1 Harm Reduction Programs and Policies, “Not In My Backyard” Mentalities, and the Canadian Criminal Justice System: An Exploratory Analysis Written by Samantha Vinje Under the Supervision of Dr. D. Scharie Tavcer An Honours Project submitted in partial fulfilment of the degree requirements for the degree of Bachelor of Arts - Criminal Justice (Honours) Mount Royal University April 2024 2 Copyright 2024 Samantha Vinje ALL RIGHTS RESERVED This thesis was completed by Samantha S. Vinje. All rights reserved to the information provided within this document. MOUNT ROYAL UNIVERSITY CALGARY, ALBERTA, CANADA 3 Table of Contents Abstract..................................................................................................................................... 5 Dedications and Acknowledgements...................................................................................... 6 PART I: BACKGROUND List of Abbreviations................................................................................................................7 Harm Reduction Programs and Policies, “Not In My Backyard” Mentalities, and the Canadian Criminal Justice System: An Exploratory Analysis............................................ 8 Definition............................................................................................................................. 9 “Not In My Backyard” and Social Exclusion...................................................................... 10 General Strain Theory........................................................................................................ 11 Public Health Versus Criminality Discourses.................................................................... 12 Research Aims and Objectives..............................................................................................12 Methodology...................................................................................................................... 14 Integrative Literature Review.............................................................................................15 Methodological Framework............................................................................................... 15 Data Collection Methods and Sources..................................................................................16 Limitations................................................................................................................... 17 Data Analysis.......................................................................................................................... 18 PART II: THEORY FOCUS Theoretical Framework......................................................................................................... 18 General Strain Theory........................................................................................................ 19 Strain Pathways............................................................................................................ 21 Adaptations to Strain.................................................................................................... 25 Disposition for Delinquency........................................................................................ 27 Predicting the Use of Delinquent Versus Non-Delinquent Adaptations...................... 27 Not In My Back Yard......................................................................................................... 29 Critiques of “Not In My Backyard”............................................................................. 30 Harm Reduction................................................................................................................. 30 Six Principles of Harm Reduction................................................................................31 PART III: MEDICAL FOCUS Tracing the Opioid Crisis in Canada Post 2000s................................................................. 32 Opioid Use............................................................................................................................... 34 Substance Use Disorder..................................................................................................... 35 Opioid Use Disorder...........................................................................................................35 Health Statistics...................................................................................................................... 36 Self-Reported Opioid Use.................................................................................................. 36 The Public Health Agency of Canada................................................................................ 37 Apparent Opioid Toxicity Deaths.................................................................................37 Hospital and Emergency Department Use................................................................... 38 Emergency Medical Services....................................................................................... 38 4 Disproportionate Harms to Indigenous Peoples in Alberta................................................39 Harm Reduction Programs or Policies Targeting Opioid Use........................................... 39 Safer Supply Programs.......................................................................................................39 Medication-Assisted Treatment..........................................................................................40 Supervised Consumption Sites...........................................................................................40 Statistics....................................................................................................................... 41 Overdose Prevention Sites................................................................................................. 42 Barriers to Receiving Health Care........................................................................................42 PART IV: CRIMINAL JUSTICE FOCUS The Controlled Drug and Substances Act............................................................................43 Insite - Canada’s First Iteration of a Safe Consumption Site............................................. 44 Drug Analysis Services...................................................................................................... 45 Statistics...................................................................................................................................46 Police Reported Crime Rates............................................................................................. 46 Limitations................................................................................................................... 46 Correctional Service Canada.............................................................................................. 47 Drug Treatment Courts.......................................................................................................48 Area Restrictions.......................................................................................................... 50 PART V: DISCUSSION Findings................................................................................................................................... 51 Enforcement Fatigue and Lack of Deterrence....................................................................53 Geographic Considerations for Alberta..............................................................................54 Increasing Toxicity of Drug Supply............................................................................. 55 Public Support as a Barrier for the Implementation of Harm Reduction Programs and Policies............................................................................................................................... 56 Stigma as a Source of Strain.............................................................................................. 57 Structural Factors............................................................................................................... 58 Discussion................................................................................................................................ 60 Limitations......................................................................................................................... 62 Recommendations for Future Research............................................................................. 63 Conclusion...............................................................................................................................64 References............................................................................................................................... 66 Appendix A............................................................................................................................. 77 Appendix B..............................................................................................................................78 Appendix C............................................................................................................................. 79 Appendix D............................................................................................................................. 80 Appendix E..............................................................................................................................81 Appendix F..............................................................................................................................82 Appendix G............................................................................................................................. 83 Appendix H............................................................................................................................. 85 5 Abstract This project explored harm reduction programs and policies in Canada targeting opioid use, their context in the criminal justice system, and how “Not In My Backyard” (NIMBY) mentalities affect their implementation. Despite the evidence surrounding the effectiveness of harm reduction programs in reducing opioid-related harms, such as safe consumption sites (SCS), governments and communities are hesitant to implement them. This project used an exploratory sequential integrative literature review for its research design and used symbolic interactionism as the methodological framework. The population of interest in this study is people with living and lived experiences using drugs (PWLLE), especially those using synthetic opioids. Although NIMBY was not mentioned as a barrier specifically in literature, stigma was identified as a significant contributor to the opioid crisis. Stigma as a source of strain seems to drive not only criminal justice contact but also increased health issues in the context of opioid overdoses. Finally, structural factors and the lack of currently available care options for PWLLE were discussed. There are critical geographical considerations for Alberta, including the increasing toxicity of the drug supply due to the presence of “street” fentanyl. Findings from this project include themes of enforcement fatigue, and the lack of deterrence drug laws provide. Despite the immense harms PWLLE encounter, some of which could be reduced with government intervention (i.e., decriminalization, regulated drug supply), there has been little political action in Alberta to date. The lack of action in Alberta and elsewhere perpetuates stigma by signalling that PWLLE are not deserving of government support. 6 Dedications and Acknowledgements Dedications Thanks to the Calgary Alpha House Society, my time working with clients inspired my research question. This paper is dedicated to the clients I worked with who have passed that I know of: K.B., C.B., M.A., B.G., W.M., M.W., G.B., L.S., W.S.; C.M.; V.S.; A.B.; and those whose passing I will not learn about. Acknowledgements Thanks to my parents for always supporting me throughout my educational journey. Thanks to L.L., who always reminded me that it takes a certain type of person to be an advocate, and we should advocate for ourselves every day by choosing happiness. Thank you to all of my Criminal Justice professors for sharing your knowledge and showing grace and kindness in your teachings. To Dr. Scharie Tavcer, a special thanks for your invaluable supervision throughout this project and for encouraging the sharing of knowledge to deepen our understanding. And to Dr. Harpreet Aulakh and Doug King, your guidance throughout the honours seminar and the encouragement to pursue further studies have been instrumental in my academic growth. Land Acknowledgement Mount Royal University is located in the traditional territories of the Niitsitapi (real people) and the people of Treaty 7, which includes the Siksika, the Piikani, the Kainai; and the Tsuut'ina, and the Îyârhe Nakoda. We are situated on land where the Bow River meets the Elbow River, and the traditional Blackfoot name of this place is Mohkinstsis, which we now call the City of Calgary. The City of Calgary is also home to the Métis Nation. 7 List of Abbreviations AAOTD: Accidental apparent opioid NIMTO: Not in my term of office toxicity death OAT: Opioid antagonist therapy AOTD: Apparent opioid toxicity death ODP: Overdose prevention sites BC: British Columbia OPS: Overdose prevention services CDSA: Controlled Drugs and Substances OUD: Opioid use disorder Act PWID: People who inject drugs CJS: Criminal justice system PWLLE: People with living and lived DTC: Drug treatment courts experiences using drugs ED: Emergency department PWUD: People who use drugs EMS: Emergency medical services SODA: Stay out of drug areas GST: General strain theory SCS: Safe consumption sites HIV: Human immunodeficiency virus SIS: Safe injection site HR: Harm reduction SSP: Safer supply programs MAT: Medically-assisted treatment SU: Substance use NFO: Non-fatal overdose SUD: Substance use disorder NIMBY: Not in my backyard 8 PART I: BACKGROUND Harm Reduction Programs and Policies, “Not In My Backyard” Mentalities, and the Canadian Criminal Justice System: An Exploratory Analysis Canada is facing the multifaceted challenges of substance use (SU), notably the surge in opioid-related harms. The Public Health Agency of Canada (PHAC) reports 42,494 “apparent opioid toxicity deaths” (AOTD) between January 2016 and September 2023 (Health Canada, 2024b, para. 2). Most harms associated with opioids are caused by synthetic opioids, such as fentanyl (Health Canada, n.d.). Misuse of prescription and synthetic opioids is a primary contributor to the ongoing overdose crisis in North America (Crepeault et al., 2023). The increase in prevalence of fentanyl and its analogs has escalated the crisis, with the introduction of highly potent and synthetic opioids into the illegal drug market (Enns et al., 2023; Mitra et al., 2020). The COVID-19 pandemic resulted in supply-chain disruptions, combined with a long-term shift in the opioid drug supply, resulting in heroin being primarily replaced in the drug supply by these other forms of opioids (Enns et al., 2023). When it is not taken exactly as prescribed, life-threatening effects can occur within 2 minutes of fentanyl use (Health Canada, 2023b). Fentanyl is odourless and tasteless, so an individual may not know they have consumed it, with a high risk of accidental overdose. Fentanyl enters the Canadian illicit drug market in three ways: the illegal importation, the illegal production from laboratories in Canada, and the theft of medical fentanyl products (Health Canada, 2023b). Fentanyl is controlled under Schedule I of the Controlled Drugs and Substances Act (CDSA) and is a cheap and street-accessible drug. The current landscape of substance use in Canada involves a complex interplay between the criminal justice system (CJS) and community-based interventions. The overdose crisis has taken thousands of lives in Canada, with death rates exceeding epidemic levels (i.e., beyond 15.0 per 100,000 people) (Marshall et al., 2021). The 2022 death rate from opioid 9 overdose in Canada was 18.8 per 100,000 population, with Alberta exceeding this rate at 33 deaths per 100,000 population (Government of Canada, 2023). Along with the increase in the number of fatal overdoses in Canada, the number of non-fatal overdoses (NFO) is also proportionally increasing (Crepeault et al., 