Mapping a moral panic: News media narratives and medical expertise in public debates on safer supply, diversion, and youth drug use in Canada

The ongoing overdose and drug toxicity crisis in North America has contributed momentum to the emergence of safer supply prescribing and programs in Canada as a means of providing an alternative to the highly volatile unregulated drug supply. The implementation and scale-up of safer supply have been met with a vocal reaction on the part of news media commentators, conservative politicians, recovery industry representatives, and some prominent addiction medicine physicians. This reaction has largely converged around several narratives, based on unsubstantiated claims and anecdotal evidence, alleging that safer supply programs are generating a "new opioid epidemic", reflecting an emerging alignment among key institutional and political actors. Employing situational analysis method, and drawing on the policy studies and social science scholarship on moral panics, this essay examines news media coverage from January to July 2023, bringing this into dialogue with other existing empirical sources on safer supply (e.g. Coroner's reports, program evaluations, debates among experts in medical journals). We employ eight previously established criteria delineating moral panics to critically appraise public dialogue regarding safer supply, diverted medication, and claims of increased youth initiation to drug use and youth overdose. In detailing the emergence of a moral panic regarding safer supply, we trace historic continuities with earlier drug scares in Canadian history mobilized as tools of racialized poverty governance, as well as previous backlashes towards healthcare interventions for people who use drugs (PWUD). The essay assesses the claims of moral entrepreneurs against the current landscape of opioid use, diversion, and overdose among youth, notes the key role played by medical expertise in this and previous moral panics, and identifies what the convergence of these narratives materialize for PWUD and healthcare access, as well as the broader policy responses such narratives activate.

From punishment to help? Continuity and change in the Norwegian decriminalization reform proposal

BACKGROUND

In 2018 the Norwegian government appointed a committee to prepare the implementation of a drug decriminalization reform. The overall goal of the committee was to propose a model where responsibility for society's response to the use and possession of illegal drugs for personal use would be transferred from the justice sector to the health service, under the catchphrase 'from punishment to help'. While the proposal ultimately did not get the necessary backing in parliament, the proposed reform still constitutes a very comprehensive and recent proposal for reforming national drug policy and it provides an ideal case for studying contemporary discourses on 'drug decriminalization'.

METHODS

The analysis of this reform proposal is guided by the post-structuralist "What's the Problem Represented to be" (WPR) approach, which is used for investigating the problem representation(s) in the proposal, as well as the rationalities, practices and deep-seated assumptions underpinning these. In doing this, the paper explores how the strategy represents both changes and continuities in discourses around illicit drugs and the people who use them.

RESULTS

Based on the WPR approach, two problem representations in the proposal are identified: the 'problem of illicit drug use' and the 'problem of criminalization'. However, the 'problem of illicit drug use' is argued to be the authoritative representation, that takes precedence over the other. In that regard, the paper points to how the proposed shift from the justice sector to the health sector would only be partial, given that the role of the police and drug law enforcement would be retained in the reform. Furthermore, the paper points to how illicit drug use continued to be fundamentally pathologized in the proposed reform.

CONCLUSION

The paper concludes with a discussion about the overall ambition of shifting from a crime-centered to a health-centered approach to people who use drugs and some reflections on the potential of an additional rights-based approach is provided.

Piloting a classification framework for the types of evidence used in alcohol policymaking

INTRODUCTION

Most studies of alcohol policy have focussed on the role of industry. However, little is known about the evidence base used in alcohol policymaking or policymakers' actions in the field. Here, we mapped the different evidence types used in a case study to construct a classification framework of the evidence types used in alcohol policymaking.

METHODS

Using a case study from the state-level in Australia, we used content analysis to delineate the evidence types cited across six phases of a policymaking process. We then grouped these types into a higher-level classification framework. We used descriptive statistics to study how the different evidence types were used in the policymaking process.

RESULTS

Thirty-one evidence types were identified in the case study, across four classes of knowledge: person knowledge, shared knowledge, studied knowledge and practice knowledge. The participating public preferenced studied knowledge. Policymakers preferenced practice knowledge over all other types of knowledge.

