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Results of a participatory needs assessment demonstrate an opportunity to involve people who use alcohol… Crabtree, Alexis; Latham, Nicole; Bird, Lorna; Buxton, Jane Dec 9, 2016

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RESEARCH Open AccessResults of a participatory needs assessmentdemonstrate an opportunity to involvepeople who use alcohol in drug useractivism and harm reductionAlexis Crabtree1,2* , Nicole Latham3, Lorna Bird4 and Jane Buxton1,2AbstractBackground: Drug users’ organizations have made progress in recent years in advocating for the health andhuman rights of people who use illicit drugs but have historically not emphasized the needs of people who drinkalcohol.Methods: This paper reports on a qualitative participatory needs assessment with people who use illicit substancesin British Columbia, Canada. We held workshops in 17 communities; these were facilitated by people who use illicitdrugs, recorded with ethnographic fieldnotes, and analyzed using critical theory.Results: Although the workshops were targeted to people who use illicit drugs, people who primarily consumealcohol also attended. An unexpected finding was the potential for drug users’ organizations and other harmreduction programs to involve “illicit drinkers”: people who drink non-beverage alcohol (e.g. mouthwash, rubbingalcohol) and those who drink beverage alcohol in criminalized ways (e.g., homeless drinkers). Potential points ofalliance between these groups are common priorities (specifically, improving treatment by health professionalsand the police, expanding housing options, and implementing harm reduction services), common values (reducingsurveillance and improving accountability of services), and polysubstance use.Conclusions: Despite these potential points of alliance, there has historically been limited involvement of illicitdrinkers in drug users’ activism. Possible barriers to involvement of illicit drinkers in drug users’ organizationsinclude racism (as discourses around alcohol use are highly racialized), horizontal violence, the extrememarginalization of illicit drinkers, and knowledge gaps around harm reduction for alcohol. Understanding thecommonalities between people who use drugs and people who use alcohol, as well as the potential barriers toalliance between them, may facilitate the greater involvement of illicit drinkers in drug users’ organizations andharm reduction services.Keywords: Illicit drugs, Non-beverage alcohol, Illicit alcohol, Harm reduction, Substance use, Participatory research,Ethnography, Drug users’ organizations* Correspondence: alexis.crabtree@alumni.ubc.ca1British Columbia Centre for Disease Control, Vancouver, Canada2University of British Columbia, Vancouver, CanadaFull list of author information is available at the end of the article© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Crabtree et al. Harm Reduction Journal  (2016) 13:37 DOI 10.1186/s12954-016-0126-xBackgroundRecent years have seen drug users’ organizations, andtheir allies make substantial progress in advocating forthe health and human rights of people who use illicitdrugs. Historically, drug users’ organizations (organiza-tions that are led by people who use illicit drugs and thatwork to improve their lives at individual and systemiclevels) have focused their efforts on currently illegal sub-stances, and not prioritized alcohol or the needs ofpeople whose substance of choice is alcohol.A key theoretical concept in studying the health ofpeople who use illicit substances is structural violence,defined as a cause of suffering that is unnatural andcaused by forces external to the individual. The term re-fers to “historically given (and often economicallydriven) processes and forces that conspire to constrainindividual agency” [1] and lead to an unequal and unjustdistribution of suffering. Analysis of instances of structuralviolence should attend to intersecting oppressions basedon gender, ethnicity, class, and other factors but must notlose sight of individual agency in the face of increased riskof suffering within marginalized communities [1, 2].This paper reports on the results of a participatoryneeds assessment with drug users1 in British Columbia,Canada, in which an unexpected finding was an oppor-tunity to engage marginalized people who drink alcoholin drug user activism and harm reduction. This papersummarizes the results of the needs assessment for drugusers; explores the rationale for greater involvement ofillicit drinkers in drug user activism based on shared pri-orities, shared values, and experiences of polysubstanceuse; and identifies barriers to drug user organizations be-coming more inclusive of illicit drinkers. We use theterm illicit drinking use to describe the consumption ofnon-beverage alcohol (alcohol not meant for humanconsumption, e.g., mouthwash and rubbing alcohol) andthe consumption of beverage alcohol in ways that arehighly criminalized (e.g., public drinking by people whoare homeless).MethodsThis paper