Synthetic Opioid key responses
- Mapping evidence-based key responses to synthetic opioids and their implementation strategies
- Field-tested Toolkit with seven implementation guides
Hamilton Supervised Injection Site Needs Assessment & Feasibility Study
Background: Drug and substance misuse is an important public health issue with significant impacts on the individual and the community. Health and social impacts include death from overdose, inability to work, family disruption and grief, crime, mental illness and addictions, unstable housing, degradation of public spaces, and concerns about neighbourhood safety. Specific to injection drug use, harms include the spread of infectious diseases such as hepatitis C virus (HCV) and human immunodeficiency virus (HIV), and the production of injection litter in the community.
Supervised injection sites (SISs) are locations where people take pre-obtained illicit drugs and inject them in a clean and supervised environment. Staff at SISs are able to respond quickly and effectively to overdoses and can link injection drug users to other health and social support services. As a harm reduction measure, SISs do not require the cessation of injection drug use, but work to minimize the risks associated with injection drug use.
In December 2016, the City of Hamilton Public Health Services (HPHS), the local public health authority for Hamilton, Ontario, was directed by its Board of Health to conduct a needs assessment and feasibility study on SISs in Hamilton in 2017.
Objectives: The objectives of the Hamilton Supervised Injection Site Needs Assessment and Feasibility Study (SIS NAFS) were:
1. To determine the need for one or more supervised injection sites (SISs) in the City of Hamilton;
2. To determine the feasibility of one or more SISs for Hamilton, including the recommended number, geographical location(s), and model type (integrated, stand alone, or mobile);
3. To involve the community and stakeholders in consultation and discussions about issues associated with drug use in Hamilton, and the feasibility of supervised injection sites as a measure to improve health among people who inject drugs.
Methods: The SIS NAFS was a mixed-methods study comprised of quantitative and qualitative components. The quantitative portion aimed to describe the need for SISs in Hamilton by analyzing available health and crime information. Health information included data on drug use and misuse, fatal and non-fatal overdoses in Hamilton, bloodborne infections and drugrelated risk factors, as well as harm reduction service demand.
The qualitative, community-based portion of the study aimed to consult community stakeholders about the need for, and feasibility of, SISs in Hamilton. The qualitative study had three major components: a survey of people who inject drugs (PWID); key informant interviews; and focus groups.
Harm Reduction Nursing Practice: The Dr. Peter Centre Supervised Injection Project
In december 2001, a Nurse was approached by an injection drug user who askedfor a “RIG” (Slang for needle and syringe) so he could use heroin. He planned just to shake up the drug with hisown aspirated blood because he had no water or facilities to “Cook” (Mix heroin with water; heating heroin to prepare it for injection) the mix. “Yes, you do,” said the Nurse, “Come with me.” and so began Supervised Injection Practices at the Dr. Peter Centre.
Help me fix: The provision of injection assistance at an unsanctioned overdose prevention site in Toronto, Canada
BACKGROUND: There is an acute public health crisis from opioid-related poisoning and overdose in Canada. The Moss Park Overdose Prevention Site (MP-OPS) - an unsanctioned overdose prevention site - opened in a downtown park in Toronto in August 2017, when no other supervised consumption services existed in the province. As an unsanctioned site, MP-OPS was not constrained by federal rules prohibiting assisted injection, and provided a unique opportunity to examine assisted injection within a supervised setting. Our objective was to examine the association between assisted injection and overdose, and whether any association between assisted injection and overdose differs according to gender.
METHODS: Drawing on data from 5657 visits to MP-OPS from October 2017 to March 2018, we used multivariable logistic regression to investigate the relationship between assisted injection and overdose. To examine the influence of gender on this relationship, we further conducted stratified analyses by gender.
