International Journal of Drug Policy 45 (2017) 917

Contents lists available at ScienceDirect

International Journal of Drug Policy

journal homepage: www.elsevier.com/locate/drugpo

Editors Choice

Canadian harm reduction policies: A comparative content analysis of

provincial and territorial documents, 20002015
T. Cameron Wilda,* , Bernie Paulyb , Lynne Belle-Islec , Walter Cavalierid , Richard Elliotte ,
Carol Strikef , Kenneth Tupperg , Andrew Hathawayh , Colleen Delli , Donald MacPhersonj,
Caitlin Sinclaira , Kamagaju Karekezia , Benjamin Tana , Elaine Hyshkaa,k
a
School of Public Health, University of Alberta, Canada
b
School of Nursing and Centre for Addictions Research of BC, University of Victoria, Canada
c
Canadian AIDS Society and Centre for Addictions Research of BC, University of Victoria, Canada
d
Canadian Harm Reduction Network, Canada
e
Canadian HIV/AIDS Legal Network, Canada
f
University of Toronto, Canada
g
School of Population and Public Health, University of British Columbia, Canada
h
University of Guelph, Canada
i
University of Saskatchewan, Canada
j
Canadian Drug Policy Coalition, Canada
k
Inner City Health and Wellness Program, Royal Alexandra Hospital, Edmonton, Canada

A R T I C L E I N F O A B S T R A C T

Article history: Background: Access to harm reduction interventions among substance users across Canada is highly
Received 20 October 2016 variable, and largely within the policy jurisdiction of the provinces and territories. This study
Received in revised form 8 February 2017 systematically described variation in policy frameworks guiding harm reduction services among
Accepted 22 March 2017
Canadian provinces and territories as part of the rst national multimethod case study of harm reduction
Available online xxx
policy.
Methods: Systematic and purposive searches identied publicly-accessible policy texts guiding planning
Keywords:
and organization of one or more of seven targeted harm reduction services: needle distribution,
Harm reduction
Policy
naloxone, supervised injection/consumption, low-threshold opioid substitution (or maintenance)
Content analysis treatment, buprenorphine/naloxone (suboxone), drug checking, and safer inhalation kits. A corpus of
101 documents written or commissioned by provincial/territorial governments or their regional health
authorities from 2000 to 2015 were identied and veried for relevance by a National Reference
Committee. Texts were content analyzed using an a priori governance framework assessing managerial
roles and functions, structures, interventions endorsed, client characteristics, and environmental
variables.
Results: Nationally, few (12%) of the documents were written to expressly guide harm reduction services
or resources as their primary named purpose; most documents included harm reduction as a component
of broader addiction and/or mental health strategies (43%) or blood-borne pathogen strategies (43%).
Most documents (72%) identied roles and responsibilities of health service providers, but fewer
declared how services would be funded (56%), specied a policy timeline (38%), referenced supporting
legislation (26%), or received endorsement from elected members of government (16%). Nonspecic
references to harm reduction appeared an average of 12.8 times per documentfar more frequently
than references to specic harm reduction interventions (needle distribution = 4.6 times/document;
supervised injection service = 1.4 times/document). Low-threshold opioid substitution, safer inhalation
kits, drug checking, and buprenorphine/naloxone were virtually unmentioned. Two cases (Quebec and
BC) produced about half of all policy documents, while 6 cases covering parts of Atlantic and Northern
Canada each produced three or fewer.
Conclusion: Canada exhibited wide regional variation in policies guiding the planning and organization of
Canadian harm reduction services, with some areas of the country producing few or no policies. Despite a
wealth of effectiveness and health economic research demonstrating the value of specic harm reduction

* Corresponding author at: School of Public Health, University of Alberta, Edmonton, AB T6G 2T4, Canada.
E-mail address: cam.wild@ualberta.ca (T. C. Wild).

http://dx.doi.org/10.1016/j.drugpo.2017.03.014
0955-3959/ 2017 Elsevier B.V. All rights reserved.
10 T.C. Wild et al. / International Journal of Drug Policy 45 (2017) 917

interventions, policies guiding Canada from 2000 to 2015 did not stake out harm reduction interventions
as a distinct, legitimate health service domain.
2017 Elsevier B.V. All rights reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Cases and scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Document retrieval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Systematic search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Screening: inclusion and exclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Purposive search1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Document verication procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Theoretical approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Document coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Analysis and results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Document characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Strengths and limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Introduction (Bowen, 2012; Euchner, Heichl, Nebel, & Raschzok, 2013;

