that these programs are a continuation of oppression on those most vulnerable to drug addiction and an act of genocide.(29;32)
With respect to needle exchange programs, people have expressed concern over finding discarded needles in the streets.(32;33) However, many of these fears and concerns can be resolved through education and efforts to increase awareness, as support for harm reduction has consistently grown in communities where SIFs and NEPs have been established.(15;17;18)
Changing negative opinions and perceptions
Despite majority support for harm reduction interventions, it remains important to educate the public and address fears and concerns that could lead to opposition to scale-up efforts. Through the documented experiences in Vancouver, the U.S., Australia and some countries in U.K., there are several strategies that have succeeded in the past to change the public culture and grow support for harm reduction:
1. Make (injection) drug use a public problem – In order to gain public attention and support, the first step for many successful programs was to convince the public that there is a public health crisis (HIV/HCV transmission, prostitution and promiscuity) and a growing public problem (crime and violence, public drug use, dirty needles) stemming from injection and illegal drug use,(22;34) and that this problem requires an official public solution.(35)
2. Ensure the public that supporting harm reduction is not equal to condoning or promoting drug addiction – In many unsuccessful experiences, studies have noted that there was insufficient education and consultation in the communities where the programs were being established.(22;27;32;36) Particularly, the messaging wasn’t targeted to their concerns and fears, such as whether harm reduction programs promote and attract illegal drug use, or whether they help people who use drugs stop and re-integrate into society. It is also important that this process involves local figures that the communities trust.(32;36)
3. Elicit public endorsement from respected (local) people and groups – In one American survey, the endorsement of NEPs by the American Medical Association directly altered the poll results positively.(19) Similarly, the endorsement by public figures (including politicians, bureaucrats and academics) and medical or human rights-based organizations has had similar effects in other communities and countries.(22;34)
4. Fend off bad press and watch out for negative portrayals in the media – In some studies and commentaries, the media has been blamed to be a significant part of the drug problem and for the lack of public support for harm reduction interventions.(19;26;32;37) In some successful experiences, there was direct engagement among harm reduction advocates with the media, including commentary writing and letters to the editors.(35;38) Furthermore, support from local newspapers can have an effect on public opinion.(35)
5. Claim the moral high ground – The arguments for harm reduction approaches should not be based solely on science and public health.(28) Confrontation with opponents of harm reduction interventions requires that supporters claim the moral high ground based on human rights— people who use drugs, much like other citizens, have equal rights to health and access to necessary health care and services, which include such interventions as NEPs and SIFs.(28;39)
6. Humanize– The public needs to feel connected to those who would benefit from harm reduction interventions. This means the gap between “us” and “them” must be bridged. Efforts should be made to ‘humanize’ people who use drugs – they are someone’s parent, son, daughter, brother or sister, just like everyone else (22;23;35;39)
Factors That May Impact Local Applicability
Although there have been common themes emerging in the opposition against harm reduction interventions, it is important that attempts to counter it should be tailored towards the context of each community.(36) For example, many strategies that worked in Vancouver, B.C., might not work in Ontario. The drug problem in Vancouver is highly visible in its downtown area, and thus, it is not difficult to convince the public that this is a growing public problem. However, the problem is not as visible in Ontario, which could create different challenges for advocates here. Furthermore, the overall public opinion in Ontario is not as supportive towards harm reduction strategies as in British Columbia, as shown by the 2012 TOSCA report.(24) The TOSCA report also showed that different stated goals of establishing SIFs garner different amounts of public support, thus, it is important that the goals are properly tailored and communicated to the community.
The strategies for changing public opinions and perceptions found in this review were similar to those identified by the HomeComing Community Choice Coalition in their 2005 guide for Ontario’s supportive housing provider, Yes, in my backyard.(40) Although harm reduction interventions and their facilities are distinct from supportive and social housing, the challenges and opposition presented by introducing these amenities into a community are quite similar. In their guide, the Coalition identified several main strategies for changing local communities’ opinions and perceptions of new social housing developments: “enlist the support of the local councilor and planner at the outset”; “explain the human rights issues to supporters”; “never accuse opponents of being “not in my backyarders” or bigots”; “answer all questions with cheerful confidence”; and “stick to your principles”. The advice in their guide could be translated into applicable strategies for inducing cultural change towards harm reduction in Ontario.
Given the inherent differences between communities and countries, it is vital to consult with the community and assess what the prevailing concerns, fears and perceptions are, before developing a comprehensive strategy to change the culture.
What We Did
We conducted a search in Medline (without date limits) using the following combination of search terms: MeSH terms: (“Harm Reduction” OR “Needle-Exchange Programs” OR “Syringes” OR “Substance Abuse, Intravenous”) AND title terms: (“opinion” OR “perception” OR “supervised injection” OR “safe injection”). We also searched the Cochrane Library for any potentially relevant systematic reviews using the following text terms: “harm reduction” OR “needle exchange” OR “methadone clinic” OR “safe injection” OR “supervised injection”) AND (“opinion” OR “attitude” OR “perception” OR “public”). Lastly, we reviewed references in the studies found. Only studies in English and French were included.
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This article first appeared on the OHTN webisie here.