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Harm reduction, methadone maintenance treatment and the root causes of health and social inequities:… Smye, Victoria; Browne, Annette J; Varcoe, Colleen; Josewski, Viviane Jun 30, 2011

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RESEARCH Open AccessHarm reduction, methadone maintenancetreatment and the root causes of health andsocial inequities: An intersectional lens in theCanadian contextVictoria Smye*, Annette J Browne, Colleen Varcoe and Viviane JosewskiAbstractBackground: Using our research findings, we explore Harm Reduction and Methadone Maintenance Treatment(MMT) using an intersectional lens to provide a more complex understanding of Harm Reduction and MMT,particularly how Harm Reduction and MMT are experienced differently by people dependent on how they arepositioned. Using the lens of intersectionality, we refine the notion of Harm Reduction by specifying the conditionsin which both harm and benefit arise and how experiences of harm are continuous with wider experiences ofdomination and oppression;Methods: A qualitative design that uses ethnographic methods of in-depth individual and focus group interviewsand naturalistic observation was conducted in a large city in Canada. Participants included Aboriginal clientsaccessing mainstream mental health and addictions care and primary health care settings and healthcare providers;Results: All client-participants had profound histories of abuse and violence, most often connected to the legacyof colonialism (e.g., residential schooling) and ongoing colonial practices (e.g., stigma & everyday racism).Participants lived with co-occurring illness (e.g., HIV/AIDS, Hepatitis C, PTSD, depression, diabetes and substanceuse) and most lived in poverty. Many participants expressed mistrust with the healthcare system due to everydayexperiences both within and outside the system that further marginalize them. In this paper, we focus on threeintersecting issues that impact access to MMT: stigma and prejudice, social and structural constraints influencingenactment of peoples’ agency, and homelessness;Conclusions: Harm reduction must move beyond a narrow concern with the harms directly related to drugs anddrug use practices to address the harms associated with the determinants of drug use and drug and health policy.An intersectional lens elucidates the need for harm reduction approaches that reflect an understanding of andcommitment to addressing the historical, socio-cultural and political forces that shape responses to mental illness/health, addictions, including harm reduction and methadone maintenance treatment.There is considerable evidence that harm reductionapproaches are effective in reducing the harms associatedwith drug use [1-3]. As Pauly notes, “harm reduction as aphilosophy shifts the moral context in health care awayfrom the primary goal of fixing individuals towards oneof reducing harm“ (italics ours) (p.6) [4]. However,although harm reduction opens opportunities forpromoting the health of people who often are stigmatizedthrough social responses to problematic substance use,harm reduction interventions do not necessarily addressthe root causes of substance use and attendant socialconditions that influence inequities in health and accessto health care for this population - “inequities [that] areexacerbated by lack of quality housing, poverty, unem-ployment, lack of social support and education” (p.8) [4].Harm reduction approaches that fail to address themultiple intersections that influence peoples’ health and* Correspondence: victoria.smye@nursing.ubc.caUniversity of British Columbia, School of Nursing. T201-2211 Wesbrook Mall,Vancouver, B.C. V6T 2B5, CanadaSmye et al. Harm Reduction Journal 2011, 8:17http://www.harmreductionjournal.com/content/8/1/17© 2011 Smye et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.well-being and their experiences of and responses tomental health and addictions care may also fail toimprove health in a meaningful way [5].In keeping with the perspectives of Hankivsky, Cormierand de Merich, we believe that peoples’ health and experi-ences are shaped by a number of intersecting variablesassociated with social identity, such as “race/ethnicity,Indigeneity, gender, class, sexuality, geography, age, dis-ability/ability, immigration status, religion etc. - variablesthat also have been associated with oppression (e.g., racismand classism) and consequent disadvantage (e.g., povertyand homelessness)” (p.7-8) [6]. For example, in the studyin which this paper is grounded, the client participantswere Aboriginal, and ‘race’ was relevant to all experience -the race-based privilege of oppression was present in theeveryday reality of peoples’ lives, including the experiencesof accessing and delivering MMT. Yet ‘race’ could not beneatly shifted apart from processes of racialization, issuesof gender, class relations, and other social relations thatstructured peoples’ lives such as their education level,employment status, health, and well-being. As Bannerjinotes, “[r]acism is after all a concrete social formation. Itcannot be independent of other social relations of powerand ruling which organize the society, such as those ofgender and class...” (p.128) [7] - the relationship betweenthese variables is complex and interdependent [6,8-10],occurring within and intersecting with societal contexts.Anderson and Reimer Kirkham note that to understandthe meaning of health within a sociopolitical and culturalcontext, there is a need for an elucidation of “the intersec-tionality and simultaneity of race, gender, and class rela-tions, the practice of racialization, the connectedness tohistorical context, and how the curtailment of life oppor-tunities created by structural inequities influences health”(p.63) [11].Intersectionality is increasingly being used in healthresearch as a lens for highlighting the inter-related andco-constructed nature of social locations and experiences[6,12,13], and for understanding differences in healthneeds and outcomes in mental health and addictions andharm reduction [14]. As Weber and Parra-Medina note,inequities are often obscured when models of practicefocus on individual bodies [and behaviour] rather thantaking into account “the social structural context as thelocus of a population’s health” (p.187) [12]. Grounded incritical feminist theoretical perspectives, intersectionalanalyses are useful in drawing attention to the dynamicsof the intersections between problematic substance use,other aspects of social identity and different forms ofoppression associated with social and structural contextsthat can guide us in the pursuit of addressing the multi-ple inequities and intersecting multiple stigmas asso-ciated with drug use.In this paper, we focus on harm reduction and metha-done maintenance treatment (MMT) to illustrate howsocial change can be promoted using an intersectionallens to examine harm reduction and MMT