Direct Action and Drug-Related Harm: Affinity-Based Tactics in the Founding and Development of the North American Harm Reduction Movement

This article asserts that anarchist-inspired direct action tactics have played a fundamental role in the development of interventions ostensibly intended to reduce drug-related harm. Drawing from observations collected during the author’s participant-observation-based ethnographic fieldwork endeavors in Canada and the U.S., the article interrogates several aspects of harm reduction philosophy and practice, including (1) The establishment of needle and syringe programs, (2) The development of autonomous local, national and international organizations by and for people who use illicit drugs, and (3) Direct drug/service user involvement in harm reduction policies and programs. Eschewing the terms ‘client’ and ‘consumer’, this article instead employs the fluid and fundamentally interchangeable term drug/service user in reference to the subjects of harm reduction and drug treatment services. Asserting that the underlying theoretical and philosophical basis of harm reduction became depoliticized during its shift from a clandestine, underground, grassroots social movement to institutionalized public health policy, the article conducts a critique of the prevailing biomedical ‘brain disease’ model or pathology paradigm for addiction research and treatment, demonstrating how the phenomena of ‘addiction’ can and must be reframed as a symptomatic, adaptive response to the shifting sociospatial characteristics of (late-) capitalist modernity.


Introduction
For the U.S. 'ex-workers collective' Crimethinc, anarchism is a way of being in the world or a political praxis of everyday life, as opposed to a dogmatic structure characterized by old, dead, bearded Russian men. Crimethinc's fighting for our lives starts by romantically recounting historical instances of people coming together without coercion, without hierarchy, and without authority, to mutually support one another in the face of violent struggle [1]. As Fighting for our lives begins [1]: In the last moment before dawn, flashlights tight in our shaking hands, we dismantled power boxes on the houses of fascists who were to host rallies the following day.
We fought those fascists tooth, nail, and knife in the streets, when no one else would even confront them in print.
In Paris, armed with cobblestones and parasols, we held the gendarmes at bay for nights on end, until we could almost taste the new world coming through the tear gas.
We fought our way through their lines to the opera house and took it over, and held discussions there twenty-four hours a day as to what that world could be.
In Chicago, we created an underground network to provide illegal abortions in safe conditions and a supportive atmosphere, when the religious fanatics would have preferred us to die in shame and tears down dark alleys… Crimethinc concludes the introduction to Fighting for our lives with the words: "I'm speaking, of course, of anarchists" [1]. Specific to the focus of this paper, the following examples serve to directly complement Crimethinc's partial list: • When our friends, children, and allies were dying in the streets from HIV/AIDS in the 1980s and 90s, we risked arrest by distributing clean syringes.
• When users were burning and cutting their lips by smoking crack out of pipes made from broken glass and toxic materials, we found cheap suppliers of Pyrex stems designed for science experiments and distributed them in the streets, sometimes even through dealers.
• When the media, our friends, families, and co-workers stigmatized us with words such as 'junky', 'crack head' and 'dope fiend'; when the authorities declared our everyday lives to be illegal -evicting us from public spaces and locking us up by the hundreds of thousands -we risked further persecution by forming underground (and sometimes semi-aboveground) networks of support, advocacy and mutual aid.
• When we began to recognize that our lives were being governed by out-of-touch legal and biomedical authorities, we learned to speak their language, and started demanding seats at the tables of power. Wary and suspicious to engage them on their terms, we formed the Vancouver Area Network of Drug Users (VANDU), the New York Users Union (NYUU), the Toronto Drug Users Union (TODUU), and the International Network of People Who Use Drugs (INPUD).
• When our voices continued to be stifled by the so-called 'experts', we began to form strategic alliances with other groups cast-out by capitalism such as queer folks and people living with HIV/AIDS, and we created manuals and guidebooks for how to work equitably with peers, showing how governments and organizations can involve and incorporate the perspectives, voices and ideas of people with lived experience of substance use without 'tokenism' or other forms of humiliation and discrimination.
Provocatively suggesting "[y]ou may already be an anarchist," Crimethinc proceeds to draw common examples from everyday life that suggest how "[a]narchism is naturally present in every healthy human being" [1]. "It isn't necessarily about throwing bombs or wearing black masks", the group insists; instead asserting that, " [t] he root of anarchism is the simple impulse to do it yourself" [1]. In these generalized terms, Crimethinc redefines anarchism as virtually any action or practice premised on the principles of autonomy, direct action, and affinity that runs counter to the normative order of capitalist societies, characterized by rigid inscriptions of hierarchy and authoritarian rules and regulations [1][2][3][4][5][6].
Each of Crimethinc's examples of anarchism-as-praxis-ofeveryday-life speaks not only to the radical, oppositional origins of harm reduction practice, but also to the various ways that the anarchist spirit of harm reduction persists in spite of its institutionalization by the rigid and increasingly depoliticized machine of public health [1,6]. The following examples therefore serve to cement the arguments presented in this paper firmly in the discourse, practice, and philosophy of harm reduction:

•
If you use any form of 'illicit' substance, either to selfmedicate, or entirely for pleasure, you are an anarchist, plain and simple -rejecting the corporate pharmacopeia of the formal medical establishment, and reclaiming pleasure from a society that systematically programs us to derive pleasure from the consumption of commercial goods are inherently anarchist impulses.

•
If you've ever questioned repressive state drug laws or elevated drug users' lived experiential knowledge above the opinions of biomedical experts, you're an anarchist.

•
If you believe that people who use drugs are human beings deserving of the same compassion, dignity, respect and support as those very few among us whose lives are not in some way dependent or 'wired', then you are an anarchist; medical and legal authorities effectively invented the "addict" as a typology of deviance, and to resist against such violent stereotypical misrepresentations is irrefutable evidence of the anarchist spirit.