describes results obtained as part of a largerqualitative, participatory study to investigate the prior-ities and values of drug users in the province of BritishColumbia, Canada. Data collection was focused on com-munities outside Metro Vancouver, which is the prov-ince’s largest metropolitan area, in order to betterunderstand the experiences of people who use drugs insmaller communities and rural areas. For full descriptionof the methodology summarized here, please see [3]. Weheld a series of 17 workshops in communities aroundBritish Columbia (see Fig. 1).These workshops were advertised to substance users bylocal harm reduction and health care organizations andwere structured around the question “What do drug usersneed to live healthy lives in their communities?” Althoughoutreach was directed toward drug users, people whoprimarily consumed alcohol were not precluded from at-tending provided they identified as current or past usersof illicit substances on occasion. Three hundred and twoparticipants attended the workshops, with mean of 18 par-ticipants (range 6 to 42) per meeting.These workshops were facilitated by current or formerillicit drug users and a paid staff person from the VancouverArea Network of Drug Users, a drug users’ organization inVancouver, British Columbia. Facilitators asked open- andclosed-ended questions to elicit discussion about prioritiesfor harm reduction and health promotion among par-ticipants, then engaged participants in a discussion of strat-egies by which progress could be made toward thesepriorities. Between workshops, the facilitators (includingauthors NL and LB) and the field researcher (AC) helddebriefing sessions to discuss ongoing results and planspecific areas of inquiry for subsequent workshops.AC took ethnographic fieldnotes at the workshops andfollowing discussions with facilitators between work-shops. Based on their experience with this population,the facilitators felt that audio recordings would not beacceptable to many participants and would discourageopen discussion. Data analysis took place in two phases.Initial analytic work took place at daily debriefing meet-ings. While not a formal academic process, these initialreflections impacted data collection and helped developideas that were refined in a more traditional process ofcritical analysis using NVivo 7 [4].Initial results were presented and feedback solicited at anannual general meeting of the BC-Yukon Association ofDrug War Survivors (a regional drug users’ organization),and minor refinement of the results took place in responseto feedback received.ResultsSummary of drug users’ priorities and valuesWorkshop discussions led to the development of sevenpriorities for change that were shared by drug user par-ticipants across the province: (1) improving interactionswith health professionals, (2) promoting access to arange of housing options, (3) improving treatment bypolice, (4) ensuring harm reduction best practices arefollowed everywhere, (5) improving social assistance, (6)supporting drug users’ organizations, and (7) engaging newand existing allies. Participants’ experiences of health care,housing, policing, and social assistance can be seen as ex-amples of the ways in which structural violence is mademanifest in drug users’ lives. The remaining three prioritiessuggested by participants—promotion of user-run organi-zations, implementation of best practices in harm reduc-tion, and the recruitment of new allies—celebrate theCrabtree et al. Harm Reduction Journal  (2016) 13:37 Page 2 of 9potential of resistance to structural violence. In these areas,participants saw opportunities to build on past victories fordrug users and to take further action to improve the healthof their communities.We identified four values underlying drug user partici-pants’ priorities for change: collectivity, activity, freedomfrom surveillance, and accountability. Collectivity in-volved a desire for connection with others that was irre-spective of substance use and entailed responsibility forthe welfare of others; participants acknowledged themany barriers they face to achieving this ideal. While ac-tively self-advocating was seen as key to achieving thepriorities, participants noted that passivity is encouragedby many of the institutions with which they interact (forexample, hospitals and police). Surveillance was ubiqui-tous in participants’ lives, and particularly intense inmedical settings; they described a paradoxical desire forprivacy and “not having to hide” (Community A, here-after referred to as “A”). Finally, accountability was con-trasted with surveillance as a system in which drug userswould have meaningful influence over the institutions intheir lives and would be accountable to them in turn.These values reflect participants’ experiences of domin-ant ideologies, particularly the emphasis placed underneoliberalism on economic productivity, individualism,and self-monitoring, and the discipline and control ofpeople who do not conform to these expectations [5].The values also demonstrate the possibilities of respond-ing to these ideologies through resistance and “strategicaccommodation” [6].For a more in-depth discussion of the priorities andvalues, please see [3].Points of alliance between drug users and illicit drinkersShared prioritiesNot all of the priorities that were identified for drugusers were shared by the illicit drinkers that attendedthe workshops. Supporting drug user-run organizations,not surprisingly, was not raised as a priority by theseparticipants, nor was developing alliances or improvingFig. 