Heichel, Knill, & Schmitt, 2013; Strike, Myers, & Millson,
Health system decision making increasingly relies on instru- 2004). From this perspective, policymaking that guides harm
mental-rational arguments to inform policies designed to allocate reduction services is highly resistant to instrumental-rational
scarce resources to services. In these deliberations, principles and arguments that rest on evidence related to effectiveness and
tools of evidence-based medicine, including results from random- health economics. This may contribute to haphazard endorse-
ized controlled trials, systematic reviews and meta-analyses, and ment and implementation of harm reduction services in many
health-economic evaluations of services are prioritized (Donald- jurisdictions. Understanding the sources of such variable
son, Mugford, & Vale, 2002; Sackett, Rosenberg, Gray, Haynes, & implementation requires data informing how a range of policy
Richardson, 1995). On the surface, the substantial evidence base stakeholders construe highly contested moral, value-laden
supporting the positive population impact and cost-effectiveness discourses about people who use drugs and their right to
of harm reduction interventions (Kimber et al., 2010; Rhodes & access health services.
Hedrich, 2010; Strang et al., 2012; Ritter & Cameron, 2006) should The present research is a component of the Canadian Harm
translate into relatively straightforward policy support for the Reduction Policy Project (CHARPP), a mixed-method, multiple-
uptake of harm reduction as a routine component of health case study drawing on four data sources (policy documents, key
systems and services. However, when decisions regarding harm informant interviews, media portrayals, and a national public
reduction services for people who use drugs are at issue, evidence- opinion survey) to describe how policies governing harm
based considerations are often less inuential than political issues reduction services are positioned within and across Canadian
regarding implementation (Hathaway & Tousaw, 2008; Hathaway, provinces and territories. As part of CHARPP, we undertook a
2001). This is particularly true in Canada and other North American systematic review of Canadian policy frameworks used for the
jurisdictions, where harm reduction services continue to be highly planning and delivery of harm reduction services. Instead of a
contentious in many contexts and access to them is at best variable review of front-line practices, our focus was to describe and
(e.g. Cooper et al., 2012; Dias & Betteridge, 2007; MacNeil & Pauly, compare Canadian governance for harm reduction services,
2010; Parker, Jackson, Dykeman, Gahagan, & Karabanow, 2012; where governance refers to . . . regimes of laws, rules, judicial
Tempalski et al., 2007; Tempalski & McQuie, 2009). decisions, and administrative practices that constrain, prescribe,
It is widely acknowledged that health policy recommenda- and enable the provision of publicly supported goods and services
tions for services are inuenced by attitudes, values, and (Lynn, Heinrich, & Hill, 2001, p. 7).
sociopolitical dynamics in addition to quality of the scientic
evidence (Pettiti, 2012; Steinberg & Luce, 2005). However, harm Methods
reduction researchers and advocates typically construe these
factors narrowly, as barriers to effective uptake of evidence, A comprehensive search of Canadian provincial and territorial
rather than objects of enquiry (DeBeck & Kerr, 2010; Fafard, government and health authority harm reduction policy docu-
2012). In contrast, we propose that research on attitudes, values ments was performed, followed by a comparative content analysis
and sociopolitical factors per se can enhance understanding of of policy texts across jurisdictions.
policymaking decisions. In this context, the contested nature of
harm reduction services suggests that they form a prototypical Cases and scope
example of morality policy in the health arena, i.e., policymaking
that involves clashes of core values about the legitimacy of A multiple case study design was used to address the research
providing certain kinds of services to a target population objective. This approach is appropriate because we are studying
 T.C. Wild et al. / International Journal of Drug Policy 45 (2017) 917 11

a contemporary phenomenon (harm reduction policy making in Document retrieval

each province/territory) where the boundaries between the
phenomenon and its context are not readily separated (Stake,
2006). Case studies examining policy issues may be constructed
at various levels of analysis, including countries, provinces,
municipalities, institutions or individuals (Gerring, 2004), and
can describe broad political, scal, and administrative contexts
shaping decisions about how resources are allocated to health
services (Deber & Mah, 2014). Because Canadian health services
for people who use drugs (PWUD) are primarily the responsi-
bility of provinces and territories (Marchildon, 2006), we dened
cases for analysis at the provincial level. Thus, the scope of this
research included harm reduction policy documents produced
from 2000 to 2015 in the 13 Canadian provinces (n = 10) and
territories (n = 3) as cases for the study, which is consistent with
Stakes (2006) recommendation of a minimum of four cases for
multiple case study comparisons. Our case denition therefore
included documents produced by provincial/territorial minis-
tries and regional health authorities delegated by the provinces
and territories to develop health service policies for each
jurisdiction.
Identified
Document retrieval methods were rened through an iterative
search and screening process that included systematic and
purposive components. As the document retrieval process
proceeded, we developed, rened, and tested a set of inclusion
and exclusion criteria. Fig. 1 provides an overview of the search,
screening and verication process, adopting a modied set of the
Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) conventions (Moher, Liberati, Tetzlaff, &
Altman, 2009).
Systematic search
For each case, provincial or territorial-level and health
authority-level searches were conducted by entering each of
36 core search terms into an internet search engine (Google). This
set of core search terms was developed by the research team, and is
listed in Table 1.
Boolean searches were conducted by entering each core search
term along with province or territory name, and, in separate
searches, one of the following key words: plan, strategy or

Records identified through database searching Records excluded

(n = 317,676) (n = 315,781)

Documents
Documents screened for relevance excluded
Screened

(n = 1895) (n = 1,373)

Documents assessed for eligibility

(n = 522)
Eligibility

Documents excluded
(n = 441)
Clinical/practice guidelines
(n = 47)
Municipal-level policy (n = 24)
Off-topic after further
assessment (n = 370)

Documents added Documents verified for

Documents from supplemental relevance by National
included from search for reference committee
original search update/progress (n =100)
strategy reports on
(n = 81)
Included

included policy Documents added through

texts (n = 19) verification process
(n = 1)

Documents included in
content analysis
(n = 101)

Fig. 1. Search, screening, and verication process.