2023). However, there has been little political action because drug use is seen as a deviant and criminal act that should be punished (Petrasko, 2023). Comparatively, the police-reported crime rate of opioid-related offences (ORO) in Canada in 2021 was 16 per 100,000 population (Moreau, 2022). The lack of urgency in declaring the overdose epidemic a national health emergency indicates how governments view the lives of people with living and lived experiences using drugs (Petrasko, 2023). Given that the risk of overdose harms and deaths intersect with multiple forms of structural marginalisation, it is vital to understand how designing, implementing, and evaluating harm reduction strategies can best reduce the burden of the opioid crisis on these already stigmatised and vulnerable populations (Milaney et al., 2022). Harm reduction (HR) is “an evidence-based, client-centred approach that seeks to reduce the health and social harms associated with addiction and substance use, without necessarily requiring people who use substances from abstaining or stopping” (Ontario Canadian Mental Health Association, n.d., para. 1). While the current overdose crisis is primarily physiologically attributed to fentanyl, some researchers attribute the core of the crisis to be due to stigma (Bowles et al., 2024), structural vulnerabilities (McNeil et al., 2015), and colonial violence (Lawson, 2020). This paper is split into five sections: (I) background, (II) theory focus, (III) medical focus, (IV) criminal justice focus, and (V) discussion. Definition When writing about issues associated with drug use, person-first language is needed to offset stigmas (Bowles et al., 2024). For notes on vocabulary, see Appendix A. While 10 “People who use drugs” (PWUD) is a common term to describe “drug user(s),” it does not account for everyone who should be involved in drug policy advocacy (Arlt, 2023, p. 1). Since this project is a literature review, not all of the individuals in the studies included currently use drugs. “People with living and lived experiences of drug use” (PWLLE) is a more temporally expensive term that allows for a variety of encounters with drugs throughout one’s life (Arlt, 2023). In this current paper, PWUD is the term for people actively using drugs, which is an important distinction when discussing harms associated with active SU. PWLLE will be the term used more broadly. Substance use (SU) includes illicit or licit drugs. Opioid use disorder (OUD) is a subset of substance use disorder (SUD). Not all PWLLE have SUD. “People who inject drugs” (PWID) is a distinction of PWUD. “Not In My Backyard” and Social Exclusion NIMBYism contributes to a cycle of stigma and displacement, resulting in the disruption of accessibility to services and support for people experiencing social exclusion (HomelessHub, 2023), and NIMBY advocates tend to be primarily white and upper-middle-class residents. At the same time, the targets of their opposition are often from minority communities, “NIMBY attitudes are often reinforced by underlying notions of inequality related to race, class, gender, and (dis)ability” (HomelessHub, 2023, p. 23). NIMBY facilities include risk-gathering amenities and polluting facilities (e.g., nuclear power plants and sewage treatment plants), but also those that create a sense of unhappiness (e.g., drug rehabilitation centres, homeless shelters, prisons) (Bao et al., 2023). The presence of NIMBY attitudes allows city councils, businesses, and neighbourhood organisations to justify policies and practices aimed at keeping neighbourhoods safe without addressing the core issues surrounding homelessness, such as the continued reliance on the police to manage homelessness (HomelessHub, 2023). These attitudes reinforce stigma by framing an already structurally vulnerable population as a threat 11 that needs to be removed from public spaces (McNeil et al., 2015). Social pain is the process by which rejection and exclusion recruit similar neural circuits as physical pain, mirroring the response one feels from physical trauma (Abrutyn, 2023). These findings are significant because social pain can be seen as a source of strain, and people who are unhoused face multiple and intersecting forms of exclusion, ranging from criminalization to being rendered invisible (HomelessHub, 2023). General Strain Theory Robert Agnew’s (1992) general strain theory (GST) is written at the social-psychology level with adolescents in mind. It focuses on negative relationships with others and the negative states (e.g., anger) that result from these relationships. These negative emotions create pressure for corrective action. Another essential aspect of GST is that not everyone reacts to strain by engaging in criminal activity (Asselin, 2011). Strain may lead adolescents to follow three paths: make use of illegitimate channels of goal achievement, attack or escape from the source of their adversity, or manage their negative affect (i.e., emotional state) through the use of illicit drugs (Agnew, 1992). Agnew’s (1992) theory focuses on three main types of strain: ​ ● Strain as the actual or anticipated failure to achieve positively valued goals, ​ ● Strain as the actual or anticipated removal of positively valued stimuli; and ​ ● Strain as the actual or anticipated presentation of negatively valued stimuli. Experiencing each type of strain increases the likelihood of individuals experiencing emotions such as disappointment, depression, fear, and anger (Agnew, 1992). Individuals may cope by acting directly on the negative emotions that result from adversity. Several emotional coping strategies, such as SU, exist (Agnew, 1992). The focus is on alleviating the negative emotions rather than cognitively reinterpreting or behaviorally altering the situation that produced those emotions (Agnew, 1992). Emotional coping is especially likely when 12 behavioural and cognitive coping are unavailable or unsuccessful (Agnew, 1992). This paper explored NIMBY as a potential source of strain and how the medical and criminal models of discourse surrounding substance use differ. If social exclusion causes the same effects as physical trauma, how do HR programs and policies targeting opioid use mediate this? Public Health Versus Criminality Discourses The role of the CJS in controlling SU and addiction includes drug treatment courts (DTC) and specialised programs in federal prisons, including prison needle exchange programs, overdose prevention services (OPS), and national substance abuse programs (Relow & Birnbaum, 2023). Community management of SU and addiction include supervised consumption sites (SCS), overdose prevention sites (ODP), drug checking services, take-home naloxone programs, safer supply programs (SSP), needle syringe programs and street outreach services (Relouw & Birnbaum, 2023). For an overview of community-based HR programs, see Appendix B. Ezukuse (2021) raises the issue that federal and provincial policy documents present competing public health versus criminality discourses. Without an exemption from the provisions of the CDSA, users and operators of SCS are exposed to the risk of criminal prosecution for certain substance-related offences (such as possession or trafficking). SCS is a health intervention, but because its federal policy is included in the CDSA, it is framed as a crime requiring a solution (Ezukuse, 2021). Research Aims and Objectives This research explored the Canadian opioid crisis, HR approaches in the context of the criminal justice system, and the effect of NIMBYism or “Not In My Backyard” mentalities, on the implementation of HR programs and policies targeting opioid use. One particular area of interest was the growing proportion of overdose deaths physically occurring in outdoor locations in Alberta (see Appendix C). The target population of interest in this 13 study were individuals who are most likely to experience opioid-related harms in medical or criminal justice contexts (e.g., deaths from opioid toxicity, incarceration for possession). After a preliminary literature review, this population seems to be adult males who are unhoused and using non-pharmaceutical opioids (e.g., “street” fentanyl). There is a wide range of HR programs and policies, such as housing-first practices and policies, and this project focused specifically on those targeting opioid use. Research questions: 1. How is NIMBYism a vehicle to reinforce the inequality of legitimate opportunities for PWUD in Canada? 2. If illicit drug use is an adaptation to strain, how does the closure of SCS and similar programs affect PWUD? Reflexivity Statement I worked as an addictions outreach worker through a homeless shelter and HR agency between April 2022 - September 2023. I had two prominent roles: providing non-emergency crisis transportation and acting as a case manager. During my time, I reversed several overdoses and made many client referrals to HR programs and agencies. My peers, colleagues, and clients all had differing levels of acceptance of HR and specific practices, such as housing-first mentalities or the distribution of supplies (such as clean needles). I appreciated the agency’s mentality of meeting clients where they are, and as this was my first role in the field, I saw tremendous value in HR. I was no longer in my position or had any conflicts of interest when I began data collection. Research Design The research design was an exploratory sequential integrative literature review, and the methodological framework was symbolic interactionism. No ethics approval was required for this project. 14 Methodology The literature reviewed in this project was varied and used mixed methods. Mixed methods research includes a qualitative and quantitative component, integration of the methodologies, and an enhanced understanding built on the strengths of both approaches (Wilkes et al., 2023). Using multiple methods to study a topic of interest can increase confidence in the findings. Multiple sources of evidence support the findings through triangulation by using multiple methods to study a topic of interest (Wilkes et al., 2023). Integrating methods allows researchers to draw on both methods’ strengths, such as achieving validity through qualitative methods and achieving reliability and generalizability through quantitative approaches (Wilkes et al., 2023). Mixed methods research, therefore, has the potential to provide generalizability to qualitative findings and context or deeper explanations of quantitative results (Wilkes et al., 2023). No set of quality standards is widely used for mixed methods research. However, Wilkes et al. (2023) discuss two frequent quality indicators. The first is through an in-depth description, including the priority and timing of the qualitative and quantitative components. Priority describes if the study places more importance on quantitative or qualitative results, and timing refers to the temporal order of data collection and analysis (Wilkes et al., 2023). Concurrent designs collect and analyze quantitative and qualitative data simultaneously or independently of each other, while sequential designs refer to collecting and analysing one component followed by another (Wilkes et al., 2023). The second quality indicator discussed refers to integrating both quantitative and qualitative results. Any mention of the interaction between qualitative and quantitative data can serve as evidence of integration at multiple phases of research; integration in the results and discussion sections is of primary concern (Wilkes et al., 2023). 15 Integrative Literature Review A literature review systematically collects and synthesises previously collected research, advancing knowledge and theory development (Snyder, 2019). An integrative literature review aims to assess, critique and synthesise the literature to enable new frameworks and perspectives (Snyder, 2019). The integrative review method is the only approach that combines diverse methodologies, such as experimental and theoretical research and can summarise past literature on a topic of interest to provide a more comprehensive understanding (Whittemore & Knafl, 2005). A mixed studies review aims to address the same overlapping or complementary review questions by combining the strengths of both qualitative and quantitative studies (Whittemore et al., 2014). The integrative review method can incorporate diverse methodologies to capture the topic’s context, processes and subjective elements (Whittemore et al., 2014). In addition, integrative reviews incorporate a wide range of purposes, such as defining concepts and reviewing theories and evidence on a particular topic (Whittemore & Knafl, 2005). The integrative review method is best suited for synthesising knowledge on primary research combined with methodological or theoretical manuscripts (Whittemore et al., 2014). An integrative literature review consists of five stages: problem identification, literature search stage, data evaluation, data analysis, conclusion drawing and verification, and presentation (Whittemore & Knafl, 2005). Methodological Framework Symbolic interactionism was used as the methodological framework to approach this study. Carter and Fuller (2016) describe social interactionism as a theory rooted in sociology “that addresses how society is created and maintained through repeated interactions among individuals” (para. 1.). Herbert Blumer, who developed the main variant, viewed social institutions existing only as individuals interact; “society is not a structure but rather a 16 continuing process” (Carter & Fuller, 2016, para. 7). Individuals in society, called actors, place meanings upon entities that are perceived as unique. Data Collection Methods and Sources This project used secondary data for the raw data collection. Secondary data was sufficient for this project due to the time limitations and the breadth of knowledge on this topic. Journals outside the discipline of criminal justice or criminology were included if deemed relevant, such as interdisciplinary journals, including social work, sociology, psychology, and health journals. Dissertations and theses that discuss NIMBY and opioid use or the criminal justice system were included when there was not enough available peer-reviewed literature on the topic. ● Search terms: ○ “harm reduction” or “safe injection” or “supervised injection” AND Canada (or cities within Canada, such as Calgary and Vancouver) AND “NIMBY” AND “strain theory” AND zoning AND community. ● Search engines: ○ Mount Royal University library website, using the search terms above. ○ Google Scholar, using the search terms above. ● Collected grey literature, including: ○ Government reports from Statistics Canada and the Public Health Agency of Canada on opioid use and the associated harms. This project used the Library of Parliament website to search research publications using the search term “substance use” and other research published by agencies, such as the Canadian Centre on Substance Use and Addiction. 