and mentalhealth and addictions more broadly. We use findingsfrom a partnership-based research project conducted inBritish Columbia, Canada, entitled, Aboriginal peoples’experiences of mental health and addictions care: Towardimproved access, to elucidate how an intersectional lenscan provide a more complex understanding of harmreduction and MMT - how harm reduction and MMTare experienced differently by people dependent on howthey are differently located (e.g., living in poverty andhomeless and/or near homeless). Using the lens of inter-sectionality, we refine the notion of harm reduction byspecifying the conditions in which both harm and benefitarise and how experiences of harm are continuous withwider experiences of domination and oppression. Thispaper is not meant to be an indictment of harm reduc-tion or MMT; rather, we use an intersectional lens to elu-cidate the need for harm reduction approaches thatreflect an understanding of and commitment to addres-sing the historical, socio-cultural and political forces thatshape responses to mental health and addictions andharm reduction.BackgroundThe Complexity of Problematic Substance Use, Addictionand Associated StigmasIn this paper, our focus is on issues pertaining to proble-matic substance. In particular, our research has focusedon people who identify as Aboriginal and who are mostimpacted by the marginalizing conditions of persistentsocial and structural inequities - poverty, homelessness,unemployment and so on. From the outset, we want to beclear that problematic substance use is not always asso-ciated with mental illness, homelessness, Aboriginal iden-tity etc., however, the issues discussed in this paperrepresent insights provided by conducting research withAboriginal people whose lives have been most influencedby these sociopolitical circumstances.In keeping with the perspective of Reist, Marlatt, Gold-ner, Parks and Fox, we understand the phrase ‘proble-matic substance use’ to encompass the concepts ofpotentially harmful substance use behaviours or patterns(e.g., impaired driving or the use of substances duringpregnancy) that are not clinical disorders and ‘substanceuse disorders’(i.e., clinical disorders defined by the DSM-IV, including dependence or addiction) (p. 4) [15]- with aspectrum of use from ‘beneficial’ to ‘non-problematic’ to‘problematic use’ (p. 8). From this perspective, substanceuse is not problematic for everyone, and one substancemay present a problem for the individual where anotherSmye et al. Harm Reduction Journal 2011, 8:17http://www.harmreductionjournal.com/content/8/1/17Page 2 of 12may not. In addition, substance use can be stable at onepoint in time and move gradually or rapidly to a differentpoint (p. 8) [15].The associated harmful consequences of problematicsubstance use may include physical illness, includingincreased risk of infection (e.g., HIV, Hepatitis C andother blood borne infections due to sharing drug para-phernalia); family breakdown; economic issues; criminalinvolvement; and a high risk of overdose leading todeath, and death by violence [16-19]. In addition, theissue of stigma is a highly pertinent concept intersectingwith [or contributing to] the harms associated with pro-blematic substance use (p.5) [20,21].In this paper we take up Goffman’s (1963) notion ofstigma as an attribute associated with ‘difference’ that isdeemed to be a less desirable difference by one person(the stigmatizer) in relation to another person (the stig-matized) - a difference, which at its extreme, might deemthe person as bad, dangerous or weak (stereotyping)(p. 12) [22]. Further as Link and Phelan argue [23,24],stigma is created through five interrelated and conver-ging social processes, for example, in the case of druguse: i) labeling of the person with problematic substanceuse as different, e.g., the ‘drug addict’ or ‘junkie’; ii) nega-tive stereotyping by linking ‘difference’ with undesirablecharacteristics and fears such as drug users as “danger-ous"; iii) ‘othering’ by creating “them” (the labeledperson) and “us” categories; iv) status loss, blame and dis-crimination of the labeled person; and, v) creation ofpower dynamics in which power is experienced by thelabeled person’s ability to access to key resources, such asmoney and social networks/institutions [25,26]. Thus,problematic substance use as a category of ‘difference’often leads to stigmatization based on the beliefs thatunderpin its perceived origins and an experience of andthe ability of the labeled person to resist stigma (or not)dependent on their social location and perceived power.Although public attitudes vary towards people withproblematic substance use and many people acknowledgethat people with drug use issues often come from difficultcircumstances, i.e., that there are social and structuralissues influencing use, there remains a strongly held viewthat “drug addicts” are to blame for their drug use [27].For example, Henderson et al. (2008) concluded thatwhile staff in their hospital study were committed to pro-viding care to people with problematic substance use,their training and experience led them to treat them dif-ferently from other patients - particularly notable in thearea of pain management (as cited in Lloyd, (2010)) [27]where physicians, as one example, are trained to the onalert to “drug seeking” behaviour in this population. AsLloyd notes, in our society, the identity as “addict, tendsto take center stage to the obscuration of all other facetsof identity and personality...” (p.13)[27].Additionally, individuals who are “addicted” or depen-dent on substances often lead “chaotic and stressful”lives and may have additional co-occurring and stigma-tizing mental health and other health issues; these inter-sect with social issues associated with their substanceuse that make diminishing or abstaining from substanceuse extremely difficult (p.16) [17,21,26,28,29]. Chaos andstress are most often related to intersecting factors, suchas poverty, unemployment, housing issues and stigmaand discrimination [17]. Lack of housing and/or mean-ingful employment have also been shown to contributeto substance use and addictions. In this paper, we usean intersectional lens to shift attention from the indivi-dual to the social and structural inequities that mayinfluence substance use, and health and well-being forthose with problematic substance use. For example, sub-stance use needs to be understood as sometimes over-lapping with violence and mental health issues, andthose problems need to be seen within the context ofsocial and structural determinants of health to ensurethe provision of integrated care [30,31].Examining Harm Reduction and MMT through anIntersectional LensGiven the complexity of problematic substance and asso-ciated stigma as presented above, the complexity of issuesthat shape practices and policies related to MMT are bestunderstood under the pragmatic philosophy of harmreduction (p.18) [17]; an approach that represents