After briefly outlining the central principles of contemporary anarchist-inspired social movement practice, this paper then turns to further detail a selection of the examples cited above, including the origins of needle exchange programs, the development of local, national and international grassroots drug user organizations, and the direct involvement of drug/service users in the programs, interventions and treatment modalities that affect their everyday lives. These examples are critically investigated through (a) an interrogation of the relevant bodies of published academic literature, (b) analysis of mainstream media representations, and (c) the author's cumulative experiences conducting participant-observation ethnography in various addiction research capacities and contexts throughout North America.
As this analysis demonstrates, the reduction of drug-related harm in North America directly evolved out of anarchist-oriented examples of direct action-driven praxis based on the principles of both autonomy from larger state and institutional bodies, and affinity with other similarly marginalized urban population groups, such as the queer community and people living with HIV/AIDS.

Methods
Drawing on contemporary anarchist political theory and emergent literature in the field of critical public health, this essay conducts a political rereading -or, rather, reframing -of the origin and development of harm reduction philosophy and practice. In order to accomplish this, the paper employs (1) an evidence-based review of published literature concerning the direct involvement of people who use drugs in harm reduction theory, philosophy, policy and practice, (2) a Foucault-informed discourse analysis of popular media representations of contemporary harm reduction and drug policy, as well as (3) observations from the authors' cumulative ethnographic research among drug/service users in the context of harm reduction and addiction treatment sites in both Canada (notably Toronto) and the United States (notably Philadelphia and New York City).
The political philosophy of anarchism encompasses many different specific traditions, ranging from radical to dogmatic. In spite of the fact that the vast majority of new social movements operate on principles derived from the general tradition of anarchism, for a variety of reasons, many groups and individuals consciously refrain from adopting this term or identity [4][5][6]. As opposed to a dogmatic political ideology, originating with the Situationist International (SI) movement in the 1960s, and encompassing the 'non-branded tactics' of contemporary new social movements [4], the form of anarchism referred to in this paper is best considered as constituting a generalized praxis of everyday life [2,3].
Anticipating the 'near-revolutionary' events in Paris during May 1968, in reference to the work of the Situationist International movement, both Debord's Society of the Spectacle and Vaneigem's The Revolution of Everyday Life, served to articulate an accessible rendering of anarchist praxis by explicitly incorporating everyday life as a key front in the battle against capitalist exploitation, posed in the terms of 'spectacle' [7,8]. Situating the centrality of everyday life in Situationist theory, Vaneigem playfully proclaimed: " [p] eople who talk about revolution and class struggle without referring explicitly to everyday life […] have a corpse stuck in their mouth" [8]. Further emphasizing everyday life in the struggle for freedom and autonomy, Vaneigem asserted that insurrectionary movements sought "the transformation of the world and the reinvention of life", insisting that this demand could not be "formulated by theorists" or experts, but instead constituted "the basis of poetic creation" [8]. Here, the revolution -"nameless, like everything springing from lived experience" -was seen to be created in the sphere of the everyday "despite, and in opposition to, the specialists of revolution", where its "explosive coherence" was forged "in the everyday clandestiny of acts and dreams" [8].
According to Debord, modern life presented itself as "an immense accumulation of spectacles", where "[a]ll that was once directly lived has become mere representation" [7]. In this context Debord argued that the spectacle represented the "chief product of present-day society", whose function was "the concrete manufacture of alienation" [7], a state that is virtually indistinguishable from what Alexander has more recently termed 'psycho-social dislocation' [9,10]. In order to meaningfully engage the ubiquitous spectacle, Debord and his Situationist colleagues advocated the construction of situations: a "moment of life concretely and deliberately constructed by the collective organization of a unitary ambiance and a game of events" [11]. Beginning "on the ruins of the modern spectacle", the construction of situations sought to disrupt the widespread, alienation-induced state of passivity and submission that Debord and the SI posed as "the very principle of the spectacle" [7]. The construction of situations was therefore explicitly intended to "break the spectator's psychological identification with the hero so as to draw him into activity by provoking his capacities to revolutionize his own life" [7].
Directly building upon the work of his Situationist antecedents, Bey advocated for 'ontological anarchy' -or, in other words, anarchism as a form of everyday life [2]. Concerning ontological anarchy, Bey suggested that each individual was "the monarch of [their] own skin", representing "a political dream, urgent as the blueness of the sky" [2]. "[D]espite its flaws", and because it was "neither political nor a system", Bey wrote that among all political ideologies, anarchism most closely conformed to this "understanding of reality, ontology, [and] the nature of being" [2].
Central to Bey's conceptualization of ontological anarchy was the temporary autonomous zone or TAZ. Arguing that "nothing but a futile martyrdom could possibly result […] from a head-on collision with the terminal State", Bey asserted that the TAZ "can provide the quality of enhancement associated with the uprising without necessarily leading to violence and martyrdom" [2]. As Bey argued, getting the TAZ started may involve tactics of violence and defense, but its greatest strength lies in its invisibility -the State cannot recognize it because History has no definition of it. As soon as the TAZ is named (represented, mediated), it must vanish, it will vanish, leaving behind it an empty husk, only to spring up again somewhere else, once again invisible because un definable in terms of the Spectacle. The TAZ is thus a perfect tactic for an era in which the State is omnipresent and all-powerful and yet simultaneously riddled with cracks and vacancies [2].