12 T.C. Wild et al. / International Journal of Drug Policy 45 (2017) 917

policy. Health authority/regional-level searches were conducted Table 1

Core search terms.
similarly, by entering core search terms along with health
authority name and then plan, strategy or policy. Searches Addiction Low threshold opioid Risk reduction
were conducted for all health authorities that existed between the Blood borne pathogen Substitution Safe crack
Buprenorphine Low threshold methadone Safe injection
years 2000 and 2015. Temporal parameters of the search were
Drug use Methadone maintenance Safe inhalation
mainly determined on pragmatic grounds, i.e. to make the review a Drug use Naloxone Street drug use
manageable process, and to ensure that documents reected Drug misuse Narcan Substance misuse
policies produced across government transitions at the federal and Harm minimization Needle Substance use
provincial/territorial levels. In each of the provinces, there has Harm reduction Syringe Supervised injection
Hepatitis C Opioid maintenance Overdose
been regional health authority restructuring since 2000. Therefore,
HIV/AIDS Reducing harm Drug checking
searches included health authorities that existed before and after Illicit drug use Reducing risk Street drug testing
restructuring, with two exceptions in the cases of Saskatchewan Injection drug use Risk management Suboxone
and British Columbia. Thirty-three health regions merged into
thirteen in Saskatchewan in 2002, while twenty-one health
regions merged into six in British Columbia in 2002. These harm reduction services. A total of 81 documents were assessed as
changes, combined with further reorganizations of both provinces meeting these inclusion criteria during initial screening.
health systems meant that we were unlikely to recover a complete
corpus of policy documents from these defunct health regions. Purposive search1
Accordingly, the research team agreed to exclude these defunct Although some update or progress reports were identied in
regions from the present search. All search terms were translated our systematic search, a purposive search for these documents was
into French for searches conducted for Quebec (the provinces also undertaken in order to ensure all policy documents were
ofcial language is French). The research team erred on the side of analysed alongside any status updates. This search was conducted
caution and included all documents that appeared to address the by entering the names of each policy document along with the key
study objectives; if doubts regarding relevance arose, the docu- terms progress and update. These purposive search processes
ment was recorded and agged for further consideration. A total of identied 19 additional policy documents that met the inclusion
522 unique documents potentially relevant for this study were criteria and were included in our review.
obtained as a result of these searches. Searches were conducted by
CS, GK, BT, and LBI. Final decisions regarding the inclusion and Document verication procedures
exclusion of each document were made by TCW in consultation
with this team. The nal list of 100 documents meeting our inclusion criteria
was reviewed by the CHARPP policy working group for relevance.
Screening: inclusion and exclusion criteria In addition, we recruited a National Reference Committee
Retrieved documents were reviewed by CS, GK, and LBI for consisting of 76 policymakers, service providers and researchers
relevance, i.e. text references to harm reduction policies, services, with an interest in harm reduction policy from across the provinces
and/or resources. The following inclusion and exclusion criteria and territories. Members of this committee were invited to verify
were developed iteratively through the document retrieval process the relevance of all included documents through an electronic
and initial reading of documents for relevance. Following Ritter survey. Their feedback veried the relevance of the documents and
and Berends (2016), we included documents that met our resulted in the addition of one other policy document which had
denition of a harm reduction policy text as a document (1) issued not been identied in the search process, resulting in a nal corpus
by, and representing, a provincial or territorial government, or (2) of 101 policy texts for analysis.
issued by, and representing, a regional, provincial or territorial
health authority, that (3) mandated future action, and (4) Data extraction
addressed harm reduction services and interventions, dened as
one or more of the following: needle distribution, naloxone, A deductive coding framework for our content analysis of
supervised injection/consumption, low-threshold opioid substitu- included policy texts was developed and rened, using preliminary
tion (or maintenance) treatment, buprenorphine/naloxone (sub- analysis of the texts included in the review.
oxone), drug checking, and safer inhalation kits, and/or (5)
produced as either a stand-alone harm reduction policy or as part Theoretical approach
of a strategy document guiding services for addiction, mental Variables included in the content analysis were derived from a
health and/or sexually-transmitted and/or blood-borne infections reduced-form logic of governance for publicly-funded human
(STBBIs). services proposed by Lynn et al. (2001). Lynn and colleagues
Because the focus of this analysis was on policy frameworks proposed ve . . . categories of variables that are included a priori
that Canadian provinces and territories use to support governance in any logic or model of governance . . . that investigators
of harm reduction services in their jurisdictions, documents were encounter in empirical governance research . . . whether they
excluded if they described policies governing harm reduction analyze those concepts through the lenses of political economy,
services (1) at the municipal level, (2) in Canadian federal prisons network analysis, systems models, or institutional approaches (p.
(these have been described elsewhere; see Betteridge & Dias, 2007; 81). These categories include: managerial roles and functions,
Zakaria, Thompson, Jarvis, & Borgatta, 2010), (3) on First Nations
reserves (services and resources for these communities are the
responsibility of the federal government), and (4) at the front-line 1
Initially, regional health authority (RHA) strategic plans were excluded on
level of clinical or community-based service provision. Harm grounds that they address all aspects of regional health service delivery and thus
