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Publications: Drug consumption rooms (DCR)
Vendula Belackova, Edmund Silins, Allison M. Salmon, Marianne Jauncey, Carolyn A. Day
Australia Harm Reduction Health and social needs People Who Inject Drugs Supervised Injecting Facility Support services
“Beyond Safer Injecting”—Health and Social Needs and Acceptance of Support among Clients of a Supervised Injecting Facility
Health and social issues in aging populations of people who inject drugs (PWID) tend to aggregate, despite risky injecting practices decreasing with age. Identifying needs and avenues of support is becoming increasingly important. We described the health and social situation among clients of a long-running supervised injecting facility (SIF) in Sydney, Australia. An interviewer-administered survey (n = 182) assessed current housing status, employment, physical and mental health, incarceration history, drug use, engagement in drug treatment, health service utilization, and willingness to accept support. Results were compared to the information provided at initial visit. Up to half of the participants transitioned between lower- and higher-risk health and social indicators over time. Willingness to accept support was greatest amongst those with higher self-perceived need. Support for mental health was a low priority, despite the high self-reporting of mental health issues. SIF clients are open to support for health and social issues, despite ongoing active drug use. Lower-threshold services such as SIFs are well-positioned to recognize and respond to deteriorating health and social issues for PWID. Facilitating care and treatment remains a challenge when the services to which people are being referred are higher-threshold with a more rigid approach.
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Tara Marie Watson, Ahmed M. Bayoumi, Shaun Hopkins, Amy Wright, Renuka Naraine, Triti Khorasheh, Laurel Challacombe, Carol Strike
Australia Canada Denmark France Germany Harm Reduction International Netherlands Police Qualitative
Creating and sustaining cooperative relationships between supervised injection services and police: A qualitative interview study of international stakeholders
BACKGROUND: Supervised injection services (SIS) operate with special exemptions from drug law enforcement. Given the expansion of SIS and the opioid overdose crisis in numerous jurisdictions, now is a critical time to examine factors that contribute to cooperative SIS-police relationships. We sought to learn about SIS-police relationships from international jurisdictions with well-established as well as newer SIS.
METHODS: We conducted 16 semi-structured telephone interviews with SIS managers (n = 10) and police liaisons (n = 6) from 10 cities in seven different countries (Australia, Canada, Denmark, France, Germany, Netherlands, and Spain). All participants provided informed consent. We focused our coding and analysis on themes that emerged from the data.
RESULTS: Five key contributors to cooperative SIS-police relationships emerged from the data: early engagement and dialogues; supportive police chiefs; dedicated police liaisons; negotiated boundary agreements; and regular face-to-face contact. Most participants perceived the less formalised, on-the-ground approach to relationship-building between police and SIS adopted in their city to be working well in general. SIS managers and police participants reported a lack of formal police training on harm reduction, and some thought that training was unnecessary given the relatively positive local SIS-police relationships they reported.
CONCLUSION: Our qualitative study provides new, in-depth empirical examples of how police in varied international jurisdictions can come to accept and work cooperatively with, not against, SIS staff and clients. Investing ongoing effort in SIS-police relationships, in a manner that best suits local needs, may hold greater and more sustainable public health value than delivering specific curricula to police.
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Paul Dietze, Marianne Jauncey, Allison Salmon, Mohammadreza Mohebbi, Julie Latimer, Ingrid van Beek, Colette McGrath, Debra Kerr
Australia International Intranasal vs Intramuscular Naloxone Opioid overdose Supervised Injecting Facility
Effect of Intranasal vs Intramuscular Naloxone on Opioid Overdose. A Randomized Clinical Trial
IMPORTANCE: Previous unblinded clinical trials suggested that the intranasal route of naloxone hydrochloride was inferior to the widely used intramuscular route for the reversal of opioid overdose.
OBJECTIVE: To test whether a dose of naloxone administered intranasally is as effective as the same dose of intramuscularly administered naloxone in reversing opioid overdose.
DESIGN, SETTING, AND PARTICIPANTS: A double-blind, double-dummy randomized clinical trial was conducted at the Uniting Medically Supervised Injecting Centre in Sydney, Australia. Clients of the center were recruited to participate from February 1, 2012, to January 3, 2017. Eligible clients were aged 18 years or older with a history of injecting drug use (n = 197). Intention-to-treat analysis was performed for all participants who received both intranasal and intramuscular modes of treatment (active or placebo).