Extending the work of both the SI and Bey, the U.S. anarchist 'ex-workers collective' Crimethinc has similarly served to reframe contemporary expressions of anarchism as praxis of everyday life [3]. Conceived as "a personal approach to life", Crimethinc interprets and defines anarchism as: a decision to think for yourself rather than following blindly … a rejection of hierarchy, a refusal to accept the 'god given' authority of any nation, law or other force as being more significant than your own authority over yourself … an instinctive distrust of those who claim to have some sort of rank or status above the others around them … a refusal to place responsibility for yourself in the hands of others [… and] a demand that each of us […] choose our own destiny [3]. As Crimethinc insisted, because "[a]lmost everyone is frustrated when they find themselves pushing against faceless, impersonal power", most individuals "want to have the right to live their own lives, to live and act as they see fit" [3]. As such, they asserted that "[i]n our everyday lives, we are all anarchists", putting anarchist principles into practice whenever we "make decisions for ourselves [and] whenever we take responsibility for our own actions rather than deferring to some higher power" [3]. Broadly defining anarchism as "the revolutionary idea that no one is more qualified than you are to decide what your life will be", Crimethinc further qualifies this notion by stating: [i]t means trying to figure out how to work together to meet our individual needs, how to work with each other rather than 'for' or against each other … preferring strife to submission and domination … not valuing any system or ideology above the people it purports to serve … being faithful to real human beings […], fighting for ourselves and for each other, not out of 'responsibility', not for 'causes' or other intangible concepts … not forcing your desires into a hierarchical order, either, but […] taking the pursuit of meaning and joy in your life upon your own shoulders [3].
As a contemporary expression of anarchism-as-praxis-ofeveryday-life, Crimethinc's contentions closely resonate with Graeber's analysis of the 'new anarchists' and Day's examination of the anarchist-driven political logic of contemporary social movements [4,5]. Until very recently, the theory and practice of anarchism was for the most part wholeheartedly dismissed, neglected or ignored within academic circles, owing to popular associations of violence, and a lack of coherent ideological structure, both of which claims have been refuted by contemporary scholars [4,5]. As opposed to actively the authority of challenging state power, therefore, direct action can be defined as an ever-evolving toolkit of critical/creative tactics and/ or expressions of opposition that contain an inbuilt alternative to normative forces of socio-spatial order characteristic of neoliberal capitalism [5]. As Day wrote, direct action thus entails: communities of various sorts working together in a circulation of struggles that are simultaneously against capitalism and for the construction of alternatives to it … constructing concrete alternatives to globalizing capital here and now, rather than appealing to state power or waiting for / bringing on the Revolution [4].
Characterized by expressions of dissent and opposition rooted in the principle of autonomy, the anarchist-inspired and affinity-based direct action tactics of contemporary social movements retain an explicit focus on everyday life [1][2][3][4][5][6]. As Graeber asserts, particularly in the context of North America, this is a movement about reinventing democracy. It is not opposed to organization [but rather] about creating new forms of organization. It is not lacking in ideology. Those new forms of organization are its ideology. It is about creating and enacting horizontal networks instead of top-down structures […] based on principles of decentralized, non-hierarchical consensus democracy … [that] aspires to reinvent daily life as a whole [5].
Furthermore, the 'logic of affinity' upon which anarchist-oriented social movements are most often based can be defined as "that which always already undermines hegemony" [4]. In tandem with varying manifestations of direct action, Day asserts that this 'anarchist logic of affinity' results in contemporary social movements definitively shifting their relationship to state power, thus moving beyond "both reform and revolution" [4]. Even the majority of self-declared 'radical' artists, activists and academics who ostensibly seek revolutionary change, as Graeber insists, may be reluctant to "accept that most of the creative energy for radical politics is coming now from anarchism -a tradition that they have hitherto dismissed" [5]. The historical genealogy and basic tenants of anarchism-as-praxis-of-everyday-life is therefore fundamental to understanding contemporary radical social movements, notably including the origin and evolution of the harm reduction movement in North America.
From a methodological perspective, therefore, it is relevant to briefly address my own professional positionality and political The example of early needle exchange efforts in North America points not only to the relative success of direct action tactics, but also works to highlight the role and importance of affinity-based alliances between HIV/AIDS activists and other marginalized, socially-vulnerable population groups [2][3][4][5][6]15]. In this case, ACT-UP's affinity-driven, direct action approach led to a fundamentally important shift in the everyday lives of street-based IDU. The founding of North American NEPs thus provides a telling example of how the implicitly anarchist principles of direct action and affinitybased mutual aid led to both substantial reductions in drug-related harm and significant changes in municipal and provincial/state drug policies across Canada and the U.S. Furthermore, such cases reaffirm contentions that organizations and networks by and for people who use drugs can in and of themselves serve as highly effective agents in the reduction of drug-related harm [19][20][21][22][23][24][25][26]. In Vancouver, Canada, for example, Insite -North America's first and only supervised injection facility (SIF) -was established through the direct action tactics of the user-driven Vancouver Area Network of Drug Users (VANDU), who earlier established an informal, unsanctioned, underground supervised injection site that directly led to the formal establishment of Insite shortly thereafter [25,26]. In a comparable example of direct action in Australia, a group of nuns -the Sisters of Charity -were instrumental in lobbying for, founding, and operating the first and only supervised injecting centre in the country, Sydney's Medically Supervised Injecting Centre (MSIC) [27,28].
Subsequent to the direct-action tactics that prompted municipal public health authorities to establish Insite owing to a public health crisis surrounding dramatically increasing rates of HIV/AIDS and Hepatitis C (HCV) transmission among Vancouver's IDU population, VANDU was responsible for innovating several new harm reduction interventions by utilizing direct action tactics, including an unsanctioned, 'peer-run', after hours NEP [20,29]. Successfully reaching high-risk populations such as injection cocaine users and street-level sex trade workers, VANDU's unsanctioned NEP intervention revealed a statistically significant association between sex trade work and late night NEP utilization [20,29].
Ethnographic observations concerning NEP policy and practice in major urban centres throughout the northeast U.S. revealed that in cities with limited access to formally sanctioned, institutionalized NEP services, in many cases there also exists long-standing underground syringe distribution programmers targeting sex trade workers operating within/direct support and cooperation from formal NEP services. As opposed to being based on the scientifically flawed principle of 'one-for-one' syringe exchange, such underground services were thus often premised on the notion of syringe distribution, where service users were not mandated to return any used syringes in order to receive any amount of sterile injection equipment [30]. Such interventions are of particular importance given research findings that suggest barriers to accessing traditional NEP models among sex trade workers in North America [31][32][33].