reduction practice guidelines written by government or health were too broad for our purposes. However, as the document retrieval process
authorities to regulate how frontline services are delivered were evolved, a number of RHA strategic plans were identied that included harm
reduction goals. Consequently, we purposively searched all RHAs for their
excluded on grounds that the focus of this analysis was not on respective strategic plans. RHA strategic plans that included at least one major
harm reduction practice, but on policy frameworks that Canadian goal related to addiction or harm reduction were identied, but are not included in
provinces and territories use to support and guide the existence of the analyses reported in this article.
 T.C. Wild et al. / International Journal of Drug Policy 45 (2017) 917
Table 2
Document descriptions.
Case Total # of documents (% of Canadian total)
British Columbia 29 (28.7%)
Alberta 9 (8.9%)
Saskatchewan 7 (6.9%)
Manitoba 8 (7.8%)
Ontario 7 (6.9%)
Quebec 19 (18.8%)
Nova Scotia 12 (11.9%)
New Brunswick 2 (2.0%)
Prince Edward Island 1 (1.0%)
Newfoundland 2 (2.0%)
Yukon 0 (0.0%)
North West Territories 3 (3.0%)
Nunavut 2 (2.0%)
Canada 101 (100%)
structures, treatments (i.e., service interventions), client character-
istics and environmental variables. These concepts are designed to
assist researchers in assessing key features of governance, even as
they locate their work in diverse theoretical2 and methodological
traditions. Lynn and colleagues argue that researchers should
conceptualize their work within these categories in order to avoid
a common tendency for policy scholars to conceptualize gover-
nance imprecisely and rhetorically, as whatever must be done to
implement change successfully (Lynn et al., 2001, p. 6). For the
present study, Lynn et al.s framework facilitated comparisons of
the relative strength of harm reduction policy documents with
regard to how these broad, instrumental features of governance
were represented in policy frameworks across cases.
Document coding
The coding framework included 18 variables drawn from Lynn
et al.s (2001) governance framework. Five managerial roles and
functions were coded, i.e. whether or not the text (a) described
roles and responsibilities for delivery of harm reduction services,
(b) referenced legislation, (c) included an endorsement from an
elected government ofcial, (d) reported a timeline, and (e) the
number of years spanned by the document. Four structures were
coded, i.e. (f) whether or not the text referenced funding or specic
funding mechanisms for harm reduction services, (g) whether the
document referenced provincial/territorial or health authority
level of oversight, (h) whether or not the text was produced by
more than one provincial/territorial ministry, and (i) how the
policy text was located (i.e. as a stand-alone harm reduction policy,
or as a component of broader addiction, addiction and mental
health, or sexually-transmitted and blood-borne pathogen strate-
gies). Seven treatments were coded, i.e. the number of times the
following harm reduction services or interventions were men-
tioned in each text: (j) needle distribution, naloxone, (k)
supervised injection/consumption, (l) low-threshold opioid sub-
stitution (or maintenance) treatment, (m) buprenorphine/nalox-
one (or Suboxone), (n) drug checking, and (o) safer inhalation kits.
One client characteristic was coded, i.e. (p) the number of people
affected by the policy, as obtained via secondary data on
population size at the provincial/territorial and health-authority
level. Finally, four generic features of the texts were recorded,
including (q) which case the document was drawn from, (r) total
2
For example, governance theorized as goal-seeking optimization of achieve-
ments within extant governance regimes, or alternatively as coalition politics
representing vested group interests, or as a reection of institutional responses to
political-economic factors.
13
Total # of pages (% of Canadian total)
1184 (26.7%)
352 (7.9%)
584 (13.2%)
176 (4.0%)
336 (4.0%)
1084 (24.4%)
336 (7.6%)
39 (0.9%)
26 (0.6%)
164 (3.7%)
0 (0.0%)
63 (1.4%)
91 (2.1%)
4435 (100%)
number of documents per case, (s) date published, and (t) the total
number of pages in the document.
Analysis and results
Document characteristics
As shown in Table 2, between 2000 and 2015, the 13 Canadian
cases (i.e., jurisdictions) produced 101 policy texts (M = 7.76;
range = 0 [Yukon] 29 [BC]). Two jurisdictions (BC and Quebec)
accounted for nearly half (47.5%) of all policy texts produced during
the study period. The documents amounted to 4435 text pages
(M = 341.2 pages/case; range = 0 [Yukon] 1184 [BC]).
Governance
Although there was some variability across cases, very similar
declarations of managerial roles and functions were observed in the
reviewed documents (Table 3). Nationally, most (72%) documents
identied roles and responsibilities of system managers or health
service providers, but fewer documents declared how services
would be funded (56%), specied a policy timeline (38%), related
services to legislation (26%), or received any ofcial governmental
endorsement (16%), and these patterns were largely repeated
across all provincial/territorial cases.
With respect to governance structures, at the national level, few
(12%) of the documents were written to guide harm reduction
services or resources as their primary named purpose; these stand-
alone harm reduction policies were observed only in four cases (BC,
Alberta, Manitoba, Quebec). The majority of documents included
harm reduction as components of addiction and/or mental health
strategies (43% of documents; Table 4), and sexually-transmitted
and blood-borne infections strategies (43% of documents; Table 4).
Across cases, most (73%) of the documents were authored by
provincial governments, although two cases (Quebec, Alberta)
produced more documents at the regional health authority level
(58% and 56% of documents within these cases; Table 4). Slightly
more than half (56%) of all documents specically declared any
funding mechanisms (Table 4).
Regarding treatments (i.e. interventions and services) endorsed
by the policy documents, a similar pattern was observed at the
national level. Nonspecic references to harm reduction appeared
approximately 19.7 times per documentfar more frequently than
references to any specic harm reduction intervention or service
(needle exchange = 4.6 times/document; supervised injection
services = 1.4 times/document). Substantial variability was ob-
served across cases with respect to the specicity of interventions
14 T.C. Wild et al. / International Journal of Drug Policy 45 (2017) 917