DISCUSSION AND CONCLUSION

The classification framework expands on models of evidence and knowledge used across public health, by mapping new evidence types and proposing an inductive method of classification. The policymakers' preferences found here are in line with theories regarding the alcohol industry's influence on policymaking. The classification framework piloted here can provide a useful tool to examine the evidence base used in decision-making. Further study of evidence types used in policymaking processes can help inform research translation and advocacy efforts to produce healthier alcohol policies.

Establishment and Enforcement of Operational Rules at an Unsanctioned Safe Drug Consumption Site in the United States, 2014-2020

Objectives. To examine how operational rules are established and enforced at an unsanctioned safe consumption site (SCS) operating in the United States. Methods. We conducted 44 qualitative interviews with people who use drugs, staff members, and volunteers at an unsanctioned SCS and analyzed them using an inductive thematic approach. Results. Rule-making processes were largely driven by concerns raised by service users rather than driven by external pressures, and iterated rapidly in response to changing needs. The unsanctioned nature of the site produced an environment where bottom-up rule-making was critical to generating a shared sense of ownership of the site and where enforcement was necessarily fluid. Conclusions. Removing external restrictions on operational rules for SCSs results in a flexible set of rules that are highly responsive to the social and public health needs of people who use drugs. Legislation and regulations of SCSs should aim to place as few hard limits on operating conditions as possible to maximize involvement of and responsiveness to people who use drugs. (Am J Public Health. 2022;112(S2):S166-S172. https://doi.org/10.2105/AJPH.2022.306714).

Scandalous decisions: explaining shifts in UK medicinal cannabis policy

BACKGROUND AND AIMS

Opening up access to scheduled drugs such as cannabis in the United Kingdom rarely happens, yet on 1 November 2018 the United Kingdom changed the law to allow cannabis-derived products to be prescribed for medicinal purposes, albeit in tightly controlled circumstances. This followed substantial media interest in the cases of two children with epilepsy. This article focuses upon the role of scandal in bringing about legislative change.

METHODS

We used political science and social policy theories (punctuated equilibrium theory and scandal theory) to guide a qualitative content analysis of media articles published in 2018 in UK national newspapers. We focused in particular on the 6-month period prior to the policy change.

RESULTS

The concentrated attention by the media given to the suffering of children with epilepsy appears to have prompted the rapid change in policy by the UK government. A variety of strategies were used to develop a highly emotive response to garner support for reform. Media stories emphasized the injustice of two extremely sick children being unable to access the medicine they apparently needed to enable them to have a 'normal' childhood. Three groups of 'claim-makers' were identified as important in influencing public opinion: families, high-profile individuals and campaigning groups.

CONCLUSIONS

The case of medicinal cannabis in the United Kingdom suggests that policy reform can occur when a scandal is successfully manufactured. We must be cautious, however, about over-emphasizing the role of scandal as a driver of policy change in this context: only a limited set of circumstances will permit a prescription for cannabis-based medicine to be issued in the United Kingdom.

We, ourselves and us: Tensions of identity, intersubjectivity and positionality stemming from the people and dancefloors project

Grounded in intersubjective participatory action research, the people and dancefloors project has sought to produce a space for the co-creation of knowledge about dancefloors and drug taking, building a platform for developing insights from the positionality of current drug users. Through film, it provides hermeneutic insight while legitimising their voices. In this paper, we share some reflections as researchers/users/activists arising from our involvement in the project. To begin with, we reflect on the motivations for the project, and the epistemic suppositions that animated it. This is followed by conversational style interviews where we re-evaluate our position in light of the project, with a particular focus on the tensions that drug use introduces between professional, personal and political domains in our lives. These reflections are useful to people who use drugs and hold privilege by nature of their social and cultural position. While questioning the silencing of personal experiences in relation to drug use, we also react to some of the traditional tendencies of academia, including institutionalised individualism, which isolates researchers and discourages them from finding political collectivity, and the subjectivist/objectivist dichotomy, which supports a tendency to objectify research participants while removing the self from the equation. Despite the challenges that arise from disentangling our multiple experiences and identities, our intersubjective dialogue inspires deeper learning about ourselves and each other, encouraging us towards a more openly political stance.