17 ○ Agency publications from social agencies, such as “history of harm reduction in Canada,” were searched. For example, the history of agencies such as Insite in Vancouver was examined. ● Since the first safe injection facility (i.e., safe consumption site) opened in Vancouver in 2003, this project excluded literature related to HR in Canada older than 2003. ● Since national surveillance of fentanyl in Canada began in 2016, this project focused on gathering literature on substance use and opioid use in Canada past 2016. ● Canadian literature was prioritised wherever possible, unless applicable, such as for theories. For example, studies looking at recidivism rates of offenders who receive substance abuse disorder treatment in the United States were excluded. The Canadian and American criminal justice systems operate differently and are not necessarily transferable. However, non-Canadian literature that discusses HR, strain theories, stigma, or other applicable themes was included. ● Due to time constraints, literature regarding needle exchange programs in federal prisons in Canada was excluded. Needle exchange programs were briefly mentioned as a part of supervised consumption services in the medical focus of this project. ● Only publications in English were included. Limitations The integrative literature review has been critiqued for its potential for bias and lack of quality research methodology, and therefore, any sampling decision must be justified and made explicit (Whittemore & Knafl, 2005). The literature search process of an integrative review should be clearly documented in the method section, including the search terms, the databases used, additional search strategies, and the inclusion and exclusion criteria (Whittemore & Knafl, 2005). Limitations include the length of the study, as data collection was limited to a few months (September 2023 to April 2024), and studies that may have 18 added value if time allowed were not included. Initially, this project planned to explore the opioid crisis throughout Canada and tailor the analysis to Alberta, as a preliminary literature review emphasised the significance of locally grounded evaluations for effective HR implementation. However, due to time constraints and the differences in reporting health and crime statistics by different agencies and geographic areas, this study focuses more on Western Canada and, where possible, specifies if a study was conducted in Alberta. Data Analysis Sequential synthesis design was used for data analysis (see Appendix D). Exploratory sequential design involves using qualitative data in the first phase of the research, followed by the quantitative phases being informed by the qualitative results (Wilkes et al., 2023). Elements of data analysis include noting patterns and themes, seeing plausibility, clustering, counting, making contrasts and comparisons, finding intervening factors, and building a logical chain of evidence (Whittemore & Knafl, 2005). The sequential synthesis design uses complementary qualitative and quantitative evidence, such as quantitative studies to generalise qualitative findings or qualitative studies to interpret or explain some qualitative findings (Hong et al., 2017). The discussion should reflect the added value and insight from combining qualitative and quantitative evidence in the literature review (Hong et al., 2017). Within each review, one or several synthesis methods could be used. The synthesis process could be quantitative, qualitative, or mixed (Hong et al., 2017). This project used grouping and clustering, textual description, and narrative synthesis for the qualitative synthesis methods. PART II: THEORY FOCUS Theoretical Framework For the theoretical framework section of this project, three main theories were looked at: general strain theory, NIMBY, and general HR principles. GST was written with 19 adolescents in mind and is a theory of crime and deviance. However, strain can be responded to by SU, suggesting this theory also applies in the context of the opioid crisis in Canada. One example of strain is that beyond over-policing, low-income Canadians are more likely to be detained when they are arrested, to be denied bail, to plead guilty to a charge, and to struggle to reintegrate (Lawson, 2020). Homelessness in Canada is also associated with a lifetime history of NFO and an increased risk for comorbid conditions, such as physical and mental health problems (Crepeault, 2023). The structural vulnerabilities PWLLE face across healthcare and medical systems was an area of interest. This section also explores NIMBY theory to undercover the potential relationships to strain PWLLE face. Lastly, HR as a theory and generalizable principles are examined, which could have implications for the CJS. General Strain Theory Agnew (1992) created a foundation for a general strain theory (GST) of crime and delinquency to overcome the criticisms of previous classical strain theories. One classical strain theorist is Merton, whose sociological anomie theory of deviance (1938) seeks to explain how some social structures pressure certain people in society who engage in nonconformist rather than conformist conduct to achieve socially prescribed goals. The earlier models of strain theory developed by Merton (1938) only focused on one type of negative relationship: relationships in which others (e.g., individuals, societal structures, or cultural realities) prevent the individual from achieving positively valued goals. Achieving monetary success and the “American Dream” are goals particularly important to the perspective of classical strain theory (Asselin, 2011; Menard, 1995). Merton’s strain theory assumes a shared cultural value system that prescribes social goals, and failure to achieve these goals results in frustration (Asselin, 2011). This frustration produces a sense of anomie or normlessness, whereby individuals who do not have the conventional means to achieve their goals reinvent their goals or innovate new criminal means to achieve them (Asselin, 20 2011). According to Merton’s theory, anomie exists when there are both universally prescribed success goals and inequality of legitimate opportunity to attain culturally prescribed success goals (Menard, 1995). Anomie is a social-structural condition rather than an individual one, and Merton argued that the effects of anomie may vary within social classes (Menard, 1995). Anomia (anomie at the individual level) recognizes that one lacks the culturally approved means to achieve culturally approved goals (Menard, 1995; Merton, 1938). While GST does not dismiss this notion, goals defined in GST are much more subjective and flexible (Asselin, 2011). Strain is redefined as any event, issue or relationship in one’s life that is perceived negatively (Asselin, 2011). The goal blockage described by Merton (1938) focuses on the goal blockage experienced by the lower-socioeconomic class individual trying to achieve monetary success or middle-class status (e.g. the American Dream). In contrast, GST is viewed as a result of pressure from negative relationships with others involving failure to achieve valued goals, removal of positively valued stimuli, or exposure to negative stimuli (Teijón-Alcalá & Birkbeck, 2019). Agnew (1992) describes the major adaptations to strain and those factors influencing the choice of delinquent (e.g., committing a crime to obtain money) versus non-delinquent adaptations (e.g., getting a job to obtain money). Another critical aspect of GST is how individuals cope with stressful life experiences: not everyone reacts to strain by engaging in criminal activity (Asselin, 2011). These negative emotions create pressure for corrective action, and according to Agnew (1992), may lead adolescents to follow three paths: ​ ● Make use of illegitimate channels of goal achievement, ​ ● Attack or escape from the source of their adversity or; ​ ● Manage their negative emotions through the use of illicit drugs. 21 Strain may also lead to multiple criminal coping strategies (e.g., vengeful behaviour and use of illicit drugs) (Baron, 2004). Experiencing each type of strain increases the likelihood that individuals will experience one or more negative emotions (e.g., disappointment, depression, fear, and anger) and stressors from multiple sources can accumulate and contribute to delinquency involvement (Wemmers et al., 2018). Agnew notes that anger is the most critical emotional reaction for GST (Wemmers et al., 2018). This emotional reaction is because emotions create pressure for corrective actions, lowering inhibitions and leading to different possible responses, including crime (Teijón-Alcalá & Birkbeck, 2019; Wemmers et al., 2018). Anger, therefore, affects the individual in several ways that are conducive to delinquency because anger results when individuals blame their adversity on others and believe that their aggression is justified (Agnew, 1992). Delinquency may still occur in response to other negative emotions, such as despair. However, it is less likely because depressive emotions like despair and hopelessness are related to deviant coping mechanisms like the use of drugs and alcohol (Asselin, 2011). Agnew (1992) identifies several cognitive, behavioural and emotional coping strategies, which all emphasise that most individuals may be able to cope with strain through legitimate (i.e., non-delinquent) channels of activity (Asselin, 2011). Strain Pathways Agnew’s GST focuses on the types of strain rather than the sources. Agnew (1992) describes three significant types of strain: ​ ● Strain as the actual or anticipated failure to achieve positively valued goals, ​ ● Strain as the actual or anticipated removal of positively valued stimuli and; ​ ● Strain as the actual or anticipated presentation of negatively valued stimuli. ​ 22 While these three strain types are theoretically distinct, they may sometimes overlap in practice (Agnew, 1992). For a summary overview of Agnew’s strain pathways, see Appendix E. Strain as the Failure to Achieve Positively Valued Goals. Agnew (1992) notes that the first type has at least three types of strain under this category: ​ ● The disjunction between aspirations and expectations (or actual achievements), ​ ● Strain as the disjunction between expectations and actual achievements and; ​ ● Strain as the disjunction between just or fair outcomes and actual outcomes. Strain as the Disjunction Between Aspirations and Expectations. Merton has described the first strain type as the disjunction between aspirations and expectations (or actual achievements) (Agnew, 1992). The goal of monetary success or the American Dream is vital in classical strain theory (Asselin, 2011), with the inability to achieve monetary success being considered a significant source of strain. Merton (1938) identified two essential elements of social and cultural structure that support those goals. The first element is the culturally defined goals, purposes, and interests. The second element is the social structure, which defines, regulates, and controls the acceptable modes of achieving these goals (Merton, 1938). Merton defines success in terms of the product, process, outcome, and activities. The same set of success symbols is held to be desirable by most people in society, which creates a social order that produces pressure to outdo one’s competitors (Menard, 1995; Merton, 1938). However, the accessibility of achieving these goals depends on the social organisation of society. Cultural goals are argued to be equally distributed amongst the population, but the means to achieve them are not (Asselin, 2011). These goals are passed down and maintained by three major institutions: the family, the school, and the workplace (Merton, 1938). 23 Strain as the Disjunction Between Expectations and Actual Achievements. The second strain type is the disjunction between expectations and actual achievements (Agnew, 1992). Agnew notes that this assigns a primary role to the social comparison process, as it plays a central role in forming individual goals or expectations. These findings are consistent with social cognitive theory (SCT). SCT is a theory of human intent and behaviour that extends internal determinants to the outside and is recognized as the established theory for exploring patterns of behaviour (Bao et al., 2023). It points out that people’s intended behaviour, or behaviour pattern, is controlled and shaped by personal and environmental factors (see Appendix F). A person’s expectations are directly influenced by their environment and have important implications for socially excluded people. For example, the implementation of NIMBY facilities, such as drug rehabilitation centres, could then recondition individuals in the surrounding environment to reassess how they view PWUD. Strain as the Disjunction Between Just or Fair Outcomes and Actual Outcomes. The third type of strain is the disjunction between just or fair outcomes and actual outcomes (Agnew, 1992). This theory claims that individuals do not necessarily enter interactions with specific outcomes in mind. Instead, they enter interactions expecting that distributive justice rules will be followed, meaning rules exist specifying how resources should be allocated (Agnew, 1992). An equitable relationship is one in which the outcome or input ratios of the actors involved in an exchange or allocation relationship are equivalent (Agnew, 1992). The outcome encompasses many positive and negative consequences, while inputs encompass the individual’s positive and negative contributions to the exchange. Individuals in a relationship will compare their outcomes and inputs to the ratio of specific others (Agnew, 1992). If the ratios are equal, the individual feels that the outcomes are fair and just, even if the outcomes are low (Agnew, 1992). 24 Using GST, Baron and Macdonald’s (2020) research explores whether extensive police contact and perceptions of procedural injustice are linked with each other and if they are associated with drug use. The researchers used a sample of 449 individuals aged 16-30 years in three municipalities in British Columbia (BC) between 2017 and 2018. For analysis, they used ordinary least squares (OLS) regressions for analysis with their findings suggesting that police contact has a direct relationship with drug use. However, it also has an indirect relationship mediated by procedural justice (Baron & Macdonald, 2020). Economic dissatisfaction, homelessness, legal cynicism, and drug-using peers are also associated with greater drug use (Baron & Macdonald, 2020). These findings are essential, as they suggest procedural justice can mediate the relationship between police contact and drug use, which could inform best practices on dealing with these populations to avoid increasing harm and potential SU as a result. Strain as the Removal of Positively Valued Stimuli from the Individual. Strain may involve more than the pursuit of positively valued goals. Agnew notes that the blockage of goal-seeking behaviour is a relatively weak predictor of aggression, mainly when the particular goal has never been experienced. However, aggression often occurs when positive reinforcement previously administered to an individual is withheld or reduced (Agnew, 1992). These theoretical findings suggest that an individual who has not accessed an SCS will not experience the same level of subjective strain as a person who actively used the sites and had them removed. Strain as the Presentation of Negative Stimuli. Delinquency and aggression have been linked to numerous noxious stimuli such as child abuse and neglect, criminal victimization, physical punishment, hostile relations with parents or peers, verbal threats and insults, physical pain, and a wide range of stressful life events (Agnew, 1992). 25 Adaptations to Strain Agnew describes a typology of the significant cognitive, emotional, and behavioural adaptations to strain. For a summary and overview of the adaptations to strain Agnew lists, see Appendix G. Individuals may employ multiple strategies, and others may not have been listed. Agnew (1992) notes that these three coping strategies constitute the primary responses to strain but are not the only adaptations possible (i.e., others, such as distraction, exist). Cognitive Coping Strategies. Individuals sometimes cognitively reinterpret objective stressors to minimise their subjective adversity. Agnew (1992) identified three cognitive coping strategies: ● Ignoring or minimising the importance of adversity, ● Maximising positive outcomes and minimising adverse outcomes and; ● Accepting responsibility for adversity. Ignoring or Minimising the Importance of Adversity. The subjective impact of objective strain depends on how much the strain relates to the individual’s central goals, values, or identities (“goals” for brevity). Individuals can minimise the strain they experience by reducing the absolute or relative importance assigned to their goals (Agnew, 1992). Therefore, people pursue various goals and tend to place the most significant emphasis on those they are most likely to achieve. Maximise Positive Outcomes and Minimise Negative Outcomes. Individuals can attempt to deny the existence of their adversity by maximising the positive outcomes or minimising the negative outcomes (Agnew, 1992). The first is lowering the standards used to evaluate outcomes or distorting one’s estimate of current or expected outcomes. Lowering one’s standards involves lowering one’s goals or raising one’s threshold for negative stimuli. In a “downward comparison,” individuals claim that their situation is less harmful or at least no worse than that of similar others (Agnew, 1992, p. 68). “Compensatory benefits” are when 26 an individual casts a positive attribute or circumstance within a troubling situation (Agnew, 1992, p. 68). The person is aided in ignoring what is noxious by anchoring their attention to what they consider the more rewarding aspects of the experience (Agnew, 1992). Accept Responsibility for Adversity. Agnew (1992) notes that undeserved strain may violate the equity principle and create fear that the strain will be repeated. Individuals can employ two strategies to combat this. The first is by cognitively minimising their positive inputs or maximising their negative inputs to a relationship (Agnew, 1992). Inputs contribute to the relationship or status characteristics believed to be relevant to the relationship. The second strategy is when individuals maximise the positive or minimise the negative inputs of others (Agnew, 1992). Behavioural Coping Strategies. There are two major behavioural coping strategies: those seeking to minimise or eliminate the source of strain and those seeking to satisfy the need for revenge (Agnew, 1992). Agnew suggests that strain creates pressure or an incentive to use crime or drugs as a coping strategy (Baron, 2004). For example, SU can soothe the psychological distress and negative emotions associated with strain (Baron, 2004). Maximising Positive Outcomes or Minimising Negative Outcomes. Maximising positive or minimising negative outcomes can assume several forms, paralleling the major strains with actions that may involve conventional or delinquent behaviour (Agnew, 1992). Vengeful Behaviour. When adversity is blamed on others, it creates a desire for revenge distinct from the desire to end the adversity (Agnew, 1992). Similarly, aggression allows people to terminate certain types of strain or gain revenge against the perpetrators (Baron, 2004). Vengeful behaviour may assume conventional or delinquent forms, but the potential for delinquency is high (Agnew, 1992). 