a con-tinuum of services that embody a philosophical, prag-matic and compassionate approach to providing carewhile minimizing the negative harms associated withsubstance use, understanding that not all people have thesame ability to change, the same level of drug use, oreven experience the same harms [5]. Two central under-lying values of a pragmatic perspective to harm reductionis i) that all life activities carry risk and ii) that elimina-tion of drug use is not necessarily attainable or desirable[4]. This approach to harm reduction is goal-oriented,humanistic [32] and in keeping with a cost benefit aware-ness [5,33]. Humanistic values explicitly highlight thevalues of respect, worth and dignity of all persons, there-fore, there is a focus of “nonjudgmental acceptance ofpersons [who use illicit drugs] as worthy of respect with-out judgment of drug use” (p.6) [5]. The active participa-tion of the client is acknowledged as important in harmreduction programs [5,32].Central to a harm reduction approach is “a focus onreducing the negative consequences of substance use forindividuals, communities and societies...rather thanfocusing on decreasing or eliminating substance use”(p.6) [5]. Harm reduction occurs gradually in a step-by-step progression toward decreased levels of overall harm[33]. In keeping with this perspective, harm reduction isSmye et al. Harm Reduction Journal 2011, 8:17http://www.harmreductionjournal.com/content/8/1/17Page 3 of 12one aspect of a comprehensive approach to the harmfulconsequences of drug use, recognizing that there aremany different strategies and programs of harm reduc-tion that meet diverse clients’ needs. Health care profes-sionals using a harm reduction approach meet clients“where they are at” in terms of their ability to change(p.14) [33], and work collaboratively with clients toestablish goals and develop a client-centered plan ofcare [17]. Lastly, a harm reduction approach is under-pinned by a commitment to change policy and/or to beintegrated into existing health policies. Examples of spe-cific harm reduction strategies include needle exchangeprograms, safe injection sites, distribution of condomsand dental dams (all products should be freely availableand offered without cost), bleach kit programs for clean-ing syringes, distribution of clean crack kits, safer sexeducation, safer drug use and education, outreach pro-grams for high-risk populations, law-enforcement co-operation, prescription of heroin and other drugs, andmethadone maintenance treatment, among others. How-ever, most of these efforts deal directly with the harmsthat emanate from individual drug using and sexualpractices, and deal less with the harms associated withthe root causes of problematic substance use (violence,poverty, racism, historical trauma and so on), and theharms associated with drug policy (such as criminaliza-tion, incarceration, poverty). Although all importantstrategies, the root causes of illicit drug use are notaddressed. MMT as a harm reduction strategy is anexemplar of how an intersectional lens can elucidate themultiple intersecting factors that shape experience.As a substitution/maintenance therapy, MMT is consid-ered the “gold standard” (p.6) [34]. “Systematic reviewshave identified MMT as the most effective form of treat-ment for opioid dependence in terms of treatment reten-tion and decreases in the use of illicit opioids” [[35-37] ascited in 21]. Methadone is a long-acting synthetic opioidthat binds to the opioid receptors in the body. Being anopioid agonist, it can significantly reduce the rates of with-drawal and cravings associated with opioid dependence[34]. Due to the fact that it is a long-acting drug, there isno euphoric effect, a fact that contributes to lower rates ofrelapse [16,17,34]. However, as Caplehorn et al. note, oneof the greatest benefits of MMT is its well documenteddecrease in mortality for individuals in treatment as com-pared to those who use opioids who are untreated [[38] ascited in 21].According to recent guidelines developed by theRNAO, that are based on a systematic review of the lit-erature, and according to Reist, MMT should ideallyencompass an interdisciplinary effort with three compo-nents: methadone prescribing, methadone dispensingand a range of comprehensive psychosocial services andsupports such as counseling services and supportsrelated to housing, employment, education, mentalhealth, or life skills and access to other health servicessuch as perinatal care and health promotion activities[17,21]- care that takes into consideration the biopsy-chosocial context of the individual client.Yet, MMT is often applied within biopsychosocial mod-els in ways that encompass varied strategies but ignore theintersecting social and structural issues that give rise toopioid addiction, resulting in particularly serious conse-quences for some groups of people - approaches that donot focus on the social forces and contexts that shape peo-ple’s health and lives, including “the situatedness of socialinequality in history and place, and its operation at themacro social structural as well as micro individual level”(p.187) [12]. MMT often involves regulating or managingthe social order and ‘marginalized’ subjects, but fails todeal with the root causes of injustice that give rise to druguse. For example, harm reduction approaches, includingMMT, that do not reflect the simultaneous interactionsbetween substance use, gender, class, violence and traumaas complex and interdependent, fail to address the uniqueneeds of women [30,31]. “Substance use and mental healthproblems frequently co-occur among women who are sur-vivors of violence, trauma, and abuse, often in complex,indirect and mutually reinforcing ways...” (p.32) [31]. Inaddition, HIV infection due to injection drug use is farmore prevalent in women, accounting for 19.2% of allAIDS diagnoses in adult women compared to 3.9% in men[39]. Harm reduction services need to attend to specificneeds of women and integrate an intersectional analysisinto drug policy and harm reduction frameworks [30].There is a need to apply what we know about differingpatterns, health impacts, pathways to problematic sub-stance use and related experiences in the design of harmreduction service provision and policy, including MMT.An intersectional lens draws attention to how and whyMMT needs to reflect approaches that address the multi-ple inequities, such as those associated with living withmental health and addictions issues, a history of traumaand violence, homelessness, and poverty - to name a few.In addition to the above issues, the historical and struc-tural inequities that have shaped the health and well-beingof Aboriginal people in Canada have resulted in greaterrisks of experiencing violence, trauma [40-42] and sub-stance use [43]. Yet little is known about the experiencesof Aboriginal persons who access mental health and addic-tions services (mainstream and Aboriginal). In 2006-2009,we