1 The sites of workshops in the drug users’ needs assessmentCrabtree et al. Harm Reduction Journal  (2016) 13:37 Page 3 of 9social assistance. The other four priorities, however,were repeatedly mentioned by those who identified asillicit drinkers; that is, they expressed a desire to see im-proved relationships with health professionals, a greaterrange of housing options, better treatment from police,and implementation of harm reduction services.Drug user workshop participants described interac-tions with health professionals that are marred by dis-crimination and surveillance. Others have similarlyfound that relationships between health care workersand drug users are characterized by mistrust, resultingin less care-seeking and lower quality therapeutic rela-tionships [7–14]. The illicit drinkers echoed these con-cerns: they felt that physicians and nurses arrive topatient encounters with pre-formed opinions about theneeds and motivations of marginalized clients and there-fore are not in a position to provide responsive care.One participant described his experience of being un-fairly judged at a hospital:Like everyone says, it’s hit and miss here. Certainclinics will treat you with respect, [but] the hospitaltriages you first. I went there for an abscess. I wasn’tusing drugs then, only drinking. They made me waiteight hours. They singled me out, they thought I wasa drug user and they were all talking. It’s a humanrights violation (Community C).Other illicit drinkers described similar concerns, and,like the drug user participants, placed a high priorityon the development of systems to ensure health carecould be obtained without judgement or loss ofconfidentiality.In addition to their concerns about health services,drug user and illicit drinker participants alike expresseddissatisfaction with the housing options available tothem, primarily centered on the need to provide shelterto those who are actively using substances. The follow-ing exchange demonstrates the constrained choicesfaced by drinkers in a town with a single shelter:Participant 1: A lot of people want to talk abouthealth, but if you’re homeless–Participant 2: They told me I had to sleep outsidebecause I was drinking.Participant 3: If you quit the drunkenness, you’ll get aplace to sleep overnight!Participant 1: And if you can’t quit the drunkenness?Participant 4: You end up sleeping in the bank, in theATM area (Community O).Similar to the views expressed by drug users, thesedrinkers find the restrictions placed on them preventingthem from meeting a basic need, a situation which couldbe ameliorated by providing shelter that allowed for ac-tive substance use among that segment of the populationunable or unwilling to restrain from it.In describing the pathways to improved relationshipswith police, drug user participants mentioned the neces-sity of decriminalization of drug use and of reformed po-lice conduct in regards to harassment, violence, andprotection of drug users. Academic researchers have alsoidentified aspects of policing as detrimental to drugusers’ health. In particular, intensive policing of drugmarkets encourages riskier drug use behaviors and inter-feres with the use of harm reduction and health services[15–19]. Incarceration is associated with increasedmorbidity from infectious and non-infectious diseases[20, 21], and negative relationships between police anddrug users may contribute to internalized stigma andinterfere with recovery [11]. Illicit drinker attendeespointed out that although their substance of choice islegal; they too suffer from the consequences of impropertreatment by police. For example, one group of friendsexplained their frequent interactions with police in theirsmall town:Participant 1: The cops always harass you, pull up onyou, ask you what you’re up to, even if you’re justsitting there.Participant 2: Even look through your backpacks.Participant 3: And we don’t have nothing, just acouple empties (Community N).While these participants expressed their frustrationwith what they perceived as being inappropriate targetsof police scrutiny, others mentioned lack of attention tohealth needs or even outright violence while in custodyas examples of the unacceptable treatment they receivefrom police. As well, and again similar to the viewsexpressed by drug user participants, illicit drinkersbrought up what they saw as a lack of action by the po-lice in protecting them when they are the victims ofcrime. In one small town, several workshop participantsdescribed how they