27 Disposition for Delinquency Agnew (1992) notes that each strain type may create a disposition for delinquency or function as a situational event that instigates a particular delinquent act. Strain creates a predisposition for delinquency in chronic or repetitive cases, and Agnew notes four factors when examining the impact of adverse events (i.e., strain): the extent to which they are more significant in magnitude or size, the recency, being of long duration, and clustered in time. For a summary overview of these factors, see Appendix H. Events closely clustered in time have a more significant effect on adverse outcomes, as they are more likely to overwhelm coping resources than events spread more evenly over time (Teijón-Alcalá & Birkbeck, 2019). As the number of stressors or strains increases, so does the likelihood of engaging in delinquent behaviour (Teijón-Alcalá & Birkbeck, 2019; Wemmers et al., 2018). Although general strains are associated with delinquency and victimization, polyvictimization is more strongly associated with delinquency than non-victimization adverse events (Wemmers et al., 2018). In addition, whether or not individuals respond to sources of strain with crime depends upon their coping strategies (i.e., cognitive coping is not criminal) (Agnew, 1992). Predicting the Use of Delinquent Versus Non-Delinquent Adaptations. The factors identified by Agnew (1992) listed below affect an individual’s choice of coping strategies by affecting the constraints to non-delinquent and delinquent coping and the disposition to engage in non-delinquent and delinquent coping. Constraints to Non-delinquent and Delinquent Coping. While many adaptations to objective strain exist, they are not equally available to everyone, as individuals are constrained in their choices by various internal and external factors (Agnew, 1992). Initial Goals, Values, and Identities of the Individual. Suppose the individual’s objective goals are high in absolute and relative importance and have few alternative goals to seek. In that case, it will be more challenging to relegate strain to an unimportant area, 28 especially if the goals receive strong social and cultural support, with the strain more likely to lead to delinquency (Agnew, 1992). Baron (2004) suggests that youth who are dealing with homelessness are having a broad range of their identities, needs, values and goals challenged, which is therefore more likely to be seen as a strain high in magnitude. Individual Coping Resources. A wide range of traits can be listed, including temperament, intelligence, problem-solving skills, interpersonal skills, self-efficacy, self-esteem and beliefs regarding crime (Agnew, 1992). These traits affect the selection of coping strategies by influencing the individual’s sensitivity to objective strain and their ability to engage in cognitive, emotional and behavioural coping (Agnew, 1992). For example, individuals with high self-esteem are more resistant to stress and should be less likely to respond to delinquency. Self-esteem influences an individual’s sensitivity to strain and ability to engage in various coping strategies (Baron, 2004; Teijón-Alcalá & Birkbeck, 2019). Conventional Social Support. Agnew argues that social support is essential because it facilitates the significant types of coping (Agnew, 1992). There are different types of support: informational, instrumental, and emotional. Adolescents with conventional support should be better able to respond to objective strains in a non-delinquent manner (Agnew, 1992). Constraints to Delinquent Coping. Agnew (1992) describes three variables that constrain delinquent coping: the costs and benefits of engaging in delinquency in a particular situation, the individual’s level of social control, and the possession of the means necessary for many delinquent acts. Macro-Level Variables. The larger social environment can affect all the above factors. The social environment can affect coping by influencing the importance of selected goals (Agnew, 1992). Specific social environments may make engaging in non-delinquent behavioural coping difficult, and certain groups may face particular constraints that make 29 non-delinquent coping less accessible (Agnew, 1992). NIMBYism as a mentality is a macro-level variable that affects the larger social environment. Not In My Back Yard The construct of “Not In My Backyard” (NIMBY) is defined as “an attitude ascribed to persons who object to the siting of something they regard as detrimental or hazardous in their own neighbourhood, while by implication raising no such objections to similar developments elsewhere” (OED, 2005, as cited by Wolsink, 2006, p. 86). For example, drug rehabilitation centres and homeless shelters are not necessarily protested by the general society. However, some may support a homeless shelter in theory but protest when one plans to implement it near their neighbourhood or the spaces they occupy. These findings highlight a form of cognitive dissonance, where individuals think they support these efforts but, in reality, are a barrier to their implementation. Another example is in gentrified neighbourhoods, where these structures already exist, and new residents demand that they be shut down. NIMBYism contributes to a cycle of stigma and displacement, resulting in the disruption of accessibility to services and support for people experiencing social exclusion, such as PWUD, who are often rejected or alienated by society. People who are unhoused (i.e., homeless) face multiple and intersecting forms of exclusion, ranging from criminalization to being rendered invisible (Homeless Hub, 2023). The over-policing of PWUD has been shown to drive feelings of distrust between substance-using communities and the police, reinforcing structural inequalities and reducing PWUD as the “others” in a community (Scher et al., 2023). Through this process of criminalization and everyday enforcement by police, PWUD believed that laws served to reinforce and legitimise the exclusion and stigmatisation they experience because of their use of illicit substances (Scher et al., 2023). Criminalization, policing, and fear of arrest are also barriers to people seeking emergency medical services 30 during overdose events (Scher et al., 2023). The presence of NIMBY attitudes allows city councils, businesses, and neighbourhood businesses and organisations to justify policies and practices aimed at perceived ‘neighbourhood safety’ without addressing the core issues surrounding homelessness, such as the continued reliance on the police to manage homelessness, the lack of appropriate resources available, or the causes such as a lack of affordable housing. Critiques of “Not In My Backyard” Rather than functioning as a well-defined concept, Wolsink (2006) notes that the term “NIMBY” is more often used negatively to imply selfish behaviour by the people opposing a development, suggesting avoiding using the concept as it lacks clarity and creates misunderstandings. According to Wolsink, personality has not been found to play a role in local facility-opposing behaviour. Instead, the psychological explanation for the oppositional behaviour is not found in the individual but only in the situation that emerges after the announcement of the proposed facility establishment (Wolsink, 2006). These findings highlight the need for targeted messaging, using stigma-free language, to increase the chances of an individual accepting these facilities. Wolsink (2006) notes that disregarding objections is not a wise policy strategy, instead suggesting openly discussing them to encourage transparency. Harm Reduction Harm reduction (HR) theories and methods refer to interventions aimed at reducing the adverse effects of certain behaviours on a person’s health without necessarily eliminating the behaviours (e.g., drug use or misuse). HR stands in opposition to the traditional medical model of addiction, which labels any illicit substance use as abuse, as well as to the moral model, which labels drug use as wrong and, therefore, justifies the criminal model, labelling it illegal (Bowles et al., 2024; Petrasko, 2023). While HR policies, programs, and practices 31 are well defined in the context of SU, they lack a broader applicability to non-drug-related harms. Hawk et al. (2017) used data from in-depth qualitative interviews with 23 patients and 17 staff members from an HIV clinic in the United States (US) to describe HR principles for use in healthcare settings. They identified and defined six HR principles and generalised them for use in healthcare settings with patients beyond those using illicit substances. These six principles include humanism, pragmatism, individualism, autonomy, incrementalism, and accountability without termination. While the principles are not discrete and overlap in some instances, Hawk et al. (2017) describes them in a way that enables healthcare professionals to consider and implement them separately. These principles emphasise shared decision-making between the provider and patient, which has been shown to improve patient satisfaction, clinical outcomes, and the financial costs of care (Hawk et al., 2017; Marshall et al., 2021). Six Principles of Harm Reduction Humanism refers to providing value, care for, respecting and dignifying patients (Hawk et al., 2017). Understanding why patients make decisions is empowering for providers; it is essential to recognize that people do things for a reason and harmful health behaviours provide some benefit to the individual. These benefits must be assessed and acknowledged to understand the balance between harms and benefits. Pragmatism (Hawk et al., 2017) recognizes that behaviours do not occur within a vacuum, and no one will achieve perfect health behaviours. Social and community norms influence health behaviours and the ability to change them. Individualism (Hawk et al., 2017) is the recognition that every person presents with their own needs and strengths, therefore requiring a spectrum of intervention options as people present with a spectrum of harm and receptivity. 32 Autonomy (Hawk et al., 2017) recognizes that although providers offer suggestions and education regarding treatment options, individuals ultimately make their own choices to the best of their abilities, beliefs, and priorities. Shared decision-making (SDM) is an approach to clinical decision-making that includes patients’ values and preferences during health-related decisions (Marshall et al., 2021). Marshall et al. (2021) suggest that SDM improves patient-reported outcomes, such as satisfaction with care and treatment retention for patients with chronic disease. Marshall et al. found preliminary evidence that providing adults with treatment options/choices or permitting involvement and decision-making may improve some clinical outcomes, such as SU, treatment retention, quality of life, arrest rates, and satisfaction with care. Incrementalism (Hawk et al., 2017) recognizes that any positive change is a step toward improved health, and positive changes can take years. Therefore, it is crucial to understand and plan for backward movements. Accountability without termination (Hawk et al., 2017) is the recognition that individuals have the right to make harmful health decisions, and providers can still help them understand that the consequences are their own. Patients are responsible for their choices and health behaviours and are not “fired” for not achieving goals. HR can be a universal precaution applied to all individuals regardless of their disclosure of negative health behaviours. Applying HR principles in healthcare settings may improve clinical care outcomes, given that the quality of the provider-patient relationship is known to impact health outcomes and treatment adherence (Duff et al., 2024; Hawk et al., 2017). PART III: MEDICAL FOCUS Tracing the Opioid Crisis in Canada Post 2000s Since the early 1980s, there has been more than a 3000% increase in the volume of opioids sold to hospitals and pharmacies for prescriptions in Canada (Belzak & Halverson, 33 2018), with North America experiencing a rapid rise in availability for prescription opioids in the early 2000s (Crepeault et al., 2023). The misuse of prescription and synthetic opioids is a primary contributor to the escalating overdose crisis in North America (Crepeault et al., 2023). There are three classes of opioids: natural (e.g., morphine, codeine), semisynthetic (e.g., heroin, oxycodone, hydromorphone), and synthetics with morphine-like actions (e.g., methadone, fentanyl, carfentanil) (American Psychiatric Association [APA], 2022). Compared to other opioids, fentanyl has a higher risk of overdose (Health Canada, 2023b). It is 20 to 40 times more potent than heroin and 50 to 100 times more potent than morphine (Health Canada, 2023b). The composition of the illegal drug supply has continued to change since 2020, with the emergence of non-pharmaceutical benzodiazepines, a new opioid subclass known as nitazenes and the tranquilliser xylazine, which are being combined with fentanyl and its analogues (Public Health Agency of Canada [PHAC], 2024). The composition varies regionally, with Ontario and Western Canada having a higher proportion of illegal drug samples containing fentanyl in 2023 compared to Eastern Canada (PHAC, 2024). Fentanyl is similar to other opioid drugs, capable of producing severe, prolonged respiratory depression, seizures, coma and hypotension, leading to death in some instances. Respiratory depression is the primary mechanism of opioid overdose fatality (Chatterton & Handy, 2023). The respiratory depression effects may be reversed with the administration of a fast-acting opioid antagonist, such as naloxone or naltrexone (Chatterton & Handy, 2023). While naloxone can be effective at treating opioid overdose, it will not reverse the effects of benzodiazepines (Chatterton & Handy, 2023; PHAC, 2024) and requires the presence of a witness to administer it and call emergency services (Behrends et al., 2024). A meta-analysis by Belzack and Halverson (2018) reviewed the available literature and determined that non-medically supervised use of fentanyl was first reported in BC and Alberta in 2011. 