Table 3
Proportion of documents declaring management roles and functions.

Case (# of documents within case) Roles and responsibilities Legislation referenced Endorsement from govt. ofcial Timeline provided
British Columbia (29) 79% 0% 14% 45%
Alberta (9) 89% 33% 0% 44%
Saskatchewan (7) 100% 14% 0% 29%
Manitoba (8) 75% 13% 0% 38%
Ontario (7) 71% 43% 0% 14%
Quebec (19) 79% 85% 42% 42%
Nova Scotia (12) 17% 0% 8% 25%
New Brunswick (2) 100% 0% 50% 100%
Prince Edward Island (1) 0% 0% 0% 0%
Newfoundland (2) 100% 50% 0% 0%
Yukon (0) n/a n/a n/a n/a
North West Territories (3) 33% 33/% 67% 33%
Nunavut (2) 50% 0/% 0% 50%

Canada (101) 72% 26% 16% 38%

endorsed in policy. For example, when considering Canadian
jurisdictions with the greatest population size, policy documents
produced by two provinces (BC, Quebec) explicitly endorsed
almost all interventions under investigation; policy documents
produced by another large province (Ontario) endorsed virtually
none of the services under review (Table 5).
Discussion
Canada has historically been regarded as an international
leader in the development of harm reduction, beginning with
early adoption of needle distribution programs in 1989, more
recent implementation of North Americans rst supervised
consumption facility in Vancouver in 2003, and North Americas
rst clinical trial of prescription heroin in 2005 (Wood et al.,
2004; Oviedo-Joekes et al., 2008). Harm reduction services were
formally introduced in Canada in 1989 when the federal health
department partnered with ve provinces to establish eight pilot
syringe exchange programs in major Canadian cities (this was
preceded by informal user-driven programs in Vancouver and
Montreal; Hankins, 1998). Federal pilot funding ended two years
later, and although provincial/territorial policy frameworks have
guided implementation and institutionalization of harm reduc-
tion services since that time, no extant research has systemati-
cally described these frameworks across the Canadian provinces
and territories.
Using a corpus of policy frameworks written from 2000 to 2015,
the present study documented wide variation across jurisdictions
in both the volume and specicity of policies guiding the planning
and organization of harm reduction services across Canada. Two
jurisdictions (BC and Quebec) produced about half of all policy
documents during the study period, yet one case (BC) produced
almost double the policy documents than the other (Quebec). In
contrast, six jurisdictions covering large parts of Atlantic and
Northern Canada each produced three or fewer policy documents
during the same 15-year period, and one jurisdiction (Yukon)
produced no policy texts at all. Variation in the volume and
specicity of policies across cases may reect context-specic
factors at play in each jurisdiction. For example, the large number
of policy documents observed in BC coincided with adoption of a
variety of innovative harm reduction intervention strategies in
response to high rates of HIV and hepatitis C transmission, fatal
drug overdoses, and an open public drug scene in Vancouver the
late 1990s and early 2000s (Tyndall et al., 2006). In contrast, rural
and remote areas of Canada have historically struggled to support
HIV/HCV, substance-related, and mental health interventions due
to limited infrastructure and capacity for providing health services
in those areas. This may account for the relative dearth of policy
documents produced in remote Canadian jurisdictions.
Notably, only a small minority of policy texts were written to
provide governance for harm reduction services as their primary
named purpose. Instead, policies were evenly split between texts

Table 4
Proportion of documents declaring structural governance features.

Case (# of documents Funding Oversight Policy framing

within case) described
Provincial Regional health Stand-alone harm Component of addiction and/or mental Component of STI/BBP
government authority reduction policy health strategies strategies
British Columbia (29) 62% 72% 28% 14% 31% 55%
Alberta (9) 78% 44% 56% 11% 56% 33%
Saskatchewan (7) 71% 71% 29% 0% 29% 71%
Manitoba (8) 0% 63% 38% 25% 38% 38%
Ontario (7) 57% 71% 22% 0% 86% 14%
Quebec (19) 53% 42% 58% 26% 42% 21%
Nova Scotia (12) 67% 100% 0% 0% 25% 67%
New Brunswick (2) 100% 100% 0% 0% 100% 0%
Prince Edward Island 0% 100% 0% 0% 100% 0%
(1)
Newfoundland (2) 0% 100% 0% 0% 50% 50%
Yukon (0) n/a n/a n/a n/a n/a n/a
North West Territories 100% 100% 0% 0% 67% 33%
(3)
Nunavut (2) 0% 100% 0% 0% 50% 50%

Canada (101) 56% 73% 27% 12% 43% 43%

 T.C. Wild et al. / International Journal of Drug Policy 45 (2017) 917 15

Table 5
Number (rates per document) of specic harm reduction services identied within cases.

Case (# of documents Harm reduction Needle Naloxone Supervised injection and Low threshold Buprenor./Naloxone Drug Safer
within cases) (unspecied) exchange consumption substitution (Suboxone) checking inhalation kits
British Columbia (29) 570 (19.7) 177 (6.1) 15 (0.5) 83 (2.9) 2 (0.1) 3 (0.1) 0 (0.0) 15 (0.5)
Alberta (9) 118 (13.1) 19 (2.1) 0 (0.0) 2 (0.2) 0 (0.0)) 0 (0.0) 0 (0.0) 1 (0.1)
Saskatchewan (7) 320 (45.7) 157 (22.4) 0 (0.0) 38 (5.4) 0 (0.0)) 1 (0.1) 0 (0.0) 2 (0.3)
Manitoba (8) 92 (11.5) 22 (2.8) 1 (0.1) 3 (0.4) 0 (0.0) 0 (0.0) 1 (0.1) 2 (0.3)
Ontario (7) 9 (1.3) 1 (0.1) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Quebec (19) 108 (5.7) 20 (1.1) 0 (0.0) 17 (0.9) 7 (0.4) 0 (0.0) 1 (0.1) 0 (0.0)
Nova Scotia (12) 52 (4.3) 66 (5.5) 2 (0.2) 2 (0.2) 3 (0.3) 27 (2.3) 0 (0.0) 2 (0.2)
New Brunswick (2) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Prince Edward Island (1) 6 (6.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Newfoundland (2) 5 (2.5) 2 (1.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
Yukon (0) n/a n/a n/a n/a n/a n/a n/a n/a
North West Territories 3 (1.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)
(3)
Nunavut (2) 9 (4.5) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)

