Synthetic Opioid key responses
- Mapping evidence-based key responses to synthetic opioids and their implementation strategies
- Field-tested Toolkit with seven implementation guides
Summary of findings from the evaluation of a pilot medically supervised safer injecting facility
In many cities, infectious disease and overdose epidemics are occurring among illicit injection drug users (IDUs). To reduce these concerns, Vancouver opened a supervised safer injecting facility in September 2003. Within the facility, people inject pre-obtained illicit drugs under the supervision of medical staff. The program was granted a legal exemption by the Canadian government on the condition that a 3-year scientific evaluation of its impacts be conducted. In this review, we summarize the findings from evaluations in those 3 years, including characteristics of IDUs at the facility, public injection drug use and publicly discarded syringes, HIV risk behaviour, use of addiction treatment services and other community resources, and drug-related crime rates. Vancouver's safer injecting facility has been associated with an array of community and public health benefits without evidence of adverse impacts. These findings should be useful to other cities considering supervised injecting facilities and to governments considering regulating their use.
Many cities are experiencing infectious disease and overdose epidemics as a result of illicit injection drug use, an activity that is also associated with a number of negative community impacts, including public drug use. Despite these harms, innovative public health programs for reducing health and community concerns remain highly controversial in North America and other settings where HIV infection is spreading rapidly among injection drug users (IDUs).
In Canada, Vancouver has been an epicentre of drug-related harm during the last decade. In response, the affected community began advocating a medically supervised safer injecting facility where IDUs could inject pre-obtained drugs under the supervision of medical staff.11 Within the facility, IDUs are typically provided with sterile syringes and emergency care in the event of overdose, as well as primary care services and referral to addiction treatment. Such facilities exist in more than 2 dozen European cities and, more recently, in Sydney, Australia.
Vancouver's safer injecting facility was opened in September 2003 as a pilot study. The legal exemption by the federal government that allowed operation of the facility was limited to 3 years and was granted on the condition that an external 3-year scientific evaluation of its impacts be conducted. Given the controversial nature of the program, stakeholders agreed that all findings from the evaluation, including this report, should be externally peer-reviewed and published in the medical literature before dissemination. In this review we report on the 3 years' findings.
Supervised Consumption Facilities: Community Consultation | London Ontario
As in many parts in Canada and Ontario, London is experiencing an opioid crisis. In response, London is committed to responding in a comprehensive manner, which includes the establishment of Supervised Consumption Facilities. As part of the application for Supervised Consumption Facilities (SCF), a community consultation process was facilitated in November – December 2017 to gather feedback from London residents for the purposes of:
• providing information to Londoners about Supervised Consumption Facilities and local need
• Obtaining feedback on perceived benefits and concerns, recommendations to address concerns and site location suggestions and considerations
Supervised Consumption: A Report to the Community of Medicine Hat
In 2016-2017, Medicine Hat experienced 10 opioid-related overdose deaths, and the South Zone had the highest rate of emergency room visits related to opioids (23% higher than the provincial average). Additionally, Medicine Hat experienced 61 EMS calls related to opioid overdose in 2016 (Alberta Health, 2017).
In 2016, Alberta Health announced funding to support the assessment of the need for and development of supervised consumption services (SCS) across the province. The Medicine Hat Coalition on Supervised Consumption Services (MHCSC) was formed to guide the needs assessment and program planning in our city. The MHCSC includes representatives from nine organizations including Alberta Health Services, the City of Medicine Hat, Medicine Hat Police Service, Medicine Hat College, the University of Calgary and numerous community-based organizations and service providers. In 2017, the MHCSC did a research study involving a survey with 185 people who use substances, follow-up interviews with 10 people and focus groups with employees working directly with people who use substances in Medicine Hat.
This report summarizes findings from our needs assessment and research. The purpose is to describe the current state of Medicine Hat’s opioid crisis and offer recommendations for evidence-based interventions to address it. Our goal is to provide information to help demystify and debunk myths associated with drug use, harm reduction and supervised consumption services more specifically.
Supervised inhalation is an important part of supervised consumption services
SETTING: The first regulated supervised inhalation site (safer smoking room) in North America has opened in Lethbridge, Alberta, as part of a supervised consumption site addressing all routes of consumption. When designing the service, we felt it was important to accommodate not just injection drug use but also inhalation because it is not the method of drug use that kills but the drug itself, all people who use drugs deserve service regardless of their mode of use, and people who use drugs should have the opportunity to use the method with the lowest risk.
INTERVENTION: We received approval from Health Canada to offer supervised inhalation services in addition to supervised injection services. Based on a European model, we worked with a local commercial heating, cooling, and ventilation (HVAC) company to create rooms with ventilation systems that complied with Canadian health and safety regulations.
OUTCOME: People who use drugs by inhalation have repeatedly told us that they want to use indoors and will do so given the option. Since opening the supervised consumption service at the end of February 2018, the response has been overwhelming and both of the inhalation rooms are constantly in use.