34 Definitions ● Using Health Canada’s (2024b) interactive data site, in the technical notes under the category of deaths, an apparent toxicity death (ATD) is defined as “a death caused by intoxication/toxicity (poisoning) resulting from substance use regardless of how it was obtained” (para. 1). ● An apparent opioid toxicity death (AOTD) is an ATD where at least one substance involved was an opioid (Health Canada, 2024b). ● An accidental apparent opioid toxicity death (AAOTD) is an AOTD categorised as accidental when the coroner or medical examiner completes their investigation and concludes the manner of death was believed to be unintentional or has not been assigned yet at the time of reporting. An AOTD will be categorized as suicide if “the coroner or medical examiner determines that the substance(s) were consumed with the intent to die” (Health Canada, 2024b, para. 9). ● Using Health Canada’s (2024b) interactive data site, in the technical notes under the category of emergency medical services, opioid-related poisoning is defined as “an acute toxicity (poisoning) where one or more of the substances is suspected of being an opioid” (para. 3). ● Pharmaceutical opioids are opioids manufactured by a pharmaceutical company and approved for medical purposes in humans. A pharmaceutical origin does not indicate how the opioids were obtained (Health Canada, 2024b). Opioid Use Fentanyl is typically injected, both medically and non-medically, while cough suppressants and antidiarrheal agents containing fentanyl are taken orally (APA, 2022). Other opioids are generally taken both by injection and orally (APA, 2022). Fentanyl addiction is due to the increased amount of the neurotransmitter dopamine in the reward areas of the brain, which 35 elicits exhilarating and relaxing effects (Chatterton & Handy, 2023). Opioid use disorder (OUD) can arise from prescription opioids or illicit opioids (APA, 2022). In addition to overdose-related deaths, OUDs are associated with other adverse outcomes, including neurocognitive impairment from non-fatal overdoses, increased criminal activity, and high-cost healthcare services use (Enns et al., 2023). Substance Use Disorder The essential feature of a substance use disorder (SUD), as noted in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), is a cluster of cognitive, behavioural, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems (APA, 2022). All drugs taken in excess can directly activate the brain reward systems, reinforcing behaviours and establishing memories (APA, 2022). Instead of achieving reward system activation through adaptive behaviours, these substances produce such an intense activation of the reward system that everyday activities may be neglected (APA, 2022). The more neutral term SUD is used to describe the wide range of the disorder, from a mild form to a severe state of chronically relapsing, compulsive pattern of drug taking (APA, 2022). Substance-related disorders are divided into two groups: SU disorders and substance-induced disorders (APA, 2022). Opioid Use Disorder As described in the DSM-5-TR, OUD consists of signs and symptoms reflecting compulsive, prolonged self-administration of opioid substances, which may be either for a purpose other than a legitimate medical one or used in a non-medical manner (APA, 2022). Most individuals with OUD have tolerance and experience withdrawal when there is a reduction in opioid use. Similar to processes that occur with other psychoactive substances, individuals with opioid use disorder often develop conditioned responses to drug-related stimuli (APA, 2022). These responses probably contribute to relapse, are difficult to 36 extinguish, and typically persist long after withdrawal is completed (APA, 2022). Individuals with OUD tend to develop such regular patterns of compulsive drug use that daily activities are planned around obtaining and administering opioids (APA, 2022). OUD is associated with externalising traits such as novelty-seeking, impulsivity, and disinhibition (APA, 2022). Family, peer, and social environmental factors all increase the risk for opioid use disorder (APA, 2022). Although not all risk factors for OUD and opioid overdose are the same, substantial overlap exists, making the risk of overdose one of the most severe potential consequences (APA, 2022). Health Statistics The volume of opioid-related harms in the first three quarters of 2023 (January 1 to September 30) remains close to what was seen at the peak of the COVID-19 pandemic in 2021 (PHAC, 2024). These numbers are the highest since data collection began in 2016, signifying the ongoing worsening of this urgent public health crisis (PHAC, 2024). Due to differences in identifying and reporting cases, comparisons over time and between provinces and territories should be interpreted cautiously (Health Canada, 2024c). Data from some provinces also show a shift in the mode of drug use from injection to inhalation (PHAC, 2024). The opioid crisis is complex and requires all levels of government, public health and public safety partners, social sectors, affected communities, and PWLLE to work together (PHAC, 2024). Self-Reported Opioid Use The 2019 Canadian Alcohol and Drugs Survey (CADS) asked questions relating to the use and problematic use of three classes of psychoactive pharmaceutical drugs: opioid pain relievers, stimulants, and tranquillisers and sedatives (Health Canada, n.d.). Of the three classes of psychoactive pharmaceuticals, the overall use of opioid pain relievers (including prescribed or non-prescribed drugs for therapeutic and non-therapeutic purposes) was the 37 most common (Health Canada, n.d.). The total self-reported number of Canadians aged 15 years or older who reported having used opioid pain relievers in the past year totalled 4.4 million in 2019, a 2% increase from 2017 (Health Canada, n.d.). Among the 14% of Canadians who used opioid pain relievers in the past year, 6% reported problematic use, which is a 3% increase from 2017 (Health Canada, n.d.). The Public Health Agency of Canada The COVID-19 pandemic has exacerbated the ongoing overdose crisis, as several jurisdictions reported higher rates of fatal overdoses and other harms following the onset of the pandemic (Health Canada, 2024b). The 2023 death rate, based on available data from January 1, 2023, to September 30, 2023, from opioid overdose in Canada, was 21.2 per 100,000 population (Health Canada, 2024c). The highest rate of provincial AOTDs in 2023 was in Alberta (41.6 per 100,000), BC (47.5 per 100,000), and Ontario (17.2 per 100,00) (Health Canada, 2024c). Statistics prepared by PHAC and published by Health Canada include the number of AOTDs, hospital and emergency department (ED) use, and emergency medical services (EMS) responses to suspected opioid poisonings. Apparent Opioid Toxicity Deaths The Public Health Agency of Canada (PHAC) reports 5,975 AOTDs between January 1, 2023, and September 30, 2023, which is, on average, 22 opioid toxicity deaths per day in Canada, representing an 8% increase from the same period in 2022 (Health Canada, 2024b). Most of the AAOTDs in Canada occurred in BC(32%), Alberta (24%), and Ontario (33%) (Health Canada, 2024b). Males accounted for 72% of AAOTDs in 2023, while those aged 20 to 59 accounted for 88% (Health Canada, 2024b). Of all AAOTDs so far in 2023, 82% involved fentanyl, 82% involved opioids that were only non-pharmaceutical, and 57% also involved a stimulant (Health Canada, 2024b). 38 Hospital and Emergency Department Use Transport to the hospital after overdose may increase access to essential services such as the provision of social services or other programs and linkage to care for physical and psychological comorbidity (Crepeault et al., 2023). There were 169,723 reported opioid-related poisoning emergency department (ED) visits from January 2016 to September 2023 (Health Canada, 2024b). Data gathered from January to September of 2023 revealed 21,708 opioid-related poisoning emergency department visits, which is 80 ED visits per day (14% higher than the same period in 2022) (Health Canada, 2024b). Among these, 77% were accidental opioid-related ED visits, with the majority of visits occurring among males (68%) and among individuals aged 20 to 49 years (74%) (Health Canada, 2024b). Fentanyl and its analogues were involved in 44% of opioid-related poisoning emergency department visits so far in 2023, and 8% involved co-poisoning with a stimulant (Health Canada, 2024b). There were 41,045 reported opioid-related poisoning hospitalizations from January 2016 to September 2023, where 65% were accidental poisonings (Health Canada, 2024b). For data gathered from January to September of 2023, there were 4,646 Opioid-related poisoning hospitalizations, which is 17 hospitalizations per day (13% higher than the same period in 2022) and 18% involved co-poisoning with a stimulant (Health Canada, 2024b). Fentanyl and its analogues were involved in 32% of opioid-related poisoning hospitalizations, according to the data gathered so far for 2023 (Health Canada, 2024b). Most accidental opioid-related poisoning hospitalizations occurred among males (91%) and among individuals aged 30 to 39 years (24%) (Health Canada, 2024b). Emergency Medical Services For data gathered from January to September of 2023, there were 33,015 EMS responses to suspected opioid-related overdoses, which is 121 EMS responses per day and 18% higher than the same period in 2022. Of the EMS responses for suspected opioid-related 39 overdoses so far in 2023 (January – September), 70% were among males, and the majority were among those aged 20 to 49 years; however, there are variations between provinces and territories (Health Canada, 2024b). The number of EMS responses most likely underestimates the number of overdoses since they can be reversed in the community by non-medical personnel using take-home naloxone (Crepeault et al., 2023). Disproportionate Harms to Indigenous Peoples in Alberta Rates of AAOTD were, on average, approximately seven times higher among First Nations (registered status) people in Alberta compared to Non-First Nations people in Alberta from January 1, 2020, to December 31, 2020 (Government of Alberta, 2021). During this period, First Nations people represented 22% of all AAOTDs in Alberta (Government of Alberta, 2021). The proportion of opioid drug poisonings involving fentanyl increased to 95% in 2020 among First Nation people compared to 44% in 2016 (Government of Alberta, 2021). Harm Reduction Programs or Policies Targeting Opioid Use Harm reduction (HR) is an evidence-based approach to substance use (Milaney et al., 2022). However, HR approaches can be limited in scope and impact (Mitra et al., 2020). The HR programs and policies under the medical focus of this project examined safer supply programs, medication-assisted treatment, supervised consumption sites, and overdose prevention sites. To conclude the medical focus of this project, the barriers that PWLLE face in accessing healthcare are discussed. Safer Supply Programs Safer supply refers to providing prescribed medications as a safer alternative to the toxic illegal drug supply to people who are at a high risk of overdosing (Health Canada, 2022), “for whom currently available care options have been ineffective or inappropriate” (para. 4). SSP may include providing and connecting people with other health and social 40 services. A study published in Health Canada (2023) captures early learnings in a four-month qualitative assessment of ten time-limited safer supply projects in sites across Canada. Participants reported experiencing greater safety and interacting less often with the street, such as being subject to less violent crime, interacting with the police less often, and no longer having to engage in survival sex. Participants in the study stated that broad access to SSP is needed to meet demand and help address the opioid crisis. Despite the benefits, SSP are hard to implement as they require government support. In a study conducted by Petrasko (2023), semi-structured interviews were conducted with eight safe supply advocates from five organisations and analysed using thematic document analysis of safer supply in Canada. Throughout the data collection, two prominent barriers were identified to safe supply implementation across Canada: the stigmatisation of drug use and political inaction. Medication-Assisted Treatment Medication-assisted treatment (MAT) is a framework used in addiction clinical and policy settings (Duff et al., 2024). One type of MAT is prescribing a class of opioid agonist therapy (OAT), where patients are dispensed oral, longer-lasting opioids (commonly methadone or buprenorphine-naloxone) that produce less intense effects under the assessment and supervision of a doctor (Duff et al., 2024). OAT is currently considered one of the most effective interventions for OUD (Crepeault et al., 2023; Duff et al., 2024). However, OAT is not universally accepted as an HR approach but is often defined as addiction treatment (Milaney et al., 2022). Retention in OAT has been considered a sign of patient success because of the chronic nature of OUD and the likeliness of relapse (Duff et al., 2024). Supervised Consumption Sites Supervised consumption sites (SCS) provide a safe, clean space for people to bring their drugs to use in the presence of trained staff (Health Canada, 2024d). SCS mitigates 41 opioid-related harms by preventing accidental overdoses and reducing the spread of infectious diseases, such as HIV (Health Canada, 2024d). In 2003, the regional health authority in Vancouver was granted a legal operating exemption by the federal government to pilot a medically supervised injection site (British Columbia Centre for Excellence in HIV/AIDS [BCCEHA], 2009). Insite was the first safe injection site (SIS) in response to the harm people who inject drugs (PWID) were facing with heroin use. Insite was North America’s first iteration of a SCS, to open on the condition that the program would be the subject of rigorous scientific evaluation (BCCEHA, 2009) and continues to operate today. There has not been a single fatal overdose at any SCS in Canada. Statistics Since January 2017, every federally exempted SCS in Canada has regularly reported its data to Health Canada (Health Canada, 2024d). However, prior to March 2020, there was no standardised reporting format. From January 2017 to October 2023, there have been 4,480,823 total SCS visits by 389,843 unique clients (Health Canada, 2024d). In that period, 52,997 opioid-related poisonings were reversed, and 424,305 total service referrals were made (Health Canada, 2024d). Service referrals can include wound care, testing for STBBIs (sexually transmitted and blood-borne infections), primary health care, mental health care, food and shelter services, legal aid, employment assistance, and other services (Health Canada, 2024d). Detailed information is available from March 2020 to October 2023 due to the regulated reporting standards. Between this period, there have been 2,272,614 total visits and 36,272 NFOs, with 15,052 of these overdoses requiring the administration of naloxone. SCS in Canada had 45 average daily visits per site, with 332,483 unique clients visiting SCS monthly and an average number of 31 new clients per site monthly (Health Canada, 2024d). When it comes to the distribution of drugs for all visits between March 2020 and October 42 2023, fentanyl was the most popular (48.6%), followed by methamphetamine (20.4%) and other opioids, including hydromorphone (11%), heroin (4.9%), and unspecified opioids (Health Canada, 2024d). Regarding the gender distribution of SCS clients, 69% identified as male, 24% identified as female, and 7% identified as non-binary or their gender was unknown. When it comes to the age distribution of SCS clients, the majority were aged 20-29 years (18%), 30-39 years (34%), and 40-49 years (28%) (Health Canada, 2024d). Between March 2020 and October 2023, 3,217 calls were made from SCS to EMS, and 3,156 were made for other medical emergencies (i.e., unrelated to overdose events) (Health Canada, 2024d). Comparatively, only 699 calls were made to law enforcement for police services. Regarding services and referrals, 724,712 were provided within the SCS space, 130,816 were provided on-site but not in the SCS space, and 50,806 were provided offsite (Health Canada, 2024d). Overdose Prevention Sites Overdose prevention sites (OPS) are typically referred to as low threshold SIS; more than 40 have been established nationwide since 2016 (Behrends et al., 2024). Federal regulations and guidelines do not govern OPS; peers often staff these services. As a result, OPS may accommodate drug practices that have not traditionally been permitted at a federally sanctioned SIS (Kennedy et al., 2020) and also allows drug inhalation, smoking, and oral ingestion on-site (Behrends et al., 2024). OPS typically offers HR services beyond naloxone and oxygen administration (Behrends et al., 2024). OPCs are part of a comprehensive harm-reduction strategy to reduce the risks of overdose and injection-associated infections (Behrends et al., 2024). Barriers to Receiving Health Care The barriers to