felt the police had been derelict intheir duties:Participant 1: There’s this one gang that goes aroundtown beating up homeless people, and the cops donothing.Participant 2: I got shot with a pellet gun by them andthe cops didn’t help.Crabtree et al. Harm Reduction Journal  (2016) 13:37 Page 4 of 9Participant 1: We tell them what kind of cars theydrive and still they don’t help us (O).The description of this incident echoes the sentimentof drug user participants that police are uninterested inprotecting the rights and safety of people who use illicitsubstances. This is in keeping with a view of the criminaljustice system as functioning in large part to protect theinterests of those in power, a group from which illicitdrinkers are clearly excluded.Finally, drug user workshop participants expressed thebelief that harm reduction services do improve theirhealth and well-being, but that these services would bemore effective if expanded and always offered in accord-ance with proven best practices. Illicit drinker partici-pants, too, seemed convinced of the value of harmreduction. Their comments, reflecting the current spars-ity of alcohol harm reduction services, emphasized thepotential benefits of adapting programs for drug users tomeet the needs of those who drink alcohol. For example,after describing the utility of supervised injection spaces,one illicit drinker asked, “What about for people whoare alcoholics? They should have a little community orbuilding for people who drink outside so they can besafe inside” (C). Other participants described the needfor education on reducing harms from non-beverage al-cohol (similar to the educational programs offered toinjection drug users) and preventing transmission of in-fections among people sharing the same bottle (inspiredby the distribution of mouthpieces for crack pipes).Shared valuesIn addition to the shared priorities described above, bothdrug user and illicit drinker workshop participantsstrongly expressed their desire to see the existing systemof surveillance and judgement from those in authority re-placed by one of mutual accountability. Drug user andillicit drinker participants were positioned similarly intheir positions relative to institutions of surveillance (e.g.policing, medical, and social assistance), although the dif-ference between illegal and legal substances does necessar-ily affect the types and sites of surveillance to which theyare subjected. Dissatisfaction with ubiquitous surveillanceis clear in this young person’s description of an encounterthat occurred while she was walking home from classes:The cops came up to me and said what was I doingoutside walking at ten at night? I said, ‘Walkinghome.’ They said, ‘You been drinking?’ I said, ‘None ofyour business!’ They just want to take you in. I’m notallowed to walk down the street? (O)An additional example of surveillance given by partici-pants in multiple communities involved staff and customersat liquor stores. The comments included one participantdescribing the owner of the community’s only liquor storeas being “like a king,” explaining that “he watches everyoneoutside” (O).Similar to drug users, illicit drinker participants par-ticularly chafed against the judgement that surveillanceof their activities entailed. One woman explained thatshe drank non-beverage alcohol and said, to an enthusi-astic response from the other participants, “There’s folksout there that do drink alcohol, hairspray. You shouldnot judge other people, that’s their right, it’s up to thepeople, what they drink out there” (C). Another partici-pant described obtaining food at one of the few placesavailable in his community: “When you go to the soupline, if you’re drunk, they kick you out. You just want toeat and they make you eat outside. We’re not dogs!” (N)His last sentence implies that, more than the surveil-lance for intoxication or the restriction on where he caneat, he reacted negatively to the implied judgment thathe is not fit to eat inside.In contrast to unidirectional surveillance and judge-ment, some illicit drinkers echoed the comments of druguser participants by voicing their desire for greater sayin the institutions that shape their lives. A serviceorganization in one community, for example, feedspeople “a bowl of soup and moldy bread” and “you getkicked out for a week for being intoxicated.” Participantswondered, “How do they get funding for that?” (O) Thisreflects their belief that the organization is not, in theiropinion, meeting the mandate for which it receives fundsand shows that drug users’ organizations could poten-tially ally with illicit drinkers to push institutions to bemore accountable to the people they serve.Polysubstance useUntil this point, drug users and illicit drinkers havebeen referred to as if they are separate and distinct cat-egories. The reality of substance use, however, is morecomplicated than that and speaks to another potentialpoint of alliance: use of drugs and alcohol by the sameindividuals.A variety of patterns of polysubstance use were identi-fied