Synthetic Opioid key responses
- Mapping evidence-based key responses to synthetic opioids and their implementation strategies
- Field-tested Toolkit with seven implementation guides
Negotiating space & drug use in emergency shelters with peer witness injection programs within the context of an overdose crisis: A qualitative study
Vancouver, Canada is experiencing an overdose crisis due to the proliferation of fentanyl and related analogues and novel overdose response interventions are being implemented across multiple high overdose risk environments, including emergency shelters. We draw on ethnographic fieldwork and qualitative interviews to examine how social, structural, and physical contexts at two emergency shelters implementing a peer-based supervised injection intervention influenced injection drug use and overdose risks. Findings reveal that the implementation of this intervention reduced stigma and shame through the normalization of drug use in shelter spaces, and yet underlying social norms and material constraints led people to inject alone in non-designated injecting spaces. Whereas these spatial dynamics of injection drug use potentially increased overdose vulnerability, an emerging sense of collective responsibility in relation to the overdose crisis led to the routinization of peer witnessing practices across the shelter environment to extend the impact of the intervention.
Non-Fatal Overdose Among a Cohort of Active Injection Drug Users Recruited from a Supervised Injection Facility
Non-fatal overdose among injection drug users (IDU) is a source of significant morbidity. Since it has been suggested that supervised injecting facilities (SIF) may increase risk for overdose, we sought to evaluate patterns of non-fatal overdose among a cohort of SIF users. We examined recent non-fatal overdose experiences among participants enrolled in a prospective study of IDU recruited from within North America's first medically supervised safer injecting facility. Correlates of recent non-fatal overdoses were identified using generalized estimating equations (GEE). There were 1,090 individuals recruited during the study period of which 317 (29.08%) were female. At baseline, 638 (58.53%) reported a history of non-fatal overdose and 97 (8.90%) reported at least one non-fatal overdose in the last six months. This proportion remained approximately constant throughout the study period. In the multivariate GEE analysis, factors associated with recent non-fatal overdose included: sex-trade involvement (Adjusted Odds Ratio [AOR]: 1.45 [95% Confidence Interval [CI] 1.07-1.99], p = 0.02) and public drug use (AOR: 1.50 [95% CI 1.09-2.06]; p = 0.01). Using the SIF for >or= 75% of injections was not associated with recent non-fatal overdose in univariate (Odds Ratio: 1.05, p = 0.73) or multivariate analyses (AOR: 1.01, p = 0.96). The proportion of individuals reporting recent non-fatal overdose did not change over the study period. Our findings indicate that a sub-population of IDU might benefit from overdose prevention interventions. Our findings refute the suggestion that the SIF may increase the likelihood of overdose.
Nurse-delivered safer injection education among a cohort of injection drug users: Evidence from the evaluation of Vancouver’s supervised injection facility
BACKGROUND: Despite growing implementation of harm reduction programs internationally, unsafe injecting practices remain common among injection drug users (IDU). In response, nursing interventions such as safer injection education (SIE) have been called for. In Vancouver, a supervised injection facility (SIF), where IDU inject pre-obtained illicit drugs under nursing supervision, opened in 2003 in an effort to reduce the impacts of unsafe injecting. We sought to characterize the state of nursing SIE practice in Vancouver and prospectively examine SIE among SIF users.
METHODS: We examined correlates of receiving SIE among participants in the Scientific Evaluation of Supervised Injecting (SEOSI) cohort. The SEOSI cohort was derived through random recruitment of SIF users. Characteristics of participants who reported receiving SIE from SIF nurses were examined using bivariate and multivariate generalized estimating equations.
RESULTS: 1087 SEOSI participants were surveyed between March 2004 and March 2005 and included in this analysis. Approximately one third of participants reported receiving SIE at baseline and an additional 13.3% reported receiving SIE during follow-up. Those receiving SIE from SIF nurses were more likely to be females (AOR=1.55; 95% CI: 1.18-2.04), persons requiring injecting assistance (AOR=1.52; 95% CI: 1.26-1.84), binge users (AOR=1.37; 95% CI: 1.14-1.64), and those using the SIF for most of their injections (AOR=1.47; 95% CI: 1.22-1.77).
CONCLUSIONS: These findings provide evidence to support the need for nurse-delivered SIE in reaching IDU most at risk for injection-related harm. SIFs may afford unique opportunities to deliver SIE to high-risk populations. Individuals receiving SIE from Vancouver's SIF nurses were likely to possess characteristics associated with adverse health outcomes, including HIV infection.
Observed Consumption Services
Observed consumption services save lives. Observed consumption services (OCS) include Overdose Prevention Services (OPS) and Supervised Consumption Sites (SCS) where people are given a safe space to use their substances under the supervision of someone trained to recognize and respond to an overdose. This enables a rapid response to an overdose, which prevents brain injury and death. Observed consumption services should be widely available throughout BC. Employing people with lived experience at these services provides optimal support for people who use drugs.