Bereaved mothers' engagement in drug policy reform: A multisite qualitative analysis

BACKGROUND

Globally, a tainted drug supply is claiming the lives of tens of thousands of people who use drugs and current measures are not quelling this crisis. Within this context, mothers who have lost a child to substance use have emerged as vocal advocates for drug policy changes. This paper explores mothers' experiences in drug policy advocacy to uncover how they are using their stories to drive policy change.

METHODS

Critical qualitative and narrative methods informed individual interviews with 43 mothers who had lost a child to substance use from across three regions in Canada: British Columbia, Prairie Provinces, and Eastern Provinces. Multisite qualitative analysis (MSQA) provided a rigorous analytical method to identify how social context informed participants' advocacy efforts within and across geographies, together with a theoretical lens from Haraway to understand mothers' activism as situated knowledge.

RESULTS

Mothers' drug policy advocacy was shaped by social context and norms, which influenced the types of advocacy targets pursued, within the constraints of the social and political ethos of each geographic region. Yet across regions, narratives of shared aims and experiences also emerged. Specifically, the notion that people of all backgrounds are dying and that losing a child to substance use can "happen to anyone" - though people who experience structural vulnerabilities are disproportionately impacted. Additionally, mothers' stories were identified as a particularly powerful tool for conveying emotional knowledge and prompting action that complements other forms of knowledge or evidence.

CONCLUSION

To date, efforts to address the drug poisoning epidemic have done little to curb casualties. Mothers whose child's death is related to substance use are one group who are bringing their experiences to advocacy efforts aimed at generating new solutions, including calls for decriminalization and legal regulation of drugs. This and other lived experience perspectives represent a critical voice in decision-making and hold the potential to inform more responsive and impactful drug policy.

Harm Reduction Works: Evidence and Inclusion in Drug Policy and Advocacy

One of harm reduction's most salient features is its pragmatism. Harm reduction purports to distinguish itself from dominant prohibitionist and abstinence-based policy paradigms by being grounded in what is realistic, in contrast with the moralism or puritanism of prohibition and abstention. This is reflected in the meme "harm reduction works", popular both in institutional and grassroots settings. The idea that harm reduction is realistic and effective has meant different things among the main actors who seek to shape harm reduction policy. Drawing on scholarly literature about harm reduction, as well as examples from recent harm reduction advocacy efforts in relation to drug policy in Canada, this paper argues that harm reduction distinguishes itself through a unique "way of knowing". Grassroots harm reduction advocates, particularly as they argue through human rights frameworks, do more than simply make claims for the provision of particular services-like needle exchange, safe consumption sites, safe supply and the like-on the basis that these are realistic paths toward the health and well-being of people who use drugs. Rather, as they marshal lived experience in support of these policy changes through peer-driven initiatives in contexts of prohibition, they make particular claims about what constitute valid, methodologically rigorous evidence bases for action in contexts where policies to date have been driven by ideology and have developed in ways that have excluded and marginalized those most affected from policymaking. In doing so, they advocate for the centrality of people who use drugs not only in policy-making processes, but in evidence production itself.

What prevents health policy being 'evidence-based'? New ways to think about evidence, policy and interventions in health

BACKGROUND

Evidence-based policy decision-making is a dominant paradigm in health but realizing this ideal has proven challenging.

SOURCES OF DATA

This paper conceptually maps health policy, policy studies and social science literature critically engaged with evidence and decision-making. No new data were generated or analysed in support of this review.

AREAS OF AGREEMENT

Barriers to evidence-based policy have been documented, with efforts made to increase the uptake of evidence.

AREAS OF CONTROVERSY

Evident complexities have been regarded as a problem of translation. However, this assumes that policy-making is a process of authoritative choice, and that 'evidence' is inherently valuable policy knowledge, which has been critiqued.

GROWING POINTS

Alternative accounts urge consideration of how evidence comes to bear on decisions made within complex systems, and what counts as evidence.

AREAS TIMELY FOR DEVELOPING RESEARCH

An 'evidence-making intervention' approach offers a framework for conceptualizing how evidence and interventions are made relationally in practices, thus working with the politics and contingencies of implementation and policy-making.

