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careers in substance use research for nursing, medical, and dentalstudents. Dr. Naegle is the author/coauthor of over 50 articlesfocusing on impairment in health professionals, and nursingroles in caring for persons with substance use disorders (SUDS),including gero-psychiatric populations. In 1989, Professor Naeglefounded the Journal of Addictions Nursing, a peer reviewedpublication and the official journal of the International Nurses’Society on Addictions (INTNSA) and served as Editor-in-Chieffor 10 years. Her contributions to addictions as a subspecialty ofpsychiatric mental-health nursing and her advocacy of nursing

roles in addictions treatment and research were recognized inthe American Nurses Association, Hildegard Peplau Award,the INTNSA President’s Award and INTNSA Spirit Award aswell as the Anderson J. Spickard Mentorship Award from theAssociation of Medical Educators and Researchers in SubstanceAbuse (AMERSA). Dr. Naegle continues to publish and conductresearch in her areas of interest which include nurse well-beingand management of health professional impairment, substanceuse in older adults, approaches to SUD education, and a part-timeclinical practice with dually diagnosed patients in the New Yorkmetropolitan area.

DOI: 10.3109/10826084.2012.653253

Committeeville and Drug Users as Social Change Agents

John Ryan

Anex, Fitzroy North, Melbourne, Victoria, Australia

Accepting an invitation to write an opinion pieceis easy. Dangerously, I decided to express my opinionhonestly. Drug use issues are passionately and oftenviciously debated in the broader community and so toowithin harm reduction practice and policy where I work.People who have used drugs or have an opinion on theissues are routinely pilloried in the media, among healthprofessionals, and in government policy circles. Peopleworking in the area of drug use are often loath to voicetheir opinions for fear of upsetting professional drug useractivists or tabloid media. Shrill cries for conformitybedevil our capacity to reflect and improve.

Switzerland and Portugal have undertaken world-leading changes in drug policy over the past 15 years, buta key role for drug users as social change agents is not re-ported (Csete, 2010; Greenwald, 2009). The major shiftsin drug policy in Switzerland and Portugal did not happenby accident. There were many players, but the key driversof change were drug users. Not paid drug user activists butindividual drug users, invariably part of large networks ofdrug users, who were confronting the status quo in eachand every act of illegal drug trafficking and consumption.

By rejecting the societal abhorrence of some forms ofdrug use, they generated enormous social discord betweenthe legal system and the community. Drug scenes thatwere not hidden behind closed doors shook the commu-nity, denying the opportunity to look the other way. Theonly way out of flagrant drug use in both countries was forthe community to more sensibly accommodate drug users.Measures such as needle and syringe programs (NSPs),heroin and other opioid-based treatment and in Portugal,changes to the entire legal framework were introduced to

Address correspondence to John Ryan, Anex, Suite 1, Level 2, 600 Nicholson Street, Fitzroy North 3068, Melbourne, Victoria, Australia; E-mail:j.ryan@anex.org.au

protect the non-drug-using part of the community just asmuch, if not more so, as drug users themselves. Drug usersand their families, neighbors, and community leaders af-forded policy and drug experts the space to change themacro level approach to drugs and dependence.

The quick shift to national roll out of NSPs in the mid-to late-1980s in Australia was a fortuitous combination ofmany factors. However, it was especially an open-mindedhealth minister, Neal Blewett, with courage and determi-nation to not follow the US into an HIV crisis, a primeminister, Bob Hawke, whose daughter was strugglingwith heroin addiction, and drug treatment practitionerDr Wodak in Sydney leading a campaign for NSPs. Inthe shadow of the key players, as in Switzerland andPortugal, were drug users.

In Australia, a fear of injecting drug users (IDUs)being a bridging population for HIV drove the successfulHIV prevention program among injectors. The rapid rollout, with police and bipartisan political support, of accessto sterile injecting equipment through NSPs coupled withbehavior change by individual drug users and their localand geographically dispersed networks were the keys tosuccess.

Moving drug users out of the shadows and giving thema voice in Australia has been attempted by government-sponsored drug user groups since then. These groups wereformed with the benevolent assistance of professionalsfrom the research and medical fields and well-meaningbureaucrats. This was also the case internationally (Fried-man, Des Jarlais, Satheran, Garber, & Cohen, 1987). Itseems that the model of the women’s suffrage movement,civil rights movement but most of all the gay rights, and

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then HIV community organizations was paternalisticallytransferred and expected to work with illicit drug users(Dickson-Gomez, 2010).