Ontario Integrated Supervised Injection Services Feasibility Study Report: London
Injection drug use continues to be associated with severe health and social harms, including infectious disease acquisition, cutaneous injection-related infections, and fatal and non-fatal overdose. People who inject drugs (PWID) often experience significant barriers to primary and acute care systems. At the community level, injection in public spaces and associated injection-related litter (e.g., discarded syringes) constitute a source of public disorder and community concern.
In response to the growing concerns regarding the harms associated with injection drug use, supervised injection services (SIS), where PWID can inject pre-obtained illicit drugs under the supervision of healthcare staff, have been implemented in various settings. Results from evaluation studies have demonstrated that SIS have largely met their stated objectives, which include: reducing public disorder; reducing risk for infectious disease transmission; reducing injecting-associated morbidity; reducing morbidity and mortality associated with overdose; and facilitating referrals to various health and social programs, including addiction treatment and housing. SIS have also been found to be highly cost-effective.
While SIS have been found to be effective in large urban centres where sizable drug scenes exist and where substantial concentrations of PWID live, little is known about the feasibility and acceptability of SIS in smaller cities or towns – or on the most effective way to deliver supervised injection services in communities where PWID are not concentrated in one geographic area. Herein, we report on SIS feasibility research undertaken in London, Ontario, which explored potential willingness to use SIS and SIS design preferences among local PWID, in addition to acceptability and feasibility of SIS from community stakeholder perspectives.
A mixed-method community-based research approach was employed to meet the study objectives. In the first study phase, a quantitative survey was conducted to investigate drug-using behaviour and related harms, heath care access, willingness to use SIS, and SIS design preferences among 199 PWID in London. In the second phase of the study, we interviewed twenty community stakeholders from five sectors: healthcare (n=5); social services (n=5); government and municipal services (n=3); police and emergency services (n=2); and the business and community sector (n=5).
Among 199 survey participants, 76 (38%) were women (including 1 transgender woman) and the median age was 39 (range: 21 - 66). In terms of ethnicity, 147 participants were white (75%), 44 (22%) identified as First Nations or Métis, and 5 had other ethno-racial backgrounds (3%). The majority of participants (n=113, 57%) reported being homeless or living in unstable housing, while 24 (12%) had been incarcerated in the past six months, and 38 (19%) reported engaging in sex work or exchanging sex for resources in the past six months. Sixty-five percent (n=129) of participants reported injecting drugs daily, with crystal methamphetamine and hydromorphone being the drugs most commonly injected. Seventy-two percent of participants reported injecting in public spaces in the previous six months, one in four reported a history of overdose, and 44 (22%) reported sharing syringes in the previous six months.
In total, 170 (86%) participants reported willingness to use SIS if one were available, while another 14 (7%) said they would not be willing to use such services. The most common reasons for using SIS included: access to sterile injection equipment, overdose prevention, injecting responsibly, safety from crime, and safety from being seen by police. Reasons for not wanting to use SIS include not wanting to be seen, fear of being caught by police, preferring to inject alone, not wanting to be known as a drug user, and inconvenience. A higher proportion of men (n=113, 93%) than women (n=57, 76%) said they were willing to use SIS. Almost all participants selected Old East (Dundas/Adelaide area) or Downtown as ideal locations for SIS programming.
Community stakeholders unanimously supported SIS, but this support was accompanied by some preferences and conditions. Some stakeholders suggested that SIS be decentralized while others suggested that SIS be centralized Downtown or in Old East. Almost all community stakeholders suggested that SIS should be accessible 24 hours, 7 days a week. Stakeholders held mixed views in terms of the proximity of SIS in their neighbourhoods. A few respondents were concerned about how the concentration of services – including SIS – could damage residents and businesses in the same area. Lastly, availability of wrap-around supports (i.e., health and social services) were discussed as a condition to supporting SIS.
London continues to experience significant preventable harm among PWID. Importantly, a majority of PWID (86%) reported that they would use SIS if one were available. Past evaluations have indicated that expressed willingness is strongly correlated with future uptake of such services, and therefore the findings reported herein suggest that PWID in London and the local community would likely benefit from the implementation of SIS. Therefore, given the data presented in this report, it is recommended that SIS be implemented in London. To address the observed geographical distribution of both public and private injection drug use, and preferences of PWID and community stakeholders, implementation of SIS in Old East and/or Downtown London is recommended, and be integrated within existing services that can provide enhanced wrap-around care for PWID (e.g., addictions treatment, primary health care, housing supports). Given the ongoing challenges associated with injection drug use in this setting, as well the evidence indicating that SIS prevent harms and promote health among PWID, it seems clear that implementing SIS in London would have high potential to improve health and public order, while also saving precious health system resources.
