Harm reduction as anarchist practice
A user's guide to capitalism and addiction in North America

Abstract

In spite of its origins as an illegal, clandestine, grassroots activity that took place either outside or in defiant opposition to state and legal authority, there is growing evidence to suggest that harm reduction in North America has become sanitized and depoliticized in its institutionalization as public health policy. Harm reduction remains the most contested and controversial aspect of drug policy on both sides of the Canada–US border, yet the institutionalization of harm reduction in each national context demonstrates a series of stark contrasts. Drawing from regional case study examples in Canada and the US, this article historically traces and politically re-maps the uneasy relationship between the autonomous political origins of harm reduction, contemporary public health policy, and the adoption of the biomedical model for addiction research and treatment in North America. Situated within a broader theoretical interrogation of the etiology of addiction, this study culminates in a politically engaged critique of traditional addiction research and drug/service user autonomy. Arguing that the founding philosophy and spirit of the harm reduction movement represents a fundamentally anarchist-inspired form of practice, this article concludes by considering tactics for reclaiming and re-politicizing the future of harm reduction in North America.

Keywords: public health; anarchism; addiction research; addiction treatment; needle exchange; supervised injection facility; harm reduction

Introduction

Starting with the premise that the philosophy of harm reduction shares a number of unique parallels with the political philosophy of anarchism (Stoller [64]), this article examines how harm reduction practice in North America became depoliticized during its institutionalization as public health policy. Understanding depoliticization as the systemic exclusion of a structural, political-economic critique in the etiology of addiction, this study traces the historical shift from grassroots, oppositional social movement to depoliticized institutional policy, interrogating the strategic alignment between harm reduction, the biomedical establishment, and the pathology paradigm. Rendering harm reduction as little more than an inflexible tool of the addiction-as-brain-disease model, this analysis suggests that the resultant disconnect between contemporary public health policy and the oppositional roots of harm reduction practice has sanitized the latter, actively drawing attention away from the role of structural factors underpinning the phenomena of drug dependence.

This article closes by reasserting the structural roots of addiction in late-capitalist 'narcotic modernity' and arguing for the depathologization of drug dependence (Derrida [23], Alexander [1], [2], Granfield [34]). Positioning harm reduction as a fundamentally anarchist-inspired practice, this study is thereby posed as a users' guide to understanding the mutually constituting relationship between capitalism and addiction in North America.

Background: The 'new anarchists', harm reduction and institutionalization

The evolution of harm reduction is a story of compromise and cooptation, revealing evidence of an uneasy historical relationship with institutionalization. Adopted as part of the European 'four pillar' approach to drug policy including prevention, treatment, and enforcement, harm reduction refers to 'interventions that seek to reduce the harms associated with substance use for individuals, families, and communities' through a comprehensive range of 'co-ordinated, user-friendly, client-centered and flexible programs and services' (City of Toronto [15], p. 6). In order to illustrate how the adoption of harm reduction by public health authorities has diluted the originary anarchist foundations of the movement, it is necessary to both detail the history of harm reduction's institutionalization, and contextualize the emergence of what Graeber ([33]) termed the 'new anarchists'.

Prior to being institutionalized as public health policy following the 1980s AIDS epidemic, harm reduction originated as an illegal activity where activists and politicized front-line workers risked arrest by distributing clean syringes (Fischer [24], Stoller [64], Roe [58]). Here, Stoller ([64], p. 101) explores the origins of San Francisco's syringe program as an underground 'act of civil disobedience by a group of pagan, hippie anarchists',{1} whose uneasy relationship to civic authorities slowly negated the group's original anarchist principles. Established as a direct result of the mid-80s moral panic surrounding HIV/AIDS among inner-city injection drug users, the earliest institutionalized harm reduction measures in Europe were needle exchange programs (Hathaway and Erickson [38]). Although it continues to remain absent in American policy discourse, harm reduction was formally introduced in Canada with the 1987 establishment of Canada's Drug Strategy{2} (Fischer [24]).