INTERVENTIONS: Clients were randomized to receive 1 of 2 treatments: (1) intranasal administration of naloxone hydrochloride 800 μg per 1 mL and intramuscular administration of placebo 1 mL or (2) intramuscular administration of naloxone hydrochloride 800 μg per 1 mL and intranasal administration of placebo 1 mL.
MAIN OUTCOMES AND MEASURES: The primary outcome measure was the need for a rescue dose of intramuscular naloxone hydrochloride (800 μg) 10 minutes after the initial treatment. Secondary outcome measures included time to adequate respiratory rate greater than or equal to 10 breaths per minute and time to Glasgow Coma Scale score greater than or equal to 13.
RESULTS: A total of 197 clients (173 [87.8%] male; mean [SD] age, 34.0 [7.82] years) completed the trial, of whom 93 (47.2%) were randomized to intramuscular naloxone dose and 104 (52.8%) to intranasal naloxone dose. Clients randomized to intramuscular naloxone administration were less likely to require a rescue dose of naloxone compared with clients randomized to intranasal naloxone administration (8 [8.6%] vs 24 [23.1%]; odds ratio, 0.35; 95% CI, 0.15-0.66; P = .002). A 65% increase in hazard (hazard ratio, 1.65; 95% CI, 1.21-2.25; P = .002) for time to respiratory rate of at least 10 and an 81% increase in hazard (hazard ratio, 1.81; 95% CI, 1.28-2.56; P = .001) for time to Glasgow Coma Scale score of at least 13 were observed for the group receiving intranasal naloxone compared with the group receiving intramuscular naloxone. No major adverse events were reported for either group.
CONCLUSIONS AND RELEVANCE: This trial showed that intranasally administered naloxone in a supervised injecting facility can reverse opioid overdose but not as efficiently as intramuscularly administered naloxone can, findings that largely replicate those of previous unblinded clinical trials. These results suggest that determining the optimal dose and concentration of intranasal naloxone to respond to opioid overdose in real-world conditions is an international priority.
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Mark Goodhew
Australia Injecting Drug Use Medically Supervised Injecting Centre Participation Participatory action research Sydney
Enhancing consumer participation in a medically supervised injecting centre through participatory action research
Consumer participation in health care refers to consumer involvement in decisions regarding the planning, delivery and evaluation of services. Consumer participation has been occurring in drug treatment services for over a decade, but progress has been slow due to poor organisational commitment, negative attitudes and power imbalances between consumers and providers. There are no reported consumer participation studies in harm reduction settings. This study investigated how the process of forming a consumer action group (CAG) influenced consumer participation at the Uniting Sydney Medically Supervised Injecting Centre (MSIC), a service designed to reduce the negative impacts of injecting drug use.
The aim of this study was to investigate how the process of forming a consumer group influenced consumer participation at MSIC. A participatory action research method was employed. The first stage investigated current levels of consumer participation at MSIC and motivation to form a CAG. Data for this stage included a consumer satisfaction survey (n=100), a staff brainstorming exercise (n=36) and structured interviews with consumers (n=12) and providers (n=7). In the second stage, MSIC consumers (n=11) and staff (n=5) developed a CAG. The third stage involved the implementation of the CAG’s goals to enhance consumer participation. The fourth stage comprised an evaluation using a consumer satisfaction survey (n=100) and structured interviews with CAG members (n=13) and MSIC staff (n=10), and the process of the author’s withdrawal from the study.
There were considerable challenges in establishing a CAG. These included: consumers’ marginalised lifestyles, MSIC’s biomedical model and negative attitudes of staff. Despite these constraints, there was active interest in developing the CAG. The group successfully implemented strategies to enhance MSIC’s consumer participation. The consumer CAG members reported that the group helped them to improve their relationships with each other and staff, reduce drug use, address health problems and consider employment in the drug treatment services. A key factor that facilitated the group’s success was the support the consumer members received from MSIC staff.
In line with previous research findings from drug treatment services, this study revealed that consumers’ drug use and lifestyles can constrain consumer participation. However, the results also demonstrated that these factors were mediated by the staff’s efforts to focus on the consumers’ strengths. Participation not only empowered consumers, but also increased their social capital and prompted them to make positive lifestyle changes. Overall, this study provides evidence that highly marginalised consumers can successfully contribute to service delivery when a strength-based approach is adopted.