health care include stigma, the perceived complexity of patients living with OUD, limited education regarding OUD and its treatment, and the lack of institutional 43 support for PWUD (Duff et al., 2024). Using thematic analysis, Galarneau et al. (2023) conducted semi-structured qualitative interviews with 19 patients recently discharged from 2 urban EDs in Vancouver, BC. Participants felt discriminated against for their drug use, which led to poorer perceived health care and indicated ED avoidance in the future as a result. Participants desired to be treated like ED patients who do not use drugs and to be more involved in their ED care. Many participants experienced discrimination related to their drug use while in the ED and felt it resulted in inferior care and poorer outcomes. Experiences of ED-based discrimination are corroborated by ED staff acknowledging being at risk of biases, frustration, and lack of empathy when interacting with PWUD (Galarneau et al., 2023). Even if EDs cannot directly increase treatment options in their space, EDs can ensure clear transitions of care (e.g., well-defined referral pathways) to various community-based SU services (Galarneau et al., 2023). When possible, in-person handovers have been suggested to increase the uptake of the referral process (Galarneau et al., 2023). Desiring involvement in one’s care (e.g., clear communication and active participation), preferring familiar care providers, and accessing EDs only as a last resort were the themes identified by Galarneau et al. regarding care in EDs. These findings could also help combat stigma, as these individuals are often viewed as wasting these resources but prefer to be treated like non-PWUD when it comes to their health care and accessing EDs as a last resort. PART IV: CRIMINAL JUSTICE FOCUS The Controlled Drug and Substances Act The Controlled Drugs and Substances Act (CDSA) is a federal law that makes the possession of certain controlled substances a criminal act. The sale, possession and production of fentanyl and its analogues is illegal (unless authorised for medical, scientific or industrial purposes) and controlled under Schedule I of the CDSA (Controlled Drugs and 44 Substances Act, SC 1996, c. 19). The CDSA provides a process for creating exemptions to criminal possession if an exemption would be in the public interest. In Canada, federally sanctioned SCS are governed by regulations under section 56 of the CDSA, with regulations that have traditionally stipulated that all clients must self-administer their injections primarily due to criminal and civil liability concerns surrounding assisted injection (Kennedy et al., 2020). Simple drug possession can be decriminalised by eliminating criminal sanctions for possession of a small amount of controlled drugs intended for personal use. The federal government can grant a province-wide exemption to Section 56.1 of the CDSA. Sections 10(4) and 10(5) of the CDSA allow a court to delay sentencing if an offender is participating in a drug treatment court (DTC) program approved by the Attorney General or attends a treatment program approved by the province. Insite - Canada’s First Iteration of a Safe Consumption Site In 2011, the Federal Minister of Health refused to exempt a safe/supervised injection site and its clients from drug possession laws (Agrawal, 2018). Conservative governments are typically “tough on crime” and, therefore, are publicly disapproving of SU and HR, which they view as enabling. As a result, a s.7 Canadian Charter of Rights and Freedoms challenge was argued in the court case Canada (Attorney General) v. PHS Community Services Society, 2011 SCC 44. The case successfully argued that this decision violated healthcare workers’ and their clients’ life, liberty, and security rights. Insites’ operation was contingent on continued academic study, with a study by Wood et al. (2006) examining crime rates in the neighbourhood where Insite is located. They compared crime rates from the year before versus the year after the SCS opened and found that the SCS was not associated with increased drug trafficking or crimes commonly linked to drug use (Wood et al., 2006). 45 Drug Analysis Services The Drug Analysis Service (DAS) helps Canadian law enforcement agencies in their activities involving illegal drugs by providing scientific and technical services (Health Canada, 2023a). Health Canada runs the Drug Analysis Service (DAS) laboratories across Canada in Vancouver, Montreal, and Toronto that analyse suspected illegal drugs seized by Canadian law enforcement agencies (Health Canada, 2023c). Fentanyl was first identified in Canada in 1989 in exhibits submitted by law enforcement agencies (Health Canada, 2023c). These statistics are based on analysed samples and may not represent all substances seized in Canada or drugs circulating on the market (Health Canada, 2024a). A single sample could contain more than one substance. According to Health Canada (2023a), from 2012 to 2022, the majority of fentanyl identifications originated from samples submitted by law enforcement agencies in Ontario (43%), BC (36%) and Alberta (16%). From January 1, 2023, to December 31, 2023, the number of opioid identifications was highest in BC (113 per 100,000 population), Ontario (77 per 100,000 population), and Alberta (100 per 100,000 population) (Health Canada, 2024a). Since 2019, over 85% of exhibits containing fentanyl have been in powder form (Health Canada, 2023a). Fentanyl found in other materials was primarily from exhibits from BC(74%) and Alberta (19%) (Health Canada, 2023a). Fentanyl in tablet form was identified in 42% of samples for DAS from Alberta, 32% from BC, and 16% from Ontario (Health Canada, 2023a). Caffeine, used as a cutting agent, has consistently been the most common co-occurrence with fentanyl in the past ten years (Health Canada, 2023a). Since late 2019, the rise in the co-occurrences of sedative/hypnotics with fentanyl can be observed (APA, 2022; Chatterton & Handy, 2023; Health Canada, 2024a). Pharmacological classes of substances frequently co-occurring with fentanyl are opioid, sedative/hypnotic and stimulant (Health 46 Canada, 2023a). In 2022, the proportion of Fentanyl samples containing two or more co-occurring substances was 53% in BC, 62% in Alberta and 77% in Ontario (Health Canada, 2023a). Statistics This paper utilises comprehensive statistics to underscore the intricate dynamics between substance use, criminality, and public health. However, the harms related to drug use extend beyond overdoses and deaths. The Canadian Substance Use Costs and Harms (n.d.) is a joint project between the Canadian Centre on Substance Use and Addiction (CCSA) and the Canadian Institute for Substance Use Research. Using data from 2007 to 2020, they report that opioid costs increased by 24.1% and estimate that crimes resulting from substance use or substance use legislation led to $10 billion in criminal justice (police, courts, correctional services) costs in 2020, with approximately half of the costs attributable to opioids, cocaine, and other stimulants were related to non-violent crime. Police Reported Crime Rates In 2021, the rate of opioid-related offences (ORO) in Canada was 16 per 100,00 population, showing a 13% increase compared to 2020 (Moreau, 2022). However, police-reported rates of heroin, ecstasy, methamphetamine and cocaine-related drug offences all decreased from 2020 to 2021 (Moreau, 2022). At the time of writing this project, these statistics are the most currently available breakdown of police-reported crime rates of ORO in Canada. Limitations There are limitations to tracking opioid use and ORO in Canada. In November 2017, the Canadian Centre for Justice and Community Safety Statistics began collecting data on ORO, which excluded heroin but included fentanyl, which is reported separately from the “other drugs” category (Moreau, 2022). Part of the increase in offences could result from the 47 new violation code. Another limitation is that the polysubstance nature of the opioid crisis may impact reporting, given that only one drug type will be recorded as the most severe violation for a criminal incident (Moreau, 2022). The “dark figure” of crime is the proportion of incidents never reported to the police, which is a limitation of all CJS statistics (Department of Justice Canada, 2022). Given the statistics previously cited in this project regarding self-reported opioid use and the national death rate from opioid overdoses, it is clear that the opioid-related harms PWUD are dying from cannot be out-policed. Correctional Service Canada Although some offences may be considered 100% attributable to alcohol or SU (such as impaired driving or drug trafficking), only a portion of other offences are a direct result of SU. Upon administration to federal custody, Results using self-report data administered to men (between 2006 and 2016) and women (between 2011 and 2016) it was shown that 42% of offences result from SU (Correctional Service Canada [CSC], 2021). Offenders were asked if they would not have committed the offence for which they were incarcerated had they not been under the influence of alcohol or other substances at the time of their offence and if they committed the offence to support their use of alcohol or other substances (CSC, 2021). Alcohol was associated more with violent (20%) than non-violent crime (7%), while other substances were equally associated with violent and non-violent crime (26% and 25%, respectively) (CSC, 2021). The Computerized Assessment of Substance Abuse for men (M-CASA) is administered on admission to federal custody, assessing pre-incarceration SU patterns and severity. Between January 2006 and March 2019, 34,202 men were assessed, and approximately 18% of surveyed offenders were indigenous (CSC, 2022). In 2006-2007, 32% of offenders reported polysubstance use (using multiple substances in one day) compared to 44% of offenders in 2018-2019. However, during this same period, the proportion of 48 offenders reporting injection drug use (IDU) decreased from 23% to 18%. Offenders reporting lifetime alcohol use remained constant at about 95% throughout the study period. In 2006-2007, 73% of offenders had an identified SU issue compared to 78% in 2018-2019. In 2006-2007, 60% of offenders reported lifetime drug use compared to 77% of offenders in 2018-2019 (CSC, 2022). Drug Treatment Courts Drug treatment courts (DTCs) offer court-appointed treatment in partnership with community addiction programs and services as an alternative to traditional court sanctions (e.g., fines, penalties, incarceration) for drug-related offences (Canadian Centre on Substance Use and Addiction [CCSA], 2023). The purpose of DTCs is to reduce criminal charges for individuals who have an identifiable SU challenge and whose criminal activity is directly or indirectly related to their use of alcohol or other drugs (CCSA, 2023). DTCs seek this by facilitating court-monitored treatment and community service support for eligible people charged under the CDSA or the Criminal Code (CCSA, 2023). Probation officers, federal and provincial prosecutors, duty counsel and judges are all involved in the DTC process (CCSA, 2023). Individuals charged with a non-violent crime under the CDSA and with a court-acknowledged SUD that directly or indirectly contributed to the offence(s) are permitted to apply to DTC programs (CCSA, 2023). The Crown screens a person’s eligibility for a DTC program. Each DTC has its eligibility criteria established by an interdisciplinary team (CCSA, 2023). The diversion of criminal penalties through participation in a DTC requires the accused to enter a guilty plea (CCSA, 2023). Each DTC defines success differently. DTCs use incentives, such as phase advancement ceremonies, and sanctions and penalties, such as jail time, to drive behavioural change (CCSA, 2023). As the DTC team recommends, graduates from DTC programs can receive a reduced sentence (CCSA, 2023). 49 Positive participant outcomes, such as reduced reoffending, are increased when the level of treatment or supervision intensity matches the severity of substance use and level of risk (CCSA, 2023). Hyrmak (2020) interviewed 11 participants, including defence counsel, probation officers, and public interest lawyers and advocates, revealing three key challenges of working in the CJS during the opioid crisis. They noted there is a lack of understanding of addiction within the CJS, and the system’s response to the opioid crisis exacerbates risks faced by PWUD, which is harmful to public health. As a result of the opioid crisis, the conditions on bail and probation orders and the resulting breaches of conditions increase the risk of custodial sentences for PWUD (Hyrmak, 2020). An abstain condition is a court order for a person to abstain from the consumption and possession of alcohol and illicit drugs (Hyrmak, 2020). Interviewees reflected that abstain conditions revealed a lack of understanding from the courts as to what SU addiction is and how it works. Interviewees discussed various issues surrounding treatment conditions as part of court orders for people with problematic SU within the CJS, including the over-imposition of rehabilitative conditions and difficulty in finding evidence-based treatment for people who are court-ordered to attend or are seeking treatment themselves (Hyrmak, 2020). The lack of effective treatment coupled with the insistence of rehabilitative conditions on bail leads to further harm for PWUD. Interviewees explained that given the frequent imposition of abstain conditions, treatment conditions, and red zone conditions (i.e., “stay out of drug areas” orders), charges of breaches of court orders are frequent (Hyrmak, 2020). There is a disconnect between the conditions imposed and the lives of individuals subject to these conditions if the release conditions are too numerous or are not crafted to recognize the circumstances of the person’s SU, which essentially creates a crime by setting the person up to fail (Hyrmak, 2020). Charges involving Administration of Justice Offences 50 are more likely to result in guilty verdicts and more likely to result in custodial sentences than any other type of offence (Hyrmak, 2020). Hyrmak (2020) notes there needs to be recognition of how the housing crisis impacts people within the CJS, such as court-imposed conditions that ultimately lead to a high incidence of administrative breaches, which causes people to be incarcerated frequently and increases their risk of overdose upon release (Hyrmak, 2020). Area Restrictions Area restrictions, prohibiting people from entering drug scenes or areas where they were arrested, are a common so illegal mechanism employed to regulate the spatial practices of PWUD (McNeil et al., 2015). Policing strategies are called red zone orders in Canada and “stay out of drug areas” (SODA). Area restrictions represent one mechanism commonly employed to regulate structurally vulnerable populations, including PWUD and people who are homeless (McNeil et al., 2015). These restrictions prohibited people from entering designated drug or sex work scenes or areas where they have been arrested. Although officially positioned as a preventative strategy to remove people from neighbourhoods where they might offend, area restrictions reinforce stigma by framing structurally vulnerable populations as a threat to be removed from urban spaces (McNeil et al., 2015). Additionally, despite being unable to access usual sources of support, including HR programs, PWUD are primarily unwilling to access support elsewhere due to concerns about facing stigma in other areas. Because PWUD rely upon resources concentrated within drug scenes, their displacement from these areas disrupts strategies that enable them to negotiate health and safety within the broader context of their structural vulnerability, thereby fostering diverse risks and harms (e.g., treatment interruptions and unsafe drug use practices). McNeil et al.’s (2015) findings also underscore how it simply might not be possible for PWUD to access resources outside of stigmatised neighbourhoods due to territorial stigmatisation. Area restrictions disrupted access to health and social resources concentrated in drug scenes such 51 as HIV care; territorial stigma prevented PWUD from accessing support in other neighbourhoods (McNeil et al., 2015). In Canada, red zone orders can be imposed as part of promised-to-appear orders issued by law enforcement officials to compel individuals released following arrest to appear in court. Red zone orders can also be a part of community supervision conditions. While these orders initially motivated PWUD to comply with area restrictions to avoid incarceration and withdrawal, rather than discouraging engagement and drugs and activities, areas where restrictions an increase or exposure to drug-related risks and violence (McNeil et al., 2015). Drug law enforcement continues to be a key structural driver of risk, harm and lower health access among PWUD (McNeil et al., 2015). Serious concerns regarding the significant public health impacts of area restrictions should be weighed and only pursued in certain circumstances. PART V: DISCUSSION Findings The views of PWLLE toward drug policy and drug law reform in the Canadian context are essential yet mainly missing from the conversation (Arlt, 2023; CCSA, 2023; Scher et al., 2023; Hyrmak, 2020). Policy direction, allocation of resources, and political attitudes and actions can all have a symbolic effect in producing or perpetuating stigma among PWUD and, therefore, affecting attitudes toward this population in society at large (Scher et al., 2023). Since SU is a multidisciplinary issue (i.e., it cannot be solved solely by medical or criminal interventions), the communication of SU and related harms in separate silos is adding to the stigma PWLLE continue to face. One example of this is evidenced by a discourse analysis conducted by Sills (2017), who argued that the reliance on medical and criminal models resulted in a misrepresentation of HR, increasing the invisibility of the clients at Insite. 