IMPLICATIONS: Supervised inhalation services provide an alternative to public drug use and an opportunity for people who use drugs to engage with harm reduction services. Other supervised consumption services in Canada may also wish to pursue exemptions for this service.
Supervised injection facilities in Canada: past, present, and future
Canada has long contended with harms arising from injection drug use. In response to epidemics of HIV infection and overdose in Vancouver in the mid-1990s, a range of actors advocated for the creation of supervised injection facilities (SIFs), and after several unsanctioned SIFs operated briefly and closed, Canada’s first sanctioned SIF opened in 2003. However, while a large body of evidence highlights the successes of this SIF in reducing the health and social harms associated with injection drug use, extraordinary efforts were needed to preserve it, and continued activism by local people who inject drugs (PWID) and healthcare providers was needed to promote further innovation and address gaps in SIF service delivery. A growing acceptance of SIFs and increasing concern about overdose have since prompted a rapid escalation in efforts to establish SIFs in cities across Canada. While much progress has been made in that regard, there is a pressing need to create a more enabling environment for SIFs through amendment of federal legislation. Further innovation in SIF programming should also be encouraged through the creation of SIFs that accommodate assisted injecting, the inhalation of drugs. As well, peer-run, mobile, and hospital-based SIFs also constitute next steps needed to optimize the impact of this form of harm reduction intervention.
Supervised injection facility use and all-cause mortality among people who inject drugs in Vancouver, Canada: A cohort study
BACKGROUND: People who inject drugs (PWID) experience elevated rates of premature mortality. Although previous studies have demonstrated the role of supervised injection facilities (SIFs) in reducing various harms associated with injection drug use, including accidental overdose death, the possible impact of SIF use on all-cause mortality is unknown. Therefore, we examined the relationship between frequent SIF use and all-cause mortality among PWID in Vancouver, Canada.
METHODS AND FINDINGS: Data were derived from 2 prospective cohort studies of PWID in Vancouver, Canada, between December 2006 and June 2017. Every 6 months, participants completed questionnaires that elicited information regarding sociodemographic characteristics, substance use patterns, social-structural exposures, and use of health services including SIFs. These data were confidentially linked to the provincial vital statistics database to ascertain mortality rates and causes of death. We used multivariable extended Cox regression analyses to estimate the independent association between frequent (i.e., at least weekly) SIF use and all-cause mortality. Of 811 participants, 278 (34.3%) were women, and the median age was 39 years (IQR 33–46) at baseline. In total, 432 (53.3%) participants reported frequent SIF use at baseline, and 379 (46.7%) did not. At baseline, frequent SIF users were on average younger than nonfrequent users, and a higher proportion of frequent SIF users than nonfrequent users were unstably housed, resided in the Downtown Eastside neighbourhood, injected in public, had a recent non-fatal overdose, used prescription opioids at least daily, injected heroin at least daily, injected cocaine at least daily, and injected crystal methamphetamine at least daily. A lower proportion of frequent SIF users than nonfrequent users were HIV positive and enrolled in addiction treatment at baseline. The median duration of follow-up among study participants was 72 months (IQR 24–123). In total, 112 participants (13.8%) died during the study period, yielding a crude mortality rate of 22.7 (95% CI 18.7–27.4) deaths per 1,000 person-years. The median years of potential life lost per death was 34 (IQR 27–42) years. In a time-updated multivariable model, frequent SIF use was inversely associated with risk of all-cause mortality after adjusting for potential confounders, including age, sex, HIV seropositivity, unstable housing, at least daily cocaine injection, public injection, incarceration, enrolment in addiction treatment, and calendar year of interview (adjusted hazard ratio 0.46, 95% CI 0.26–0.80, p = 0.006). The main study limitations are the limited generalizability of findings due to non-random sampling, the potential for reporting biases due to reliance on some self-reported information, and the possibility that residual confounding influenced findings.
CONCLUSIONS: We observed a high burden of premature mortality among a community-recruited cohort of PWID. Frequent SIF use was associated with a lower risk of death, independent of relevant confounders. These findings support efforts to enhance access to SIFs as a strategy to reduce mortality among PWID. Further analyses of individual-level data are needed to determine estimates of, and potential causal pathways underlying, associations between SIF use and specific causes of death.
Supervised injection facility use and exposure to violence among a cohort of people who inject drugs: A gender-based analysis
BACKGROUND: Supervised injection facilities (SIFs) have been established in many settings, in part to reduce risks associated with injecting in public, including exposure to violence. However, the relationship between SIF use and experiencing violence has not yet been thoroughly evaluated. We sought to longitudinally examine the gender-specific relationship between SIF use and exposure to violence among people who inject drugs (PWID) in a Canadian setting.
METHODS: Data were drawn from two prospective cohort studies of PWID in Vancouver, Canada, between December 2005 and December 2016. Semi-annually, participants completed questionnaires that elicited data concerning sociodemographic characteristics, behavioural patterns, violent encounters and health service utilization. We used multivariable generalized estimating equations (GEE) to estimate the independent association between exclusively injecting drugs at a SIF and experiencing physical or sexual violence among men and women PWID, respectively.