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Danielle Horyniak, Peter Higgs, Rebecca Jenkinson, Louisa Degenhardt, Mark Stoové, Thomas Kerr, Matthew Hickman, Campbell Aitken, Paul Dietze
Australia Cohort Injecting Drug Use Longitudinal studies
Establishing the Melbourne injecting drug user cohort study (MIX): rationale, methods, and baseline and twelve-month follow-up results
BACKGROUND: Cohort studies provide an excellent opportunity to monitor changes in behaviour and disease transmission over time. In Australia, cohort studies of people who inject drugs (PWID) have generally focused on older, in-treatment injectors, with only limited outcome measure data collected. In this study we specifically sought to recruit a sample of younger, largely out-of-treatment PWID, in order to study the trajectories of their drug use over time.
METHODS: Respondent driven sampling, traditional snowball sampling and street outreach methods were used to recruit heroin and amphetamine injectors from one outer-urban and two inner-urban regions of Melbourne, Australia. Information was collected on participants’ demographic and social characteristics, drug use characteristics, drug market access patterns, health and social functioning, and health service utilisation. Participants are followed-up on an annual basis.
RESULTS: 688 PWID were recruited into the study. At baseline, the median age of participants was 27.6 years (IQR: 24.4 years – 29.6 years) and two-thirds (67%) were male. Participants reported injecting for a median of 10.2 years (range: 1.5 months – 21.2 years), with 11% having injected for three years or less. Limited education, unemployment and previous incarceration were common. The majority of participants (82%) reported recent heroin injection, and one third reported being enrolled in Opioid Substitution Therapy (OST) at recruitment. At 12 months follow-up 458 participants (71% of eligible participants) were retained in the study. There were few differences in demographic and drug-use characteristics of those lost to follow-up compared with those retained in the study, with attrition significantly associated with recruitment at an inner-urban location, male gender, and providing incomplete contact information at baseline.
CONCLUSIONS: Our efforts to recruit a sample of largely out-of-treatment PWID were limited by drug market characteristics at the time, where fluctuating heroin availability has led to large numbers of PWID accessing low-threshold OST. Nevertheless, this study of Australian injectors will provide valuable data on the natural history of drug use, along with risk and protective factors for adverse health outcomes associated with injecting drug use. Comprehensive follow-up procedures have led to good participant retention and limited attrition bias.
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Allison M. Salmon, Ingrid van Beek, Janaki Amin, Andrew Grulich, Lisa Maher
Australia Epidemiology HIV prevalence Injecting Drug Use Medically Supervised Injecting Centre Psychostimulants Supervised Injecting Facilities Sydney
High HIV testing and low HIV prevalence among injecting drug users attending the Sydney Medically Supervised Injecting Centre
OBJECTIVE: Measure the self-reported prevalence of HIV, history of HIV testing and associated risk factors among injecting drug users (IDUs) attending the Sydney Medically Supervised Injecting Centre (MSIC).
METHODS: Cross-sectional survey of IDUs attending the Sydney MSIC (n=9,778).
RESULTS: The majority of IDUs had been tested for HIV (94%), most within the preceding 12 months. Self-reported prevalence of HIV was only 2% (n=162) and homosexuality (AOR 20.68), bisexuality (AOR 5.30), male gender (AOR 3.33), mainly injecting psychostimulants (AOR 2.02), use of local health service (AOR 1.56) and increasing age (AOR 1.62) were independently associated. Among the 195 homosexual male sample 23% were self-reported being HIV positive. HIV positive homosexual males were more likely to report mainly psychostimulant injecting than other drugs, a finding not replicated among the heterosexual males.
CONCLUSIONS: The associations in this sample are consistent with other data indicating Australia has successfully averted an epidemic of HIV among heterosexual IDUs. The absence of any significant associations between HIV positive sero-status and the injecting-related behaviours that increase vulnerability to BBV transmission suggests that HIV infection in this group may be related to sexual behaviours. In particular, the strong associations between homosexual males and psychostimulant injectors with HIV positive sero-status suggests that patterns of infection within this group reflect the epidemiology of HIV in Australia more generally, where men who have sex with men remain most vulnerable to infection.