52 NIMBY as a framework was not explicitly named in much of the literature reviewed. However, given the previously cited benefits of HR programs and policies and the extreme harms to PWUD in their absence, it explains why more have not been implemented. One example of this is federally-sanctioned safe injection sites, which have had zero fatal overdoses on site. Although there are numerous fatal overdoses (e.g., 20+) daily in Canada, and opioid-related harms have notably gotten worse since the COVID-19 pandemic, Alberta has closed down sites rather than opening new ones. Salvalaggio et al. (2023) reviewed the 2020 report commissioned by the Alberta government in 2019, which documents the socioeconomic impacts of seven SCS by the province. They note that the government’s 2020 report fits the criteria associated with pseudoscience. After the report’s release, all plans for the proposed new SCS across Alberta were cancelled, and it has since been used to justify the closure of two SCS in Alberta. (Salvalaggio et al., 2023). The SCS closures are temporally associated with increased poisoning deaths, a temporal trend not observed in Alberta’s other municipalities, and the emergency responses and hospitalisation rates for drug poisoning events demonstrate similar increases (Salvalaggio et al., 2023). Salvalaggio et al.’s (2023) review found that SCS mitigates drug poisoning-related harm and unsafe drug use practices, facilitates the uptake of substance use treatment and other health services, is associated with improvements in public order (e.g., reductions in publicly discarded syringes), does not increase drug-related crime, and are cost-effective. However, despite the evidence supporting SCS as a policy approach, only five of the ten provinces (and none of the territories) have implemented them (Manson-Singer & Allin, 2020). Ezukuse (2021) notes the flaws of SCS policies mandating the inclusion of community groups’ opinions in the decision-making process. These policies allow room for prejudice and stigma against PWLLE, which will only cause further harm to this population. 53 They note that expecting or requiring an SCS to reduce crime rates is not logical, as no other health clinic or hospital’s continued operation is contingent on doing so (Ezukuse, 2021). Laws about alcohol (e.g., public intoxication) and other drugs are used as a vehicle to perform stigma toward PWLLE (Scher et al., 2023). North American communities and governments are reluctant to permit, adequately fund, and implement evidence-based practices to prevent the harm associated with the current unregulated supply (Bowles et al., 2024). Salvalaggio et al. (2023) note that health policy must be based on available evidence, protect the right of structurally vulnerable populations to access healthcare and not be contingent on favourable public opinion or prevailing political ideology. Another example is Scher et al. (2023), who conducted a thematic analysis of qualitative data from 24 semi-structured interviews with a diverse sample of people who use illicit drugs. The researchers found two main themes: the experience of stigma as a consequence of criminalization and the perceived benefits of drug law reform. Their findings show how Canada’s drug laws may shape public attitudes toward PWUD and, therefore, the harms of structural, social, and self-stigma experienced by PWUD (Scher et al., 2023). Participants believed that current drug laws produced and encouraged the public attitudes and structural inequities they experienced. Scher et al.'s findings matter not only because PWUD experience stigma in impactful ways but also because they suggest that the criminalization of drugs shapes the experience of structural, social, and self-stigma. Finally, participants believed that efforts to destigmatize PWLLE would be inconsequential without the enactment of more comprehensive forms of drug law reform, such as the decriminalisation of illegal drugs (Scher et al., 2023). Enforcement Fatigue and Lack of Deterrence In Canada and elsewhere around the world, the primary approach to addressing drug use and drug possession has been through punitive drug laws, prohibition, and policing 54 (Scher et al., 2023). However, this approach has failed to reduce the number of PWUD substantially. Instead, aggressive policing tactics have been found to exacerbate the social, health, legal, and environmental issues experienced by PWUD (Scher et al., 2023). In a study conducted by Butler et al. (2022), semi-structured interviews with 16 police officers took place across nine jurisdictions in BC, using a combined technique of inductive and deductive thematic analysis to help understand how the health and social service systems’ capacity to meet the community’s needs has directly impacted policing. Officers vocalised that the CJS has little influence on deterring or preventing drug use in terms of reduced harm or improved public safety. They also questioned the framing of drugs as a criminal issue rather than a health issue. Officers recognized that individuals’ health, social, and justice outcomes differed based on socioeconomic status. Officers highlighted that in many cases, structural vulnerability among PWUD, rather than drug use itself, was what drove people into criminal justice contact. The participants expressed a sense of enforcement fatigue, with officers questioning their role in perpetuating an ineffective system (Butler et al., 2020). They noted frustration dealing with the same individuals repeatedly and the inability to help them, acknowledging a service gap that no agency or actor is filling. Enforcement fatigue is a central theme because officers themselves note the harm contact with the CJS creates and the structural inequities underlying SU. Instead, criminal drug laws structurally produce an unregulated and illegal drug market where it is impossible to control drug toxicity and where marginalised PWUD are often pushed to procure illegal substances from dangerous and unpredictable environments (Scher et al., 2023). Geographic Considerations for Alberta SU and addiction affect every community, however; there is a geographic concentration in Western Canada, with Alberta and BC being Canada’s opioid hotspots 55 (Gibbs et al., 2023). Greene et al. (2023) produced a study with results showing that the value of SCS might differ across locations, pointing to the need for further locally grounded examinations of HR service uptake and experience. They conducted semi-structured interviews with 50 PWUD in Lethbridge, Alberta. In August 2020, government funding was retracted from North America’s busiest SCS in Lethbridge, forcing it to close its doors (Salvalaggio et al., 2023). Participants were asked about their experiences with and perceptions of SCS access and changes to SCS provisions (Greene et al., 2023). Participants reported regular and frequent access and positive experiences with the SCS despite noting specific operational barriers, such as long wait times. Overall, changes to SCS provisions produced a range of negative consequences for PWUD in Lethbridge (Greene et al., 2023). Findings from this study provide preliminary indications of the importance of understanding how contextual and locally specific elements (location, limits on permitted SU route administration, and social aspects) can work together to facilitate SCS uptake and even overcome traditional SCS barriers. Increasing Toxicity of Drug Supply Though the population of PWUD was highest in Alberta and BC, the difference was not substantial enough to explain why these provinces have approximately double the rate of deaths than Canada as a whole. Fentanyl was detected much more frequently in samples seized by law enforcement in Western Canada than in Eastern Canada (Gibbs et al., 2023). It appears the increase in opioid-related harms in Canada is being driven by the increased toxicity of the supply rather than an increase in the number of PWUD in the general population (Gibbs et al., 2023). Additionally, the concerns about the increased dangers associated with the local drug supply in Alberta may be more related to an increase in 56 fentanyl concentration rather than the addition of benzodiazepine (Chatterton & Handy, 2023). Public Support as a Barrier for the Implementation of Harm Reduction Programs and Policies After an exploration of NIMBY theory, one possible explanation for the lack of implementation of HR programs and policies is due to the lack of public support. However, some literature from Alberta shows that lack of support from the general society is not the primary barrier to implementing these programs. Morris et al. (2023) examined cross-sectional data from an online panel survey to assess views on policy responses to SU and addiction of Albertans and Saskatchewans. The researchers recruited 1602 adults in March 2021 and found that the majority of respondents (Alberta: 63.5% and Saskatchewan: 56.3%) supported SSP despite the Alberta and Saskatchewan governments not endorsing these initiatives. Morris et al.’s findings show that most Canadians from these provinces support the efforts to expand safer supply; this suggests that a lack of public support is not the main barrier to implementation (Morris et al., 2023). Instead, political support from the government appears to be the main barrier to implementing SSP and SCS. For example, Manson-Singer and Allin (2020) compared Alberta and Manitoba’s political and policy contexts to determine what factors have contributed to the difference in provincial policy outcomes, where Alberta has established SCS and Manitoba has not. In the comparative analysis, they found three necessary conditions for establishing SCS: the framing of an opioid epidemic as a public health matter and the alignment of the establishment of SCS with the provincial government’s values and political will (Manson-Singer & Allin, 2020). Although Alberta currently has SCS, they are geographically sparse, and the government tends to advocate for treatment-based rather than harm-reduction approaches. 57 Another example is a study conducted by Berrigan and Zucchelli (2022), who used a discrete choice experiment to assess public preferences for SCS with a sample of 203 adults. Their findings suggest that a set of attributes influences respondents’ preference for SCS, finding that community members also questioned the role of the police (e.g., would they allow drug trafficking on site? Would PWUD be targeted going to and from the site?). Respondents had negative preferences for sites that increased costs to the healthcare system. Respondents had positive preferences for sites that would reduce fatal overdoses, reduce the volume of improperly discarded syringes, and provide compensation to those impacted by the establishment of sites (Berrigan & Zucchelli, 2022). The researchers noted that some positive characteristics identified by respondents (such as a reduction in fatal overdoses) are already being met by SCS. A straightforward strategy mentioned was marketing the benefits of SCS to the general public from a reliable source (i.e., the government) to increase the awareness and benefits of these services, and therefore, combatting moral stigma. Stigma as a Source of Strain Media framing is influential to the public and can promote the dehumanisation of PWUD. Laws prohibiting most drug use have labelled PWUD as socially deviant and subsequently deserving of the harm associated with drug use, primarily blaming PWUD for their own circumstances (Bowles et al., 2024). These negative attitudes can be internalised by PWUD, resulting in depression and reduced self-esteem (Bowles et al., 2024). To demonstrate this, Scher et al. (2023) theorised stigma at a much broader societal or even cultural scale and as a performative process that helps delineate between legitimate individuals deserving of care and concern and those deemed illegitimate, undeserving, and stigmatised. They highlight a performative process by elaborating on how stigma experienced by PWUD in a variety of settings (e.g., healthcare, workplace, family) leads to them avoiding those contexts, reinforcing their invisibility in those areas, and reinforcing the stigmatising 58 idea that PWUD do not deserve health care, or cannot manage stable employment (Scher et al., 2023). Within medical systems, PWUD often avoid seeking treatment until their health issue advances and is unavoidable. The avoidance is due to previous experiences of discrimination, such as being invalidated by medical professionals, and accusations of drug seeking and overall mistreatment from hospital staff (Bowles et al., 2024). When providers have these views towards patients who use drugs, perceiving such patients as aggressive and manipulative, it subsequently results in sub-optimal delivery of healthcare (Bowles et al., 2024). The social marginalization created through stigma also hinders PWUD from accessing health care services (Scher et al., 2023). As such, the reduction of stigma toward PWUD could have essential implications within efforts to facilitate and increase the well-being of people who use drugs and the pursuit of positive change (Scher et al., 2023). Within criminology literature, previous studies have examined the relationship between crime and stigmatizing views against criminal offenders. One of these studies is Egan (2021), who administered an online survey to 132 men. A multiple regression analysis was used to examine the relationship between the perceived stigma of SU, incarceration, and the risk of relapse. Their results indicated that perceived stigma was a significant predictor of increased risk of SU relapse post-incarceration (accounting for 19% of the risk of relapse scores post-incarceration). Stigma as a predictor for SU recidivism in the context of the CJS suggests the need for further examination into the relationships between social exclusion and opioid-related harms. Structural Factors Another theme identified in this project is the existence of structural factors pushing opioid-related harms for those who are structurally marginalized in Canadian society. One example of this is how women may be more likely to self-report unintentional fentanyl 59 exposure. Mitra et al. (2020) examine differences in self-reported unintentional exposure to fentanyl between men and women who use drugs. Their results found that being a woman was positively associated with self-reported unintentional fentanyl exposure, with women being more than two times as likely to self-report that they were unintentionally exposed to fentanyl compared to men. Another example is the comorbidities associated with being unhoused. People who do not have stable housing might not receive adequate healthcare and represent a large number of individuals with comorbid substance disorders, mental health disorders, physical health problems, and past trauma (Crepeault et al., 2023). Those