RESULTS: Among 5657 visits to MP-OPS, 471 (8.3%) received assisted injection, of which 242 (51.4%) were received by women and 226 (48.0%) by men. Using multivariable logistic regression, assisted injection was not associated with overdose in the overall sample (adjusted odds ratio [aOR]1.58, 95% confidence interval [CI]: 0.94, 2.67). In gender-stratified models, women receiving assisted injection were more than twice as likely (aOR 2.23, 95% CI: 1.17, 4.27) to experience overdose than women who did not receive assisted injection, and no association between assisted injection and overdose was found among men.
CONCLUSION: Findings that women receiving assisted injecting are at higher odds of overdose within the supervised setting of the MP-OPS are consistent with previous literature on assisted injection in community settings. Rules banning assisted injection in supervised consumption services may be putting a group of people, particularly women and those injecting fentanyl, at higher risk of health harms by denying them access to a supervised space where prompt overdose response is available.
Highs and Lows: An Interrupted Time-Series Evaluation of the Impact of North America’s Only Supervised Injection Facility on Crime
North America is currently experiencing an opioid crisis. One proposed solution to combat problems associated with injection drug use is the use of supervised injection facilities. These facilities provide drug users a space to inject pre-obtained drugs without any legal repercussions. Research on these facilities has focused on public health outcomes, and generally found positive results. Far fewer studies have investigated the impact supervised injection facilities have on crime. The current study provides an interrupted time-series analysis on the impact of North America’s only supervised injection facility on crime. Analyses of city wide crime data evidence no impact of the supervised injection facility on crime. Disaggregated analyses indicate a significant decrease in crimes in the district where the supervised injection facility is located. Implications of the findings are discussed.
Housing Overdose Prevention Site Manual
As part of a temporary emergency response offered by BC Housing, various non-profit housing providers and Vancouver Coastal Health (VCH), Housing Overdose Prevention Sites (HOPS) provide a space for residents who inject drugs to inject, with sterile equipment, in the building where they reside. Persons who inject drugs (PWID) are encouraged to inform staff or trained Peers (fellow residents or non-residents who are persons with lived experience with drug use) if they are using the room for injection. This service was initiated due to increasing mortality from illicit drug overdoses in the province of British Columbia (BC), Canada. To date spaces for smoking illicit substances are not provided.
Impact : A socio-economic review of supervised consumption sites in Alberta
The Government of Alberta appointed the Supervised Consumption Services Review Committee to evaluate the social and economic impacts of current and proposed supervised consumption sites. This report contains the findings of the Committee's review, including engagement with affected communities.
Impact of a medically supervised safer injecting facility on drug dealing and other drug-related crime
North America's first medically supervised safer injecting facility (SIF) recently opened in Vancouver, Canada. One of the concerns prior to the SIF's opening was that the facility might lead to a migration of drug activity and an increase in drug-related crime. Therefore, we examined crime rates in the neighborhood where the SIF is located in the year before versus the year after the SIF opened. No increases were seen with respect to drug trafficking (124 vs. 116) or assaults/robbery (174 vs. 180), although a decline in vehicle break-ins/vehicle theft was observed (302 vs. 227). The SIF was not associated with increased drug trafficking or crimes commonly linked to drug use.
Impact of a medically supervised safer injection facility on community drug use patterns: a before and after study
PROBLEM: Illicit use of injected drugs is linked with high rates of HIV infection and fatal overdose, as well as community concerns about public drug use. Supervised injecting facilities have been proposed as a potential solution, but fears have been raised that they might encourage drug use.
DESIGN: A before and after study.
PARTICIPANTS AND SETTING: 871 injecting drug users recruited from the community in Vancouver, Canada.
KEY MEASURES FOR IMPROVEMENT: Rates of relapse into injected drug use among former users and of stopping drug use among current users.
STRATEGIE FOR CHANGE: Local health authorities established the Vancouver supervised injecting facility to provide injecting drug users with sterile injecting equipment, intervention in the event of overdose, primary health care, and referral to external health and social services.