conducted a study in partnership with a team of Abori-ginal and non-Aboriginal researchers, community agenciesand leaders in mental health and addictions and commu-nity members to explore Aboriginal peoples’ experiencesof mental health and addictions care in an urban Canadiancontext to inform the design of safe and effective [mental]health and addiction services. In Canada, the termSmye et al. Harm Reduction Journal 2011, 8:17http://www.harmreductionjournal.com/content/8/1/17Page 4 of 12‘Aboriginal’ is often used to refer to diverse groups of indi-genous people who include First Nations, Métis, and Inuitpeople.MethodsStudy Design and Data CollectionA qualitative design using ethnographic methods of in-depth individual and focus group interviews and naturalis-tic observation was used. Study participants were Aborigi-nal clients from diverse Nations (as they describedthemselves) including, Nisga’a, Plains Cree, Cree,Kwagiulth, Cowichan, Blackfoot, Métis, Gitxsan, Dené,Saulteaux Cree, Ojibway, Sioux, Coast Salish, Haida,Sto’lo, Sarcee and Six Nations (n = 39; individual in-depthinterviews (n = 18: 8 males, 10 females) and three focusgroups (n = 21: 11 males, 10 females) who accessed main-stream and other mental health and addictions servicesand health care providers, Aboriginal and non-Aboriginal(n = 24; individual in-depth interviews) working withinthose settings. Ethical approval was sought and obtainedby both the Behavioural Research Ethics Board of theUniversity (BREB #H06-80439) and the local ethics com-mittee of the regional health authority. In addition, thestudy was guided by ethical guidelines of the Royal Com-mission on Aboriginal Peoples (1993), and the principlesof Ownership, Control, Access, and Possession (OCAP)for research with First Nations [44,45].Purposive and theoretical sampling was used to recruitAboriginal clients and health care professionals from men-tal health and addictions settings. Because the purpose ofthe study was to inform an understanding of how toimprove mainstream mental health and addictions servicesso they are more responsive to the needs of Aboriginalclients, the settings chosen were five community-basedmental health and primary health care agencies. Eligibleclient participants were persons who had no cognitiveimpairment and identified as 19 years or older, and Abori-ginal persons accessing mental health and/or addictionsservices within these settings. Health professionals whowere interviewed were working within the research sitesand included the designations of mental health nurse(RPNs, RNs, LPNs), community outreach worker, psychol-ogist, psychiatrist, social worker and support worker.Recruitment was facilitated through ‘liaison’ people on siteas well as through informational study pamphlets thatwere approved by ethics and posted at the study-sites. Thequalitative interview/focus group guides for client partici-pants prompted exploration in the following areas: the rea-sons for seeking care in this particular setting; assumptionsand expectations about the care; experiences of seekingcare; and, interest in Aboriginal traditional healing prac-tices. The guide for health care providers promptedexploration related to their experiences providing care toAboriginal clients and their understanding of why clientsseek care in their setting. Interviews occurred within themental health and/or addictions care setting or within aninformal setting and ranged between 30 and 60 minutes.With permission, interviews and focus groups were audio-taped and transcribed. An honorarium of $30 was pro-vided as a way thanking participants for their time. Allparticipants were assured complete confidentiality andprovided written informed consent to the study.Data AnalysisUsing an interpretative thematic analysis, data was ana-lyzed in a multi-step process using comparative codingstrategies [46,47]. Using NVivo, a computer software pro-gram, transcripts were first coded in ‘chunks’ of data as ameans to organize and group the data. As new data con-tinued to be gathered, whole interviews were read repeat-edly to identify recurring, converging and contradictorypatterns of interaction, key concepts, preliminary themes,illustrative examples and linkages to theory [47]. In addi-tion, coded transcripts were compared to identify simila-rities and differences in the coding process. In this way,initial coding strategies were revised and refined as partof regular reflective discussions with the research team.Finally, exemplars from coded categories and themeswere retrieved using NVivo and compared within andacross transcripts. At this point, interpretations werereviewed using a sub-sample of participants to checkdescriptive and interpretive validity. Resonating with par-ticipants’ experiences of their complexity of life, the find-ings of this study were discussed using an intersectionallens - as a set of complex interrelations rather than a setof discrete variables. For example, one of the core find-ings which we discuss in this paper underscores theimportance of understanding how harm and benefit aredifferentially experienced by clients of mental health andaddictions services dependent on their histories andsocial location/position.Results/DiscussionIn this study, client participants presented with signifi-cant levels of co-occurring illnesses including schizoaffec-tive disorder, mood disorders, depression, anxiety,suicidal ideation, alcohol and drug use, HIV, Hepatitis Cand PTSD associated with complex trauma. Several parti-cipants were residential school survivors and most hadlong histories of trauma, beginning in early childhoodand for many, continuing into the present. These factorshave been long understood to be associated with mentalhealth and addiction issues. For example, residentialschools which included industrial schools, boardingschools, student residences, and hostels, located through-out Canada, the last of which closed in 1996, have beenthe most often cited cause of the mental health concernsof Aboriginal people in Canada. Although residentialSmye et al. Harm Reduction Journal 2011, 8:17http://www.harmreductionjournal.com/content/8/1/17Page 5 of 12schooling was not uniformly negative for all people,5 itsoverall impact has been devastating [48-53]. In responseto this understanding, in 2006, the federal governmentannounced the approval of the Indian Residential SchoolsSettlement Agreement and the new Truth and Reconci-liation Commission [54].Many of the client participants in this study reportedbeing on methadone, an aspect of the study, we reporton in this paper. Further, all of the health care providersworked with clients who had previously accessed MMTor were attempting to access MMT. Using an intersec-tional analysis, we use the findings of this study tounderscore the importance of understanding how harmand benefit are differentially experienced by clients ofmental health and addictions services dependent ontheir histories and social location/position.The