As a rational and pragmatic response to addiction, harm reduction 'recognizes drug use as an inescapable fact, rather than a moral issue, and seeks to reduce the individual and social costs of abuse rather than to eliminate all drug use per se', thereby reframing drug user behavior 'in practical terms of cost-benefit analysis rather than ... ideology' (Hathaway and Erickson [38], p. 471). Here, the cost-benefit or 'bottom line' analysis of harm reduction is a calculation based not only on users' drug-related harms, but also the larger 'social costs' of addiction (Hunt and Stevens [42], City of Toronto [15]). Concerns regarding 'public order' and 'public safety' have constituted perhaps the primary justification for institutional harm reduction interventions (Fischer et al.[25], Small et al.[63]). From this perspective, it is relevant to raise the question whose harm does harm reduction policy seek to mitigate and reduce, that of the drug/service user or the social body politic? (Hunt and Stevens [42]).

Contemporaneous to the institutional adoption of the biomedical disease model, neoliberal health policy served to de-medicalize the subject of addiction treatment (Rosenbaum [60]), variously rearticulating the in-built relations of authority underlying 'patient' in the terms of 'client' or 'consumer'. Here, the former patient is transformed into a 'client' of treatment services whose counterpart is the treatment service provider. The displacement of doctor/patient by the client/provider dynamic is, however, further complicated by the notion of consumption, catalyzing a subsequent metamorphosis into the unambiguous designation consumer. Composed of a plural and shifting materiality, in the alchemy of 'substitution' treatment, the consumption of methadone therefore takes the place of 'junk' (Fraser and valentine [29]). In recognition of the deceptive 'medicine as business' rationality underlying the designations 'client' and 'consumer', effectively resituating subjects in a passive, one-way relationship to capitalist forces of production/consumption, this essay employs the term 'user' in reference to both harm reduction and drug treatment subjects, positing the designation drug/service user as a potentially productive, fluid interchangeability (Brooke and Stringer [10]).

Suggesting institutionalization has effectively sanitized harm reduction's oppositional political origins, Roe ([58], p. 244) articulates a historic tension between those who see the movement as a 'medical means of promoting health and mitigating harm', and a more activist faction positing harm reduction as 'a platform for broader and more structural social change'. Institutional harm reduction advocates, Roe ([58], p. 245) asserts, engage in cooperation with state bodies ignorant to the fact that 'the health problems they address are substantially created by the ideology of the systems in which they work'. Politicized proponents, by contrast, focus on a structural critique involving a 'political analysis of "risk" and "harm" as by-products of social, economic, racial or political inequality' (p. 245). A by-product of the 'branding' accompanying the reversal of harm reduction from a '"bottom up" movement' to a '"top down" policy', Roe suggests that harm reduction policy rooted in cost/benefit analysis may merely represent a new guise of control designed to 'minimize risk from, and maximize control over, marginal populations' such as drug/service users (p. 245). Harm-reduction-as-public-health-policy, as Keane ([46], p. 231) similarly concludes, thus 'avoids confronting the very things that produce the most harm for drug users: drug laws, dominant discourses of drug use and the stigmatization of users'.

Approximately corresponding to the dawn of harm reduction's global institutionalization, and building on the 1960s avant-garde notion of the 'revolution of everyday life' (Debord [20], Vaneigem [70]), radical leftist movements underwent a series of shifts away from utopian notions of revolution and toward what Bey ([6]) termed 'ontological anarchy' and the insurrectionist model of the 'temporary autonomous zone'. In his analysis of the 'political logic of the newest social movements', Day ([19], p. 716) describes how contemporary activists have repudiated 'universalizing conception[s] of social change', instead emphasizing 'an anarchist logic of affinity' centrally driven by direct action. Examining what he terms 'the new anarchists', Graeber ([33], p. 62) defines direct action as 'rejection of a politics which appeals to governments to modify their behavior, in favor of physical intervention against state power in a form that prefigures an alternative'.

