Synthetic Opioid key responses
- Mapping evidence-based key responses to synthetic opioids and their implementation strategies
- Field-tested Toolkit with seven implementation guides
Increasing public support for supervised injection facilities in Ontario, Canada
AIM: To determine the level and changes in public opinion between 2003 and 2009 among adult Canadians about implementation of supervised injection facilities (SIFs) in Canada.
DESIGN: Population‐based, telephone survey data collected in 2003 and 2009 were analysed to identify strong, weak, and intermediate support for SIFs.
SETTING: Ontario, Canada.
PARTICIPANTS: Representative samples of adults aged 18 years and over.
MEASUREMENTS: Analyses of the agreement with implementation of SIFs in relation to four individual SIF goals and a composite measure.
FINDINGS: The final sample sizes for 2003 and 2009 were 1212 and 968, respectively. Between 2003 and 2009, there were increases in the proportion of participants who strongly agreed with implementing SIFs to: reduce neighbourhood problems (0.309 versus 0.556, respectively); increase contact of people who use drugs with health and social workers (0.257 versus 0.479, respectively); reduce overdose deaths or infectious disease among people who use drugs (0.269 versus 0.482, respectively); and encourage safer drug injection (0.213 versus 0.310, respectively). Analyses using a composite measure of agreement across goals showed that 0.776 of participants had mixed opinions about SIFs in 2003, compared with only 0.616 in 2009. There was little change among those who strongly disagreed with all SIF goals (0.091 versus 0.113 in 2003 and 2009, respectively).
CONCLUSIONS: Support for implementation of supervised injection facilities in Ontario, Canada increased between 2003 and 2009, but at both time‐points a majority still held mixed opinions.
Injection drug use cessation and use of North America's first medically supervised safer injecting facility
BACKGROUND: Vancouver, Canada has a pilot supervised injecting facility (SIF), where individuals can inject pre-obtained drugs under the supervision of medical staff. There has been concern that the program may facilitate ongoing drug use and delay entry into addiction treatment.
METHODS: We used Cox regression to examine factors associated with the time to the cessation of injecting, for a minimum of 6 months, among a random sample of individuals recruited from within the Vancouver SIF. In further analyses, we evaluated the time to enrolment in addiction treatment.
RESULTS: Between December 2003 and June 2006, 1090 participants were recruited. In Cox regression, factors independently associated with drug use cessation included use of methadone maintenance therapy (Adjusted Hazard Ratio [AHR] = 1.57 [95% Confidence Interval [CI]: 1.02–2.40]) and other addiction treatment (AHR = 1.85 [95% CI: 1.06–3.24]). In subsequent analyses, factors independently associated with the initiation of addiction treatment included: regular SIF use at baseline (AHR = 1.33 [95% CI: 1.04–1.72]); having contact with the addiction counselor within the SIF (AHR = 1.54 [95% CI: 1.13–2.08]); and Aboriginal ancestry (AHR = 0.66 [95% CI: 0.47–0.92]).
CONCLUSIONS: While the role of addiction treatment in promoting injection cessation has been well described, these data indicate a potential role of SIF in promoting increased uptake of addiction treatment and subsequent injection cessation. The finding that Aboriginal persons were less likely to enroll in addiction treatment is consistent with prior reports and demonstrates the need for novel and culturally appropriate drug treatment approaches for this population.
Is Vancouver Canada's supervised injection facility cost-saving?
Objective: To determine whether Vancouver's Insite supervised injection facility and syringe exchange programs are cost-saving—that is, are the savings due to averted HIV-related medical care costs sufficient to offset Insite's operating costs?
Methods: The analyses examined the impact of Insite's programs for a single year. Mathematical models were used to calculate the number of additional HIV infections that would be expected if Insite were closed. The life-time HIV-related medical costs associated with these additional infections were compared to the annual operating costs of the Insite facility.
Results: If Insite were closed, the annual number of incident HIV infections among Vancouver IDU would be expected to increase from 179.3 to 262.8. These 83.5 preventable infections are associated with $17.6 million (Canadian) in life-time HIV-related medical care costs, greatly exceeding Insite's operating costs, which are approximately $3 million per year.
Conclusions: Insite's safe injection facility and syringe exchange program substantially reduce the incidence of HIV infection within Vancouver's IDU community. The associated savings in averted HIV-related medical care costs are more than sufficient to offset Insite's operating costs.
‘It's our safe sanctuary’: Experiences of using an unsanctioned overdose prevention site in Toronto, Ontario
BACKGROUND: Overdose prevention sites (OPSs) are spaces where people can consume drugs under the supervision of trained volunteers or staff and receive help in the event of an overdose. Unsanctioned OPSs are a grassroots response to the current opioid crisis in Canada.