key findings were that a) stigma and discrimina-tion intersected with other disadvantages to profoundlyshape people’s lives and their access to and experienceswith MMT, b) the policy context of MMT constrainedpeople’s lives, with significant consequences and theseexperiences and consequences varied with people’s sociallocations, and c) in concert with poverty and other disad-vantages, these constraints contributed to housinginstability and homelessness for many. Although harmreduction is based on the values of non-judgment andnon-coercive approaches to service delivery [5] and thereare many positive outcomes associated with MMT, manyof the participants in this study experienced ‘harm’ asso-ciated with “the intersectionality of disadvantages”(p.763) [55].Stigma and DiscriminationIn keeping with the findings of several authors[21,25,56], the attitude of providers was cited as a bar-rier to access to care in particular settings by several cli-ent and health care professional participants. Ourfindings provide a glimpse into how stigma and discri-mination shape access to MMT. The following interviewexemplar illustrates the stigma experience of several cli-ent participants (CP),And its easy to kick a wounded dog, I mean, youknow, I mean that’s what happens down here, [ser-vice providers] don’t mean to do it, they don’t getup in the morning with a plan to go ‘I’m going to gokick ten junkies today,’ they don’t do it, its just asthe day builds, as the day builds they just desensitize,year after year they get desensitized to needs andthen they just start dealing with what the immediateneeds are.For this participant, his identity as a “junkie” inter-sected with a perception of provider (physician)desensitization and/or stigmatization of the “junkie” toexplain discriminatory treatment within the site wherehe accesses methadone. Although this may not havebeen a case of enacted stigma, i.e., where a person isactively discriminated against [22], this participant mayhave perceived stigma [22,57] because of the negativethoughts and feelings associated with an expectation ofstigma and discrimination e.g., through fear, shameand guilt. It is not uncommon, for example, for clientsto experience “MMT as punitive and shaming ratherthan therapeutic even when the professional may betrying to follow guidelines designed to protect the cli-ent” (p. 15) [21]. Regardless of the dynamic or form ofstigma, stigmatization is a powerful force that ofteninterferes with access to MMT [21,27,56]. Indeed,research has shown that ‘drug user’ status can be abarrier to accessing health care and can affect thequality of care received [4,21,56,58,59]. A slightly dif-ferent experience of discrimination is expressed byanother client in the following,Within the system there is some prejudice people inthere and I try not to get too mad with them when Ifind out that they’re prejudice, they don’t likeNatives and they don’t like drug addicts.For several participants in this study, in addition tosubstance use as an axis of discrimination, stigma(enacted or perceived) also was attached to an expecta-tion of racialization, a process that is neither neutral norwithout consequence. Given their multiple social loca-tions, many people in this study expressed uncertaintyabout why they were treated poorly by some providers.For example, living as an Aboriginal person in Canadacarries with it the “burden of history” [60], and prejudiceand racism continue to manifest as new forms of colonialprocesses and practices erupt; however, persons livingwith mental illness and/or substance use issues and/orHIV/AIDS and/or Hepatitis C also live with stigma andprejudice associated with those diagnoses [26,61-63] andconsequent life circumstances, such as poverty and incar-ceration. Sadly, the social construction of identity/identi-ties (including disease or illness associated and groupidentity (p. 3) [26]) interferes with both the ability of peo-ple to access and remain in MMT. In keeping with theperspective of Stuber, Meyer, & Link [64], in ourresearch, we have found that analysis of the issues usinga singular focus on racism or classism or problematicdrug use (as examples of oppression), misses how themeaning and experiences of stigma and prejudice inter-sect with other important variables to create new formsof discrimination. The stigma associated with drug use isusually only one aspect of an intersecting set of stigmas(p. 47) [27].Smye et al. Harm Reduction Journal 2011, 8:17http://www.harmreductionjournal.com/content/8/1/17Page 6 of 12Applying an intersectional approach to analyses ofexperiences of stigma and discrimination has numerousadvantages. It acknowledges the complexity of how peo-ple experience stigma and discrimination and recognizesthat the experience of discrimination may be unique. Italso takes into account the social context of the group.It places the focus on society’s response to the indivi-dual as a result of the confluence of various factors anddoes not require the person to slot themselves into rigidcompartments or categories, i.e., it captures more fullythe reality of stigma and discrimination as it is experi-enced by individuals. This approach allows the particu-lar experience of stigma and discrimination, based onthe intersection of factors involved, to be acknowledgedand remedied. Attention to multiple disadvantagedsocial statuses is important to identifying the root causesof health disparities [65] and to designing effective inter-ventions [64].In the following interview example, a provider (P)working in a harm reduction setting discusses metha-done maintenance treatment,Those on the methadone program...their ultimateobjective is to get on methadone and stay on metha-done and stay off heroine and then they can useother drugs and there’s no consequence to that, otherthan its affecting their health and it affects the, youknow, the methadone and so on ... and because I’man addictions counselor I have a hundred and twentypatients on the methadone maintenance program. Sothose patients are referred to a counselor for supportand for counseling and also to deal with any othersubstance abuse that they may be experiencing. Inabout eighty-five percent of the cases those on themethadone program have a dependency on crack,cocaine or some other drug so my role is to do anassessment and refer them to day programs or treat-ment centers or to out patient counseling to helpthem more in a harm reduction philosophy... My pre-ference is abstinence, abstinence because of thehealth, you know, it promotes health...This excerpt reflects the policy context in which MMTis situated, i) a shoestring approach is supported (120 cli-ents), ii) there is an absence of attention to the socialdeterminants of health, and iii) policies are constrainedby the criminalization of drug use. It obviously alsoreflects the attendant discourses taken up by some healthcare professionals working in the field. Although ourobservations of the care provided