The difference for drug user groups is their reliance onexternal support. The civil rights movement had leader-ship from both educated and middle-class African Amer-icans. Similarly, the homosexual law reform movementnaturally grew into ACT-UP (AIDS Coalition to UnleashPower) and AIDS Councils. Drug user groups grew freshout of the HIV response, but well after the social transfor-mations in the West of the 1960s. The reasons why IDUgroups have failed to become powerhouses of reform aresaid to include poverty, lack of education, stigmatization,illegality, and addiction (Moore & Wenger, 1995). Mightit also be that they are an invention of government orothers, rather than something that has grown out of thecommunity? You can never leave behind your black skin,as Franz Fanon might say of African Americans, but youcan often deny your drug using, past and present. The rollout of the peer-based Narcotics Anonymous suggests thatmutual support groups of drug users are successful if mea-sured by their active participation and geographic spread,but they are furtive, surely a key success factor in this area.

Numerically, the majority of the Australia’s 3500 NSPsare commercial pharmacies (60%). However, they ac-count for only about 10% of the more than 30 millionneedles provided to illicit drug injectors annually. Mostneedles are distributed by programs run by hospitals andcommunity health centers. Typically, the people actuallyproviding the frontline, face-to-face transactions are ad-ministration workers, nurses, and other officers, who dothis as one element of their broader job.

It is not a requirement of their employment, or NSPwork, that they are knowledgeable about illicit druguse, and generally speaking, most are not. My colleaguerecently spoke with a woman at a rural NSP. She was anadministration worker, who did NSP provision as part ofher job. She described how she felt when a client cameinto the hospital: “I’m a bit nervous about it, you knowpeople walking in, not knowing about how people aregoing to be. Are they rational? You know, I try to notmake eye contact with them. Give them what they want,the quicker they get out the better I can be with it.”

In comparison, drug user organizations represent lessthan 5% of distribution. The numbers are approximate asthere is still no national minimum data set in Australia forthe NSP.

In areas with highest levels of injecting, NSP outletsemploy staff who concentrate on NSP work (called pri-mary NSPs). There are only about 50 of these services inAustralia. Many of these primary NSP staff have intimatepersonal knowledge of and or experience with drug use,but they work within the structure of the health service,mostly government run.

Unfortunately, many people who inject drugs obtainequipment informally rather than through NSPs. Abo-riginal injectors often prefer to visit mainstream healthNSPs rather than Aboriginal-controlled health services,most of which continue to refuse to supply syringes

anyway. The challenge is that aboriginal people accessNSP services at higher rates than their proportionatepopulation, they are incarcerated more often (whereinitiation to and injecting occur very riskily) and yet theirown community-controlled health services do not servicethem, purportedly because they have other more pressingpriorities, fear it would encourage drug use and shameabout injecting in the community.

The distinction between self-interest and self-helpgroups sometimes made in the scant literature on druguser organizations bedevils drug user groups in Australia(Trautmann, 1995). Dilettantes peering into drug useissues accord significant trust to user activists, even if theactivists are not actually well connected to the vast diver-sity of people who inject. How can drug user organiza-tions, funded by government, be anything but supplicantsof a political patronage system when their constituencydoes not enjoy community legitimacy and is often de-spised? The same also envelopes most researchers in thisdemocracy as they and drug user activists become at bestgentle persuaders whenever they come out of their com-fortable research domain, being stakeholder managed bydepartments as they enjoy the prestige and self-interestedopportunities in government appointed “committeeville”?

That user groups in Australia have not paid detailedattention to the shortcomings of the drug user treatmentsystems or the mental health system is a reflection ofthe disconnection between the professional user advo-cates and the many people struggling with life and theinadequacy of our societal approach to drugs. This is notunique to Australia (Dickson-Gomez, 2010). It reflectsan individualistic approach to public health problems(Stimson, 1991), especially when the significantenvironmental changes required, classification of drug-user-related issues out of the criminal and into the healthsystem, are beyond the scope of work for public offi-cials. User groups reflect their government sponsorship.Traditionally, in Australia, they focus on communicablediseases, for which they are funded, and regard standardsof mental health care or drug treatment outside their silo.

According to Crofts and Herkt (1995), the “mere ex-istence” of drug user groups has had a “profound effecton the nature of the response to HIV among IDUs.” Theydid not offer evidence for the “profound effect” and notedthat they (the drug user groups) have been little evaluatedor documented. Interestingly, this continues to be the case.