in the workshops. Some participants described beingomnivorous in their consumption of psychoactive sub-stances. As one said, “I’m a crackhead, alcoholic, pot-head; five months clean, but I smoke lots of pot to keepaway from it. I’m trying to stay away from the booze,too, but I had some last night” (L). Others explainedhow alcohol had been a gateway drug to other sub-stances: “It was in past years definitely opiates, but alco-hol was the catalyst to all of it. I’d get totally run downon alcohol and flip flop back and forth for many years”(Q). Still others described a trajectory in the other direc-tion; as one said, “I was addicted to cocaine… My drugCrabtree et al. Harm Reduction Journal  (2016) 13:37 Page 5 of 9of choice now is alcohol. When I do have money, that’smy downfall” (G).Clearly, “illicit drinkers” and “drug users” as categoriesare neither exclusive nor stable. This reflects the createdand fluid nature of the boundary between legal and (cur-rently) illegal psychoactive substances. When combinedwith the common priorities and values described by par-ticipants, this polysubstance use provides further ration-ale for including illicit drinkers in drug user organizing.DiscussionBarriers to collaboration between drug users and illicitdrinkersA unique contribution of this research was identifyingthe opportunity to involve illicit drinkers in drug users’organizations based on shared priorities, shared values,and the realities of polysubstance use. Given the potentialof this alliance, it is perhaps surprising that inclusion ofillicit drinkers in drug user activism is not more wide-spread.2 We identified four potential reasons for this exclu-sion: racism, horizontal violence, extreme marginalizationof illicit drinkers, and knowledge gaps around alcoholharm reduction.RacismIn our needs assessment, illicit alcohol was moststrongly raised as an issue for further exploration atworkshops held in northern communities. This corre-sponds to provincial data showing that the highest percapita rates of alcohol consumption in British Columbiaoccur in the northern and interior regions and thenorthern part of Vancouver Island [22] and that alcoholabuse rates are higher among homeless people in thenorthern city of Prince George than they are in Victoriaor Vancouver [23]. The proportion of attendees identify-ing as Indigenous also rose as we traveled north, untilIndigenous attendees outnumbered non-Indigenous by afactor of two to one or more. Such a trend follows localdemographics, as the northern regions of BC have pro-portionally more Indigenous residents.In Canada and in many other colonial states, Indigenouspeoples experience elevated proportions of substance usein general and alcoholism (and alcohol-related harms) inparticular, although they also have higher proportions ofnon-drinkers [24–27]. The burden of substance use andmental health disorders in Indigenous communities is dir-ectly tied to the ongoing experience of colonialism, eco-nomic and political marginalization, and the legacy ofresidential schools [28, 29].Indigenous people’s use of alcohol is framed differentlyin public discourses than non-Indigenous’. They are por-trayed as having a genetic predisposition to the abuse ofalcohol and in lacking control around its use and there-fore in need of external controls to be placed on them[24]. These discourses serve the purposes of dominantgroups by facilitating non-Indigenous control of Indigen-ous people and resources and the apprehension of Indi-genous children [24, 30–32]. By creating the sense thatIndigenous alcohol use is a “special case,” they may alsohamper efforts to create links between drug users’ orga-nizations and illicit drinkers.One of the authors (LB) is the past president of theWestern Aboriginal Harm Reduction Society (WAHRS),the world’s first Indigenous-specific harm reductionorganization. WAHRS encourages participation fromillicit drinkers, in contrast to the policy of most user-runharm reduction organizations, due to the large impact ofalcohol on Indigenous communities and its intimate tiesto histories of colonization, forced assimilation, and resi-dential school systems. This suggests both that involve-ment of illicit drinkers in drug users’ organizations ispossible, and that an acknowledgement of Indigenous-specific substance use issues may facilitate greater par-ticipation of illicit drinkers.Horizontal violenceHorizontal violence is an idea whose origins lie in crit-ical theory. It refers to oppressive acts committed by in-dividuals or groups that are themselves marginalized andoppressed. When they are prevented from taking actionagainst their oppressors, they may instead internalize theworldview of their oppressors and strike out againstmembers of communities that are similarly lacking inpower [33–35].Horizontal violence has been described in the relation-ships between members of specific subgroups of drugusers. Simmonds and Coomber [8] found that certaindrug users characterize members of other subpopula-tions (for example, the non-homeless toward homelessor