Towards an ontological politics of drug policy: Intervening through policy, evidence and method

Increasing attention has been paid to matters of ontology, and its accompanying politics, in the drug policy field. In this commentary, we consider what an 'ontological politics' might mean for how we think about what drug policy is and what it might become, as well as for how we think about (and do) research in drug policy. Thinking ontopolitically questions the tacitly accepted status of 'drug problems', calls into question the realist presumptions which underpin much drug policy analysis, and provokes thinking about what counts as 'evidence' and the 'evidence-based policy' paradigm itself. We call attention to the inventive possibilities of method when grappling with the challenges thrown forth by the ontological turn, with a renewed focus on practice and relations. An ontological politics disrupts consensual claims and draws critical attention to objects that might otherwise appear 'finished' or 'ready-made', not least the things we call 'drugs' and 'drug policy'. Working with 'drug policy multiples' invites new thinking and dialogue to provoke an ethico-political mode of intervention in the field of drug policy and drugs research.

Critical studies of harm reduction: Overdose response in uncertain political times

North America continues to witness escalating rates of opioid overdose deaths. Scale-up of existing and innovative life-saving services - such as overdose prevention sites (OPS) as well as sanctioned and unsanctioned supervised consumption sites - is urgently needed. Is there a place for critical theory-informed studies of harm reduction during times of drug policy failures and overdose crisis? There are different approaches to consider from the critical literature, such as those that, for example, interrogate the basic principles of harm reduction or those that critique the lack of pleasure in the discourses surrounding drug use. Influenced by such work, we examine the development of OPS in Canada, with a focus on recent experiences from the province of Ontario, as an important example of the impacts associated with moving from grassroots harm reduction to institutionalised policy and practice. Services appear to be most innovative, dynamic, and inclusive when people with lived experience, allies, and service providers are directly responding to fast-changing drug use patterns and crises on the ground, before services become formally bureaucratised. We suggest a continuing need to both critically theorise harm reduction and to build strong community relationships in harm reduction work, in efforts to overcome political moves that impede collaboration with and inclusiveness of people who use drugs.

Problematisation and centralised assessment in drug treatment sector reform

In the construction of drug use as a 'social problem' (Bacchi, 2015), ease of access to drug treatment aims to enable an immediate response when people seek help. However, as treatment demand exceeds supply, establishing qualifications with regards to efficiency and effectiveness of access, it has been argued, will improve treatment pathways for those most in need. In 2014, drug sector reform in Victoria, Australia introduced policies that supported centralised intake and assessment (CI&A). In 2016, a significant change of policy saw assessment being disaggregated to treatment services. This paper explores the problematisations at these two points to clarify the processes impacting drug treatment governance. Policies, reviews, and allied documents have been explored using an application of Bacchi's (2009) 'what's the problem represented to be' analytical approach. This application aims to stage an encounter between day-to-day policy as a socio-material practice (Bacchi, 2012) and problematisation in the development of contrasting 'realities' at each point. At Time 1, problematisation was about access and navigating treatment. CI&A were introduced as part of sector reform, however an independent review documented disruption to client flow and stakeholder concerns. At Time 2, the policy focus was on quickly establishing a therapeutic relationship with clients. Across these two policy events, the problem representation of uncertainty regarding service effectiveness and efficiency was maintained. This may reflect a deeper characterisation whereby 'drug problems' are accepted and understood as value neutral, and government and services are obliged to take responsibility for their amelioration. The power differential in so called 'collaborative' approaches to policy development may have contributed to silences regarding the salience of organisational factors, such as funds redistribution and recommissioning, and the limited involvement of clients in policy making processes. The shift in emphasis from system design to clinical practice across the two policy events appeared to elevate the status of treatment providers and affirm government's legitimacy in governing.

Deconstructing prohibitionist ideology: A sociocognitive approach to understand opinions on UK drug policy and the law

BACKGROUND

There is increasing support to include people who use drugs (PWUD) into debates about drug policy reform in order to improve policy legitimacy and outcomes. The aim of this paper is thus to critically analyse the perspectives of PWUD on UK drug policy and the law. This is the first empirical study to apply the four philosophical positions that underpin drug policy debates: Millian liberalism, legal moralism, strict libertarianism and paternalism (MacCoun and Reuter, 2001) to understand opinions and ideology.