in this setting suggestthat the community of professionals within the organiza-tion, including this individual, generally were committedto the provision of compassionate non-judgmental carewithin a harm reduction framework, the ideologyprojected by this provider belies a frustration with MMTand drug use more broadly - a reflection of the perspec-tives of many people in broader society.Today, many people believe that MMT perpetuatesdrug use because of the misconception that it merelyreplaces one addictive opioid with another rather thanseeing it as a treatment for opioid use [32]. As Cheungobserves, this school of thought often is associated withthe idea that abstinence-oriented treatment is the onlyway to achieve a “drug-free” state in society [32]. Thisideology is also perpetuated in treatment programs thatdo not accept clients on methadone. As one client parti-cipant noted, “Yeah, I think that they should put moretreatment centers out there that are accessible to metha-done [patients]...because a lot of them don’t acceptmethadone [patients].” Societal and institutional stigma,reflected in the political commitment and resourcesavailable to harm reduction programs, client positioningwithin the health care system and attitudes of health careprofessionals can pose significant barriers to the accessi-bility of MMT and other harm reduction programs foropioid dependent individuals [4,66]. As Keane notes:Prohibitionist policies threaten the freedom of users,damage their health and constitute them as marginaland stigmatized subjects excluded from normativecategories of citizenship such as ‘the general public’(p.229) [67]Participant experiences of health care in this study werenot influenced by one dimension of inequity, rather theywere influenced by differential access to the social deter-minants of health and related multiple intersectingdimensions such as racism, classism, abilism and so on -dimensions that intersect with dominant ideologiesregarding drug use and attendant assumptions, stereo-types and values. As Benoit notes, “[t]hose who face ser-ious health concerns and at the same time are subject tomultiple stigmas by virtue of their age, sex, gender, sexualorientation, race, ethnicity, socioeconomic or other socialdeterminants, are less likely to access key resources andtherefore differentially positioned to buffer themselvesagainst the damaging impact of intersecting stigmas”(p. 5)[26].Constrained Lives: Harm Reduction, MMT and IndividualAgencyAlthough MMT supports access to other interventions(e.g., anti-retroviral therapies) and there can be numerouspositive outcomes, some participants found MMT highlyrestrictive; individual choice and freedom were limited bythe policies and practices attached to MMT. As Youngnotes in her examination of the notion of ‘inequality,’ insti-tutional structures and processes (including institutionalSmye et al. Harm Reduction Journal 2011, 8:17http://www.harmreductionjournal.com/content/8/1/17Page 7 of 12rules and policies) “can inhibit the capacities of some peo-ple” at the same time as they expand the options of others(p.10) [68]. Many of the participants in our studydescribed the ways in which their lives have been con-strained by MMT. Individual agency was affected in sev-eral ways. Limits were placed on the freedom of somepeople to move from one area to another and choiceswere limited by power inequities. For example, several ofthe women in the study had children, who had beenapprehended by the state as a consequence of the complexintersections of poverty, gender and problematic drug useand attendant social circumstances such as difficultiesaccessing safe housing; they described difficulty visitingtheir children because they could not access enoughmethadone (carries) to make the trip i.e., they were ondaily doses of methadone and/or they could not access apharmacy that dispensed methadone where their childrenwere living, and/or they could not afford reliable transpor-tation (sometimes needing to hitchhike) to see theirchildren.Although many people (Aboriginal and non-Aborigi-nal) experience the effects of the limits placed on agencythrough restrictive guidelines regarding MMT, Aborigi-nal experiences of MMT are impacted by sociopoliticalfactors that are unique to their experience. For example,Aboriginal children represent approximately 40% of the76,000 children and youth placed in care in Canada [69]- a fact associated with poverty, problem substance useand inadequate housing [70](notably Aboriginal peopleonly comprise 4-5% of the overall Canadian population).These conditions mediate the extent to which womenreport substance use patterns and access MMT andother harm reduction services. To provide effective andsafe harm reduction, including MMT and other services,it is necessary to understand the social context(s) inwhich these experiences emerge [71,72].In a similar but slightly different vein, several partici-pants experienced MMT as being incompatible with a“normal” life and improved quality of life. In the follow-ing example, a client participant discusses such limita-tions,... I’m going to be up there this summer or nextsummer [to see my relatives], but I’m on methadoneright now so I have to get off the methadone, I’monly on twenty-two mls (milliliters) but by June Ishould be off.A health care professional also discusses this issue inthe following,How can you travel with a drug habit? A raging drughabit... try and get that [methadone], it would be anightmare to try and get that, some doctor inanother province or something or other communityto prescribe it, good luck... try and navigate thatwhole thing on your own...For the client participant above and as the health pro-fessional notes, MMT can be highly constraining, includ-ing the lack of freedom to travel because of the inabilityof many to access methadone in other locales. However,what was also problematic in this case, as noted in a laterdiscussion with this participant, was that MMT was notexperienced as an informed choice. He believed he hadbeen coerced by his doctor inappropriately; he perceivedthat he had used heroin minimally and now, six yearslater, he experienced MMT as seriously constraining - anexperience shared by several other participants.In keeping with the perspective of this client, a healthcare professional critiques the issue of “recruitment” toMMT as problematic in the following interview example,“I mean look at the methadone scene, I mean these drugsstarted to pop up all over not because they care for thepeople, [but because] there is money!” In our study, therewas a general cynicism expressed regarding how MMT isbeing offered by some providers. Although most partici-pants (clients and health care professionals) acceptedMMT as a harm reduction approach, several believedthat it was being used by some in power, such as a few“doctors... and pharmacists”, as a means to make money“off of the backs of addicts.” In our study, these viewswere fueled by a