Chemsex, PnP, crystal meth: What does harm reduction really look like?
For a few years now, our team at Clinique médicale l’Actuel has noticed an increase in patients using crystal meth. At the start of the pandemic, to address our patients’ distress and increased substance use, we secured private funding to set up a support program for our patients who use crystal meth and practise chemsex, also called PnP or party ‘n play. We also convinced the Quebec Ministry of Health and Social Services to carry out a pilot project with this population at the clinic.
The program that was rolled out is based on three pillars: peer involvement, capacity building for service providers, and development of a network of partners that can work together to support people who PnP. These pillars require stakeholders to commit to the “no wrong door” principle as much as possible, meaning our patients receive appropriate consideration and attention regardless of the office they go to. This approach also requires taking down administrative, ideological and inter-institutional operational barriers that further impede access to support for people who are already living with stigmatization and rejection. The program’s aims include both individual support and organizational development, in order to create a continuum of care truly adapted to support people, regardless of their path or stage of recovery.
One of the initial findings – which should come as no surprise – was that before restructuring networks and recommending care, we first needed to address our own practices and identify our own gaps.
What lessons can we learn?
The first thing we learned was that chemsex is a much more complex issue in our clinical setting than we had previously thought. Like opening a Pandora’s box, examining the issue shed light on a multiplicity of more-or-less obvious secondary factors that we had to identify, acknowledge and try to resolve. These factors mainly involve medical community involvement, stigmatization (even within support systems), and the underlying urgency to manage this problem.
All our responses to these issues place harm reduction front and centre: the main harms that we can try to address are those perpetuated by our institutions.
The challenges preventing the medical community from integrating a psychosocial approach became apparent right away. A number of structural limitations in standard medical care complicate the provision of services for people who PnP: inconsistencies with staff whose approach may vary, limited predetermined time slots for patients. This in particular hinders building a relationship between the person and the medical team. In fact, many people who PnP will need several meetings before they are comfortable talking about their drug use; others will never discuss it if they perceive being misunderstood by the team assigned to them. Short medical appointments are also not ideal, since in many cases, caring for a person who uses crystal meth or who PnPs will involve several related issues: mental health, HIV, hepatitis C, sex work, immigration, trauma and gender transition, to name a few. At the clinic, we had to put a process in place to ensure that medical care is modelled in a way that best suits people who PnP, specifically through the availability of appropriate psychosocial services and team training.
The importance of doing work upstream
The second challenge involved providing staff training. In fact, an obvious impediment to learning is the existence of prejudice, even within a community of allies such as LGBTQIA2+ service providers. The stories of people who PnP can be powerful, unsettling or heavy, especially when they intersect with mental health or even psychiatric health issues. Our clients are the people who repeatedly come to the clinic for post-exposure prophylaxis treatment or who are often late or don’t show up for their appointments. Because they are not considered to be an “easy client group”, they don’t naturally attract sympathy. Their life stories and trajectories may generate resistance among healthcare professionals at the clinic, value judgments or even anecdotal sensationalism. It’s clear that the professionals close to this population also risk developing a subjective or defensive attitude, including team members who have a current or past history of substance use, or who have experienced losses of friends, colleagues and patients related to drug use. Therefore, we stress the importance of doing work upstream to ensure that knowledge and attitudes are brought up to the same level with all teams within the organization.
Resisting the sense of urgency
The last challenge involves the combined sense of urgency and helplessness associated with the use of crystal meth or PnP. These are both normal reactions given the complexity of cases that we see, as well as an inherent expression of the pressure experienced by the teams. These sentiments are even stronger for a caregiver in a situation where it is not immediately possible or even desirable to “provide care”. Becoming overwhelmed by a sense of urgency can interfere with the creative nature of an intervention and prevent us from understanding the full complexity of our patients’ situations. Urgency reduces a situation to a time-bound need, to resolve the problem overall and right away based on objectives that are likely not those expressed by our patients.
Overcoming the feeling of helplessness means humbly taking on a go-between role: people who PnP are the sole experts of their situation and we need to link them to support. This also means finding allies and not thinking that the solution lies squarely on our shoulders alone. The goal is not to be right. The goal is to optimize our care efforts to ensure our patients are in the best possible health, that they follow their treatment plan, when applicable, and that they come to their appointments as often as possible. It’s time to revisit the harm reduction paradigm to ensure that it is adequate and entirely relevant for people who use crystal meth.
Jonathan Bacon (he/him) is an interventions coordinator at Clinique médicale l’Actuel, responsible for the development of various mental health and substance use support programs. Proud of his street outreach work with sex workers in the Village, Tiohtià:ke/Montreal, he also coordinates the clinic’s psychosocial team. He is also the president of CRIPHASE, an organization that provides support to men who have experienced sexual abuse as children. He is currently completing a specialized graduate program (DESS) in law and health policy at the University of Sherbrooke.
A graduate of HEC Montréal and the University of Ottawa, Jean-Sébastien Rousseau initially worked as a communications and public relations strategist. Having personal experience with substance use, he made a huge change in his life that ultimately brought him to where he is now, working with LGBTQIA2+ communities, of which he is a proud member. He regularly talks about crystal meth recovery while building awareness of the related issues among various stakeholders. As a member of the Clinique médicale l’Actuel team, he provides support to people with substance use challenges or dependency.