Abandoning the rhetoric of state revolution in favor of everyday expressions of resistance rooted in autonomy and affinity, Graeber ([33], p. 68) suggests that direct action tactics are 'less about seizing state power' than 'exposing, de-legitimatizing and dismantling mechanisms of rule while winning ever-larger spaces of autonomy from it'. Fundamentally premised on the notion of autonomy, both Day's ([19]) arguments concerning the logic of affinity and Graeber's ([33]) contentions regarding direct action resonate closely with Bey's ([6], p. 101) notion of the temporary autonomous zone or TAZ: 'an uprising which does not engage directly with the State, a guerrilla operation that liberates an area (of land, of time, of imagination) and then dissolves itself to reform elsewhere/else when, before the State can crush it'. In this sense, Bey's ([6]) TAZ resembles what Deleuze and Guattari ([22], p. 7) termed rhizomes: multiplicitous and non-hierarchical forces that establish 'connections between semiotic chains, organizations of power ... and social struggles'.

A self-described 'ex-workers' collective', the contemporary US anarchist network Crimethinc embodies the spirit of Graeber's ([33]) 'new anarchism'. Provocatively concluding 'you may already be an anarchist', Crimethinc's (2002, p. 4) Fighting for our lives begins by recounting historical instances of struggle and mutual support, posing anarchism as a praxis of everyday life:

Whenever you act without waiting for instructions or official permission, you are an anarchist. Any time you bypass a ridiculous regulation when no one's looking, you are an anarchist. If you don't trust the government ... to know better than you when it comes to things that affect your life, that's anarchism too. And you are especially an anarchist when you come up with your own ideas and initiatives and solutions.

Borrowing from Crimethinc's (2002) romantically accessible rendering, this article understands anarchism as the generalized 'political logic' of contemporary radical social movements, composed by everyday practices of resistance grounded in the notions of autonomy, affinity, and direct action (Bey [6], Graeber [33], Day [19]).

Anarchist political theory, the founding philosophy of harm reduction and the reframing of institutionalized public health policy

Extending this framework, it is crucial to account for the ways that the institutionalization of harm reduction has confined the anarchist spirit of the movement. Sharing a startling number of commonalities, a comparative analysis of the basic principles underlying social anarchism and the founding philosophy of harm reduction illustrates the direct correlations between institutionalization and depoliticization. Moreover, examining the parallels between anarchist praxis and harm reduction theory reveals the implications of institutionalization and attendant discursive/political reframing of harm reduction and/as public health policy.

The abovementioned aspects of 'new anarchism' extend directly from the founding principles of social anarchism: anti-authoritarianism, distrust of hierarchy, and mutual aid. Directly related to the notion of autonomy, anti-authoritarianism typically manifests as the rejection of state governance and its decentralized institutions of (legal and biomedical) control. Captured in the sentiment 'no gods, no masters' (Guerin [36]), most manifestations of social anarchism are also inherently non-hierarchical, standing against any form of hierarchy premised on race/ethnicity, gender/sexuality, religion, or social class. Mutual aid, the third principle of social anarchism, represents a direct expression of affinity that often manifests in 'intentional communities' living outside conventional society (Bey [6], Graeber [33], Day [19], Guerin [36]).

The core values of anarchism are reflected in many elements of the founding philosophy – if not always the actual practice – of harm reduction. Growing out of the oppositional spirit of the movement, harm reduction discourse might therefore be seen as a disguised language developed to describe an emergent anarchist model of care for capitalism's most oppressed, yet symptomatic victims. The recognition of addiction as a health issue as opposed to a moral-criminological question represents perhaps the central founding trope of harm reduction (Fischer [24], Hathaway and Erickson [38], Keane [46], City of Toronto [15], Roe [58]). Correspondingly, the universal adoption of the addiction-as-disease paradigm can be understood as the central engine behind the institutionalization of harm reduction (Miller [53], Keane [46], Roe [58]). Actively obscuring the role of structural factors, the biomedical model instead locates addiction in the static intersection of substance and subject, suturing up drug dependence as a case of faulty neuro/chemical circuitry (Sedgwick [62], Alexander [1], [2], Bourgois [7], Granfield [34], Reith [56], Roe [58]).