METHODS

Forty interviews were conducted with PWUD about the meaning of and motivation for their substance consumption and about their opinions on drug policy and the law. The responses were analysed using the sociocognitive approach pioneered by van Dijk 2014; 2015 from the field of critical discourse studies. The analysis involved connecting personal experiences, knowledge and opinions to broader values, attitudes and ideology, specifically the analysis focused upon the extent to which participants challenged or supported prohibitionist ideology.

RESULTS

The opinions of those PWUD studied were diverse and complex. There was some support for prohibition, but overwhelmingly there was resistance and challenge to it. We theorise the challenge to prohibitionist ideology on a continuum from anti-prohibition to pro-reform. Key themes from the analysis included: knowledge gaps regarding terminology; uncertainty about and lack of consideration of policy and reform; political dissonance; apprehension about public attitudes and behaviours; reform rooted in social welfare and human rights ideology; and apathy through counter-culture.

CONCLUSION

The findings demonstrate a lack of clarity amongst some PWUD regarding drug policy and reform. Educational initiatives outlining the different reform approaches would therefore provide PWUD with invaluable knowledge and help facilitate their enagement into reform debates. Despite a lack of clarity and consistency within opinions, participants were united in their discussion of human rights, health, economics and education; therefore these topics could help frame future approaches that seek to include PWUD into debates about drug policy.

'Potential issues of morbidity, toxicity and dependence': Problematizing the up-scheduling of over-the-counter codeine in Australia

Until February of 2018, Australians were able to purchase low-dose codeine products (LDCPs) over-the-counter from pharmacies. In 2017, following review and public consultation, Australia's therapeutic drug regulator rescheduled LDCPs to prescription-only, in line with other higher-dose codeine and opioid products. In this article, we draw on Bacchi's 'what's the problem represented to be' approach to 'work backwards', analysing this 'solution' and the particular 'problematisation' of codeine it produces and relies on. We analyse the 'final decision and reasons for decisions' document, which outlines the consultation and decision-making process leading to the rescheduling of LDCPs. We contend that abuse and dependence of codeine by people with chronic pain is the 'problem' constituted by the decision to reschedule LDCP. We consider the ethical and political implications of this problematisation. First, we argue that this problematisation limits the ways the LDCP consumption, particularly by people with chronic pain, can be understood. This problematisation effaces the multiple reasons people with chronic pain may consume LDCPs long term and works to naturalise notions of 'misuse'. We next argue that notions of the 'legitimate patient' and the 'illegitimate consumer' or 'abuser' are in different ways positioned as primarily responsible for managing their health. From here we argue that the problematisation of LDCPs in Australia produces codeine as the sole agent of harm in ways that background wider harm-producing social arrangements. Our analysis also suggests that the 'problem' of LDCPs unreflexively reinforces medical authoring and expertise as the primary solution. Finally, we suggest that the use of LDCPs in Australia could instead be re-problematised as an issue of 'chronic health mismanagement'. Responses to this problematisation would require a reorientation away from attempts to reduce accessibility such as up-scheduling to significantly more focus on long-term healthcare engagement for people consuming LDCPs to manage chronic health issues.

"Towards eliminating viral hepatitis": Examining the productive capacity and constitutive effects of global policy on hepatitis C elimination

In 2016 the World Health Organization published the first global health strategy to address viral hepatitis, setting a goal of eliminating viral hepatitis as a major public health threat by 2030. While the field has been motivated by this goal, to date there has been little critical attention paid to the productive capacity and constitutive effects of this policy. How is governing taking place through the mechanism of this global strategy, and how are its goals and targets shaping what is made thinkable (indeed, what is made as the real) about hepatitis C and its elimination? And with what effects? Taking the Global Health Sector Strategy on Viral Hepatitis, 2016-2021 as a text for analysis, we draw on poststructural thinking on problematisation and governmental technologies to examine how 'elimination' - as a proposal - constitutes the problem of hepatitis C. We critically consider the conceptual logics underpinning the elimination goal and targets, and the multiple material-discursive effects of this policy. We examine how governing takes place through numbers, by analysing 'target-setting' (and its accompanying practices of management, quantification and surveillance) as governmental technologies. We consider how the goal of elimination makes viral hepatitis visible and amenable to structuring, action and global management. Central to making viral hepatitis visible and manageable is quantification. Viral hepatitis is made as a problem requiring urgent global health management not through the representation of its effects on bodies or situated communities but rather through centralising inscription practices and comparison of estimated rates. It is important to remain alert to the multiple makings of hepatitis C and draw attention to effects which might be obscured due to a primary focus on quantification and management. To do so is to recognise the ontopolitical effects of governmental technologies, especially for communities 'targeted' by these strategies (including people who inject drugs).