Governments rely on them to provide “the” druguser voice. Oddly, they are not mandated to provideconsumers’ perspectives on alcohol, cannabis, ecstasy,cocaine, or the myriad synthetic drugs ebbing and flowingthrough markets. Sometimes, this appearance of “voice”can be mere tokenism, allowing governments to seemas though they have consulted with affected populations,which of course is an absurdity. I have often wondered ifsome government bureaucrats, the many with extremelylimited experience of drug use and drug users, havedifferent expectations of professional drug user activistsbecause they are titillated by an almost voyeuristic drugexperience.

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The argument that drug users have been slow to orga-nize, reflecting the “degree to which they have been dis-enfranchised” (Crofts & Herkt, 1995), is weak after 20years of funding in most Australian states and territories.Drug users are numerous, variable, and primarily do notidentify as such. Compared with, for example, gay peo-ple, women, and ethnic groups, drug use self-identity mayonly be fleeting, partial, and mostly secondary to indi-vidual’s affiliation with class, ethnicity, and political al-legiance, let alone musical taste or his/her football team.

Contrary to Crofts and Herkt’s description of drug-using cultures as being relatively homogenous inAustralia (Crofts & Herkt, 1995), they are highly diverse,with differences between and amid ethnicity, class,location, mental health status, gender, and age, to namebut a few. Representing this diversity is an enormouschallenge for the small number of professionalized druguser activists in Australia. The shifts from occasionaldrug use to severely dependent and back again are noteasily defined, but a functional but dependent drug userlives in a very different world to someone one livingrough, scamming and scheming just for the next drug hit.

As has been suggested by Bennett, Jacques, andWright(2011), there is a risk that a user group can be an “elitefew”, most successful at advocating on behalf of their owndirect interests. An amphetamine drug user activist, frus-trated with the ageing cohort of heroin drug user activists,described them to me some years ago as the “smackoc-racy” (smack being slang for heroin).

I am a true believer in the transformative potential ofdrug user groups. I have faith in their value and values.I was a member of a state-based injecting drug userorganization (SBIDUO) and a committee of managementmember. As the organization veered toward collapse,with the chair and manager both dramatically departing, Iwas persuaded to be Chairman. An accidental president,unanimously elected, there being no one else willing andavailable to prevent the organization from imploding.

A true believer does not require suspending criticalthinking. There are many unresolved challenges for druguser groups. The SBIDUO in Victoria, Australia, has ex-isted since government funding in the 1980s. This veryfunding diminishes its capacity to press for change. It andits members have little choice but to conform to protectincome. This SBIDUO has cycled between function anddysfunction. The bad times have been sometimes due tomalfeasance by employees, committee members with lit-tle or no governance skills or capacity, and inappropriatelyskilled staff. These challenges have been repeated in otherparts of the country. They arose from complicated factors,including a determination to have declared current userson committees and management, and as staff members. Itdramatically reduces the available talent pool.

The criminalization of drug users deters many fromengaging as members in a formalized drug user group,limiting the range of people willing to work there.The working culture has from time to time crystallizeddisrespect for not only drug laws but legal compliancemore generally. Minimum standard governance and

accountabilities have sometimes been evaded, just as thedrug laws are often flouted. Recently, a board of non-drugusers was appointed to remedy near collapse in one state,and for the first time, recruitment for a new executiveofficer did not rate personal drug use as an essential orpreferred prerequisite.

The criminalization of most psychoactive drugs smoth-ers the capacity of drug users to play a transparent and in-fluential role, even in systems specifically servicing them,such as drug user treatment and harm reduction programs.The vulnerability of addiction itself reinforces powerless-ness in such systems, even when it is addiction to legaldrugs such as alcohol. Most of the health sector has beencontrolled by professional health administrators and theyunwillingly yield to their clients. In the area of drugs,where volition is not assumed, the power of the provideris reinforced.

The value of drug user employees’ perspective in thiscontext is emaciated by the current management obses-sions with risk aversion, criminal record checks, and min-imum qualifications. There are many drug users acrosssociety, quietly going about their business, with a muchdeeper understanding of drug-related issues than whatthey read in the newspaper, and some of them work inharm reduction programs too.

A founding member of the above SBIDUO, and stillworking daily with diverse IDUs in a hospital-auspicedNSP, likes to say: “I am a bridge, not a pier.” She worksin a professional manner, complies with policy, and hasa management that respects her work ethic, interpersonalskills, and personal experience. Her leadership is based onnever denying her drug using, but showing people sunkenin the vortex of the daily grind of dependence that theyneed not think they are on a path to nowhere—that thereis a bridge to self-determination.

Declaration of Interest

The author reports no conflicts of interest. The authoralone is responsible for the content and writing of thearticle.