Returning to our comparative analysis, anti-authoritarian direct action manifests in harm reduction when front-line service providers elevate the value of users' experiential knowledge over biomedical authorities (Friedman et al.[30], Vancouver Area Network of Drug Users [VANDU] 2004, 2010, Allman et al.[3], Canadian Harm Reduction Network [12], Canadian HIV/AIDS Legal Network [13]). Here, in perhaps the most progressive (read: anarchist) models, the service provider would be a peer, thus circumventing obvious forms of authoritarian control{3} (Coyle et al.[17], Latkin [49], Orme and Starkey [54], Allman et al.[3], Kerr et al.[48], Mason [52], Friedman et al.[31], Canadian HIV/AIDS Legal Network [13], Cheng and Smith [14], VANDU 2010). While reframing addiction in the terms of pathology merely results in a shift from criminological to biomedical forms of hierarchical authority{4} (Keane [46], Roe [58]), the ethical and human rights imperatives of direct user involvement in harm reduction are encapsulated in the global drug users' mantra nothing about us, without us (Canadian HIV/AIDS Legal Network [13]), where lack of agency commitment may reflect the transgression of normative hierarchical authority (Mason [52]).

Combined with its ostensibly 'user-friendly', 'client-centred' approach (City of Toronto [15], p. 6), the mandated inclusion of drug/service users in some forms of harm reduction further illustrates the movement's non-hierarchical orientation{5} (VANDU 2004, Allman et al.[3], Kerr et al.[48], Canadian Harm Reduction Network [12], Canadian HIV/AIDS Legal Network [13], Cheng and Smith [14]). The non-hierarchical, direct action nature of harm reduction practice is demonstrated in models based on a strong emphasis on user inclusion in every dimension of service by equitably engaging users in a condition of collaborative autonomy (VANDU 2004, 2010, Greater London Alcohol and Drug Alliance [35], Allman et al.[3], Kerr et al.[48], Canadian Harm Reduction Network [12], Canadian HIV/AIDS Legal Network [13], Cheng and Smith [14]).

Extending this argument, the articulation of harm reduction as an ethical and human rights issue represents an overt discourse of affinity and mutual aid. Here, it is important to emphasize that in North America, the institutionalization of harm reduction was catalyzed by an underground, oppositional network of people living, working, and dying in the streets (Stoller [64], Roe [58]). Evidenced in tactical affinity-based alliances with other marginal urban populations such as people with HIV/AIDS, the logic of affinity (Day [19]) manifests in a multiplicity of harm reduction interventions, representing both the essence of its radical origins, and the force with the most potential to re-politicize practice. Established by the direct action tactics of the radical Aids Coalition to Unleash Power (ACT-UP), the establishment of Pennsylvania's first syringe exchange program provides a telling case in point (Maskovsky [51]).

The dopefiend ethic and the spirit of neoliberalism

Narrow biopolitical analyses of drug/service users function to reproduce binary structures, albeit radically inverted (Keane [47]). Reframing illicit drug use as an expression of freedom and resistance, such critiques articulate the state of 'outlaw addiction' encapsulated in Bourgois and Schonberg's ([8]) righteous dopefiend, a distorted representation of US 'rugged individualism' reflecting the broken-record dreamscape of late-capitalist America. Here, the righteous dopefiend forms a typology of deviance not only actively produced by the intoxicating infrastructure of (post-)industrial narcotic modernity (Derrida [23]), but also central to its operation of control (Deleuze [21], Brodie and Redfield [9], p. 4). Considering the righteous dopefiend ethic in relation to the US 'war on drugs', perhaps the most contested element of harm reduction is the movement's supposed 'value-free', 'amoral' stance toward drug use. Given the contested (physical, ideological, and discursive) battlefield of the 'war on drugs', in other words, claiming an 'amoral' position in fact euphemistically articulates a radical revisioning of addiction (Keane [46]).

