Synthetic Opioid key responses
- Mapping evidence-based key responses to synthetic opioids and their implementation strategies
- Field-tested Toolkit with seven implementation guides
Estimated Drug Overdose Deaths Averted by North America's First Medically-Supervised Safer Injection Facility
BACKGROUND: Illicit drug overdose remains a leading cause of premature mortality in urban settings worldwide. We sought to estimate the number of deaths potentially averted by the implementation of a medically supervised safer injection facility (SIF) in Vancouver, Canada.
METHODOLOGY/PRINCIPAL FINDINGS: The number of potentially averted deaths was calculated using an estimate of the local ratio of non-fatal to fatal overdoses. Inputs were derived from counts of overdose deaths by the British Columbia Vital Statistics Agency and non-fatal overdose rates from published estimates. Potentially-fatal overdoses were defined as events within the SIF that required the provision of naloxone, a 911 call or an ambulance. Point estimates and 95% Confidence Intervals (95% CI) were calculated using a Monte Carlo simulation. Between March 1, 2004 and July 1, 2008 there were 1004 overdose events in the SIF of which 453 events matched our definition of potentially fatal. In 2004, 2005 and 2006 there were 32, 37 and 38 drug-induced deaths in the SIF's neighbourhood. Owing to the wide range of non-fatal overdose rates reported in the literature (between 5% and 30% per year) we performed sensitivity analyses using non-fatal overdose rates of 50, 200 and 300 per 1,000 person years. Using these model inputs, the number of averted deaths were, respectively: 50.9 (95% CI: 23.6–78.1); 12.6 (95% CI: 9.6–15.7); 8.4 (95% CI: 6.5–10.4) during the study period, equal to 1.9 to 11.7 averted deaths per annum.
CONCLUSIONS/SIGNIFICANCE: Based on a conservative estimate of the local ratio of non-fatal to fatal overdoses, the potentially fatal overdoses in the SIF during the study period could have resulted in between 8 and 51 deaths had they occurred outside the facility, or from 6% to 37% of the total overdose mortality burden in the neighborhood during the study period. These data should inform the ongoing debates over the future of the pilot project.
Evaluation of a fentanyl drug checking service for clients of a supervised injection facility, Vancouver, Canada
BACKGROUND: British Columbia, Canada, is experiencing a public health emergency related to opioid overdoses driven by consumption of street drugs contaminated with illicitly manufactured fentanyl. This cross-sectional study evaluates a drug checking intervention for the clients of a supervised injection facility (SIF) in Vancouver.
METHODS: Insite is a facility offering supervised injection services in Vancouver’s Downtown East Side, a community with high levels of injection drug use and associated harms, including overdose deaths. During July 7, 2016, to June 21, 2017, Insite clients were offered an opportunity to check their drugs for fentanyl using a test strip designed to test urine for fentanyl. Results of the drug check were recorded along with information including the substance checked, whether the client intended to dispose of the drug or reduce the dose and whether they experienced an overdose. Logistic regression models were constructed to assess the associations between drug checking results and dose reduction or drug disposal. Crude odds ratios (OR) and 95% confidence intervals (CI) were reported.
RESULTS: About 1% of the visits to Insite during the study resulted in a drug check. Out of 1411 drug checks conducted by clients, 1121 (79.8%) were positive for fentanyl. Although most tests were conducted post-consumption, following a positive pre-consumption drug check, 36.3% (n = 142) of participants reported planning to reduce their drug dose while only 11.4% (n = 50) planned to dispose of their drug. While the odds of intended dose reduction among those with a positive drug check was significantly higher than those with a negative result (OR = 9.36; 95% CI 4.25–20.65), no association was observed between drug check results and intended drug disposal (OR = 1.60; 95% CI 0.79–3.26). Among all participants, intended dose reduction was associated with significantly lower odds of overdose (OR = 0.41; 95% CI 0.18–0.89).
CONCLUSIONS: Although only a small proportion of visits resulted in a drug check, a high proportion (~ 80%) of the drugs checked were contaminated with fentanyl. Drug checking at harm reduction facilities such as SIFs might be a feasible intervention that could contribute to preventing overdoses in the context of the current overdose emergency.