Canada (101) 1292 (12.8) 464 (4.59) 18 (0.18) 145 (1.44) 12 (0.1) 31 (0.3) 2 (0.02) 22 (0.2)

conceiving and locating harm reduction services as part of
addiction and/or mental health strategies or as part of strategies
to address sexually-transmitted and blood-borne infections. These
results are informative when viewed in conjunction with our
ndings that almost half of the documents produced by the
jurisdictions did not make any explicit reference to funding
arrangements for harm reduction services, and that four juris-
dictions did not mention funding at all.
From the perspective of management roles and functions, within
and across jurisdictions, uniformly low references to supporting
legislation, endorsement by an elected ofcial, and timelines for
developing and implementing policy and programs suggest that
the policy documents under investigation may have been written
more for rhetorical purposes than for health system planning. This
interpretation is reinforced by our ndings in the domain of
treatment interventions showing that generic references to harm
reduction dominated the policy texts under review: nonspecic
references to harm reduction appeared three to twelve times more
frequently than any specic harm reduction intervention or service
at the national level, and this pattern was replicated in almost
every jurisdiction. In the entire corpus under review, needle
exchange was the most commonly-declared intervention sup-
ported by policy, but all other harm reduction interventions went
virtually unmentioned in policy texts. Even needle exchange was
not uniformly mentioned at the case level and was absent in four
jurisdictions, and only once in the policies governing Canadas
most populous Province (Ontario).
Collectively, our results suggest that publicly-available Canadi-
an provincial/territorial policy frameworks have been very slow to
articulate policies containing specic managerial components and
intervention approaches to guide comprehensive governance
strategies for harm reduction services. As such, the present results
reinforce our view that Canadian policies governing harm
reduction services over the study period were produced in a
morality policy environment, as demonstrated by the preponder-
ance of rhetorical calls in our corpus to support unspecied
services, using unclear funding arrangements, in service of
improving either infectious disease outcomes or addiction out-
comes. Despite a wealth of effectiveness and health economic
research demonstrating the value of specic harm reduction
interventions, Canadian policy makers during the study period
appeared to view specic harm reduction interventions as too
politically contentious to be named or supported, preferring
instead to endorse the generic concept as a more palatable
alternative. As such, the present results suggest that policies
guiding Canada from 2000 to 2015 did not stake out harm
reduction interventions as a distinct, legitimate health service
domain. Further research is needed to describe patterns of
resilience or acquiescence among service providers in response
to a morality policy environment. For example, despite clear
evidence of public health benet (Kim, Irwin, & Khoshnood, 2009;
Wheeler, Davidson, Jones, & Irwin, 2012), the rst community-
based naloxone delivery program in Canada was implemented in a
jurisdiction that, according to our analysis, did not ofcially
endorse this harm reduction intervention in its policy frameworks
(Dong et al., 2012).
Strengths and limitations
Very little research has described provincial/territorial harm
reduction policy frameworks used in Canada, and this study
provides the rst empirical data in this area. Methodologically,
study strengths include comprehensive document retrieval
procedures, and involvement of stakeholders from across the
country in a structured process to verify the relevance of the policy
texts reviewed. In addition, the content-analytic procedures
facilitated systematic cross-case descriptions of governance and
policy features using a common set of variables that apply to
Canada and beyond. These methodological strengths lend them-
selves well not only to within-country analyses, as demonstrated
here, but also to international comparative studies designed to
describe governance of harm reduction services across countries
and over time. Such research may assist in documenting the extent
to which morality policy environments inuence harm reduction
policymaking in other countries, and in formulating cross-national
governance standards for institutionalizing harm reduction
services as part of routine health care.
This study used Lynn et al.s (2001) reduced-form logic of
governance to guide the a priori content coding framework, and
this approach does have limitations. Specically, the content codes
used in this study referred solely to instrumental features of
governance in this area, i.e. policy texts designed to achieve
particular purposes or outcomes with respect to recognition and
implementation of harm reduction services. Beyond these
utilitarian features of governance, scholars recognize that policies
also serve important symbolic, expressive and/or communicative
functions (Pierce, 2011; Sunstein, 1996). These non-instrumental
functions of policy documents and frameworks involve (often
implicit) messages about underlying values that can intentionally
or unintentionally inuence attitudes and behaviours. The present
results are thus limited because our coding framework excluded
assessment of the non-instrumental functions of the policy texts.