Moreover, perhaps the supposed amorality of harm reduction masks something more sinister beneath the process of institutionalization: insidious neoliberalism, disguised as progressive practice, played out on the stage of public health (Miller [53], Keane [46], Reith [56], Roe [58]). Given its 'self-legitimating ideology', Granfield ([34], p. 29) argues that harm reduction's central adherence to the biomedical model of addiction is hegemonic. Following from the explicitly political origins of harm reduction, however, the phenomenon of addiction cannot be reduced to questions of pathology, but instead represents a direct symptom of the social, political, and economic forces of (late-)capitalist modernity (Porter [55], Alexander [1], [2], Granfield [34], Hickman [40], Reith [56]). According to this re-conceptualization, the neoliberal phase of 'our narcotic modernity' (Derrida [23]) assumes the locus and engine of 'disease', situating drug dependence as an adaptive response to the forces of control and exploitation that make up its experiential landscape (Buck-Morss [11], Porter [55], Ronell [59], Sedgwick [62], Alexander [1], [2], Hickman [40], Reith [56]).

Although varying articulations of this critique appeared much earlier,{6} Tabor's ([65]) Capitalism Plus Dope Equals Genocide bears direct relevance to this discussion. An imprisoned member of the Black Panther Party, Tabor ([65], p. 2) wrote: 'drug addiction is a social phenomenon that grows organically' from the capitalist system. 'The government', he continued, 'is totally incapable of addressing ... the true causes of drug addiction, for to do so would necessitate effecting a radical transformation of this society'. Conventional drug treatment programs, Tabor concluded 'do not deal with the causes of the problem ... deliberately negat[ing] ... the socio-economic origin of drug addiction' (p. 2). While this trajectory explicitly calls for revolutionary change, contemporary social movements often eschew totalizing conceptions of state overthrow, instead forming temporary spaces of autonomous resistance beyond the gaze of institutional authority (Bey [6], Graeber [33], Day [19]). Before the utopian revolution, in other words, activists continue to work for change within the present system, where anarchism forms a common feature of front-line harm reduction practice, manifesting in subtle forms that often fall outside the radar of public health authorities. Reaffirming the founding anarchist spirit of harm reduction, we might therefore refer back to Crimethinc's (2002, p. 5) insistence: 'you are especially an anarchist when you come up with your own ideas and initiatives and solutions'.

Underground crack kit distribution. Abandoning one-for-one exchange in favor of syringe distribution. Actively encouraging unsanctioned secondary distribution. Peer-based naloxone training. Bathrooms inside harm reduction organizations acting as informal safe injection sites. Clandestine ibogaine treatment teams. Sympathetic physicians writing narcotics scripts under the guise of 'pain management'.{7} In such instances, the radical spirit of harm reduction persists, shifting from political ideal to everyday practice, directly informed by a relationship of collaborative autonomy with the drug/service user (Cheng and Smith [14]). Here, the anarchist principles fuelling such manifestations of harm reduction again suggest a rhizomatic movement with the potential to resist the inevitability underlining Weber's ([71]) depiction of institutionalization, constituting a horizontal multiplicity of forces based on 'connection and heterogeneity' that may be 'shattered in a given spot, but will start up again' (Deleuze and Guattari [22], pp. 7–9).

Reclaiming the future of harm reduction as anarchist practice

Working toward re-politicization, it is necessary to trace different models for integrating anarchism – or, rather, the fundamental political spirit of harm reduction – into the very fabric of everyday life, where anarchist expressions of harm reduction are already happening, both from within and from without. In the first case, harm reduction is being reclaimed through underground, autonomous acts of resistance (however temporary), and the establishment of informal, off-the-books practices (Bey [6], Graeber [33]). Perhaps such tactics take place so easily and so often simply because public health authorities have little conception of the on-the-ground pragmatics of harm reduction practice. Front-line workers can get away with so much, in other words, largely because the bureaucrats who dictate policy are seldom able to understand the everyday reality of providing care for those whose lives are dominated by the harsh, hyper-capitalist black-market economies of power created by the war on drugs (Bourgois and Shonberg [8]). At the other end of the spectrum, by contrast, the anarchist spirit persists in organized efforts to radicalize drug policy. Spanning a broad range of factions – from the US Drug Policy Alliance to the Canadian Students for Sensible Drug Policy, and from radical academics to autonomous drug user networks – such groups work toward reorienting the future of harm reduction by directly engaging the state, fighting for voices at the tables of power.