Equality, efficiency and effectiveness: going beyond RCTs in A. L. Cochrane's vision of health care

A. L. Cochrane's Effectiveness and Efficiency frequently appears as a key reference in debates over, and a justification for, contemporary evidence-based medicine. Cochrane's concern in this text with the equality of care as the ultimate rationale for why effectiveness and efficiency of cure are needed has, however, largely disappeared from debate. In this article, we reconsider Cochrane's approach through the use of case studies of plural forms of medicine in the Czech Republic, namely traditional Chinese medicine, homeopathy and spa care. In addition to bringing equality back into the picture, we also identify four expansions to Cochrane's original vision arising from the difficulties of separating cure from care; the overlap between prevention and cure; the complex actions of some multi-faceted therapies; and recent reconceptualisations of the placebo effect. In conclusion, we suggest that instead of the widely used strictly vertical "evidence pyramid", a descriptor of the horizontal and additive ordering of evidence might be more appropriate. We also argue that in healthcare systems characterised by a multiplicity of approaches, if we want to truly benefit from this heterogeneity, we must take seriously each medical tradition's approaches to prevention, cure, care, as well as efficiency, efficacy and equality.

The implementation of overdose prevention sites as a novel and nimble response during an illegal drug overdose public health emergency

BACKGROUND

Drug-related overdoses were declared a public health emergency in British Columbia, Canada in April, 2016 facilitating the scale-up of responses including rapid sanctioning and implementation of overdose prevention sites (OPSs). OPSs are a health service providing supervised injection and immediate overdose response. In BC, OPSs were operational within weeks of sanctioning. In the first year of operation over 20 OPSs were established with approximately 550,000 visits and no overdose deaths at any site. In this paper, we examine the implementation of OPSs as a novel and nimble response to prevent overdose deaths as a result of injection drug use.

METHODS

A multiple case study design was used with the Consolidated Framework for Implementation (CFIR) informing the analysis. Three sites in a single city were included with each site constituting a case. In this paper, we focus on qualitative interviews with 15 staff and their perceptions of the implementation of the OPSs as well as provincial and local documents.

RESULTS

The legislative process to implement OPSs was unprecedented as it sanctioned supervised injection services as an extraordinary measure under a declared public health emergency. Innovative and inclusionary practices were possible within state-sanctioned OPSs, as the sites were government-directed yet community-developed, with PWUD centred in service design, implementation and delivery. OPSs lack permanency and may be limited to the duration of the public health emergency.

CONCLUSION

The rapid implementation of OPSs provides an international example of an alternative to lengthy and often onerous sanctioning processes for supervised consumption services (SCSs). Overdose prevention sites provide an example of a novel service design and nimble implementation process that combines the benefits of state-sanctioned injection services with community-driven implementation. Such evidence questions the continued acceptability of governments' restrictive sanctioning processes, which have limited expansion of SCSs internationally and the implementation of services that are not necessarily aligned with the needs of PWUD.

Using the Advocacy Coalition Framework and Multiple Streams policy theories to examine the role of evidence, research and other types of knowledge in drug policy

BACKGROUND AND AIMS

The prevailing 'evidence-based policy' paradigm emphasizes a technical-rational relationship between alcohol and drug research evidence and subsequent policy action. However, policy process theories do not start with this premise, and hence provide an opportunity to consider anew the ways in which evidence, research and other types of knowledge impact upon policy. This paper presents a case study, the police deployment of drug detection dogs, to highlight how two prominent policy theories [the Advocacy Coalition Framework (ACF) and the Multiple Streams (MS) approach] explicate the relationship between evidence and policy.

