Synthetic Opioid key responses
- Mapping evidence-based key responses to synthetic opioids and their implementation strategies
- Field-tested Toolkit with seven implementation guides
Rationale for evaluating North America's first medically supervised safer-injecting facility
Many cities throughout the world are experiencing ongoing infectious disease and overdose epidemics among illicit injection drug users (IDUs). In particular, HIV and hepatitis C virus (HCV) have become endemic in many settings and bacterial infections, such as endocarditis, have become extremely common among this population. In an effort to reduce these public health concerns, in September 2003, Vancouver, Canada, opened a pilot medically supervised safer- injecting facility (SIF), where IDUs can inject pre-obtained illicit drugs under the supervision of medical staff. Before and since the facility's opening, there has been a substantial misunderstanding about the rationale for evaluating SIF as a public-health strategy. This article outlines the evidence and rationale in support of the Canadian initiative. This rationale involves limitations in conventionally applied drug-control efforts, and gaps in current public-health policies in controlling the spread of infectious diseases, and the incidence of overdose among IDUs.
Recommendations from the Toronto Residents’ Reference Panel on Supervised Injection Services
This report is intended to support potential planning discussions concerning supervised injection services in Toronto by identifying the prospective concerns of residents and describing a consultation process that would provide sufficient opportunities for city residents to become better informed and to express their views.
Reduction in overdose mortality after the opening of North America's first medically supervised safer injecting facility
BACKGROUND: Overdose from illicit drugs is a leading cause of premature mortality in North America. Internationally, more than 65 supervised injecting facilities (SIFs), where drug users can inject pre-obtained illicit drugs, have been opened as part of various strategies to reduce the harms associated with drug use. We sought to determine whether the opening of an SIF in Vancouver, BC, Canada, was associated with a reduction in overdose mortality.
METHODS: We examined population-based overdose mortality rates for the period before (Jan 1, 2001, to Sept 20, 2003) and after (Sept 21, 2003, to Dec 31, 2005) the opening of the Vancouver SIF. The location of death was determined from provincial coroner records. We compared overdose fatality rates within an a priori specified 500 m radius of the SIF and for the rest of the city.
FINDINGS: Of 290 decedents, 229 (79·0%) were male, and the median age at death was 40 years (IQR 32–48 years). A third (89, 30·7%) of deaths occurred in city blocks within 500 m of the SIF. The fatal overdose rate in this area decreased by 35·0% after the opening of the SIF, from 253·8 to 165·1 deaths per 100 000 person-years (p=0·048). By contrast, during the same period, the fatal overdose rate in the rest of the city decreased by only 9·3%, from 7·6 to 6·9 deaths per 100 000 person-years (p=0·490). There was a significant interaction of rate differences across strata (p=0·049).
INTERPRETATION: SIFs should be considered where injection drug use is prevalent, particularly in areas with high densities of overdose.
FUNDING: Vancouver Coastal Health, Canadian Institutes of Health Research, and the Michael Smith Foundation for Health Research.
Rigidity, dyskinesia and other atypical overdose presentations observed at a supervised injection site, Vancouver, Canada
OBJECTIVE: In midst of the overdose crisis, the clinical features of opioid overdoses seem to be changing. Understanding of the adverse effects of synthetic opioids such as fentanyl is currently limited to clinical settings. Insite, a supervised injection site in Vancouver, Canada, provides an opportunity to better understand illicit drug overdose presentations.
METHODS: A review of clinical records at Insite for October 2016 to April 2017 was undertaken to quantify atypical overdose presentations. Overdose reports were reviewed for the number of atypical opioid overdose presentations, temporal trends over the study period, concurrent symptoms, and interventions employed by staff.
RESULTS: Insite staff responded to 1581 overdoses during the study period, including 497 (31.4%) that did not fit a typical presentation for opioid overdoses. Of these, 485 fit into five categories of atypical features: muscle rigidity, dyskinesia, slow or irregular heart rate, confusion, and anisocoria. Muscle rigidity was the most common atypical presentation, observed in 240 (15.2%) of the overdose cases, followed by dyskinesia, observed in 150 (9.2%). Slow or irregular heart rate was observed in 69 (4.4%) cases, confusion in 24 (1.5%), and anisocoria in 2 (0.1%) of overall overdose cases.
DISCUSSION: The similarity of atypical overdose cases at Insite with anesthesiology case reports supports the understanding that the illicit drug supply is contaminated by fentanyl and other synthetic opioids. Atypical overdose presentations can affect clinical overdose response. The experience at Insite highlights the potential for supervised consumption sites to be innovative spaces for community learning and knowledge translation.
Risk creating and risk reducing: Community perceptions of supervised consumption facilities for illicit drug use
Progressive public health authorities in high-income countries have advocated supervised consumption facilities, where people who use illicit drugs can consume them in a hygienic, supervised environment, as a way of reducing drug-related risks to both people who use drugs and communities. However, the planning of such facilities has often met with strong reactions from the local community. ‘Not in my backyard’ (NIMBY) type reactions are frequently encountered and public opinion polling is limited in its ability to provide detailed insights into the reasons why people support or oppose these facilities in Toronto and Ottawa. We explore perceptions of residents and business representatives to the proposed implementation of supervised consumption facilities, and examine their perceptions of risks from these facilities. We collected qualitative data from 2008–2010 using focus groups and interviews with 38 residents and 17 business representatives in these two large Canadian cities lacking supervised consumption facilities. We used thematic analysis to examine expressed benefits and risks regarding supervised consumption facilities amongst community members. These participants saw these facilities as potentially risk-reducing, but recognised that the facilities could also create risks for their communities. While community members accepted that facilities could have positive health effects, they expressed a level of concern regarding the risk of public nuisance associated with supervised consumption facilities that seemed unwarranted based on the existing evidence. Discussions on the risks involved in the establishment of supervised consumption facilities should move beyond a focus on the benefits to facility users, to exploring community-level benefits and risks, and integrate evidence regarding actual risk experiences from other locations. Similar approaches may apply to NIMBY concerns related to other contentious issues.