16 T.C. Wild et al. / International Journal of Drug Policy 45 (2017) 917
To address this limitation, we are conducting further analyses of
the corpus of policy texts to describe the language used in each
case to dene and conceptualize harm reduction, to legitimize and
prioritize certain services (e.g. needle exchange) over others (e.g.
safer inhalation kits), to identify how target populations for harm
reduction services are characterized, and to explore the extent to
which utilitarian versus social justice perspectives are emphasized
in policy (cf. Edwards, 2009; Hathaway, 2001).
Several other study limitations should be noted. In particular,
the document retrieval procedures focused on publicly-available
policy texts obtained using a commercial search engine (Google).
Generalizability of the study results is limited to the extent that not
all provincial/territorial harm reduction policy documents may be
available using this approach. It is possible that other search
strategies would recover additional documents, and future
research should explore whether other document retrieval
methods enhance the corpus of texts. Related to this point,
provincial/territorial policy stakeholders typically produce addi-
tional documents, not easily accessible to the public, that contain
more concrete operational planning material than those recovered
using the present search methods. Future research should attempt
to systematically acquire these materials in order to provide
additional detail on important issues such as funding commit-
ments, policy implementation, and guidance on governance for
service providers. Finally, the present focus on provincial/
territorial and regional health-authority level documents has both
strengths and limitations. Because Canadian provinces and
territories have legislative authority over the delivery of health
services and often provide funding for those services (Marchildon,
2006), our approach is appropriate for describing consistency and
variability in broad policy frameworks governing harm reduction
services at this level of case denition. However, chronic under-
funding of health services for PWUD has resulted in organization
and funding of these services at municipal levels. Our study results
are limited, therefore, because we did not dene cases at this level
of analysis.
Despite these limitations, the present study provided a
systematic description of ofcial harm reduction policies across
Canada. Our results documented both consistency and variabil-
ity in provincial/territorial harm reduction policy frameworks
across Canada. Our approach is well-suited to provide a high-
level descriptive overview of how different jurisdictions
incorporate key features of governance into policy frameworks
that are used to institutionalize and implement harm reduction
services. Our results suggest that, despite increasing evidence of
effectiveness for a variety of harm reduction interventions,
Canadian provinces and territories have been slow to develop
comprehensive governance frameworks to institutionalize these
services.
Acknowledgements
The research reported in this paper was supported by an
operating grant from the Canadian Institutes of Health Research
(MOP 137073) to TCW and EH.
Conicts of interest
There are no known conicts of interest.
References
Betteridge, G., & Dias, G. (2007). Hard time: HIV and hepatitis C prevention
programming for prisoners in Canada. Toronto: Canadian HIV/AIDS Legal
Network, Prisoners HIV/AIDS Support Action Network (PASAN).
Bowen, E. A. (2012). Clean needles and bad blood: Needle exchange as morality
policy. Journal of Sociology & Social Welfare, 39(2), 121141.
Cooper, H., Des Jarlais, D., Ross, Z., Tempalski, B., Bossak, B. H., & Friedman, S. R.
(2012). Spatial access to sterile syringes and the odds of injecting with an
unsterile syringe among injectors: A longitudinal multilevel study. Journal of
Urban Health, 89(4), 678696.
Dias, G., & Betteridge, G. (2007). Hard time: HIV and hepatitis C prevention
programming for prisoners in Canada. Toronto: Canadian HIV/AIDS Legal
Network. online: http://www.aidslaw.ca/site/hard-time-hiv-and-hepatitis-c-
prevention-programming-for-prisoners-in-canada/?lang=en.
DeBeck, K., & Kerr, T. (2010). The use of knowledge translation and legal proceedings
to support evidence-based drug policy in Canada: Opportunities and ongoing
challenges. Open Medince, 4(September (3)), e167e170.
Deber, R. B., & Mah, C. L. (2014). Canadian case studies in health policy and
management. Toronto: University of Toronto Press.
Donaldson, C., Mugford, M., & Vale, L. (2002). Evidence-based health economics.
London: BMJ Press.
Dong, K. A., Taylor, M., Wild, T. C., Villa-Roel, C., Rose, M., Salvalaggio, G., et al. (2012).
Community based naloxone: A Canadian pilot program. Canadian Journal of
Addiction Medicine, 3, 49.
Edwards, N. C. (2009). Revisiting our social justice roots in population health
interventionresearch. Canadian Journal of Public Health, 100, 405408.
Euchner, E.-M., Heichl, S., Nebel, K., & Raschzok, A. (2013). From morality policy to
normal policy: Framing of drug consumption and gambling in Germany and the
Netherlands and their regulatory consequences. Journal of European Public
Policy, 20(3), 372389.
Fafard, P. (2012). Public health understandings of policy and power: Lessons from
INSITE. Journal of Urban Health, 89(6), 905914.
Gerring, J. (2004). What is a case study and what is it good for? American Political
Science Review, 98(2), 341354.
Hankins, C. (1998). Syringe exchange in Canada: Good but not good enough to stem
the HIV tide. Substance Use and Misuse, 33(5), 11291146.