Canadian Broadcasting Corporation(CBC) news headline on September 11, 2008 that read,“Methadone kickbacks could lead to criminal investiga-tion"; allegedly, several local pharmacies were reported tobe paying “drug addicts” a fee each time they were dis-pensed methadone - money that was reportedly beingused by some to buy illicit drugs [73]. In addition, thepractice of charging daily dispensing fees rather thanweekly dispensing fees ($15/day) was alleged to be thepractice in some pharmacies, even though “weekly dis-pensing” was written on the prescription. The experienceof ‘being taken advantage of’ because of being an “addict”in addition to the rules and regulations associated withMMT engendered a sense of vulnerability, and, to a beliefby some participants, that they were being punished fortheir drug use. Although people with problematic sub-stance use are not inherently vulnerable to stigma, theydo face disadvantages relative to their ability to accessresources and enact agency, i.e., enact control over theirbodies and lives.The “regime of control” has been reported elsewhere inthe methadone literature in relation to random drug testsand urine screens that are used to ensure people usingmethadone are not “topping up” with illicit heroin orother drugs [74] as well as methadone consumption [25];according to Vigilant, there is a ‘felt’ or ‘perceived’ stigmaSmye et al. Harm Reduction Journal 2011, 8:17http://www.harmreductionjournal.com/content/8/1/17Page 8 of 12associated with these sorts of institutional regulations[74,27]- a perception that is created by policies that rein-force societal biases, e.g., those biases based in a moralstance against drug use, rather than those that focus onthe sociopolitical and cultural context in which drug useoccurs. For people most marginalized by social and struc-tural inequity such as Aboriginal people, ‘constrainedlives’ may make them the target of profound stigmatiza-tion that may appear as insurmountable because of otherintersecting issues, poverty, homelessness and so on. Inaddition to the constraints posed by treatment itself,many of the participants in this study (79%) were alsoconstrained by unstable housing and limited optionsrelated to same.Harm Reduction, MMT and HomelessnessWomen and men whose poverty leads them to live inunsafe housing units in sections of the city where pro-blematic drug use surrounds them, whose need foraccess to MMT and antiretroviral treatment leads toconfinement to particular urban settings, and whoseAboriginality may further limit their housing choiceswithin particular areas, exemplify the need to examineharm reduction and MMT using an intersectional analy-sis. An Aboriginal participant who was accessing MMTin our study describes his living arrangements in the fol-lowing, “... Native housing, you know what, it’s a realcrack house right?... I wish I worked there, you know, atnights, I wish they hired me at nights not to let peoplein, I wouldn’t.” For this participant and many others,housing conditions acted as a barrier to positive out-comes. Here, an intersectional lens draws attention tothe disturbing ways that homelessness, poverty, sub-stance use and racialization intersect to exacerbate peo-ples’ experiences of social suffering, i.e., to those humanconditions with roots and consequences associated withsocial, economic and political power - suffering that isboth created by the way power is inflicted on humanexperience and how this power shapes the response toit. As noted by Kleinman et al., “the trauma, pain anddisorders to which atrocity gives rise [ongoing colonialprocesses and practices] are health conditions; yet theyare also political and cultural matters” (p.ix) [63].Another participant, an Aboriginal woman who liveswith HIV illness, Hepatitis C and mental illness,describes her experience in the following,There must be something wrong with me, I won’t goshower, I take sponge baths in my room... the hotelis so skungy...we share a bathroom...like if itscatchable...For this woman, the hotel she was living in generatedtremendous fear of further health compromise. Thevermin and filth of the hotels where many of the partici-pants in this study reside is well documented in otherplaces [75]. Although the lives of the Aboriginal menand women with mental health illness on MMT whoare living in poverty resemble those of other impover-ished people, the intersection of poverty, mental illness,HIV/AIDS, Hepatitis C, and gender (as examples) bringswith it a special set of circumstances and challenges tosuccessful harm reduction. We argue that intersectionsacross these multiple axes of differentiation do not haveadditive effects; rather the findings of our study suggestthat peoples’ experiences, although similar across somedimensions, are differentiated by the disadvantages (andadvantages) posed by their location across these axes.ConclusionsHarm reduction, including MMT, “driven solely by redu-cing the harm of drug use is not sufficient to addressinequities in health and access to health care for thosewho are street involved” (p.8) [4]. As Pauly notes, theroot causes of problematic substance use must beaddressed in conjunction with the social determinants ofhealth [4], determinants such as stigma. The harms thatemanate from drug policy and health policy must also beconsidered.Regardless of the intent of health care providers, stigmaand discrimination were experienced by the participantsin our study in everyday attempts to access mental healthand addictions services, including harm reduction ser-vices. In keeping with the perspective posed by Stuber etal. [64], our research points to the need for more work tobe done to fully understand the often unintentionalimpact of stigma and discrimination as social processeslinked to the reproduction of inequality and exclusion,and the many ways in which stigma and discriminationaffect persons marginalized by social and structuralinequity, including the possible negative consequencesrelated to health and well-being. As Rossiter and Morrowargue, “the adoption of an intersectional perspective andanti-oppression framework in anti-stigma and discrimi-nation work will both allow for greater understandingand awareness of intersecting social identities and thelayering of stigma and discrimination, and promise betteroutcomes for the reduction of stigma and discriminationat both social and structural levels” [14]. In addition, asLloyd notes, the entrenched and widely held view thatpersons who use drugs are solely culpable for their condi-tion needs to be addressed [27]; people, including healthprofessionals and the media regarding the causes andnature of addiction.People’s lives were also constrained by the way in whichservices were offered. Employment opportunities, accessto children, attachments to family and community inother geographic locations and so on, were constrained bySmye et al. Harm Reduction Journal 2011, 8:17http://www.harmreductionjournal.com/content/8/1/17Page 9 of 12treatment. In our research, we have found that somewomen’s capacity to parent is limited by MMT policiesregarding carries and social housing policies related tochildren. To determine the constellation of risks for awoman in the context of being, as one example, a singlemother in MMT, Aboriginal, unemployed and homelessor near homeless, we need to explore how and wherethese identities intersect to shape this woman’s personalexperience. As Collins et al. discuss, in the context ofresearch examining the constellation of intersecting risksfor inner city women with severe mental illness [8], wemust understand the multiple systems of power at work inwomen’s lives.Lastly, in this study, most of the participants were liv-ing in unstable housing or were homeless. We definehomelessness in much the same way as Patterson et al.