Opening Canada’s first Health Canada-approved supervised consumption sites
SETTING: In response to the opioid overdose crisis, a Public Health Emergency was declared in British Columbia (BC) in April 2016. There were 1448 deaths in BC in 2017 (30.1 deaths per 100,000 individuals).
INTERVENTION:
Approximately one third of all overdose deaths in BC in 2016 (333/993) and 2017 (482/1448) occurred within the region served by Fraser Health Authority (FH). We identified a need for a supervised drug use site in Surrey, the city with FH’s highest number of overdose deaths in 2016 (n = 122). In order to ensure low-barrier services, FH underwent an internal assessment for a supervised drug use site and determined that a supervised injection site was unlikely to meet the needs of individuals who consumed their drugs using other routes, choosing instead to apply for an exemption to the Controlled Drug and Substances Act in order to open a Supervised Consumption Site (SCS).
OUTCOMES: In assessing population needs, injection was identified as the mode of drug administration in only 32.8% of overdose deaths in FH from 2011 to 2016. Other routes of drug (co-) administration included oral (30.6%); smoking (28.8%); intranasal (24.2%); and unknown/other (17.1%). Interviews with potential service users confirmed drug (co-) administration behaviours and identified other aspects of service delivery, such as hours and co-located services that would help align the services better with client needs. With Health Canada’s approval, SafePoint in Surrey opened for supervised injection on June 8, 2017 and received an exemption to allow oral and intranasal consumption on June 26, 2017.
IMPLICATIONS:
By assessing drug use practices, the evolving needs of people who use substances, and tailoring services to local context, we can potentially engage with individuals earlier in their substance use trajectory to improve the utility of services and prevent more overdoses and overdose deaths.
Overdose Prevention Site Manual
As part of a temporary emergency response offered by Vancouver Coastal Health (VCH), the Overdose Prevention Site (OPS) is a unique health care setting where PWID inject under supervision of peers, lay staff and in some instances clinical providers. The service was initiated due to increasing mortality from illicit drug overdoses in the province of British Columbia, Canada.
The OPS is a welcoming, safe, and supportive environment for PWID.
Overdose Prevention Society - Year End Report 2018
The Overdose Prevention Society was founded in response to the fentanyl crisis. We are a low-barrier supervised injection and inhalation site in the Downtown Eastside of Vancouver, British Columbia. What makes us unique is our peer staffing model - employing community members and active drug users to provide a meaningful employment opportunity and a safe way to make money. We have reversed hundreds of overdoses and helped to foster self-growth, self esteem
and community within this dark time. We are committed to meeting people where they are at and helping to make their lives better in any way we can.
Overdue for a change: Scaling up Supervised Consumption Services in Canada
This report documents a research project that was undertaken in 2018 to explore the current state of supervised consumption services (SCS) in Canada, to monitor legal and policy changes affecting SCS, and to identify facilitators and barriers faced by current and future SCS operators.
Peer worker involvement in low-threshold supervised consumption facilitiesin the context of an overdose epidemic in Vancouver, Canada
Overdose prevention sites (OPS) are a form of supervised consumption facility that have been implemented in Vancouver, Canada as an innovative response to an ongoing overdose epidemic. OPS are primarily staffed by peers – people who use(d) drugs (PWUD) – trained in overdose response. We sought to characterize peer worker involvement in OPS programming, including how this shapes service dynamics and health outcomes among PWUD. Data were drawn from a rapid ethnographic study examining the implementation, operations and impacts of OPS in Vancouver from December 2016 to April 2017. We conducted approximately 185 h of observational fieldwork at OPS and 72 in-depth qualitative interviews with PWUD. Data were analyzed thematically, with a focus on peer worker involvement at OPS and related outcomes. OPS implementation and operations depended on peer worker involvement and thus allowed for recognition of capacities developed through roles that peers were already undertaking through local programming for PWUD. Peer involvement at OPS enhanced feelings of comfort and facilitated engagement with OPS among PWUD. These dynamics and appreciation of peer worker expertise enabled communication with staff in ways that fostered harm reduction practices and promoted health benefits. However, many peer workers received minimal financial compensation and experienced considerable grief due to the emotional toll of the epidemic and lack of supports, which contributed to staff burnout. Our findings illustrate the specific contributions of task shifting OPS service delivery to peer workers, including how this can enhance service engagement and promote the reduction of harms among PWUD. Amidst an ongoing overdose epidemic, expanding formalized peer worker involvement in supervised consumption programming may help to mitigate overdose-related harms, particularly in settings where peers are actively involved in existing programming. However, efforts are needed to ensure that peer workers receive adequate financial support and workplace benefits to promote the sustainability of this approach.