RESULTS: Of 1930 PWID followed for a median of four years, 679 (35.2%) were women and the median age was 41 years at baseline. In total, 353 (52.0%) women and 694 (55.5%) men reported experiencing at least one incident of violence during follow-up. In multivariable analyses, exclusive SIF use was associated with decreased odds of experiencing violence among men after adjusting for potential confounders (Adjusted Odds Ratio [AOR] = 0.64; 95% confidence interval [CI]: 0.46–0.89). Exclusive SIF use was not significantly associated with experiencing violence among women in adjusted analyses (AOR = 0.97; 95% CI: 0.57–1.66).
CONCLUSION: In light of the recent expansion of SIFs in Canada, our finding of a protective association between exclusive SIF use and exposure to violence among men is encouraging. The fact that we did not observe a significant association between SIF use and experiencing violence among women highlights the need for social-structural interventions that are more responsive to the specific needs of women PWID in relation to violence prevention.
Supervised Injection Facility Utilization Patterns: A Prospective Cohort Study in Vancouver, Canada
INTRODUCTION: Although the health and community benefits of supervised injection facilities are well documented, little is known about long-term patterns of utilization of this form of health service. The present study seeks to longitudinally characterize discontinuation of use of a supervised injection facility in Vancouver, Canada.
METHODS: Data were drawn from 2 community-recruited prospective cohorts of people who inject drugs between December 2005 and December 2016. In 2018, extended Cox regression for recurrent events was used to examine factors associated with time to cessation of supervised injection facility use during periods of active injection.
RESULTS: Of 1,336 people who inject drugs that were followed for a median of 50 months, 847 (63.4%) participants reported 1,663 6-month periods of supervised injection facility use cessation while actively injecting drugs (incidence density of 26.6 events per 100 person-years). An additional 2,282 (57.8%) of the total 3,945 6-month periods of supervised injection facility use cessation occurred during periods of injection cessation. In multivariable analyses, enrollment in methadone maintenance therapy (adjusted hazard ratio=1.41) and HIV seropositivity (adjusted hazard ratio=1.23) were positively associated with supervised injection facility use cessation during periods of active injection, whereas homelessness (adjusted hazard ratio=0.59), at least daily heroin injection (adjusted hazard ratio=0.70), binge injection (adjusted hazard ratio=0.68), public injection (adjusted hazard ratio=0.67), nonfatal overdose (adjusted hazard ratio=0.73), difficulty accessing addiction treatment (adjusted hazard ratio=0.69), and incarceration (adjusted hazard ratio=0.70) were inversely associated with this outcome (all p<0.05). The most commonly reported reasons for supervised injection facility use cessation were injection drug use cessation (42.3%) and a preference for injecting at home (30.7%).
CONCLUSIONS: These findings suggest that this supervised injection facility successfully retains people who inject drugs at elevated risk of drug-related harms and indicate that many supervised injection facility clients neither use this service nor inject drugs perpetually.
Supervised Injection Sites: A Position Paper by Ontario’s Police Leaders
The Ontario Association of Chiefs of Police does not support the establishment or operation of injection facilities in Ontario.
Support of supervised injection facilities by emergency physicians in Canada
Background:
Despite evidence supporting the implementation of supervised injection facilities (SIFs) by multiple stakeholders, no evaluation of emergency physicians’ attitudes has ever been documented towards such facilities in Canada or internationally. The primary goal of our study was to determine the opinions and perceptions of emergency physicians regarding the implementation of SIFs in Canada.
Methods:
We conducted a national electronic survey of staff and resident emergency physicians in Canada using an iteratively designed survey tool in consultation with content experts. Invitations to complete the survey were sent via email by the Canadian Association of Emergency Physicians. Inclusion criteria required respondents to have treated an adult patient in a Canadian emergency department within the preceding 6 months. The primary measure was the proportion of respondents who would support, not support or were unsure of supporting SIFs in their community with the secondary measure being the likelihood of respondents to refer patients to a SIF if available.
Results:
We received 280 responses out of 1353 eligible physicians (20.7%), with the analysis conducted on 250 responses that met inclusion criteria (18.5%). The majority of respondents stated they would support the implementation of SIFs in their community (N = 172; 74.5%) while 10.8% (N = 25) would not and 14.7% (N = 34) did not know. The majority of respondents said they would refer their patients to SIFs (N = 198; 84.6%), with 4.3% (N = 10) who would not and 11.1% (N = 26) who were unsure.
Conclusion:
The findings from our study demonstrate that the majority of emergency physician respondents in Canada support the implementation of such sites (74.5%) while 84.6% of respondents would refer patients from the emergency department to such sites if they did exist. Given that many Canadian cities are actively pursuing the creation of SIFs or imminently opening such sites, it appears that our sample population of emergency physicians would both support this approach and would utilize such facilities in an effort to improve patient-centered outcomes for this often marginalized population.
