Synthetic Opioid key responses
- Mapping evidence-based key responses to synthetic opioids and their implementation strategies
- Field-tested Toolkit with seven implementation guides
ARCHES Report to Mayor and City Council
On February 28th 2018, ARCHES received federal exemption from Health Canada, Office of the Controlled Substances, to operate a Supervised Consumption Services (SCS) facility in Lethbridge. This exemption was received in response to the growing opioid crisis in Canada, claiming a total of 2,138 lives in Alberta since January 1st, 2016.
SCS provide a hygienic environment for people to consume pre-obtained drugs under medical supervision. ARCHES SCS is the first, and remains the only, in North America to offer four modes of consumption, which include: inhalation, injection, intranasal (snorting) and ingestion (swallowing). There are 13 injection booths and 2 inhalation rooms in our medically supervised drug consumption room. SCS has four teams consisting of Registered Nurses, Licensed Practical Nurses, Primary Care Paramedics, Addiction Counsellors, Harm Reduction Specialists and Peer Support Workers. Together they function as a multi-disciplinary team, each within their own scope of practice and working together towards program objectives.
There is a substantial body of evidence identifying that SCS facilities reduce the risk of HIV/HCV transmission, increase access to health and social services including treatment, and reduce public drug consumption and related debris. ARCHES has operated the SCS in line with the objectives identified in the evidence. The following section outlines the efforts that ARCHES has made to meet these objectives in the last year and a half of operation.
Assessing support for supervised injection services among community stakeholders in London, Canada
OBJECTIVES: Few qualitative studies have examined support for supervised injection services (SIS), and these have been restricted to large cities. This study aimed to assess support for SIS among a diverse representation of community stakeholders in London, a mid-sized city in southwestern Ontario, Canada.
METHODS: This qualitative study was undertaken as part of the Ontario Integrated Supervised Injection Services Feasibility Study. We used purposive sampling methods to recruit a diversity of key informants (n=20) from five sectors: healthcare; social services; government and municipal services; police and emergency services; and the business and community sector. Interview data, collected via one-to-one semi structured interviews, were coded and analyzed using thematic analyses through NVivo 10 software.
RESULTS: Interview participants unanimously supported the implementation of SIS in London. However, participant support for SIS was met with some implementation-related preferences and/or conditions. These included centralization or decentralization of SIS; accessibility of SIS for people who inject drugs; proximity of SIS to interview participants; and other services and strategies offered alongside SIS.
DISCUSSION: The results of this study challenge the assumptions that smaller cities like London may be unlikely to support SIS. Community stakeholders were supportive of the implementation of SIS with some preferences or conditions. Interview participants had differing perspectives, but ultimately supported similar end goals of accessibility and reducing community harms associated with injection drug use. Future research and SIS programming should consider these factors when determining optimal service delivery in ways that increase support from a diversity of community stakeholders.
At-a-glance – Supervised Injection Services: a community-based response to the opioid crisis in the City of Ottawa, Canada
In response to the current opioid crisis in Canada, establishing safe injection services (SIS) in high risk communities has become more prevalent. In November 2017, The Trailer opened in Ottawa, Canada and tracks client use, overdose treatment and overdoses reversed. We analyzed data collected between November 2017 and August 2018. During peak hours, demand for services consistently exceeded The Trailer’s capacity. Overdoses treated and reversed in this facility increased substantially during this period. Results suggest The Trailer provided an important though not optimal (due to space restrictions) harm reduction service to this high-risk community.
Attendance, drug use patterns, and referrals made from North America's first supervised injection facility
BACKGROUND: North America's first government sanctioned supervised injection facility (SIF) was opened in Vancouver in response to the serious health and social consequences of injection drug use and the perseverance of committed advocates and drug user groups who demanded change. This analysis was conducted to describe the attendance, demographic characteristics, drug use patterns, and referrals made during the first 18 months of operation.
METHODS: As part of the evaluation strategy for the SIF, information is collected through a comprehensive on-site database designed to track attendance and the daily activities within the facility. All users of the SIF must sign a waiver form and are then entered into a database using a unique identifier of their choice. This identifier is used at each subsequent visit to provide a prospective record of attendance, drug use, and interventions.
RESULTS: From 10 March 2004 to 30 April 2005 inclusive, there were 4764 unique individuals who registered at the SIF. The facility successfully attracted a range of community injection drug users including women (23%) and members of the Aboriginal community (18%). Although heroin was used in 46% of all injections, cocaine was injected 37% of the time. There were 273 witnessed overdoses with no fatalities. During just 12 months of observation, 2171 individual referrals were made with the majority (37%) being referred for addiction counseling.
INTERPRETATION: Vancouver's SIF has successfully been integrated into the community, has attracted a wide cross section of community injection drug users, has intervened in overdoses, and initiated over 2000 referrals to counseling and other support services. These findings should be useful for other settings considering SIF trials.
BC Overdose Prevention Services Guide 2019
This guideline is intended for service providers and Public Health practitioners offering overdose prevention services (OPS) in the community. OPS were initiated by the BC Minister of Health in Dec. 2016 due to increasing mortality from illicit drug overdoses. While this document provides guidance for the majority of circumstances service providers and practitioners may encounter, knowledge and practice are always evolving and you are encouraged to connect regularly with your local Harm Reduction Program leads and Medical Health Officers. Although there may be overlap between OPS and Supervised Injection/Consumption Services (SIS/SCS), a separate provincial guideline has been produced and should be referred to by SIS/SCS sites approved by Health Canada.
The guidance in this document primarily concerns and references injection drug use, however the authors recognize that clients may prefer to use drugs in other ways. Consequently, the guideline may also be applied to clients who ingest their drugs orally (i.e. swallow) or nasally (i.e. snort).