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Allison M. Salmon, Robyn Dwyer, Marianne Jauncey, Ingrid van Beek, Libby Topp, Lisa Maher
Australia Drug Consumption Rooms Injecting Drug Use Injecting-related disease Injecting-related injuries Medically Supervised Injecting Facilities Supervised Injecting Facilities
Injecting-related injury and disease among clients of a supervised injecting facility
BACKGROUND: The process of drug injection may give rise to vascular and soft tissue injuries and infections. The social and physical environments in which drugs are injected play a significant role in these and other morbidities. Supervised injecting facilities (SIFs) seek to address such issues associated with public injecting drug use.
AIMS: Estimate lifetime prevalence of injecting-related problems, injury and disease and explore the socio-demographic and behavioral characteristics associated with the more serious complications.
DESIGN, SETTING, PARTICIPANTS: Self-report data from 9552 injecting drug users (IDUs) registering to use the Sydney Medically Supervised Injecting Centre (MSIC).
FINDINGS: Lifetime history of either injecting-related problems (IRP) or injecting-related injury and disease (IRID) was reported by 29% of the 9552 IDUs; 26% (n=2469) reported ever experiencing IRP and 10% (n=972) reported IRID. Prevalence of IRP included difficulties finding a vein (18%), prominent scarring or bruising (14%) and swelling of hands or feet (7%). Prevalence of IRID included abscesses or skin infection (6%), thrombosis (4%), septicaemia (2%) and endocarditis (1%). Females, those who mainly injected drugs other than heroin, and those who reported a history of drug treatment, drug overdose, and/or sex work, were more likely to report lifetime IRID. Frequency and duration of injecting, recent public injecting, and sharing of needles and/or syringes were also independently associated with IRID.
CONCLUSIONS: IRPs and IRIDs were common. Findings support the imperative for education and prevention activities to reduce the severity and burden of these preventable injecting outcomes. Through provision of hygienic environments and advice on venous access, safer injecting techniques and wound care, SIFs have the potential to address a number of risk factors for IRID.
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Ingrid van Beek, Jake A. Rance, Stuart Gilmour, Jo Kimber, Richard P. Mattick, John Kaldor
Australia Drug Consumption Facilities Drug treatment Injecting Drug Use Medically Supervised Injecting Centre Referral uptake Supervised Injecting Facilities Sydney
Process and predictors of drug treatment referral and referral uptake at the Sydney Medically Supervised Injecting Centre
INTRODUCTION AND AIMS: Low-threshold drug services such as drug consumption rooms (DCRs) have been posited as referral gateways to drug treatment for injecting drug users (IDUs). We examined the process and predictors of drug treatment referral and referral uptake at an Australian DCR.
DESIGN AND METHODS: We undertook behavioural surveillance of the Sydney Medically Supervised Injecting Centre (MSIC) client cohort between May 2001 and October 2002. Data were collected for 3715 IDUs on demographics, injecting and drug use behaviours at registration and all subsequent MSIC service utilisation, including referrals. Referral uptake (defined as presentation for assessment at the relevant agency) was traced via reply-paid postcards included with written referrals.
RESULTS: Sixteen per cent of clients who received written referrals to drug treatment had confirmed drug treatment referral uptake. Factors associated with drug treatment referral were frequent MSIC attendance [adjusted odds ratios (AOR = 9.4], receipt of written health (AOR = 4.8) or psychosocial (AOR = 4.3) referrals, heroin as main drug injected (AOR = 1.9) and completion of high school education (AOR = 1.6). Factors associated positively with drug treatment referral uptake were recent sex work (AOR = 2.6) and at least daily injection (AOR = 2.3). Previous psychiatric illness or self-harm was associated negatively with drug treatment referral uptake (AOR = 0.2).
DISCUSSION AND CONCLUSIONS: MSIC engaged IDUs successfully in drug treatment referral and this was associated with presentation for drug treatment assessment and other health and psychosocial services. To improve rates of drug treatment referral and uptake, those with a history of mental health issues may require more intensive referral and case management.
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Allison M. Salmon, Ingrid van Beek, Janaki Amin, John Kaldor, Lisa Maher
Ambulance attendance Australia Drug Consumption Rooms Injecting Drug Use MSIC Opioid-Related Overdose Overdose management Supervised Injecting Facilities Sydney
The impact of a supervised injecting facility on ambulance call-outs in Sydney, Australia
AIMS: Supervised injecting facilities (SIFs) are effective in reducing the harms associated with injecting drug use among their clientele, but do SIFs ease the burden on ambulance services of attending to overdoses in the community? This study addresses this question, which is yet to be answered, in the growing body of international evidence supporting SIFs efficacy.