Community House
This evaluation was undertaken to examine the provision of services within these two Overdose Prevention Sites (OPS), focused primarily on the impacts on clients using the OPS. In the context of the withdrawal of funding by the provincial government, this evaluation also sought to explore the potential impacts if the OPS at Street Health and St. Stephen’s were forced to close. Furthermore, the report examines the implementation process, as well as the service delivery model to identify what worked well, and the challenges encountered. The ways in which both OPS work with priority populations such as people experiencing homelessness, women and members of the LGBTQI2S population, and people who inject stimulants like crystal methamphetamine is examined. Finally, stafing considerations are explored.
Examining the potential role of a supervised injection facility in Saskatoon, Saskatchewan, to avert HIV among people who inject drugs
BACKGROUND: Research predicting the public health and fiscal impact of Supervised Injection Facilities (SIFs), across different cities in Canada, has reported positive results on the reduction of HIV cases among People Who Inject Drugs (PWID). Most of the existing studies have focused on the outcomes of Insite, located in the Vancouver Downtown Eastside (DTES). Previous attention has not been afforded to other affected areas of Canada. The current study seeks to address this deficiency by assessing the cost-effectiveness of opening a SIF in Saskatoon, Saskatchewan.
METHODS: We used two different mathematical models commonly used in the literature, including sensitivity analyses, to estimate the number of HIV infections averted due to the establishment of a SIF in the city of Saskatoon, Saskatchewan.
RESULTS: Based on cumulative cost-effectiveness results, SIF establishment is cost-effective. The benefit to cost ratio was conservatively estimated to be 1.35 for the first two potential facilities. The study relied on 34% and 14% needle sharing rates for sensitivity analyses. The result for both sensitivity analyses and the base line estimates indicated positive prospects for the establishment of a SIF in Saskatoon.
CONCLUSION: The opening of a SIF in Saskatoon, Saskatchewan is financially prudent in the reduction of tax payers’ expenses and averting HIV infection rates among PWID
Expanding supervised injection facilities across Canada: lessons from the Vancouver experience
The opioid crisis has led to an unprecedented rise in the number of overdose deaths across Canada. In response, there has been an expansion of supervised injection facilities (SIFs), with several new SIFs approved or under review across the country. Much of the evidence for the benefits of SIFs in reducing overdose mortality, infectious-related complications, and public disorder comes from Insite in Vancouver, North America’s first SIF. While implementing SIFs in other Canadian cities is a major step forward in combating the opioid epidemic, the diversity within our country’s socio-demographic and political landscape leaves the application of SIFs in these new settings a matter of uncertainty. This commentary highlights key lessons learned from Vancouver and the potential modifications required to enhance implementation in other cities to ensure the success of new SIFs across Canada.
FAQ: Supervised Consumption Services at Sheldom M. Chumir Health Centre
What are supervised consumption services? What is the difference between “Safe injection” and “supervised consumption”? Do we need supervised consumption services? Why provide supervised consumption services? Will supervised consumption services increase crime in the community? Do supervised consumption services encourage people to experiment with, and use,
drugs? Will introducing the services attract more people to use narcotics? Will supervised consumption services attract people who sell drugs? Why aren’t we putting more resources into prevention and treatment? What is the status of the application to Health Canada to provide Supervised
Consumption Services at Sheldon M. Chumir Health Centre? ...
Fentanyl self-testing outside supervised injection settings to prevent opioid overdose: Do we know enough to promote it?
Since 2013, North America has experienced a sharp increase in unintentional fatal overdoses: fentanyl, and its analogues, are believed to be primarily responsible. Currently, the most practical means for people who use drugs (PWUD) to avoid or mitigate risk of fentanyl-related overdose is to use drugs in the presence of someone who is in possession of, and experienced using, naloxone. Self-test strips which detect fentanyl, and some of its analogues, have been developed for off-label use allowing PWUD to test their drugs prior to consumption. We review the evidence on the off-label sensitivity and specificity of fentanyl test strips, and query whether the accuracy of fentanyl test strips might be mediated according to situated practices of use. We draw attention to the weak research evidence informing the use of fentanyl self-testing strips.