Ethnographic observations of user-driven, underground harm reduction interventions suggest that many such groups are entirely staffed by volunteers, and given their target populations (i.e. largely female sex trade workers), outreach was most often conducted by all-women staff, organized in accordance with anarchist-inspired consensus-based decision making principles. A hallmark of contemporary anarchist organizing, the essence of consensus-based decision making is that "rather than voting, [collectives] try to come up with proposals acceptable to everyone -or at least, not highly objectionable to anyone" [5].
One organization that was studied extensively by the author experienced an internal struggle within the collective concerning the notion of incorporation. Because the group subsisted on precarious funding and depended heavily on cooperation with the local NEP convictions as author. My personal methodological emphasis lies in the area of ethnographic participant-observation, participatory action research, and in-depth qualitative interviewing. As both a formally trained academic, as well as a highly-engaged community-based activist and advocate, I have been extensively involved in numerous addiction research initiatives across both Canada and the U.S. in a variety of capacities and contexts. These commitments have ranged from working as an interviewer for national surveillance surveys of risk behaviors among injection drug users (IDUs), to helping establish autonomous user-driven support and advocacy groups, conducting program evaluations of various harm reduction and opioid dependency treatment interventions, engaging in research and activism concerning unsanctioned harm reduction interventions, and serving as co-investigator for a formal needs assessment concerning the potential implementation of supervised injection facilities (SIFs).
As Foucault argued, there is an intimate historical relationship between discourse, power and knowledge, as evidenced in how the development of new medical and legal discourses and institutions have had a direct impact on the social construction of typologies of deviance in the case of both the homosexual and the addict [12][13][14]. Complementing its ethnographic emphasis, this article additionally employs Foucault-inspired discourse analysis to examine media representations of the issues under investigation. In tandem with anarchist-oriented social movement theory, therefore, participantobservation ethnography and Foucaultian discourse analysis form the primary methodological foundations of this work.

The anarchist origins of harm reduction practice in Canada and the United States
The founding and development of needle exchange programs (NEP) in North America: Needle and syringe exchange programs (NEPs) in North America emerged contemporaneously with the HIV/AIDS epidemic in the mid-late 1980s, beginning as an 'illegal', grassroots practice conducted by politicized front line health practitioners and activists who risked criminal persecution and arrest by distributing clean syringes among injection drug users [6,15,16]. In his analysis of the origins of harm reduction, Roe asserts that, Health authorities in North America began to work around the laws ... Criminal subcultures were now presented as 'communities' with specific medical needs that could not be isolated or ignored. Health authorities were now more willing to defy the letter of drug laws, and to risk the penalties for possession of criminal 'paraphernalia', including syringes … Community activists provided them with an arms-length means to evade the law while developing new techniques to address the spread of HIV/AIDS. This unlikely coalition of public health authorities and activists challenged the enforcement of drug laws [15].
In the U.S. context, and specifically the case of Philadelphia, the city's first -and, to date, only -formally sanctioned NEP, Prevention Point Philadelphia (PPP), was established through the radical direct action-based tactics of the AIDS Coalition to Unleash Power (ACT-UP), who "fought a successful battle to legalize and gain city funding for syringe exchange" in the early-mid 1990s [17]. ACT-UP's activities began in New York City, and soon spread to nearby Philadelphia, serving to challenge existing legal frameworks, along with the attitudes of local politicians, public health and law enforcement authorities [17,18]. Here, Maykuth noted that ACT-UP's strategy of "confronting the law head-on" resulted in judges "exonerate[ing] needle exchangers … saying the threat the activists were trying to prevent outweighed the harm they caused by violating the law"; such rulings subsequently resulted in either the relaxing of U.S. state laws, or law enforcement officials (in/)formally "look[ing] the other way" [18]. level non-profits with an explicit harm reduction orientation, such as the New York City-based Harm Reduction Coalition and the Toronto-based Canadian Harm Reduction Network. Such groups have served to significantly increase capacity building efforts among user-driven organizations, providing further evidence to support the fundamentally important role of tactical relationships of affinity [4]. Sharing numerous similarities with the variously politicized Consumer/Psychiatric Survivor, Anti-Psychiatry and/or Mad Pride movements that have proliferated on a global scale, perhaps the most obvious difference with the burgeoning movement among people who use drugs is that while being 'mad' is not illegal, the 'illicit' identity of the drug user decidedly is, demonstrating how drug prohibition effectively serves as a primary structural barrier to the expansion and proliferation of such groups. Pointing to the divisive politics that continue to plague the movement [6], however, although the meetings that led to the formation of CAPUD took place in Toronto, Canada, the organizers -composed of a small group of prominent, high-profile drug user activists and advocates, including a majority of non-users -neglected to invite representatives from either the local Toronto Drug Users Union (TODUU) or the Canadian Harm Reduction Network to take part in the discussions. This example demonstrates how affinities within and between drug user organizations in North America are to some extent restricted by persistent divisions across regional, social class, gender and ethnic lines, representing a central obstacle to continued progress [6].