Safer injecting education for HIV prevention within a medically supervised safer injecting facility
BACKGROUND: Requiring help injecting has recently been independently associated with syringe sharing and HIV incidence among injection drug users (IDUs) in Vancouver. We examined IDUs who were receiving safer injecting education within a supervised injecting facility (SIF) in Vancouver.
METHODS: The Scientific Evaluation of Supervised Injecting (SEOSI) cohort is based on a representative sample of SIF users. We examined the prevalence and correlates of receiving safer injecting education within the SIF using univariate and logistic regression analyses.
RESULTS: Between May 31, 2003 and Oct 22, 2004, 874 individuals of the SEOSI cohort have completed the baseline questionnaire, among whom 293 (33.5%) received safer injecting education. In multivariate analyses, requiring help with an injection in the last 6 months (OR = 2.20 [95% CI: 1.62–2.98]) and sex-trade involvement in the last 6 months (OR = 1.54 [1.09–2.16]) were independently associated with receiving safer injecting education within the SIF.
CONCLUSIONS: Since requiring help injecting has previously been associated with HIV incidence, it is encouraging that this risk factor was associated with receiving safer injecting education within the SIF. Nevertheless, prospective evaluation is necessary to examine if receiving safer injecting education is associated with reduced HIV risk behaviour and blood-borne disease incidence.
Safer Injection Facilities in North America: Their Place in Public Policy and Health Initiatives
The continuing threat posed by HIV, HCV, drug overdose, and other injection-related health problems in both the United States and Canada indicates the need for further development of innovative interventions for drug injectors, for reducing disease and mortality rates, and for enrolling injectors into drug treatment and other health care programs. Governmentally sanctioned “safer injection facilities” (SIFs) are a service that many countries around the world have added to the array of public health programs they offer injectors. In addition to needle exchange programs, street-outreach and other services, SIFs are clearly additions to much larger comprehensive public health initiatives that municipalities pursue in many countries. A survey of the existing research literature, plus the authors' ethnographic observations of 18 SIFs operating in western Europe and one SIF that was recently opened in Sydney, Australia, suggest that SIFs target several problems that needle exchange, street-outreach, and other conventional services fall short in addressing: (1) reducing rates of drug injection and related-risks in public spaces; (2) placing injectors in more direct and timely contact with medical care, drug treatment, counseling, and other social services; (3) reducing the volume of injectors' discarded litter in, and expropriation of, public spaces. In light of the evidence, the time has come for more municipalities within North America to begin considering the place of SIFs in public policy and health initiatives, and to provide support for controlled field trials and demonstration projects of SIFs operating in injection drug-using communities.
Safer injection facility use and syringe sharing in injection drug users
Safer injection facilities provide medical supervision for illicit drug injections. We aimed to examine factors associated with syringe sharing in a community-recruited cohort of illicit injection drug users in a setting where such a facility had recently opened. Between Dec 1, 2003, and June 1, 2004, of 431 active injection drug users 49 (11·4%, 95% CI 8·5–14·3) reported syringe sharing in the past 6 months. In logistic regression analyses, use of the facility was independently associated with reduced syringe sharing (adjusted odds ratio 0·30, 0·11–0·82, p=0·02) after adjustment for relevant sociodemographic and drug-use characteristics. These findings could help inform discussions about the merits of such facilities.
Safer washrooms for people who use drugs. Overdose Prevention & Response in WASHROOMS: Recommendations for service providers (Version 3)
To give guidance for service providers to develop safer washroom policies and protocols with a focus on overdose
prevention.
Saving Lives. Changing Lives. Summary Report on the findings from an Evaluation of London’s Temporary Overdose Prevention Site (TOPS), Ontario
Middlesex-London, Ontario, along with many other Canadian communities is experiencing an opioid crisis that has taken the lives of many people in our community. At the same time, there are increased rates of HIV infection and infectious endocarditis in people who use injection drugs (PWUD). Together, this overlapping drug and infectious disease crisis has drawn attention to a complex public health issue requiring the attention of local public health authorities and community partners.
In December 2017, to assist communities with this public health need, the Ministry of Health and Long-Term Care (MOHLTC) introduced a strategy: the establishment of Overdose Prevention Sites (OPS). Communities in need could apply to the MOHLTC to obtain approval and funding to establish an OPS. These sites are a low barrier, time-limited service for people to consume drugs in a supervised environment and facilitate connections to other health and social services. With the support of community partners, the Middlesex-London Health Unit and Regional HIV/AIDS Connection (RHAC) opened Ontario’s first legally sanctioned Temporary Overdose Prevention Site (TOPS) at 186 King Street on February 12, 2018.
In the summer of 2018, a process and outcome evaluation was conducted to capture lessons learned in the first six months of operation, and to document the site’s progress in meeting its intended outcomes.