DESIGN: Ecological study of patterns in ambulance attendances at opioid-related overdoses, before and after the opening of a SIF in Sydney, Australia.
SETTING: A SIF opened as a pilot in Sydney's 'red light' district with the aim of accommodating a high throughput of injecting drug users (IDUs) for supervised injecting episodes, recovery and the management of overdoses.
MEASUREMENTS: A total of 20,409 ambulance attendances at opioid-related overdoses before and after the opening of the Sydney SIF. Average monthly ambulance attendances at suspected opioid-related overdoses, before (36 months) and after (60 months) the opening of the Sydney Medically Supervised Injecting Centre (MSIC), in the vicinity of the centre and in the rest of New South Wales (NSW).
RESULTS: The burden on ambulance services of attending to opioid-related overdoses declined significantly in the vicinity of the Sydney SIF after it opened, compared to the rest of NSW. This effect was greatest during operating hours and in the immediate MSIC area, suggesting that SIFs may be most effective in reducing the impact of opioid-related overdose in their immediate vicinity.
CONCLUSIONS: By providing environments in which IDUs receive supervised injection and overdose management and education SIF can reduce the demand for ambulance services, thereby freeing them to attend other medical emergencies within the community.
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Sanjana Mitra, Beth Rachlis, Ayden Scheim, Geoff Bardwell, Sean B. Rourke, Thomas Kerr
Acceptability Canada Design Feasibility research People Who Inject Drugs Supervised Consumption Facilities Supervised Injection Services
Acceptability and design preferences of supervised injection services among people who inject drugs in a mid-sized Canadian City
BACKGROUND: Supervised injection services (SIS) have been shown to reduce the public- and individual-level harms associated with injection drug use. While SIS feasibility research has been conducted in large urban centres, little is known about the acceptability of these services among people who inject drugs (PWID) in mid-sized cities. We assessed the prevalence and correlates of willingness to use SIS as well as design and operational preferences among PWID in London, Canada.
METHODS: Between March and April 2016, peer research associates administered a cross-sectional survey to PWID in London. Socio-demographic characteristics, drug-use patterns, and behaviours associated with willingness to use SIS were estimated using bivariable and multivariable logistic regression models. Chi-square tests were used to compare characteristics with expected frequency of SIS use among those willing to use SIS. Design and operational preferences are also described.
RESULTS: Of 197 PWID included in this analysis (median age, 39; interquartile range (IQR), 33-50; 38% female), 170 (86%) reported willingness to use SIS. In multivariable analyses, being female (adjusted odds ratio (AOR) 0.29; 95% confidence interval (CI) 0.11-0.75) was negatively associated with willingness to use, while public injecting in the last 6 months (AOR 2.76; 95% CI 1.00-7.62) was positively associated with willingness to use. Participants living in unstable housing, those injecting in public, and those injecting opioids and crystal methamphetamine daily reported higher expected frequency of SIS use (p < 0.05). A majority preferred private cubicles for injecting spaces and daytime operational hours, while just under half preferred PWID involved in service operations.
CONCLUSIONS: High levels of willingness to use SIS were found among PWID in this setting, suggesting that these services may play a role in addressing the harms associated with injection drug use. To maximize the uptake of SIS, programme planners and policy makers should consider the effects of gender and views of PWID regarding SIS design and operational preferences.
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Carol Strike, Tara Marie Watson, Gillian Kolla, Rebecca Penn, Ahmed M. Bayoumi
Canada Public opinion Supervised Injection Facilities
Ambivalence about supervised injection facilities among community stakeholders
BACKGROUND: Community stakeholders express a range of opinions about supervised injection facilities (SIFs). We sought to identify reasons for ambivalence about SIFs amongst community stakeholders in two Canadian cities.