with a history of NFO are at a greater risk of future fatal and non-fatal overdose and other serious health complications (Crepeault et al., 2023). In the multi-variable analysis, positive urine drug tests for fentanyl, receiving income assistance, and homelessness were positively associated with a lifetime history of NFO (Crepeault et al., 2023). Homelessness and SU may result in some behaviours, such as public injection or using drugs alone, which can heighten the risk of overdose (Crepeault et al., 2023). In Canada, many structural barriers continue to drive homelessness, including lack of affordable housing and living wages, stigma and discrimination, and access to supportive housing (Crepeault et al., 2023; McNeil et al., 2015). These structural vulnerabilities are further evidenced in an analysis by Loverock et al. (2024) that found a positive association between income inequality and mortality outcomes. They found greater income inequality resulted in an increased risk of suicide, fatal drug overdose, and chronic liver disease from alcohol consumption (i.e., liver cirrhosis), called “deaths of despair” (p. 1). At the same time, social cohesion and access to mental health professionals mediated the association (Loverock et al., 2024). One explanation for why mental health utilization was associated with an increased risk of deaths of despair is that people who access mental health services may feel stigma (Loverock et al., 2024). These 60 negative experiences or stereotyping reduce further treatment seeking, which may lead to a subsequent increased risk of death related to untreated mental illness (Loverock et al., 2024). Another possible explanation for these findings is that existing mental health resources and support are not specialized enough to treat complex mental illnesses and prevent premature deaths in Canada (Loverock et al., 2024). These findings are another example of the need for more complex care pathways for those whose lives are affected by SU. Discussion Overall, this literature review pointed out the calls for multi-system changes for how Canada is currently approaching opioid-related harms and excluding PWLLE in this conversation. A central theme found in this project was the lack of deterrence punitive approaches to SU provided. Enforcement fatigue is a part of this as a result, with different studies pointing towards the frustration the ineffectiveness of the CJS causes and how it perpetuates harm, reinforcing a cycle for those who are structurally marginalized by society. Studies including PWLLE (Scher et al., 2023), law enforcement officers (Butler et al., 2020), defence counsel and probation officers (Hyrmak, 2020), and healthcare professionals (Hawk et al., 2020) all point to the increased harms related to opioid use that could be avoided upon multi-system and multidisciplinary efforts to combat the overdose crisis. Notably, many harms associated with the unregulated and increasingly toxic drug supply could be combatted with SSP and mass drug law reforms. There are geographical considerations for Alberta due to the increasingly toxic supply. Alberta has traditionally had conservative governments, and some research indicates that the general public supports implementing HR programs and policies, indicating it is political inaction causing disproportionate harm to PWUD. These harms are highlighted by Salvalaggio et al.’s (2023) study that called out the Alberta government for a 2019 report deemed pseudoscience, resulting in the province closing two SCS and cancelling all plans for new SCS across the province. The SCS closures 61 are temporally associated with increased poisoning deaths, a temporal trend not observed in Alberta’s other municipalities. The emergency responses and hospitalization rates for drug poisoning events demonstrate similar temporally associated increases (Salvalaggio et al., 2023). Their review referenced many benefits associated with SCS and the bias encouraged by the government to promote stigma against PWUD. NIMBY is often accompanied by “Not In My Term of Office” (NIMTO), especially in urban planning and development (Bao et al., 2023, p. 13). NIMTO is the opposition of local administrators or politicians, who are reluctant to approve the construction of these facilities during their term of office because they fear it will affect their political future (Bao et al., 2023). The lack of action by politicians, and therefore the government, reinforces the stigma against PWLLE. Protecting the rights of structurally vulnerable populations (i.e., people experiencing homelessness) to access healthcare and other essential services should not rely on public opinion (Ezukuse, 2021; Salvalaggio et al., 2023; Petrasko, 2023). Stigma as a source of strain is evident, and NIMBY mentalities serve to exclude PWUD socially, further harming this already vulnerable population. Agnew’s (1992) GST serves as an explanation for why social exclusion can result in illicit drug use as a coping mechanism. Harm-reduction principles and approaches have many benefits. However, these principles are not widely adopted by the CJS. One example is a principle that Hawk et al. (2017) identified: accountability without termination. DTC is an excellent example of a harm-reduction program in the CJS. However, they cannot accommodate such a principle, with many DTC programs considering SU relapse an instant exit from the program (CCSA, 2023). Notably, there is a long way to go before the medical and criminal models at SU work together seamlessly. However, there is an urgent need for government intervention on all levels., which is especially true in Alberta, where the death rate from opioid overdoses is higher than the Canadian national average. PWUD are dying, and although there will always 62 be harm related to SU, doing nothing when there are evidence-based approaches, including a regulated supply or SSP and SCS implementation. Inaction kills, and by not making more efforts to combat the opioid crisis in Alberta, the Alberta government is a part of the structural marginalization PWLLE face daily. The policy implications of this project are a call to action for the Alberta government to immediately apply for a CDSA exemption for province-wide “safer” supply. Other implications of this project are the potential for exploring and implementing HR principles at all levels of the criminal justice system. Another potential policy implication of this project is the idea of standardized reporting. A prevalent theme in the statistics gathered in this project was that direct comparisons cannot be made due to differences in reporting. However, there is immense evidence of the crossover between medical and criminal structural vulnerabilities and the prevalence of PWLLE in these environments; efforts to collect complementary health and crime data uniformly should be revised. Limitations This paper has several limitations. Because of the multidisciplinary nature of SU in Canada, literature regarding the topic could be challenging to understand at times. For example, I have no medical background, so reading some health-related literature was more difficult. Another limitation is the analysis. Because of reporting differences, the police-reported crime rates for ORO and the death rate from fatal opioid overdoses cannot be compared. Public health data was also more frequently published and accessible than criminal justice statistics. Another limitation of this project is the omission of specific provincial policies. The lack of examination of Alberta Health regulations or acts, which could have significantly enriched this project, is a missed opportunity for a more comprehensive study. 63 Recommendations for Future Research Recommendations for future research include conducting qualitative interviews with a variety of actors in the system, including police officers, housing workers, outreach workers, and PWLLE, on how NIMBY has affected their level of service care (if at all). Most research on NIMBY has focused on polluting facilities, and there does not seem to be research specific to Alberta about NIMBY mentalities when it comes to PWLLE and SU and the extent to which they may be present. One potential area for future research is the Calgary Drop-In Centre. This emergency homeless shelter has operated in Calgary for 60+ years and is located in the downtown East Village. The East Village has been gentrified, and residents complain about the centre, demanding it be shut down despite its longstanding history and essential service. Since it can be challenging to get ethics approval for research involving vulnerable populations, this urban area would allow access to shelter and housing workers, outreach workers, first responders, community members, and other impactful voices. Since some research indicates that public support is not the main barrier to the implementation of SSP, another recommendation for future research is to explore this further. When the Federal Minister of Health declined to extend Insite’s exemption from the CDSA so it could not continue its operation, the Supreme Court of Canada (SCC) overruled the decision. In Canada (Attorney General) v. PHS Community Services Society, the SCC unanimously declared the disproportionate harm this produces to PWUD, violating healthcare workers and their clients’ section 7 Charter rights to life, liberty, and security rights. However, despite the 2011 decision, provincial governments are not responsible for applying for an exemption. In other words, while an application for exemption cannot be unreasonably denied, there is no urgency for governments to apply in some cases, as seen in Alberta. Consequently, governments that do not apply, such as the Alberta government, are not held accountable for the harm they could have avoided. Competing policy implications present 64 further problems within the Constitution’s division of powers (i.e., healthcare is provincial; crime is federal) and the complicated interplay between the criminal justice system and healthcare systems within the context of CDSA exemptions. For example, does it violate the Charter for an individual to be charged with a drug offence (i.e., simple possession) in one province when other areas in Canada have decriminalized small amounts of possession? These factors warrant a thorough analysis of policies and regulations, likely requiring a multidisciplinary team of researchers. Conclusion This project explored HR programs and policies targeting opioid use in the community and the CJS and the effect of NIMBY attitudes on their implementation. NIMBY was not explicitly mentioned in much of the literature reviewed in this project. However, evidence of NIMBY is particularly evident in the CJS when it comes to area restrictions, such as SODA area orders. Since there are limited resources available for PWUD, restrictions to spaces upon CJS contact can increase harm, such as overdoses, without being able to access services like SCS in these spaces or other health care services. This project provided a broad overview of Canada’s currently available HR programs and policies targeting opioid use, using comprehensive statistics to generalize the qualitative findings. Canada is in the midst of an opioid crisis, with more than 20 deaths occurring daily from opioid-related poisonings. Despite the immense harms PWUD encounter, some of which could be reduced with government intervention (i.e., decriminalization, regulated drug supply), there has been little political action in Alberta to date. The lack of action in Alberta and elsewhere perpetuates stigma by signalling that PWLLE are not deserving of government support. Findings from this project include themes of enforcement fatigue, with actors in the CJS acknowledging the structural harms behind SU that likely drove a person into contact with the system and the ineffectiveness of its current operations. 65 Another prominent theme related to this was the lack of deterrence. Drug policies have not and will not stop SU despite years of trying with no success. There are critical geographic considerations for Alberta, including the increasingly toxic supply due to the presence of non-pharmaceutical fentanyl. Public support was examined as a barrier to the implementation of HR programs and policies targeting opioid use with the NIMBY theory in mind. Although NIMBY was not mentioned as a barrier specifically in much literature, stigma was identified as a significant contributor to the opioid crisis. Stigma as a source of strain seems to drive not only CJS contact but also increased health issues in the context of opioid overdoses. Finally, structural factors and the lack of currently available care options for PWUD were discussed. 66 References Agnew, R. (1992). Foundation for a general strain theory of crime and delinquency. Journal of Criminology, 30(1), 47-87. https://doi.org/10.1111/j.1745-9125.1992.tb01093.x Agrawal, S. (2018). 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The integrative review: updated methodology. Journal of Advanced Nursing, 52(5), 546–553. https://doi.org/10.1111/j.1365-2648.2005.03621.x Wolsink, M. (2006). Invalid theory impedes our understanding: A critique on the persistence of the language of NIMBY. Transactions - Institute of British Geographers, 31(1), 85–91, https://doi.org/10.1111/j.1475-5661.2006.00191.x. Wood, E., Tyndall, M. W., Lai, C., Montaner, J. S. G., & Kerr, T. (2006). Impact of a medically supervised safer injecting facility on drug dealing and other drug-related crime. Substance Abuse Treatment, Prevention and Policy, 1(1), 13–13. https://doi.org/10.1186/1747-597X-1-13 77 Appendix A Vocabulary Notes 78 Appendix B Community-based Harm Reduction Programs and Policies Targeting Opioid Use 79 Appendix C Location of Unintentional Opioid Poisoning Deaths Note. Adapted from Government of Alberta. (2024, May). Alberta substance use surveillance system [Data set]. Health Analytics Interactive Data. https://healthanalytics.alberta.ca/SASVisualAnalytics/?reportUri=%2Freports%2Freports%2 F1bbb695d-14b1-4346-b66e-d401a40f53e6§ionIndex=0&sso_guest=true&reportViewO nly=tru e&reportContextBar=false&sas-welcome=fals A private residence is a secured residence, whether the deceased lived there permanently or part-time or the residence belongs to another individual (Government of Alberta. 2024). A public location is a non-secure location accessible to others (Government of Alberta. 2024). Other facilities include all other facilities not specified above, excluding hotels (which are a separate category). These facilities might include private residences where ownership is unclear, shelters, addiction facilities, or certain types of supportive housing (Government of Alberta, 2024). 80 Appendix D Sequential Synthesis Design Figure 3 Synthesis of results Note. From Hong, Q. N., Pluye, P., Bujold, M., & Wassef, M. (2017). Convergent and sequential synthesis designs: implications for conducting and reporting systematic reviews of qualitative and quantitative evidence. Systematic Reviews, 6(1), 61–61. https://doi.org/10.1186/s13643-017-0454-2 CC-BY-4.0 81 Appendix E Strain Pathways Note. Adapted from Agnew, R. (1992). Foundation for a general strain theory of crime and delinquency. Journal of Criminology, 30(1), 47-87. https://doi.org/10.1111/j.1745-9125.1992.tb01093. 82 Appendix F Social Cognitive Theory Figure 1 Three-way interaction diagram of social cognitive theory. Note. Adapted from Bao, W., Chen, Y., Cui, C., Xia, B., Ke, Y., Skitmore, M., & Liu, Y. (2023). How to shape local public acceptance of Not-in-My-Backyard infrastructures? A social cognitive theory perspective. Sustainability (Basel, Switzerland), 15(22), 15835. https://doi.org/10.3390/su152215835 CC BY 4.0 Personal factors include self-efficacy, self-control, and results expectations (Bao et al., 2023). Environmental factors include social environment, fairness, and trust (Bao et al., 2023). Behavioural factors include individual acceptance, rejection, and choice (Bao et al., 2023). 83 Appendix G Adaptations to Strain 84 Note. Adapted from Agnew, R. (1992). Foundation for a general strain theory of crime and delinquency. Journal of Criminology, 30(1), 47-87. https://doi.org/10.1111/j.1745-9125.1992.tb01093.x 85 Appendix H Disposition for Delinquency Based on the Impact of Adverse Events Note. Adapted from Agnew, R. (1992). Foundation for a general strain theory of crime and delinquency. Journal of Criminology, 30(1), 47-87. https://doi.org/10.1111/j.1745-9125.1992.tb01093.x