Drug/service user involvement in harm reduction and drug treatment policy and practice
Above and beyond the growing drug user movement at local, national and international scales, the increasing involvement of people who use illicit drugs in all areas of harm reduction, addiction treatment, and drug policy more generally -from policy development, planning and implementation, to service delivery, research and evaluation -provides additional insight into the role and significance of affinity-based direct action tactics [2][3][4][5][6]. Growing out of the HIV/ AIDS movement, the Canadian HIV/AIDS Legal Network's 2008 position paper 'Nothing About Us Without Us'; Greater Meaningful Involvement of People Who Use Illegal Drugs: A Public Health, Ethical and Human Rights Imperative [39], has effectively provided the foundation for increased 'consumer' or 'service user involvement' among people who use illicit drugs in all aspects of the policies, programs and services that affect their everyday lives. Drawing on standard protocols that have been established among people living with HIV/AIDS, this paper asserts that it is unethical, irresponsible, and unacceptable to design and implement policies and interventions ostensibly designed in the interests of people who use drugs without their direct involvement and active consultation in literally every stage of the process [39]. Given the reframing of people who use drugs as 'clients' or 'consumers' of harm reduction and/or addiction treatment services under contemporary neoliberal public health discourse, institutionalized efforts to engage or involve PUD is, however, often conducted in a superficial and/or tokenistic manner in order to foster the illusion of ethical 'best practices' [35,39,40].
The subtitle of the Canadian HIV/AIDS Legal Network's seminal 2008 publication provides a telling case in point [39]. By emphasizing drug/service user involvement as first and foremost a public health imperative, the document effectively deprioritizes the ethical and for donations of scant material resources, some collective members believed that incorporation would enable them to secure more stable sources of funding, thus, in turn allowing the group to expand their limited service delivery range. Other members, by contrast, adamantly insisted that incorporation would serve to threaten compromise and potentially negate the group's autonomy, thus resulting in less flexibility and independence in their day-to-day operations. Here, empathy for female sex trade workers espoused by the all-women's collective can be seen as a direct expression of affinity, while the organization's unsanctioned, underground status effectively situated their work as a form of direct action, where collective volunteers risked persecution or arrest for conducting syringe distribution without approval from municipal authorities.

The establishment of local, national and international groups of people who use drugs
The establishment of local, national and international organizations by and for people who use illicit drugs provides additional evidence regarding the centrality of affinity-based direct action tactics in harm reduction practice throughout Canada and the U.S. The development of user-driven groups in North America, however, has not advanced to nearly the same extent as other regions such as Australia, where government funding for user groups formed an integral aspect of the government's response to HIV/AIDS starting in the mid-1980s [34]. In Canada, for instance, there exists only one well-organized, government-supported user-driven organizationthe Vancouver Area Network of Drug Users, or VANDU -along with a handful of smaller, fledgling, under-funded user groups such as the Toronto Drug Users Union (TODUU) [20,21,24,26,29,35,36]. In Canada, therefore, significant structural barriers to the establishment, growth and development of user-driven organizations persist, including public stigma and misconception, lack of funding, and on-going criminalization [35,[37][38][39][40][41][42]. According to Zoe Dodd, cofounder of the Toronto Drug Users' Union (TODUU), the group's mandate: is to be recognized as valued and valid participants in the development of policies and programs that affect our everyday lives. The vast majority of institutional user involvement in Ontario is tokenistic, superficial and in some cases even perpetuates the profound and persistent stigma surrounding people who use illicit drugs. In the absence of any formal means of funding or support, TDUU was established in the tradition of autonomous, user-led, user-governed organizations throughout the world, in hopes of inspiring increased capacity, consultation and user involvement in all areas, including research, policy development and treatment service delivery for people who use drugs… In Ontario there is an acute lack of support, funding and resources, and the TODUU strives to correct this imbalance by re-establishing an independent voice for drug users through capacity-building, skills development and empowerment projects [35].
The present situation in the United States bears many similarities, where user groups lack material and financial support, yet continue to persevere despite on-going stigmatization and criminalization. The primary difference between Canada and the U.S., however, is that although harm reduction interventions were threatened -and in many cases actively dismantled -by the former Conservative Federal government of Canada [43,44], harm reduction remains entrenched in municipal and provincial drug policy [44,45], while the term 'harm reduction' does not even enter official policy discourse in the United States [46]. In the highly repressive U.S. context, however, front-line public health practitioners have been responsible for the innovation of highly successful -albeit in many cases 'underground' -tactics that have been disseminated and adopted throughout the world [6].
Across North America, organizations by and for PUD have in many cases been supported by strategic alliances with national-

s Best Practices in Harm Reduction Peer Projects
lists potential barriers and challenges to institutional involvement among drug/service users, including the issue of authorities "not being able to relinquish power and control" [40].
Perhaps one of the primary activities of the PAG over the early period of its existence was to serve as a consultancy body for MMT research, much of which was conducted by the Canadian Centre for Addiction and Mental Health (CAMH), an internationally recognized research institution based in Toronto, Canada. Over the years, CAMH researchers consulted the PAG on a wide range of MMT-related issues and topics, including service user satisfaction, prescription opioid abuse, anti-stigma and awareness-raising campaigns, along with more banal, everyday facets of MMT such as urine drug screening and take home dose policies. In 2008, however, the CPSO witnessed a series of allegations regarding both confidentiality concerns relating to the unauthorized release of MMT service user data for CAMH research purposes, and the overall conditions faced by MMT service users under the regulations set forth by the CPSO.
In 2008, renowned Toronto-based physician, HIV/AIDS specialist and methadone prescriber Dr. Phillip Berger lodged a formal complaint with the Ontario Human Rights Tribunal [51,52]. Insisting that the provincial regulations set forth by the CPSO served to both discriminate against addiction treatment service users, and compromise their constitutional right to health care-related confidentiality, Berger's battle with the Ontario Human Rights Tribunal received extensive news coverage in Canada, inspiring critical debate surrounding opiate dependency treatment, medical privacy, and the role of regulatory institutions responsible for governing MMT. "Only methadone patients must disclose personally identifying information to the college as a condition of receiving treatment", wrote Dr. Berger in an opinion piece published in a prominent Toronto newspaper: Most are unaware that their names are entered permanently into a College registry. The College provides information from the registry, and from the physician audits, to researchers who publish on the methadone program -all done without the knowledge or consent of either patients or physicians [53].