FINDINGS: We used purposive sampling methods to recruit various stakeholder representatives (n = 141) for key informant interviews or focus group discussions. Data were analyzed using a thematic process. We identified seven reasons for ambivalence about SIFs: lack of personal knowledge of evidence about SIFs; concern that SIF goals are too narrow and the need for a comprehensive response to drug use; uncertainty that the community drug problem is large enough to warrant a SIF(s); the need to know more about the “right” places to locate a SIF(s) to avoid damaging communities or businesses; worry that a SIF(s) will renew problems that existed prior to gentrification; concern that resources for drug use prevention and treatment efforts will be diverted to pay for a SIF(s); and concern that SIF implementation must include evaluation, community consultation, and an explicit commitment to discontinue a SIF(s) in the event of adverse outcomes.
CONCLUSIONS: Stakeholders desire evidence about potential SIF impacts relevant to local contexts and that addresses perceived potential harms. Stakeholders would also like to see SIFs situated within a comprehensive response to drug use. Future research should determine the relative importance of these concerns and optimal approaches to address them to help guide decision-making about SIFs.
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ARCHES Alberta Canada Harm Reduction Lethbridge Supervised Consumption Services
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.
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Geoff Bardwell, Ayden Scheim, Sanjana Mitra, Thomas Kerr
Canada London Mid-sized cities Stakeholder opinion Supervised Consumption Facilities Supervised Injection Services Support
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.
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Mark W. Tyndall, Thomas Kerr, Ruth Zhang, Evelyn King, Julio G. Montaner, Evan Wood
Canada HIV/AIDS Harm Reduction Injection Drug Use Insite Supervised Injection Facility Vancouver
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.
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Cheryl Prescott, Meaghan Thumath, Monica Durigon, Marcus Lem, Jane Buxton, Mark Tyndall
British Columbia Canada Overdose Prevention Services
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.
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Registered Nurses’ Association of Ontario
Canada Drug consumption rooms Harm Reduction Health workers Nurses Practice Guidelines Supervised Injection Services
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.
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Evan Wood, Thomas Kerr, Will Small, Kathy Li, David C. Marsh, Julio S.G. Montaner, Mark W. Tyndall
Canada Public Order Supervised Injecting Facilities Vancouver
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.
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Dania Notta, Brian Black, TianXin Chu, Ronald Joe, Mark Lysyshyn
Canada Fentanyl Insite Overdose Supervised Injection Site Vancouver
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.
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Thomas Kerr, Mark W. Tyndall, Ruth Zhang, Calvin Lai, Julio S.G. Montaner, Evan Wood
Canada Drug consumption room Harm Reduction Supervised Injecting Facilities Vanvouver
Circumstances of First Injection Among Illicit Drug Users Accessing a Medically Supervised Safer Injection Facility
There have been concerns that safer injecting facilities may promote initiation into injection drug use. We examined length of injecting career and circumstances surrounding initiation into injection drug use among 1065 users of North America’s first safer injecting facility and found that the median years of injection drug use were 15.9 years, and that only 1 individual reported performing a first injection at the safer injecting facility. These findings indicate that the safer injecting facility’s benefits have not been offset by a rise in initiation into injection drug use.
METHODS: First, we examined length of injecting career. To avoid the potential bias resulting from participants’ potential unwillingness to report that their first injection was within the safer injecting facility, we calculated duration of injection drug use by subtracting each participant’s age at first injection from the participant’s current age rather than asking this question directly. Later in the interview, we assessed the circumstances surrounding initiation into injection drug use among SEOSI participants. Variables of interest included injection by someone else during first injection, injection with a used syringe during first injection, and location of first injection (including within the safer injecting facility). As a subanalysis, we compared the overall rate of initiation into injection drug use among SEOSI participants since the safer injecting facility had opened with the expected rate of initiation among local street youths during a similar follow-up period.
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Shelley Marshall, Paula Migliardi, Aliya Jamal, Chelsea Jalloh, Margaret Ormond
Benefits Canada Harm Reduction Spatial needs and preferences Supervised Consumption Services Winnipeg
Consumption Spaces Consultation and Needs Assessment. Winnipeg
This study took place on the ancestral lands of the Anishinaabeg, Cree, Oji-Cree, Dene, and Dakota peoples, and the homeland of the Métis nation, Treaty 1 territory. We approach this project in partnership and collaboration and with a commitment to reconciliation.
This study captured perspectives on safety and harms of drug use as they relate to spaces in which drugs are consumed, with implications for SCS in inner-city Winnipeg.