METHODS: We used rapid evaluation methods to study the experiences of 30 individuals accessing the smoking and injection services at the first unsanctioned OPS in Toronto, Ontario using semi-structured interviews. Data were analyzed using an applied thematic analysis approach to identify emergent themes related to service user experiences, characteristics of the risk environment, and recommended changes to the service model.
RESULTS: The OPS represented a safe sanctuary and brought a sense of belonging to a community that often experiences discrimination. Valued aspects included: shelter; protection from violence; safety from overdoses; free equipment; information about health and social services; food and beverages; and socializing and connecting with others. Integrating peer workers in the design and delivery of services encouraged service users to visit the site. The OPS changed the risk environment by: providing access to the first supervised smoking service in Toronto; having few explicit rules and a communal approach to making new rules; allowing assisted injection, and negotiating with police to allow people to access the site with minimal contact. Service users noted the need to ensure a safe space for women and recommended extended hours of operation and moving to a more permanent space with heat and lighting for both smoking and injecting drugs.
CONCLUSION: The unsanctioned OPS in Toronto served an important role in defining new, community-led, flexible responses to opioid overdose-related deaths at a time of markedly increasing mortality. Providing harm reduction services in diverse settings and expanding services to include smoking and assisted injection may increase access for marginalized people who use drugs.
‘It's too much, I'm getting really tired of it’: Overdose response and structural vulnerabilities among harm reduction workers in community settings
BACKGROUND : In response to the devastating overdose epidemic across Canada, overdose education and naloxone distribution programs (OEND) targeted at people who use drugs have been scaled-up. The ways in which people who use drugs (PWUD) – who experience social and structural vulnerabilities due to their drug use – enact advice from these health education campaigns remains underexplored. This study examines structural vulnerabilities that constrain PWUD as they attempt to implement OEND program advice.
METHODS: Data were drawn from an ethnographic study of “Satellite Sites”, a program where PWUD are employed by a community health center to operate satellite harm reduction programs within their homes. Data collection included participant observation within the Satellite Sites, complemented by semi-structured interviews and a focus group with Satellite Site workers. Thematic analysis was used to explore impacts of responding to overdose.
RESULTS: OEND advice includes not injecting alone, carrying naloxone, and calling 911 if overdose occurs. The ability of Satellite Site workers to respond according to public health guidelines is complicated by contextual and structural factors, including a lack of supervised injection services, vulnerability to eviction, and continued criminalization of drug use. Participants described how responding to increasing numbers of overdoses was stressful, with stress compounded by their close relationships with those who were overdosing. These factors were impacting the willingness of Satellite Site workers to continue to supervise drug use.
CONCLUSION: OEND programs are essential and effective; however, they are a response to a crisis within a policy and legal environment framed by the criminalization of drug use. Efforts to expand access to complementary interventions, such as supervised injection services, safer supply interventions, and protection against evictions, are necessary to complement OEND programs and address multiple contextual factors within the risk environment for overdose. Additionally, criminalization will continue to impede and constrain the public health response to drug use.
Lessons learned from supervised consumption and overdose prevention sites in Canada
This webinar focus on lessons learned from a national teleconference network for supervised consumption site (SCS) and overdose prevention site (OPS) service providers.
Initiated in September 2017, this teleconference network serves as a forum for current and prospective service providers to share information and promising practices related to SCS and OPS. To date, more than 60 individuals from 20 Canadian cities have participated. The teleconference network seeks to assist communities in building their capacity to offer SCS/OPS by sharing challenges and innovations among service providers.
This webinar engage participants in a discussion with experts on key themes related to the development of an SCS or an OPS.
Losing the uphill battle? Emergent harm reduction interventions and barriers during the opioid overdose crisis in Canada
Canada continues to experience an escalating opioid overdose crisis that has claimed more than 8000 lives in the country since 2016. The presence of the synthetic opioid fentanyl and its analogues is a central contributor to the increases in preventable opioid-related deaths. However, a number of converging social-structural factors (e.g., the continued criminalisation of drug use, political changes) and political barriers are also complicating and contributing to the current crisis. We briefly outline four harm reduction interventions (i.e., injectable opioid agonist treatment, naloxone distribution programs, overdose prevention sites, and drug checking services) as emerging and rapidly expanding responses to this crisis in Canada. These examples of innovation and expansion are encouraging but also occurring at the same time that the opioid overdose crisis shows few signs of abating. To truly address the crisis, Canada needs political environments at all government levels that are responsive and foster harm reduction innovation and drug policy experimentation.