steroid users toward other drug users) as irrespon-sible in order to “displace acknowledgement” of theirown risky behaviors and to minimize their own differ-ence and stigmatization. Additionally, Radcliffe and Ste-vens [36] described how certain drug users receivingaddiction treatment (such as women and cannabis users)used the pejorative label “junkie” to distance themselvesfrom the stigma (and self-stigma) of using drug treat-ment services.Horizontal violence is a potential factor that keeps drugusers and illicit drinkers from working effectively together.Facilitators suggested that drug users can judge and evenstrike out at particularly marginalized people who drinkalcohol when they are themselves experiencing discrimin-ation and oppression. In addition, reflecting on their ownperceptions of the inherent difficulty of working withdrinkers, several facilitators concluded that many of theirnegative stereotypes of drinkers were based on a need tofeel superior in their own choice of illicit substances.Crabtree et al. Harm Reduction Journal  (2016) 13:37 Page 6 of 9Challenging horizontal violence through consciousness-raising was seen, therefore, as a potential route to closeralliances in the future.Extreme marginalization of illicit drinkers and the need forconsciousness-raisingIn Vancouver and in many other major cities around theworld, leaders in the drug user communities and their al-lies have worked to politicize people who use illicit sub-stances. This means awakening drug users to their ownpower to bring about lasting change and shifting focusfrom immediate needs (for example, daily food provision)to the institutions and political, economic, and socialstructures that influence how immediate needs are met[37–39]. It is necessary because the marginalization ofillicit drug users creates a barrier to their engagement inself-advocacy. In the early days of the Vancouver AreaNetwork of Drug Users, inspired by theories of populareducation and liberation theology, community organizersencouraged drug users to recognize their power to effectchange; as one founder put it, “The biggest obstacle tomaking the situation better was the marginalization ofdrug users, and the distance that addicts are from society.So the first thing we got involved in was the demarginali-zation of drug users” [37].Illicit drinkers are an extremely marginalized popula-tion; a process of consciousness-raising may be neces-sary in order for them to take part in drug users’organizations. Consciousness-raising is a term from thewomen’s movement that refers to a group process ofsharing experiences and learning about how they are tiedto systemic problems of power and oppression [40, 41].A similar concept within critical theory is conscientiza-tion, “the process in which men [sic], not as recipients,but as knowing subjects, achieve a deepening awarenessboth of the socio-cultural reality which shapes their livesand of their capacity to transform that reality” [42]. Thefacilitator contrasted the situation of illicit drinker par-ticipants with those of Vancouver drug users now, whoshe felt had a consciousness of the links between thepersonal injustices they face and broader societal trends.This explained, according to her, the focus by illicitdrinkers on small, immediate goals (such as longer shel-ter hours rather than expanded access to affordable sup-portive housing) and the lack of emphasis placed bydrinkers on collective action as a strategy to achievechange. A process of engaging with illicit drinkers anddeveloping their sense of their own political powercould, then, promote full participation of illicit drinkersin user-run organizations.Knowledge gapsThe majority of our workshop facilitators were experi-enced activists and leaders in the drug user community.As such, they felt very confident in their knowledge ofharm reduction strategies for a variety of substances androutes of administration (injection, inhalation, etc.). Thisconfidence did not, however, extend to their knowledge ofharm reduction strategies for alcohol and particularlynon-beverage alcohol. In particular, they felt that withouta better understanding of the effects of non-beverage alco-hol on the body, they could not advise drinkers on stepsthey could take to maintain their health. They believedthis barrier could easily be overcome, however, throughconsultation with scientific experts and collaboration withexperienced illicit drinkers.ConclusionsAs part of a participatory assessment of drug users’health and harm reduction needs, we identified three po-tential points of alliance between drug users and illicitdrinkers: shared priorities, shared values, and polysub-stance use. We also identified four potential barriers tocollaboration: racism, horizontal violence, extrememarginalization of illicit drinkers, and lack of knowledgeabout alcohol harm reduction. Our results suggest that,although potentially challenging, involving illicit drinkersin drug users’ organizations has great potential for work-ing toward the goals of both groups.A limitation