[76] to include both the absolutely (“street”) homeless aswell as those at imminent risk of homelessness. Thepaths in and out of homelessness usually involve someform of inadequate housing. In addition, “while themost visible homeless individuals are those living on thestreets, many more individuals are precariously housedin rooming houses, transitional housing, substandardrental suites, shacks and cabins without running water,and other forms of substandard or unaffordable hous-ing” - those individuals who are both inadequatelyhoused and inadequately supported are particularlyat-risk for homelessness (p. 17) [76]. Absolute homeless-ness refers to those without any physical shelter. Hous-ing is considered an important social determinant ofhealth and housing for Aboriginal peoples is notably lag-ging in comparison to non-Aboriginal people in bothurban and rural settings. For example, it is estimatedthat 41% of all Aboriginal peoples in British Columbia(BC), Canada are at-risk of homelessness and 23% areabsolutely homeless [76,77]. People with severe addic-tions and/or mental illness also can be found in thisgroup - they make up anywhere from 33% to over 60%of the overall homeless population [76].Although harm reduction is not a panacea and it isnot feasible to believe that it will address all socialoppressions, as Boyd notes, “harm reduction initiativescan provide a shift in policy and practice that bringsocial factors to the foreground. It can also pave theway for compassionate health and human-rights modelsof care, and the rejection of drug policy based on puni-tive ideology” (p.5) [78]. However, harm reduction mustmove beyond a narrow concern with the harms directlyrelated to drugs and drug use practices to address theharms associated with the determinants of drug use,such as homelessness, and the harms of drug and healthpolicy.To consider long-term structural change in broadsocial systems is a daunting task, but operating from asocial justice framework, it is one that we see as essen-tial to making any substantial headway to address healthdisparities. Concerted political action as well as theforging of alliances across the domains of many groups- policy makers; researchers working from multipleparadigms which include participatory and community-based approaches; the media; grassroots activists; profes-sional organizations; and most importantly, communitygroups, are needed to bring about the kinds of changenecessary to reduce health disparities [6,12].Pauly argues for harm reduction approaches/interven-tions that integrate more fully with “primary health careand the social determinants of health within a social jus-tice framework” (p.8) [4]. In addition, we argue for rela-tional practices that mitigate the effects of socialinequity and address mental health and addictions ser-vices, including harm reduction - practices that reflectan understanding of the ways in which health and well-being (and health care) are shaped by the contextualfeatures of peoples’ lives [79]. Harm reduction tools,including MMT, need to reflect an understanding thatsystems of power/oppression that operate across theaxes of race, class, gender, ability and so on, are inter-locking; to focus on drug use to the exclusion of otherfactors is problematic.List of AbbreviationsMMT: Methadone Maintenance Treatment; PTSD: Post Traumatic StressDisorder; RNAO: Registered Nurses Association of Ontario.AcknowledgementsThis research was funded by the Canadian Institutes of Health Research(CIHR). We also gratefully acknowledge: Dr. Evan Adams, Dr. Betty Calam, Ms.Nadine Caplette, Dr. Elliot Goldner, Ms. Tonya Gomes, Dr. Peter Granger, Ms.Barbara Keith, Mr. William Mussell, Mr. Perry Omeasoo, Dr. Paddy Rodney, Dr.Colin van Uchelen, co-investigators; Ms. Lorna Howes, Mr. Sri Pendakur, Mr.Ron Peters, Ms. Deborah Senger, Ms Leah Walker, collaborators; Ms. TanuGamble, Social Science Researcher; Ms. Viviane Josewski, Research Manager;Ms. Nancy Clark, Research Assistant, Ms. Tej Sandhu, Student. In addition, weare grateful to our Community Aboriginal Advisory Team for their time andsupport to this research and in particular to Ms. Roberta Price and Ms.Doreen Littlejohn (also a collaborator). For the duration of this study, Dr.Victoria Smye was supported by a CIHR New Investigator Award (2006-2009).Dr. Annette J Browne is supported by a CIHR New Investigator Award and aScholar Award from the Michael Smith Foundation of Health Research.Authors’ contributionsVS was the principle investigator on the study, designed and participated inall aspects of the study, including the data analysis and interpretation of thedata and drafted the manuscript. AJB was a co-investigator, assisted in thedesign and in all aspects of the study, including the data analysis andinterpretation of the data and assisted with the drafting of the manuscript.CV assisted in the interpretation of the data and the drafting of themanuscript. VJ participated in data analysis and interpretation of the dataand assisted with the final draft of the manuscript. All authors read andapproved the final manuscript.Conflicts of interestsThe authors declare that they have no competing interests.Received: 13 February 2011 Accepted: 30 June 2011Published: 30 June 2011Smye et al. Harm Reduction Journal 2011, 8:17http://www.harmreductionjournal.com/content/8/1/17Page 10 of 12References1. International Federation of Red Cross and Red Crescent Societies (IFRC):Spreading the light of science: Guidelines on harm reduction related toinjecting drug use Geneva: International Federation of Red Cross and RedCrescent Societies; 2003.2. Wood E, Kerr T, Small W, Li K, Marsh D, Montaner JS, Tyndall MW: Changesin public order after the opening of a medically supervised saferinjecting facility for illicit injection drug users. Can Med Assoc J 2004,171:731-734.3. 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HarmReduction Journal 2011 8:17.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitSmye et al. Harm Reduction Journal 2011, 8:17http://www.harmreductionjournal.com/content/8/1/17Page 12 of 12

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