Having become a stand-in go-to body for researchers seeking to incorporate a superficial and tokenistic form of consumer involvement into their MMT-related research, the CPSO -and by extension the PAG -were therefore effectively complicit in the exploitation of MMT service users for the purpose of traditional public health science research. This example not only reflects badly on the CPSO (and, to a lesser extent, the largely impotent and powerless PAG), but perhaps more significantly also on the research institutions and human ethics boards, who themselves instigated and directly profited from MMT service user data through a complete disregard for their privacy.
"Patients receiving methadone for addiction treatment", as another Toronto newspaper article reported, "are the only group catalogued […] by the CPSO, which has in turn shared their information for the purposes of scientific studies" [51]. The crux of this issue, asserted Berger, is that "it violates almost every privacy issue in the book", adding that the CPSO extended itself far beyond its jurisdiction and mandate, concluding in no uncertain terms that the CPSO was, "not in the business of regulating patients" [51].
The second case study in the potential dangers of institutional drug/service user involvement takes the form of an ethnographic anecdote drawn from observations conducted during a meeting of the Ontario Minister's Advisory Group (MAG) on Mental Health and Addictions, attended in a research capacity by the author. In the Fall of 2008, the acting Ontario Minister of Health publicly committed to developing a 10-year mental health and addiction strategy for human rights dimensions of this struggle, thus reinforcing the traditional, fiscal conservative 'cost / benefit' or 'bottom line' argument in support of harm reduction, explicitly based on quantitative, epidemiologically-driven, rational public health science [46,[47][48][49][50]. As Hathaway asserts, harm reduction avoids moral challenges to prohibition in favor of cost-benefit analyses that address problems in pragmatic rather than ideological terms … [where] efforts to persuade based on strict rationality reinforce endangerment themes over drug use entitlement […] overlooking the deeper morality of the movement with its basis in concern for human rights [46].
Arguing that harm reduction in Canada is dominated by a deceptive discourse supposedly driven by an amoral and value neutral stance towards the use of illicit drugs, Hathaway suggests that in the perception of public health authorities, the notions of "autonomy and rights have no apparent value in themselves" [46]. Closely resonating with such claims, Keane insists that the ostensibly amoral orientation of harm reduction policy effectively serves to disguise what is in fact an explicitly moral commitment; given the politically contested nature of harm reduction, as Keane asserts, claims of value neutrality are "not neutral", but instead represent "a committed and critical standpoint" [49].
Despite the absence of state support, in recent years Canada has witnessed the rapid proliferation of grey literature concerning user/ peer involvement in harm reduction policy and practice [35,[37][38][39][40][41][42]. Drawing from a series of ethnographic observations in the context various 'addiction' research initiatives, it is therefore relevant to briefly present contemporary examples of drug/service user involvement that clearly convey the oftentimes highly superficial and tokenistic nature of such efforts.
As a regulatory body responsible for overseeing methadone maintenance treatment (MMT) policy and practice, as well as the conduct of methadone prescribing physicians across the province, the College of Physicians and Surgeons of Ontario (CPSO) established the Methadone Patients' Advisory Group (PAG) in the early 2000s, representing the first and only group of its kind in Canada, if not North America. From its inception, however, the PAG's activities and orientation have been highly restricted, in spite of nominal changes to the Group's political structure and organization. During the first several years of its existence, for example, the Chair of the PAG was held not by an MMT service user, but a senior member of CPSO staff, who was responsible for both composing the agenda and facilitating PAG meetings with the help of administrative staff also employed by the CPSO. It was not until 2007 that the PAG appointed its first 'patient elected' Chair.
A document introduced in 2005 that all members were legally obligated to sign; the PAG's Code of Conduct provides additional evidence of the limited power afforded by Group members. The Code of Conduct begins by stating that as a member of the PAG, each individual must: Recognize that you [sic.] are not a spokesperson for the College; the President of the College is the principal spokesperson for the College referring all requests for information on College activities back to the College. In addition, you [sic.] recognize that you are not a spokesperson for all patients … [and] respect the boundaries of College staff whose role is neither to report to nor work for group members … As this excerpt suggests, the limited power granted to members of the PAG was attributable to two related issues, namely (1) the fact that the Group was forced to work under the extremely conservative institutional confines of the CPSO, and (2) the persistence of stigma relating to MMT users among public health professionals, whose fears of relinquishing control or shifting any modicum of power directly into the hands of PAG members was explicitly evident, as reflected As Hathaway suggests, corresponding to the HIV/AIDS epidemic of the 1980s, the human rights dimension that formed the centre piece of the founding theory and philosophy of harm reduction has been fundamentally negated by the movement's explicit emphasis on social and fiscal costs, or in other words its "one-sided focus on harm precluding drug use benefits" [46]. "Preferring to keep such ideological, liberty-based values out of the analysis", Hathaway concludes, institutionalized public health harm reduction interventions instead overwhelmingly emphasize a "morally neutral form of inquiry wherein autonomy and rights have no apparent value in themselves" [46]. Closely corresponding to Szasz's assertions concerning agency, autonomy and human beings' fundamental 'right to drugs', Hathaway's analysis suggests that harm reduction's recurrent recourse to -and inherent privileging of -the supposedly value-neutral, amoral nature of 'bottom line' analysis of harm reduction interventions only extends to a hypothetical modeling of the fiscal and social costs of drug-related harm, at the expense of debates concerning the human benefits of illicit drug use more generally [46,52,54]. Containing an irrefutable logical appeal among fiscal conservatives, the strategically deployed, ubiquitous cost/benefit or 'bottom line' analysis that has come to characterize the primary rationale for promoting harm reduction as institutionalized public health policy thereby does not extend to drug use itself, where drug/service users', 'right to autonomy' [46] continues to remain ignored or overlooked in contemporary harm reduction discourse and debate [52,54].