Hathaway, A. D. (2001). Shortcomings of harm reduction: Toward a morally invested
drug reform strategy. International Journal of Drug Policy, 12, 125137.
Hathaway, A. D., & Tousaw, K. I. (2008). Harm reduction headway and continuing
resistance: Insights from safe injection in the city of Vancouver. International
Journal of Drug Policy, 19, 1116.
Heichel, S., Knill, C., & Schmitt, S. (2013). Public policy meets morality: Conceptual
and theoretical challenges in the analysis of morality policy change. Journal of
European Public Policy, 20(3), 318334.
Kim, D., Irwin, K. S., & Khoshnood, K. (2009). Expanded access to naloxone: Options
for critical response to the epidemic of opioid overdose mortality. American
Journal of Public Health, 99(3), 402407.
Kimber, J., Palmateer, N., Hutchinson, S., Hickman, M., Goldberg, D., & Rhodes, T.
(2010). Harm reduction among injection drug users-evidence of effectiveness.
In T. Rhodes, & D. Hedrich (Eds.), Harm reduction: Evidence, impacts, challenges
EMCDDA monographs, Luxembourg: Publications ofce of the European Union.
Lynn, L. E., Heinrich, C. J., & Hill, C. J. (2001). Improving governance: A new logic
forempirical research. Washington, DC: Georgetown University Press.
MacNeil, J., & Pauly, B. M. (2010). Impact: A case study examining the closure of a
large urban xed site needle exchange in Canada. Harm Reduction Journal, 7(11).
http://dx.doi.org/10.1186/1477-7517-7-11.
Marchildon, G. P. (2006). Health systems in transition: Canada. Toronto: University of
Toronto Press.
Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & The PRISMA Group (2009).
Preferred reporting items for systematic reviews and meta-analyses: The
PRISMA statement. PLoS Medicine, 6(7), e1000097. http://dx.doi.org/10.1371/
journal.pmed1000097.
Oviedo-Joekes, E., Nosyk, B., Brissette, S., Chettiar, J., Schneeberger, P., Marsh, D. C., et
al. (2008). The North American Opiate Medication Initiative (NAOMI): Prole of
participants in North Americans rst trial of heroin-assisted treatment. Journal
of Urban Health: Bulletin of the New York Academy of Medicine, 85(6). http://dx.
doi.org/10.1007/s11524-008-9312-9.
Parker, J., Jackson, L., Dykeman, M., Gahagan, J., & Karabanow, J. (2012). Access to
harm reduction services in Atlantic Canada: Implications for non-urban
residents who inject drugs. Health and Place, 18(2), 152162.
Pettiti, D. B. (2012). Prevention and the science and politics of evidence. In H. S.
Faust, & P. T. Menzel (Eds.), Prevention vs. treatment: Whats the right balance?
(pp. 96110). New York: Oxford University Press.
Pierce, R. (2011). The expressive function of public health policy: The case of
pandemic planning. Public Health Ethics, 4(1), 5362.
Rhodes, T., & Hedrich, D. (2010). Harm reduction: Evidence, impacts, challenges.
EMCDDA monographs. Luxembourg: Publications ofce of the European Union.
Ritter, A., & Berends, L. (2016). Twenty years of (non)reform in Victorian alcohol and
otherdrug treatment policy. Drug and Alcohol Review, 35(3), 250254. http://dx.
doi.org/10.1111/dar.12374.
Ritter, A., & Cameron, J. (2006). A review of the efcacy and effectiveness of harm
reduction strategies for alcohol, tobacco and illicit drugs. Drug & Alcohol Review,
25(6), 611624.
Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1995).
Evidence based medicine: What it is and what it isnt. British Medical Journal, 312
(7023), 871875.
Stake, R. E. (2006). Multiple case study analysis. New York: Guilford Press.
Steinberg, E. P., & Luce, B. R. (2005). Evidence based? Caveat emptor!. Health Affairs,
24, 8092.
Strike, C. J., Myers, T., & Millson, M. (2004). Finding a place for needle exchange
programs. Critical Public Health, 14(3), 261.
Strang, J., Babor, T., Caulkins, J., Fischer, B., Foxcroft, D., & Humphreys, K. (2012). Drug
policy and the public good: Evidence for effective interventions. Lancet, 379
(9810), 7183.
 T.C. Wild et al. / International Journal of Drug Policy 45 (2017) 917
Sunstein, C. R. (1996). On the expressive function of law. University of Pennsylvania
Law Review, 144, 20212053.
Tempalski, B., & McQuie, H. (2009). Drugscapes and the role of place and space in
injection drug use-related HIV risk environments. International Journal of Drug
Policy, 20(1), 413. http://dx.doi.org/10.1016/j.drugpo.2008.02.002.
Tempalski, B., Flom, P., Friedman, S. R., Des Jarlais, D., Friedman, J., McKnight, C., et al.
(2007). Social and political factors predicting the presence of syringe exchange
programs in 96 US Metropolitan areas. American Journal of Public Health, 97(3),
437447.
Wheeler, E., Davidson, P. J., Jones, T. S., & Irwin, K. S. (2012). Community-based opioid
overdose prevention programs providing naloxoneUnited States, 2010.
MMWR, 61(6), 100105. United States Centres for Disease Control and
Prevention.
17
Tyndall, M. W., Wood, E., Zhang, R., Lai, C., Montaner, J., & Kerr, T. (2006). HIV
seroprevalence among participants at a supervised injection facility in
Vancouver, Canada: Implications for prevention, care and treatment. Harm
Reduction Journal, 3, 36. http://dx.doi.org/10.1186/1477-7517-3-36.
Wood, E., Kerr, T., Small, W., Li, K., Marsh, D. C., Montaner, J. S. G., et al. (2004).
Changes in public order after the opening of a medically supervised safer
injecting facility for illicit injection drug users. Canadian Medical Association
Journal, 171(7), 731734.
Zakaria, D., Thompson, J. M., Jarvis, A., & Borgatta, F. (2010). Summary of emerging
findings from the 2007 National Inmate Infectious Diseases and Risk-behaviours
Survey. Ottawa: Correctional Service of Canada.