EFFECTS OF CHANGE: Analysis of periods before and after the facility's opening showed no substantial increase in the rate of relapse into injected drug use (17% v 20%) and no substantial decrease in the rate of stopping injected drug use (17% v 15%).
LESSONS LEARNT: Recently reported benefits of supervised injecting facilities on drug users' high risk behaviours and on public order do not seem to have been offset by negative community impacts.
Impact of supervised drug consumption services on access to and engagement with care at a palliative and supportive care facility for people living with HIV/AIDS: a qualitative study
INTRODUCTION: Improvements in the availability and effectiveness of highly active antiretroviral therapy (HAART) have prolonged the lives of people living with HIV/AIDS. However, mortality rates have remained high among populations that encounter barriers to accessing and adhering to HAART, notably people who use drugs. This population consequently has a high burden of illness and complex palliative and supportive care needs, but is often unable to access these services due to anti-drug policies and discrimination. In Vancouver, Canada, the Dr. Peter Centre (DPC), which operates a 24-bed residential HIV/AIDS care facility, has sought to improve access to palliative and supportive care services by adopting a comprehensive harm reduction strategy, including supervised injection services. We undertook this study to explore how the integration of comprehensive harm reduction services into this setting shapes access to and engagement with care.
METHODS: Qualitative interviews were conducted with 13 DPC residents between November 2010 and August 2011. Interviews made use of a semistructured interview guide which facilitated discussion regarding how the DPC Residence's model of care (a) shaped healthcare access, (b) influenced healthcare interactions and (c) impacted drug use practices and overall health. Interview transcripts were analysed thematically.
RESULTS: Participant accounts highlight how the harm reduction policy altered the structural-environmental context of healthcare services and thus mediated access to palliative and supportive care services. Furthermore, this approach fostered an atmosphere in which drug use could be discussed without the risk of punitive action, and thus increased openness between residents and staff. Finally, participants reported that the environmental supports provided by the DPC Residence decreased drug-related risks and improved health outcomes, including HAART adherence and survival.
CONCLUSIONS: This study highlights how adopting comprehensive harm reduction services can serve to improve access and equity in palliative and supportive care for drug-using populations.
Implementation contexts and the impact of policing on access to supervised consumption services in Toronto, Canada: a qualitative comparative analysis
BACKGROUND: Supervised consumption services (SCS) are being implemented across Canada in response to a variety of drug-related harms. We explored the implementation context of newly established SCS in Toronto and the role of policing in shaping program access by people who inject drugs (PWID).
METHODS: We conducted one-to-one qualitative semi-structured interviews with 24 PWID. Participants were purposively recruited. Ethnographic observations were conducted at each of the study sites as well as in their respective neighbourhoods. Relevant policy documents were also reviewed.
RESULTS: Policing was overwhelmingly discussed by participants from both SCS sites. However, participant responses varied depending on the site in question. Subthemes from participant responses on policing at site #1 described neighbourhood police presence and fears of police harassment and drug arrests before, during, or after accessing SCS. Conversely, subthemes from participant responses on policing at site #2 described immunity and protection from police while using the SCS, as well as a lack of police presence or fears of police harassment and arrests. These differences in implementation contexts were largely shaped by differences in local neighbourhoods and drug scenes. Police policies highlighted federal laws protecting PWID within SCS, but also the exercise of discretion when applying the rule of law outside of these settings.
CONCLUSIONS: Participants’ perspectives on, and experiences with, policing as they relate to accessing SCS were shaped by the implementation contexts of each SCS site and how neighbourhoods, drug scenes, and differences in policing practices affected service use. Our findings also demonstrate the disconnect between the goals of policing and those of SCS. Until larger structural barriers are addressed (e.g. criminalization), future SCS programming should consider the impact of policing on the SCS implementation context to improve client experience with, and access to, SCS. Keywords: Supervised consumption services, Supervised injection sites, Police, Surveillance, Implementation context