Methodology for evaluating Insite: Canada's first medically supervised safer injection facility for injection drug users
Many Canadian cities are experiencing ongoing infectious disease and overdose epidemics among injection drug users (IDUs). In particular, Human Immunodeficiency Virus (HIV) and hepatitis C Virus (HCV) have become endemic in many settings and bacterial and viral infections, such as endocarditis and cellulitis, have become extremely common among this population. In an effort to reduce these public health concerns and the public order problems associated with public injection drug use, 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. The SIF was granted a legal exemption to operate on the condition that its impacts be rigorously evaluated. In order to ensure that the evaluation is appropriately open to scrutiny among the public health community, the present article was prepared to outline the methodology for evaluating the SIF and report on some preliminary observations. The evaluation is primarily structured around a prospective cohort of SIF users, that will examine risk behavior, blood-borne infection transmission, overdose, and health service use. These analyses will be augmented with process data from within the SIF, as well as survey's of local residents and qualitative interviews with users, staff, and key stakeholders, and standardised evaluations of public order changes. Preliminary observations suggest that the site has been successful in attracting IDUs into its programs and in turn helped to reduce public drug use. However, each of the indicators described above is the subject of a rigorous scientific evaluation that is attempting to quantify the overall impacts of the site and identify both benefits and potentially harmful consequences and it will take several years before the SIF's impacts can be appropriately examined.
Mobile supervised consumption services in Rural British Columbia: lessons learned
BACKGROUND: In 2016, a public health emergency was declared in British Columbia due to an unprecedented number of illicit drug overdose deaths. Injection drug use was implicated in approximately one third of overdose deaths. An innovative delivery model using mobile supervised consumption services (SCS) was piloted in a rural health authority in BC with the goals of preventing overdose deaths, reducing public drug use, and connecting clients to health services.
METHODS: Two mobile SCS created from retrofitted recreational vehicles were used to serve the populations of two mid-sized cities: Kelowna and Kamloops. Service utilization was tracked, and surveys and interviews were completed to capture clients’, service providers’, and community stakeholders’ attitudes towards the mobile SCS.
RESULTS: Over 90% of surveyed clients reported positive experiences in terms of access to services and physical safety of the mobile SCS. However, hours of operation met the needs of less than half of clients. Service providers were generally dissatisfied with the size of the space on the mobile SCS, noting constraints in the ability to respond to overdose events and meaningfully engage with clients in private conversations. Additional challenges included frequent operational interruptions as well as poor temperature control inside the mobile units. Winter weather conditions resulted in cancelled shifts and disrupted services. Among community members, there was variable support of the mobile SCS.
CONCLUSIONS: Overall, the mobile SCS were a viable alternative to a permanent site but presented many challenges that undermined the continuity and quality of the service. A mobile site may be best suited to temporarily provide services while bridging towards a permanent location. A needs assessment should guide the stop locations, hours of operation, and scope of services provided. Finally, the importance of community engagement for successful implementation should not be overlooked.
Modelling the combined impact of interventions in averting deaths during a synthetic‐opioid overdose epidemic
BACKGROUND & AIMS: The province of British Columbia (BC), Canada has experienced a rapid increase in illicit drug overdoses and deaths during the last four years, with a provincial emergency declared in April 2016. These deaths have been driven primarily by the introduction of synthetic opioids into the illicit opioid supply. This study aimed to measure the combined impact of large‐scale opioid overdose interventions implemented in BC between April 2016 and December 2017 on the number of deaths averted.
DESIGN: We expanded on the mathematical modelling methodology of our previous study to construct a Bayesian hierarchical latent Markov process model to estimate monthly overdose and overdose‐death risk, along with the impact of interventions.
SETTING/CASES: Overdose events and overdose‐related deaths in BC from January 2012 to December 2017.
INTERVENTIONS: The interventions considered were take‐home naloxone kits, overdose prevention/supervised consumption sites and opioid agonist therapy.
MEASUREMENTS: Counterfactual simulations were performed with the fitted model to estimate the number of death events averted for each intervention, and in combination.
FINDINGS: Between April 2016 and December 2017, BC observed 2177 overdose deaths (77% fentanyl‐detected). During the same period, an estimated 3 030 (2 900 – 3 240) death events were averted by all interventions combined. In isolation, 1 580 (1 480 – 1 740) were averted by take‐home naloxone, 230 (160 – 350) by overdose prevention services, and 590 (510 – 720) were averted by opioid agonist therapy.
CONCLUSIONS: A combined intervention approach has been effective in averting overdose deaths during British Columbia's opioid overdose crisis in the period since declaration of a public health emergency (April 2016 to December 2017). However, the absolute numbers of overdose deaths have not changed.