of this research was that participants werenot a random sample of substance users. The networksused to recruit, particularly those of facilitators and so-cial service organizations, influenced who attended.People who depend on social service agencies for sur-vival often become entangled in organizational politics,and therefore previous experiences with an agency affectwhether a person will attend an event with which theyare affiliated. We did our best to make the workshopsand meetings as low barrier as possible and thereforeopen to a broad range of participants (including thoseoften excluded from research), however, by providinghonoraria to support participation, not requiring sign-upor consent in advance, and holding meetings in locationsaccessible and familiar to substance users.A strength of this research has been in its uptake andeffects. Because it was conducted in partnership with anorganization interested in acting on the results, we wereable to quickly establish a follow-up research project fo-cused on connecting with illicit drinkers in Vancouver’sDowntown Eastside, which subsequently led to the for-mation of an activist group for illicit drinkers, the East-side Illicit Drinkers Group for Education (EIDGE).EIDGE’s ongoing work includes providing support andeducation to members through weekly meetings, part-nering with a legal non-profit to create a “drinkers’rights” card, participating in a national research projecton managed alcohol programs, and advocating for anon-residential managed alcohol program in Vancouver.Crabtree et al. Harm Reduction Journal  (2016) 13:37 Page 7 of 9Health care and harm reduction practitioners may in-corporate this research into their practice by attendingto opportunities to engage with people who drink non-beverage alcohol. In particular, it may be useful to ex-pand harm reduction services for illicit drinkers and toexplore how their specific needs in health care deliverycan best be met. Drug users’ organizations should alsoconsider how they may use their considerable expertisein activism and peer-based programming to supportillicit drinkers in achieving their goals. Attention shouldbe paid to the barriers that illicit drinkers face in becom-ing involved with self-advocacy for substance users and tominimize these barriers whenever possible. Illicit drinkersare some of the most marginalized members of society;expanded outreach to this group from health care pro-viders and drug users’ organizations has the potential tocontribute greatly to their improved well-being.Endnotes1The term “drug user” is used in this paper in additionto “person who uses illicit drugs.” This term is used tobe in keeping with the terminology employed at the Van-couver Area Network of Drug Users, a partnerorganization for our research and to avoid the use of ac-ronyms. We celebrate the fact that our participants arealso family members, friends, workers, volunteers, andcommunity members, in addition to drug users. Add-itionally, we call attention to Jauffret-Roustide’s use ofthe term, in contrast with the pejorative “drug addict,”as “a responsible, self-reliant citizen able to adopt pre-ventive behaviors” [38].2There are undoubtedly exceptions to this generalization,of course. Of note, the Vancouver Area Network of DrugUsers conducted a brief project in which people couldexchange rice wine (non-beverage alcohol) for beveragealcohol [43].AcknowledgementsThe authors gratefully acknowledge the BC-Yukon Association of Drug WarSurvivors, the Vancouver Area Network of Drug Users (particularly Diane Tobin,Laura Shaver, Alex Sherstobitoff, Aiyanas Ormond, and Ann Livingston), and allthe workshop participants who shared their experiences and insights.FundingThis study was funded by the harm reduction services program of the BCCentre for Disease Control. AC is supported by a CIHR-UBC-BCCDC MD/PhDstudentship.Availability of data and materialsOriginal transcripts will not be shared.Authors’ contributionsAC and JB designed the study. AC collected the data and conducted theprimary data analysis. NL and LB facilitated workshops and contributed todata analysis. AC and JB wrote the manuscript. All authors read andapproved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Consent for publicationNot applicable.Ethics approval and consent to participateEthics approval was granted by the University of British ColumbiaBehavioural Research Ethics Board (certificate H10-01257).Author details1British Columbia Centre for Disease Control, Vancouver, Canada. 2Universityof British Columbia, Vancouver, Canada. 3Vancouver Coastal Health,Vancouver, Canada. 4Vancouver Area Network of Drug Users, Vancouver,Canada.Received: 27 August 2016 Accepted: 5 December 2016References1. Farmer P. On suffering and structural violence: a view from below.Daedalus. 1996;125(1):261–83.2. Farmer P. Women, poverty, and AIDS. In: Farmer P, Connors M, Simmons J,editors. Series in Health and Social Justice. Monroe, Maine: CommonCourage Press; 1996.3. Crabtree A. 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