METHODS

The two theories were interrogated with reference to their descriptions and framings of evidence, research and other types of knowledge. The case study methodology was employed to extract data concerned with evidence and other types of knowledge from a previous detailed historical account and analysis of drug detection dogs in one Australian state (New South Wales). Different types of knowledge employed across the case study were identified and coded, and then analysed with reference to each theory. A detailed analysis of one key 'evidence event' within the case study was also undertaken.

RESULTS

Five types of knowledge were apparent in the case study: quantitative program data; practitioner knowledge; legal knowledge; academic research; and lay knowledge. The ACF highlights how these various types of knowledge are only influential inasmuch as they provide the opportunity to alter the beliefs of decision-makers. The MS highlights how multiple types of knowledge may or may not form part of the strategy of policy entrepreneurs to forge the confluence of problems, solutions and politics.

CONCLUSIONS

Neither the Advocacy Coalition Framework nor the Multiple Streams approach presents an uncomplicated linear relationship between evidence and policy action, nor do they preference any one type of knowledge. The implications for research and practice include the contestation of evidence through beliefs (Advocacy Coalition Framework), the importance of venues for debate (Advocacy Coalition Framework), the way in which data and indicators are transformed into problem specification (Multiple Streams) and the importance of the policy ('alternatives') stream (Multiple Streams).

When the Brain Leaves the Scanner and Enters the Clinic

Addiction neuroscience promises to uncover the neural basis of addiction by mapping changes in the “diseased brains” of people with “drug addictions.” It hopes to offer revolutionary treatments for addiction and reduce the stigma experienced by those seeking treatment for a medical, rather than moral, condition. While the promises of addiction neuroscience have received considerable attention, relatively few studies have examined how neuroscientific discourses and promises play out in drug treatment settings. Instead of asking how neuroscience might measure or treat a preexisting addiction “problem,” we draw on poststructuralist ideas to trace how neuroscientific discourses produce addiction as a certain type of “problem” and the effects of these particular problematizations. Based on interviews with a range of different types of treatment providers working in Victoria, Australia, we discuss three themes that reveal neuroscientific discourses at work: (1) constituting pathological subjects, (2) neuroplasticity and “recovery,” and (3) the alleviation of guilt and shame via references to the “diseased brain.” On the basis of our analysis, we argue that dominant neuroscientific discourses produce patients as pathologized subjects, requiring medical treatment. We also contend that the intersection of neuroscientific and recovery discourses enacts “recovery” in terms of brain “recovery” through references to neuroplasticity. Further, when neuroscientific and moral discourses intersect, addicted subjects are absolved from the guilt associated with immoral behavior emerging from a “hijacked brain.” We conclude by emphasizing the need for future critical work to explore the complex ways in which neuroscientific discourses operate in localized care ecologies.

Recasting Participation in Drug Policy

Calls for “evidence-based policy” and greater community “participation” are often heard in the drug policy field. Both movements are in different ways concerned with the same questions about how “drug problems” ought to be governed and the place of “expertise” and “engagement” in democratic societies. However, these calls rely on the assumption that knowledges, publics, expertise, and issues of concern are fixed and stable, waiting to be addressed or called to action, thus obscuring ontological questions about what “participation” (be that lay or expert) may do or produce. There has been limited research in the drugs field that has taken “participation” as an object of study in itself and through critical examination attempted to open up new possibilities for its remaking. In this article, we draw on science and technology studies scholarship that has sought to illuminate the relations between public deliberation and government decision-making in public affairs involving technical claims and the generative capacity of such engagement (including for democracy itself). We describe various rationales for participation and examples of experiments that have sought to remake participatory processes in other policy domains. This literature provides fruitful ground for a reengagement with (and possibly a reconfiguration of) “evidence-based policy” or community “participation” in drug policy. Through this exploration, we hope to recast and more sensitively articulate the concept of “participation” in deliberations about public affairs involving technical claims in drug policy, thus opening up possibilities for experiments and practices that redistribute expertise, “slow down” reasoning, attend to emergent publics, and disrupt consensual claims as to “what counts” and what does not.