Repoliticizing the future of harm reduction therefore entails several immediate points of departure. First, harm reduction needs to be re-conceptualized as a living document, creating fluid, in/formal spaces where practice can adapt to accommodate changing community needs. Second, politicized policy actors, user groups, activists, and academics need to radicalize the terms of debate surrounding addiction by challenging stigma, deconstructing the disease model, and revealing the structural forces that create and perpetuate harm (Alexander [1], Keane [46], Roe [58]). Here, shifting away from the quantitative, epidemiological tradition in drug research is equally important to increasing capacity-building efforts toward collaborative autonomy (Cheng and Smith [14]). In reclaiming the future of practice, it is therefore imperative to place users at the very center of harm reduction, re-situating people with lived experience as the driving force behind the radical political spirit of the movement (Coyle et al.[17], Latkin [49], Orme and Starkey [54], Ruefli and Rogers [61], VANDU 2004, 2010, Greater London Alcohol and Drug Alliance [35], Allman et al.[3], Kerr et al.[48], Mason [52], Friedman et al.[31], Canadian Harm Reduction Network [12], Canadian HIV/AIDS Legal Network [13]).

Conclusion: a users' guide to capitalism and addiction

Comparing these different trajectories, we might conclude that the US is characterized by the innovation of practical (albeit largely underground) models of everyday resistance within the decidedly more repressive 'war on drugs'. Evidenced in the establishment of the first and only sanctioned supervised injection facility in North America, the Canadian experience on the other hand has been distinguished by progressive policy reform leading to the widespread policy embrace of harm reduction. Acknowledging the accomplishments of grassroots US practitioners, where harm reduction does not even enter official policy discourse, what are the consequences of Canada's more advanced stage of institutionalized harm reduction, as measured in the cost/benefit terms of depoliticization? While Canada's experience is commonly celebrated, interventions such as supervised injection sites seek to manage drug users in the interests of 'public order', prompting criticism that such programs lack focus on underlying structural issues, thus merely representing a new form of 'governmentality' (Foucault [26], [27], Miller [53], Fischer et al.[25]) – yet another deceptive strategy to 'minimize risk from, and maximize control over' the bodies and behaviors of non-conformist (illicit) consumers (Roe [58], p. 245).

Enlarging the scope of critique, Miller ([53], p. 173) asserts 'the claim of amorality due to harm minimization's 'scientific' basis is a moralistic claim in itself, which furthers the standpoint that science and objectivity are preferable to other forms of knowledge'. Owing to its perceived methodological objectivity, science – particularly public health science conducted in the name of harm reduction – is consistently positioned as the antithesis to ideologically based claims regarding drugs (Hwang [45]). Although its underlying foundations are seldom questioned, it is a matter of 'fact' that science is always already ideological. Blindly clinging to its ostensible objectivity, science can never advance an explicitly political position. Furthermore, because quantitative data can neither represent experience, nor convey the voices of research subjects, biomedical inquiry is fundamentally unable to engage in a structural critique of addiction.

Although social research cannot single-handedly fix institutional public health policy or automatically realign harm reduction with its anarchist origins, to re-emphasize Roe's ([58], p. 243) argument, politically committed, theoretically engaged forms of social research based on true collaborative autonomy with users can actively work toward re-politicizing the future of harm reduction practice by engaging in a 'direct political critique of the social and legal systems that create harm'.{8} In Alexander's ([1], p. 520) terms, addiction professionals must change 'the terms of debate on addiction' by acknowledging capitalism's role in mass-producing addiction, and 'refut[ing] the reduction of addiction to a "drug problem" or a "disease"'. Playfully rephrasing the terms of this struggle in the form of an equation, if as in Tabor's ([65]) manifesto, capitalism + dope = genocide, then borrowing from Stoller ([64]), we might conclude that genocide + anarchism = harm reduction.

