Ontario Integrated Supervised Injection Services Feasibility Study Report: London
(2017)
Injection drug use continues to be associated with severe health and social harms, including infectious disease acquisition, cutaneous injection-related infections, and fatal and non-fatal overdose. People who inject drugs (PWID) often experience significant barriers to primary and acute care systems. At the community level, injection in public spaces and associated injection-related litter (e.g., discarded syringes) constitute a source of public disorder and community concern.
In response to the growing concerns regarding the harms associated with injection drug use, supervised injection services (SIS), where PWID can inject pre-obtained illicit drugs under the supervision of healthcare staff, have been implemented in various settings. Results from evaluation studies have demonstrated that SIS have largely met their stated objectives, which include: reducing public disorder; reducing risk for infectious disease transmission; reducing injecting-associated morbidity; reducing morbidity and mortality associated with overdose; and facilitating referrals to various health and social programs, including addiction treatment and housing. SIS have also been found to be highly cost-effective.
While SIS have been found to be effective in large urban centres where sizable drug scenes exist and where substantial concentrations of PWID live, little is known about the feasibility and acceptability of SIS in smaller cities or towns – or on the most effective way to deliver supervised injection services in communities where PWID are not concentrated in one geographic area. Herein, we report on SIS feasibility research undertaken in London, Ontario, which explored potential willingness to use SIS and SIS design preferences among local PWID, in addition to acceptability and feasibility of SIS from community stakeholder perspectives.
A mixed-method community-based research approach was employed to meet the study objectives. In the first study phase, a quantitative survey was conducted to investigate drug-using behaviour and related harms, heath care access, willingness to use SIS, and SIS design preferences among 199 PWID in London. In the second phase of the study, we interviewed twenty community stakeholders from five sectors: healthcare (n=5); social services (n=5); government and municipal services (n=3); police and emergency services (n=2); and the business and community sector (n=5).
Among 199 survey participants, 76 (38%) were women (including 1 transgender woman) and the median age was 39 (range: 21 - 66). In terms of ethnicity, 147 participants were white (75%), 44 (22%) identified as First Nations or Métis, and 5 had other ethno-racial backgrounds (3%). The majority of participants (n=113, 57%) reported being homeless or living in unstable housing, while 24 (12%) had been incarcerated in the past six months, and 38 (19%) reported engaging in sex work or exchanging sex for resources in the past six months. Sixty-five percent (n=129) of participants reported injecting drugs daily, with crystal methamphetamine and hydromorphone being the drugs most commonly injected. Seventy-two percent of participants reported injecting in public spaces in the previous six months, one in four reported a history of overdose, and 44 (22%) reported sharing syringes in the previous six months.
In total, 170 (86%) participants reported willingness to use SIS if one were available, while another 14 (7%) said they would not be willing to use such services. The most common reasons for using SIS included: access to sterile injection equipment, overdose prevention, injecting responsibly, safety from crime, and safety from being seen by police. Reasons for not wanting to use SIS include not wanting to be seen, fear of being caught by police, preferring to inject alone, not wanting to be known as a drug user, and inconvenience. A higher proportion of men (n=113, 93%) than women (n=57, 76%) said they were willing to use SIS. Almost all participants selected Old East (Dundas/Adelaide area) or Downtown as ideal locations for SIS programming.
Community stakeholders unanimously supported SIS, but this support was accompanied by some preferences and conditions. Some stakeholders suggested that SIS be decentralized while others suggested that SIS be centralized Downtown or in Old East. Almost all community stakeholders suggested that SIS should be accessible 24 hours, 7 days a week. Stakeholders held mixed views in terms of the proximity of SIS in their neighbourhoods. A few respondents were concerned about how the concentration of services – including SIS – could damage residents and businesses in the same area. Lastly, availability of wrap-around supports (i.e., health and social services) were discussed as a condition to supporting SIS.
London continues to experience significant preventable harm among PWID. Importantly, a majority of PWID (86%) reported that they would use SIS if one were available. Past evaluations have indicated that expressed willingness is strongly correlated with future uptake of such services, and therefore the findings reported herein suggest that PWID in London and the local community would likely benefit from the implementation of SIS. Therefore, given the data presented in this report, it is recommended that SIS be implemented in London. To address the observed geographical distribution of both public and private injection drug use, and preferences of PWID and community stakeholders, implementation of SIS in Old East and/or Downtown London is recommended, and be integrated within existing services that can provide enhanced wrap-around care for PWID (e.g., addictions treatment, primary health care, housing supports). Given the ongoing challenges associated with injection drug use in this setting, as well the evidence indicating that SIS prevent harms and promote health among PWID, it seems clear that implementing SIS in London would have high potential to improve health and public order, while also saving precious health system resources.