Introduction: cultivation, medication, activism and cannabis policy

Purpose

The purpose of this paper is to introduce the special issue on Illicit Cannabis Cultivation in a Time of Policy Change.

Design/methodology/approach

The paper reviews some of the different adaptations made by cannabis growers in countries where cannabis has not been legalised.

Findings

Cannabis growers are adjusting to different legal settings by focusing on home production. Participation in cultivation is a crime, but can also be activism: an effort to change the law. Medical use of cannabis is a particularly important driver here. Having to break the law to alleviate symptoms and treat illnesses provides both a greater sense of urgency and a level of sympathy not usually granted to illicit drug users.

Practical implications

Grass-roots advocacy may drive policy change.

Originality/value

This is an original assessment of current state of knowledge on cannabis cultivation in countries where cannabis cultivation remains restricted.

Drug Problematizations and Politics

This article puts in question the usefulness of the concept of “problem” or “problems” in alcohol and drug research and theory. A focus on problematizations is defended as a more effective political intervention. Particular attention is directed to the place of problematization as a mediating concept in understanding how practices constitute “objects” and “subjects,” a proposition commonly linked to “the ontological turn.” To access and analyze problematizations, the article puts forward a Foucault-influenced poststructural analytic strategy called “What’s the Problem Represented to be?” (WPR approach). Previously applied to the policy field, this article illustrates the usefulness of the WPR approach to interrogate the full range of governmental and knowledge practices. Examples of application of WPR from the alcohol and other drug field are highlighted throughout. The article extends this work by directing particular attention to the forms of politics facilitated through such an analytic strategy and to the importance of applying this form of questioning to one’s own propositions and policy proposals.

Prehending Addiction: Alcohol and Other Drug Professionals' Encounters With "New" Addictions

This article investigates the ways new forms of addiction are encountered by professionals working in the area of alcohol and other drugs. Combining interviews with policymakers, service providers, and peer advocates in three countries (Australia, Canada, and Sweden), and Mike Michael's utilization of the notion of prehension for science communication, we track the notions of addiction, drugs, and subjectivity that emerge when alcohol and other drug professionals encounter what Fraser, Moore and Keane call the addicting of nonsubstance-related practices. The analysis has three parts: constituting addiction unity, questioning addiction unity, and conflicting logics of addicting processes. We argue that specific articulations of drugs and health and specific health professional and addiction subjects are made anew in these encounters. These notions of drugs, health, and subjectivity shape how alcohol and other drug professionals engage with substance-related addictions. In concluding, we consider the implications of new addictions for professional practice.

"What constitutes a 'problem'?" Producing 'alcohol problems' through online counselling encounters

Typically, health policy, practice and research views alcohol and other drug (AOD) 'problems' as objective things waiting to be detected, diagnosed and treated. However, this approach to policy development and treatment downplays the role of clinical practices, tools, discourses, and systems in shaping how AOD use is constituted as a 'problem'. For instance, people might present to AOD treatment with multiple psycho-social concerns, but usually only a singular AOD-associated 'problem' is considered serviceable. As the assumed nature of 'the serviceable problem' influences what treatment responses people receive, and how they may come to be enacted as 'addicted' or 'normal' subjects, it is important to subject clinical practices of problem formulation to critical analysis. Given that the reach of AOD treatment has expanded via the online medium, in this article we examine how 'problems' are produced in online alcohol counselling encounters involving people aged 55 and over. Drawing on poststructural approaches to problematisation, we not only trace how and what 'problems' are produced, but also what effects these give rise to. We discuss three approaches to problem formulation: (1) Addiction discourses at work; (2) Moving between concerns and alcohol 'problems'; (3) Making 'problems' complex and multiple. On the basis of this analysis, we argue that online AOD counselling does not just respond to pre-existing 'AOD problems'. Rather, through the social and clinical practices of formulation at work in clinical encounters, online counselling also produces them. Thus, given a different set of circumstances, practices and relations, 'problems' might be defined or emerge differently-perhaps not as 'problems' at all or perhaps as different kinds of concerns. We conclude by highlighting the need for a critical reflexivity in AOD treatment and policy in order to open up possibilities for different ways of engaging with, and responding to, people's needs in their complexity.