Framed as a user's guide to late-capitalist narcotic modernity, this article suggests the expression 'fighting for our lives' (Crimethinc [18]) embodies the political project of harm reduction in its 'new anarchist', user-driven manifestations (Graeber [33]). Returning to the US anarchist collective Crimethinc ([18], pp. 23–24), this article closes with a prayer that bears directly on the struggle between harm reduction, institutionalization and depoliticization: 'Thank the heavens [we] have nothing. Help [us] not to hate the ones [we] must destroy'; on the back cover of the publication read the words: 'The future is unwritten'.

Acknowledgments

This article is both dedicated and profoundly indebted to the critical/creative co-conspiracy of Jon Paul Hammond, who died in Philadelphia on 5 November 2010, battle-scarred by the drug war, a militant harm reductionist, political agitator, and queer Quaker anarchist to the very end.

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{1} In spite of its centrality to their organizational structure, owing to acute public discomfort with the term 'anarchism,' the group consistently attempted to downplay their political orientation. Featuring on a list of things 'not to the say to the media', Stoller ([64], p. 104) noted members were urged to conceal their 'political leanings, such as anarchism or paganism'.

{2} Within 1 year of taking office, Canadian Prime Minister Stephen Harper unveiled the Conservative government's National Anti-Drug Strategy in 2007. Based on a three-prong approach including prevention, treatment, and enforcement, the new Strategy suggested harm reduction was being written out of Canadian drug policy altogether. Moreover, signaling a return to moral-criminological ideologies, responsibility for the new Anti-Drug Strategy was shifted from Health Canada to the Department of Justice (Government of Canada [32]).

{3} Martin ([50], p. 34) suggests that '[b]ecause no one officially runs AA', the 12-step movement represents 'the world's largest functioning anarchy'. Eschewing any formal relationship to biomedical authorities, Robinson ([57], p. 169) notes that AA aspires to remain 'uninvolved in outside philosophical, political or social issues'. The notion of powerlessness in the first step, however, represents a significant source of contention regarding the ideological underpinnings of the movement, particularly in relation to gender (Valverde and White-Mair [67], Herndon [39], Hillhouse and Fiorentine [41]).

{4} i.e. the clinical gaze of epidemiologists, addiction doctors, treatment counsellors, and public health scientists.

{5} For manuals, best practices and lessons learned regarding user involvement in the development and delivery of harm reduction policy, see: Toronto Harm Reduction Task Force ([66]), Mason ([52]), Canadian Harm Reduction Network ([12]), Canadian HIV/AIDS Legal Network ([13]), Cheng and Smith ([14]).

{6} For example, see Cocteau ([16], p. 20): 'I therefore became an opium addict again because the doctors who cure – one should really say, quite simply, who purge – do not seek to cure the troubles which cause the addiction; I had found again my unbalanced state of mind; and I preferred an artificial equilibrium to no equilibrium at all'.

{7} Stemming primarily from the author's cumulative ethnographic observations at harm reduction and addiction treatment sites in Canada (Toronto) and the US (Philadelphia), further evidence of these phenomena can be found in numerous media references. For controversy surrounding 'safer crack use kits', see: Fox News ([28]) and Bailey ([5]). Concerning syringe conflict, see: Hunter ([43], 2010). Regarding ibogaine, see Alper et al. ([4]) and Hamilton ([37]).

{8} 'This is a challenge to academics, policy experts and service providers', reads the VANDU Manifesto for a Drug User Liberation Movement (2010): 'we do not want to be used as cheap labour, we do not want to be studied while we die, or be turned into clients while resources are given to 'service' agencies. We will not tolerate actions that exploit the labour, activist work, or experiences of people who use drugs. Finally, we expect responsible researchers, experts and academics to support us'.