While the body has long been a site of struggle and resistance for stigmatized identities along the axes of social class, gender and sexuality, ethnicity and 'race', civil rights, gay pride, and the successive waves of feminism have made enormous gains since the inception of these various social movements during the twentieth century. Although it is impossible to deny that systemic racism, classism, homophobia, and gender discrimination persist in present day North American culture, perhaps the more important point is that in each case, these once stigmatized and oppressed identities have slowly been reclaimed, rearticulated and reasserted as a source of strength and solidarity, power and pride. The illicit drug user, however, represents perhaps one of the last openly stigmatized, de-valued -and arguably disposable -identities in contemporary North American popular culture. Through tactical alliances of affinity and solidarity, however, both from within (i.e. in the form of local, national and international networks and organizations of people who use drugs) and from without (that is, in collaborative alliance with population groups who were once similarly marginalized, oppressed and stigmatized, such as the queer community, people living with HIV/AIDS, and the mad pride or psychiatric/consumer survivor movement) drug/ service users or people with lived experience of illicit substance use have initiated the process of stepping out of the shadows, coming out of the closet, or otherwise embracing and reclaiming their identities, rearticulating the notion of 'using' and the corresponding identity of the 'user' in positive, explicitly politicized terms, increasingly becoming cognizant of the crucially important, literal life and death political stakes underlying the concepts of autonomy, (free?) will, and affinity-based direct action among and between users and user-driven networks/organizations of people who use illicit drugs [4][5][6]46,55].
The fundamental recognition of harm reduction as an inherently political issue or question may in/directly inspire and/or serve to reinsert and re-centre the notion of human rights in addiction/treatment and drug policy discourse. In relation to harm reduction, illicit drug use, and what we might term the 'politics of addiction' more broadly, the question of human rights shares a series of intimate intersections with notions of both 'autonomy' and 'pleasure' [56]. "If the right to autonomy -to our bodies, minds, and selves -means anything", wrote Szasz "it means a right to suicide" [54]. Correspondingly, Szasz asserted that the notion of 'pro-choice' must therefore mean "the right the province, beginning with a series of meetings between the key stakeholder groups that composed the Minister's Advisory Group, including a number of high-profile physicians and public health science researchers, Chairs and CEOs from major mental health and addiction research and treatment institutions throughout Ontario, along with a smattering of individuals with a variety of different backgrounds constituting mental health and addiction 'consumer representatives' [35,45].
During the first meeting, the tables and chairs in the large boardroom at the Ontario Ministry of Health corporate headquarters were arranged in a wide circle such that each participant could see one another, with the Minister and his team of aides positioned at the centre-point of the arrangement. In front of each of the assembled 'advisors' was a printed nameplate bearing each individual's name, title and institutional affiliation. As the meeting began, following the Minister's brief opening remarks, the delegates were invited to introduce themselves and describe their professional and/or personal relationship to mental health and/or addiction. Approximately halfway through the introductions, the only late member of the Advisory Group appeared at the door, and quietly made his way to the only remaining open seat. Once the individual -a man who, based on his appearance, was likely the youngest invited participant -was finally settled, he began skimming through the binder of information placed in front of him, before briefly examining his nameplate.
It was at this point that the Minister of Health interrupted the group and turned to invite the late arrival to introduce himself. Giving his name, the man awkwardly began by explaining his initial confusion at receiving an invitation to take part in the Minister's Advisory Group on Mental health and Addictions, explaining that his first assumption was that he was invited owing to his research in the area of addiction treatment. Momentarily pausing, the man again picked up his nameplate and continued in a more articulate tone: "I now realize, however, that no one here had any idea of the fact that I have a PhD, or that I'm currently employed as a full-time Assistant Professor at X----University… In other words, I now understand that I was in fact invited as the 'token junky' [here the man raised his fingers to indicate quotations marks] so that you could all pat yourselves on the back for being so socially progressive and ethically responsible by incorporating a superficial and tokenistic degree of quasi-'consumer involvement' [again raising his fingers to indicate quotations marks]. Regardless, I am needless to say flattered to be here," he continued, redirecting his gaze towards the Minister as a slight tone of sarcasm crept into his voice, "and I very much looking forward to critically engaging each and every one of you throughout the course of this project". With this the young man sat back down, and after a few moments of awkward silence, one of the Minister's aides hurriedly thanked the individual and invited the group to continue introductions where they had left off.

Discussion
As the cumulative evidence presented throughout this paper has demonstrated, the historical development of the harm reduction movement in North America has been strongly influenced by anarchist-inspired, affinity-based direct action tactics, revealing tangible indications of future promise. Investigation of institutionalized consumer involvement, however, suggests a high prevalence of superficial and tokenistic drug/service user consultation and involvement. In order to begin to meaningfully engage this seemingly irreconcilable tension, it is therefore necessary to further interrogate the notion of autonomy by tracing how this concept relates to the notion of 'pleasure', an acutely under-represented -yet fundamentally central -facet of harm reduction debates, that directly relates to the ethical and human rights foundations upon which harm reduction philosophy and praxis were established.
people with lived experience of substance use and/or mental health issues (PWLE). Here, the notion of autonomy with respect to users and user-run organizations serves to underline the importance of addressing systemic barriers and inequities such as resource allocation, and thus explicitly recognizes the value and importance of lived experience or experiential knowledge [35].