The guideline does not cover opioid smoking. Although law enforcement follows trends in the chemical composition of illicit drugs and their cutting agents, very little is known about what chemical by-products are produced when these drugs are burned, or their effects on health. Also, unlike injecting, swallowing or snorting, smoking illicit drugs will release these unknown chemicals into the air. In non-emergency situations where clients are smoking drugs inside, it is recommended to do so with open windows and staff to allow the room to clear of smoke before entering.
OPS provide designated spaces for the purpose of monitoring people who use drugs for signs of an overdose. This permits rapid intervention if an overdose occurs to prevent brain injury and death. For an overview of OPS protocols and service recommendations, see Appendix A: Overdose Prevention & Response Protocol Recommendations for Service Providers (Vancouver Coastal Health and Fraser Health, 2016). For guidelines and resources for OPS within supportive housing and homeless shelters, see Appendix B: Guidelines and Resources for Supportive Housing Providers, Homeless Shelter Providers and Regional Health Authorities on Overdose Prevention and Response.
Best Practice Guidelines: Implementing Supervised Injection Services
Implementing supervised injection services is a best practice guideline (BPG) that supports decision-making around the most effective approaches for delivering supervised injection services (SIS) to people who inject drugs. These approaches promote engagement, support positive health outcomes, and help reduce harms associated with injection drug use.
The BPG's 11 evidence-based recommendations aim to promote health equity for people who inject drugs through harm reduction, culturally safe, and trauma-informed practices and policies in SIS. The recommendations apply to nurses and health workers providing SIS. However, since people who inject drugs access services and supports in other health and social service settings, this BPG is a critical resource for all sectors.
The recommendations are provided in three areas:
- Practice recommendations that provide guidance on how to engage, develop, and maintain trusting and respectful relationships with people who inject drugs
- Education recommendations that describe key educational methods, design, and strategies that promote knowledge development in health workers and students, which support high quality care in SIS
- Organizational and health system level recommendations that outline operational and policy considerations that support accessible, relevant, equitable, and comprehensive care and services in SIS.
Changes in injecting practices associated with the use of a medically supervised safer injection facility
Injection drug users (IDUs) are vulnerable to serious health complications resulting from unsafe injection practices. We examined whether the use of a supervised safer injection facility (SIF) promoted change in injecting practices among a representative sample of 760 IDUs who use a SIF in Vancouver, Canada. Consistent SIF use was compared with inconsistent use on a number of self-reported changes in injecting practice variables. More consistent SIF use is associated with positive changes in injecting practices, including less reuse of syringes, use of sterile water, swabbing injection sites, cooking/filtering drugs, less rushed injections, safe syringe disposal and less public injecting.
Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users
BACKGROUND: North America's first medically supervised safer injecting facility for illicit injection drug users was opened in Vancouver on Sept. 22, 2003. Although similar facilities exist in a number of European cities and in Sydney, Australia, no standardized evaluations of their impact have been presented in the scientific literature.
METHODS: Using a standardized prospective data collection protocol, we measured injection-related public order problems during the 6 weeks before and the 12 weeks after the opening of the safer injecting facility in Vancouver. We measured changes in the number of drug users injecting in public, publicly discarded syringes and injection-related litter. We used Poisson log-linear regression models to evaluate changes in these public order indicators while considering potential confounding variables such as police presence and rainfall.
RESULTATS: In stratified linear regression models, the 12-week period after the facility's opening was independently associated with reductions in the number of drug users injecting in public (p < 0.001), publicly discarded syringes (p < 0.001) and injection-related litter (p < 0.001). The predicted mean daily number of drug users injecting in public was 4.3 (95% confidence interval [CI] 3.5–5.4) during the period before the facility's opening and 2.4 (95% CI 1.9–3.0) after the opening; the corresponding predicted mean daily numbers of publicly discarded syringes were 11.5 (95% CI 10.0–13.2) and 5.4 (95% CI 4.7–6.2). Externally compiled statistics from the city of Vancouver on the number of syringes discarded in outdoor safe disposal boxes were consistent with our findings.
INTERPRETATION: The opening of the safer injecting facility was independently associated with improvements in several measures of public order, including reduced public injection drug use and public syringe disposal.
Changing risk and presentation of overdose associated with consumption of street drugs at a supervised injection site in Vancouver, Canada
BACKGROUND: British Columbia is experiencing a public health emergency due to overdoses resulting from consumption of street drugs contaminated with fentanyl. While the risk of overdoses appears to be increasing, the overdose rate and severity of overdose presentations have yet to be quantified.
METHODS: Insite is a supervised injection site in Vancouver. Data from Insite’s client database from January 2010 to June 2017 were used to calculate overdose rates as well as the proportion of overdoses involving rigidity and naloxone administration over time in order to estimate changes in the risk and severity of overdose resulting from changes in the local drug supply.
RESULTS: The overdose rate increased significantly for all drug categories. Heroin used alone or with other drugs continues to be associated with the highest overdose rate. The overdose rate associated with heroin increased from 2.7/1000 visits to 13/1000 visits over the study period, meaning that clients were 4.8 times more likely to overdose in the most recent period as in the baseline period. The proportion of overdose events involving rigidity, a known complication of intravenous fentanyl use, increased significantly from 10.4% to 18.9%. The proportion of overdoses requiring naloxone administration increased significantly from 48.4% to 57.1% and is now similar across all drug categories.
CONCLUSIONS: The risk and severity of overdoses at Insite have increased since the emergence of illicit fentanyl. This information derived from supervised injection site data can be used to inform local harm reduction efforts and the response to the overdose emergency.