Findings and Analysis for Overdose Prevention Society
An unprecedented overdose crisis is killing thousands of people across Canada, and nowhere is the death toll more pronounced and shockingly tragic than in British Columbia, where 1,449 people have died from illicit drug overdoses in 2017. Fuelling the loss of life is a toxic drug supply tainted by fentanyl and carfentanil and inadequate drug policies continuing to focus on prohibition and criminalization. This policy approach has been shown to push substance use further underground, thereby increasing the harms to society.
Within this environment, people who use substances and their advocates have taken a leading role upholding the health and safety of those at risk by setting up overdose prevention sites offering low-barrier harm reduction services. One such site was located along East Hastings Street near Columbia Street in Vancouver’s Downtown Eastside. Founded and run by the Overdose Prevention Society (OPS), the site and its model of service delivery have proven extremely effective in saving lives for a community in dire need.
In the beginning of 2018, Data for Good Vancouver partnered with OPS to analyze data contained in two anonymized data sets, one relating to self-reported substance use (data from the Downtown Eastside Market); the other, visit volumes and health outcomes at the site. On January 13, 2018, volunteers from Data for Good Vancouver took part in a “datathon” where the raw data was analyzed. The findings, insights, and recommendations from that analysis are summarized in the following report.
From risky places to safe spaces: Re-assembling spaces and places in Vancouver's Downtown Eastside
Vancouver's Downtown Eastside (DTES) neighbourhood is commonly associated with stigmatized and criminalized activities and attendant risks and harms. Many spaces/places in this urban neighbourhood are customarily portrayed and experienced as risky and harmful, and are implicated in experiences of structural (and physical) violence and marginalization. Drawing on 50 qualitative interviews, this paper explores how spaces/places frequently used by structurally vulnerable people who use drugs (PWUD) in the DTES that are commonly associated with risk and harm (e.g., alleyways, parks) can be re-imagined and re-constructed as enabling safety and wellbeing. Study participants recounted both negative and positive experiences with particular spaces/places, suggesting the possibility of making these locations less risky and safer. Our findings demonstrate how spaces/places used by PWUD in this particular geographical context can be understood as assemblages, a variety of human and nonhuman forces – such as material objects, actors, processes, affect, temporal elements, policies and practices – drawn together in unique ways that produce certain effects (risk/harm or safety/wellbeing). Conceptualizing these spaces/places as assemblages provides a means to better understand how experiences of harm, or conversely wellbeing, unfold, and sheds light on how risky spaces/places can be re-assembled as spaces/places that enable safety and wellbeing.
Gendered violence & overdose prevention sites: A rapid ethnographic study during an overdose epidemic in Vancouver, Canada
BACKGROUND AND AIMS: North America's overdose epidemic is increasingly driven by fentanyl and fentanyl‐adulterated drugs. Risk Environment, including low‐threshold models (termed Overdose Prevention Sites; OPS), are now being debated in the United States and implemented in Canada. Despite evidence that gendered and racialized violence shape access to harm reduction among women who use drugs (WWUD), this has not been examined in relation to OPS and amidst the overdose epidemic. This study explores how overlapping epidemics of overdose and gendered and racialized violence in Vancouver's Downtown Eastside, one of North America's overdose epicenters, impacts how marginalized WWUD experience OPS.
DESIGN: Qualitative analysis using rapid ethnographic fieldwork. Data collection included 185 hours of naturalistic observation and in‐depth interviews; data were analyzed thematically using NVivo.
SETTING: Vancouver, Canada.
PARTICIPANTS: 35 WWUD recruited from three OPS.
MEASUREMENTS: Participants' experiences of OPS and the public health emergency.
FINDINGS: The rapid onset and severity of intoxication associated with the use of fentanyl‐adulterated drugs in less regulated drug use settings not only amplified WWUD's vulnerability to overdose death but also violence. Participants characterized OPS as safer spaces to consume drugs in contrast to less regulated settings, and accommodation of assisted injections and injecting partnerships was critical to increasing OPS access among WWUD. Peer administered injections disrupted gendered power relations to allow women increased control over their drug use, however, participants indicated that OPS were also gendered and racialized spaces that jeopardized some women's access.
CONCLUSION: Although women who use drugs in Vancouver, Canada appear to feel that Overdose Prevention Sites (OPS) address forms of everyday violence made worse by the overdose epidemic, OPS remain ‘masculine spaces' that can jeopardize women's access.