THE AUTHORJohn Ryan (BA/LLB) workedat Anex for the past 10 years,where he is now the CEO.Anex is a non-governmentpolicy development and trainingorganization committed to theprevention of drug-related harm.He is the Chief Editor of theAnex Bulletin, an Australianharm reduction broadsheet,and is currently leading anadvocacy campaign for theintroduction of needle and

syringe programs in Australian prisons. John has previouslyworked in NSP frontline service delivery, research at theAustralian Research Centre in Sex, Health and Society, and policy

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for the Victorian Government’s Drug Policy Expert Committee.Having from earliest child hood grown up surrounded by alcoholand other drug consumption, he also worked for many years in thehospitality sector.

REFERENCES

Bennett, T., Jacques, S., & Wright, R. (2011). The emergence andevolution of drug user groups in the UK.Addiction Research andTheory, 19, 556–565.

Crofts, N., & Herkt, D. (1995). A history of peer-based drug-userorganisations in Australia. Journal of Drug Issues, 25, 599–616.

Csete, J. (2010). From the mountaintops: What the world can learnfrom drug policy change in Switzerland. New York, NY: OpenSociety Foundations.

Dickson-Gomez, J. (2010). Can drug users be effective changeagents? Yes, but much still needs to change. Substance Use andMisuse, 45, 154–160.

Friedman, S., Des Jarlais, D., Satheran, J., Garber, J., & Cohen,H. (1987). AIDS and self-organization among intravenous drugusers. The International Journal of the Addictions, 22, 201–219.

Greenwald, G. (2009).Drug decriminalization in Portugal: Lessonsfor creating fair and successful drug policies. Washington, DC:Cato Institute.

Moore, L., & Wenger, L. (1995). The social context of nee-dle exchange and user self-organization in San Francisco:Possibilities and pitfalls. Journal of Drug Issues, 25, 583–598.

Stimson, G. (1991). HIV, drugs, and public health in England: Newwords, old tunes. The International Journal of the Addictions,26, 1263–1277.

Trautmann, F. (1995). Peer support as a method of risk reduction ininjecting drug-user communities: Experiences in Dutch projectsand the “European Peer Support Project”. Journal of Drug Is-sues, 25, 617–628.

DOI: 10.3109/10826084.2012.650090

Drug Users as Social Change Agents in Asia: The Diversity of Experienceand Challenges

Mukta Sharma1and Anindya Chatterjee2

1HIV/AIDS Asia Regional Program (HAARP), Bangkok, Thailand; 2Regional Support Team, Joint United NationsProgramme on HIV and AIDS, South Africa

Asia is home to one of the largest populations of drugusers in the world, with 4.5 million injecting drug usersand many million more noninjecting drug users. In manyparts of Asia, the punitive approach to the supply andtrafficking of drugs extends to dealing with people whouse drugs; therefore, people who use drugs are widely re-garded as part of the problem rather than part of a solution.They are seldom seen as responsible individuals who canact as agents of change, with the ability to change theirown, their families’, and their community’s lives for thebetter. Prejudice and misinformation on drugs and peo-ple who use them continues to be a serious barrier to aneffective response to drug treatment and HIV prevention,treatment, and care.

HIV infection spreads rapidly among drug-using pop-ulations through the use of unsterile needles and syringesand sexual networks. The advent of the HIV and AIDSepidemics in this region in the late 1980s and early 1990sdisproportionately affected drug-using populations. Theprovision of effective pharmacological treatment for drugusers and HIV care and treatment was highly inadequate.

Address correspondence to Mukta Sharma, HIV/AIDS Asia Regional Program (HAARP), HLSP, Bangkok 10310, Thailand; E-mail:mukta.sharma@haarp-online.org

Frequent occurrence of discrimination in health-care set-tings was the norm at that time. With their backs againstthe wall, faced with regular incarceration, and forced toundergo various sorts of involuntary “treatment,” youngpeople who used drugs in Asia started to organize them-selves. Examples began to emerge of drug users gettingtogether voluntarily to provide assistance to seriously illfriends and community members, as they were unable toget assistance from the health sector in the face of rampantstigma and discrimination. Several organizations in a va-riety of shapes and forms started to be formalized—fromyouth clubs providing peer support to organizing userfriendly drug dependence treatment or care and treatmentfor HIV and AIDS.

At present, the involvement of drug users at the pro-gram and policy level in Asia is diverse. It ranges fromwidespread use of active drug users as poorly paid ser-vice providers and outreach workers in harm reductionprograms within national AIDS programs, to formal reg-istered organizations such as the Asian Network of Peo-ple who Use Drugs (ANPUD). The latter is constituted

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