Conclusion
As Canadian scholar Bruce K. Alexander suggests in his writings on the 'globalization of addiction' [9,10], popular debates regarding the aetiology, origin or roots of addiction as either a moral-criminological issue or biomedical brain disease / pathology are utterly futile and irresolvable because "in a free-market society [addiction] is neither -it is a political problem" [9]. Politically engaged and committed addiction professionals can take action and effect meaningful change, Alexander insists, first and foremost by "changing the terms of debate on addiction": we can insist that valid discussion must recognize that addiction is mass-produced in [free-market capitalist] society, and that, therefore, society as well as individuals must change. We can refute the reduction of addiction to a 'drug problem' or a 'disease'. We can show why it is essential to create an environment fit for moderation [9]. Following Alexander, a reconsideration of Keane's critique of the purported 'value-neutrality' and 'amorality' of harm reduction, in tandem with Szasz's insistence concerning 'our right to drugs', facilitates a series of concluding theoretical recommendations [49,52,54]. To resituate Keane's essential arguments concerning 'harm reduction, morality and the promise of human rights' in the blatantly oppressive and brutally harsh battleground of the North American 'war on drugs,' claiming to espouse a 'value neutral' or 'amoral' perspective is, in actual fact, a thinly disguised, euphemistic reframing of what is an explicitly and unabashedly political position [49]. As Keane succinctly summarizes, "in a context where drugs are predominantly identified as bad (or even evil) and drug use as pathological, a view that drug use is neither right nor wrong is not neutral", but instead represents a radical political conviction [49].
In reclaiming harm-reduction-as-institutionalized-publichealth-policy from the sterile, quantitative, epidemiologicallyobsessed, depoliticized confines of public health science [6,47,52], it is therefore fundamentally necessary to explicitly acknowledge, accept, and moreover actively engage the political dimensions of harm reduction theory, philosophy and practice, directly interrogating the fluid, shifting, amorphous structural (i.e. socio-political-economic) forces and factors that are so seldom understood as simultaneously both contributing to the (human-generated) production of harm, and, at the same time, limiting, con(s)t(r)aining, sanitizing, and rendering increasingly rigid the interventions, policies, and programs that are ostensibly designed and implemented to minimize, mitigate and/ or reduce drug-related harm. As this work has argued throughout however, in the immediate short-term, following the political/poetic, critical/creative, art/activist tactics of contemporary anarchistinspired, direct action-driven social movements, it is equally important to directly create, participate and engage in individual and collective acts of resistance through networks of affinity-based direct action here and now [2][3][4][5][6][7]. In this spirit, the paper therefore closes with a challenge posed by the radical, autonomous, userdriven Vancouver Area Network of Drug Users (VANDU) in their 2010 Manifesto for a Drug-User Liberation Movement: we have had enough of self-selecting leaders and token spokespeople. People who use drugs should be represented by leaders and organizations that are accountable to us and by leaders who put our collective interests above individual narrow agendas. This is a challenge to academics, policy experts and service providers: we do not want to be used as cheap labour, we do not want to be studied while we die, or be turned to use or abstain from using any particular drug" [54]. In a closely related trajectory, Hathaway takes up the notion of the fundamental human right to autonomy through questions concerning (free?) will. The primary source of contention and (moral-ideological) conflict underpinning drug policy debates, Hathaway insists, is the essentially contested nature of the balance of power between drugs and the human will … [yet] harm reduction opts for a morally neutral form of inquiry wherein autonomy and rights have no apparent value in themselves… [thus] promotion of the movement is contingent on explicating its underlying morality [46]. Related to what Szasz termed 'pharmacological autonomy' [54], the more general right to autonomy is often linked to arguments rooted in contextually-based questions concerning the 'right to life', along with the 'right to die/death', each of which, as Szasz remarks, entails endless and varying sets of "existential choices and ethical perplexities" [54]. Setting aside such ethical quandaries and debates, however, we might simply note the interchangeable (and perhaps identical) nature of Szasz's notion of 'pharmacological autonomy' [54], and what he has elsewhere described as our 'right to drugs': If we had a free market in drugs, we could buy all the barbiturates, chloral hydrate, and morphine we want and could afford. We would then be free to die -easily, comfortably, and surely -without any for recourse to 'death doctors' or violent means of suicide [54].
Here it is additionally relevant to note the close parallels and similarities between Szasz's notion of 'pharmacological autonomy' [54], and Houborg's notion of 'political pharmacology', defined as the user-driven contestation and conflict concerning "medicoadministrative technocracy". Explicitly focusing on how drug/ service users "engag[e] not only in political questions" relating to harm reduction and addiction treatment policy and practice, through the tactical deployment of political pharmacology drug/ service users individually and collectively espouse "technical and epistemological questions about […] what constitutes reliable and relevant knowledge" regarding what are variously termed 'foreign,' 'illicit,' or 'controlled' substances. From the right to autonomy, to the right to life/death, to the right to self-medication, we therefore arrive at what Szasz described as our fundamental human 'right to drugs' [52]. Asserting that "the most important symbol of the right to our bodies now resides in our reasserting our right […] to all drugs, not just to one or another so-called recreational drug", Szasz states that the 'real drug problem' lies in the fact that the vast majority of the North American public does not want "legally unrestricted access to drugs" [54]. Anchored in and by the political traditions of humanitarianism and libertarianism, Hathaway notes that harm reduction has been reframed and rearticulated as a series of rational policy interventions explicitly based on (social) 'cost/benefit' and/or (fiscal) 'bottom line' calculations that preclude any consideration of either the multiplicity of structural forces that directly serve to create harm and perpetuate 'addictive' behaviors, or the radical, anarchist-oriented socio-political ideologies upon which the harm reduction movement was originally founded, and, in many ways, continues to thrive and grow, albeit often outside the limited, rigid, narrow and depoliticized confines of state institutions [6,46]. Particularly when coupled with an emphasis on humanitarianism and/or human rights, libertarianism shares a close inter-relationship with the historical trajectory of anarchismas-praxis-of-everyday-life as detailed at the beginning of this paper. Initially derived from the psychiatric/consumer survivor movement, in this sense the notion of 'collaborative autonomy' may represent a crucial point of departure for future partnerships between state/ institutional bodies and people with lived experience (PWLE) of illicit drug use and treatment. Here, as Cheng and Smith explain, collaborative autonomy, speaks directly to the question of equitable engagement and/or collaboration between service providers and