In response to the growing concerns regarding the harms associated with injection drug use, supervised injection services (SIS), where PWID can inject pre-obtained illicit drugs under the supervision of healthcare staff, have been implemented in various settings. Results from evaluation studies have demonstrated that SIS have largely met their stated objectives, which include: reducing public disorder; reducing risk for infectious disease transmission; reducing injecting-associated morbidity; reducing morbidity and mortality associated with overdose; and facilitating referrals to various health and social programs, including addiction treatment and housing. SIS have also been found to be highly cost-effective.
While SIS have been found to be effective in large urban centres where sizable drug scenes exist and where substantial concentrations of PWID live, little is known about the feasibility and acceptability of SIS in smaller cities or towns – or on the most effective way to deliver supervised injection services in communities where PWID are not concentrated in one geographic area. Herein, we report on SIS feasibility research undertaken in London, Ontario, which explored potential willingness to use SIS and SIS design preferences among local PWID, in addition to acceptability and feasibility of SIS from community stakeholder perspectives.
A mixed-method community-based research approach was employed to meet the study objectives. In the first study phase, a quantitative survey was conducted to investigate drug-using behaviour and related harms, heath care access, willingness to use SIS, and SIS design preferences among 199 PWID in London. In the second phase of the study, we interviewed twenty community stakeholders from five sectors: healthcare (n=5); social services (n=5); government and municipal services (n=3); police and emergency services (n=2); and the business and community sector (n=5).
Among 199 survey participants, 76 (38%) were women (including 1 transgender woman) and the median age was 39 (range: 21 - 66). In terms of ethnicity, 147 participants were white (75%), 44 (22%) identified as First Nations or Métis, and 5 had other ethno-racial backgrounds (3%). The majority of participants (n=113, 57%) reported being homeless or living in unstable housing, while 24 (12%) had been incarcerated in the past six months, and 38 (19%) reported engaging in sex work or exchanging sex for resources in the past six months. Sixty-five percent (n=129) of participants reported injecting drugs daily, with crystal methamphetamine and hydromorphone being the drugs most commonly injected. Seventy-two percent of participants reported injecting in public spaces in the previous six months, one in four reported a history of overdose, and 44 (22%) reported sharing syringes in the previous six months.
In total, 170 (86%) participants reported willingness to use SIS if one were available, while another 14 (7%) said they would not be willing to use such services. The most common reasons for using SIS included: access to sterile injection equipment, overdose prevention, injecting responsibly, safety from crime, and safety from being seen by police. Reasons for not wanting to use SIS include not wanting to be seen, fear of being caught by police, preferring to inject alone, not wanting to be known as a drug user, and inconvenience. A higher proportion of men (n=113, 93%) than women (n=57, 76%) said they were willing to use SIS. Almost all participants selected Old East (Dundas/Adelaide area) or Downtown as ideal locations for SIS programming.
Community stakeholders unanimously supported SIS, but this support was accompanied by some preferences and conditions. Some stakeholders suggested that SIS be decentralized while others suggested that SIS be centralized Downtown or in Old East. Almost all community stakeholders suggested that SIS should be accessible 24 hours, 7 days a week. Stakeholders held mixed views in terms of the proximity of SIS in their neighbourhoods. A few respondents were concerned about how the concentration of services – including SIS – could damage residents and businesses in the same area. Lastly, availability of wrap-around supports (i.e., health and social services) were discussed as a condition to supporting SIS.
London continues to experience significant preventable harm among PWID. Importantly, a majority of PWID (86%) reported that they would use SIS if one were available. Past evaluations have indicated that expressed willingness is strongly correlated with future uptake of such services, and therefore the findings reported herein suggest that PWID in London and the local community would likely benefit from the implementation of SIS. Therefore, given the data presented in this report, it is recommended that SIS be implemented in London. To address the observed geographical distribution of both public and private injection drug use, and preferences of PWID and community stakeholders, implementation of SIS in Old East and/or Downtown London is recommended, and be integrated within existing services that can provide enhanced wrap-around care for PWID (e.g., addictions treatment, primary health care, housing supports). Given the ongoing challenges associated with injection drug use in this setting, as well the evidence indicating that SIS prevent harms and promote health among PWID, it seems clear that implementing SIS in London would have high potential to improve health and public order, while also saving precious health system resources.
Ontario Integrated Supervised Injection Services Feasibility Study Report: London
Ontario Integrated Supervised Injection Services Feasibility Study Report: London
PDF Document
English