The characteristics of desirable and safe spaces for drug consumption described by participants reflected the principles of harm reduction: pragmatic, non-judgemental, respect for autonomy, privacy, resources, meaningful involvement, and inclusion. Some of the desirable spatial characteristics described are key features of SCS (material supplies, access to resources, human support or helpers), while other desirable characteristics such as convenience, privacy, and autonomy, are more challenging for SCS to deliver. Still, many participants indicated that they would likely access SCS, provided services are developed according to the priorities and values of those who would use them.
Providers were supportive of SCS, but realistic about the challenges for development and implementation in the local context. Still, providers were supportive of efforts to establish SCS if this is a service that people who use drugs would value and access.
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Calgary Canada Crime Disorder Police Service Sheldon M. Chumir Health Centre Statistics Supervised Consumption Facility Supervised Consumption Services Supervised Consumption Sites
Crime & Disorder near the Sheldon M. Chumir Health Centre’s Supervised Consumption Services (SCS) Facility
The Calgary Police Service supports the medically endorsed, evidence-based spectrum of treatment and services designed to serve the needs of those with addiction-related issues, and the communities of which they are a part. The Service recognizes that supervised consumption sites are one piece of a broader set of programs, policies, and practices that fall under the umbrella of harm reduction.
On January 29, 2019, the Calgary Police Service released the report “Crime & Disorder near the Sheldon M. Chumir Health Centre’s Supervised Consumption Services (SCS) Facility: 2018 Statistical Overview” which showed an increase in crime and disorder within the area over the three-year average. Since that report, the CPS has made concerted efforts to address crime and disorder issues while continuing to be actively engaged with community and agency partners.
The purpose of this report is to provide a statistical overview of reported crime and disorder for the 1st quarter (Q1) of 2019 in the 250m study area around the SCS. The statistics reported here are not directly comparable to the previous yearly report, as such, please see the Appendix for a quarterly and yearly comparisons. The analysis in this report includes a comparison of the study area to the Centre City and the rest of the city, and a timeline from January 2018 to March 2019. The findings show that increased police presence in 2019 corresponds to decreased crime and disorder issues.
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Tara Marie Watson, Gillian Kolla, Emily van der Meulen, Zoë Dodd
Canada Critical theory Harm Reduction Ontario Opioids Overdose Prevention
Critical studies of harm reduction: Overdose response in uncertain political times
North America continues to witness escalating rates of opioid overdose deaths. Scale-up of existing and innovative life-saving services – such as overdose prevention sites (OPS) as well as sanctioned and unsanctioned supervised consumption sites – is urgently needed. Is there a place for critical theory-informed studies of harm reduction during times of drug policy failures and overdose crisis? There are different approaches to consider from the critical literature, such as those that, for example, interrogate the basic principles of harm reduction or those that critique the lack of pleasure in the discourses surrounding drug use. Influenced by such work, we examine the development of OPS in Canada, with a focus on recent experiences from the province of Ontario, as an important example of the impacts associated with moving from grassroots harm reduction to institutionalised policy and practice. Services appear to be most innovative, dynamic, and inclusive when people with lived experience, allies, and service providers are directly responding to fast-changing drug use patterns and crises on the ground, before services become formally bureaucratised. We suggest a continuing need to both critically theorise harm reduction and to build strong community relationships in harm reduction work, in efforts to overcome political moves that impede collaboration with and inclusiveness of people who use drugs.
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Sanne Wright
Amsterdam Canada Design Design frameworks Harm Reduction Netherlands Safe Injection Site USA Urban Public Health Vancouver
Designing the Debate: Assessing the Role of Design Practices in Safe Injection Sites
A safe injection site is an urban public health intervention that saves lives. While they remain illegal in the United States, safe injection sites (SIS) reduce incidences of death and disease related to injection drug use in the cities where they exist. As in many healthcare facilities, the design of SIS must be considered to ensure their success. This thesis determines to what extent design frameworks for health and healthcare are being applied to urban public health interventions, such as SIS, and how design is used to improve user experiences of SIS. Previously conducted studies suggest that established design frameworks meant to improve physical and psychological patient outcomes are exclusively applied to private, residential healthcare facilities as opposed to public, short term healthcare facilities like SIS. However, an analysis of SIS in Amsterdam, the Netherlands and Vancouver, Canada reveals that these spaces are highly designed to improve user safety, hygiene, and stress levels. Similarly, harm reduction organizations in the U.S. have intentionally used design to the same end in both their own spaces and in proposals for hypothetical SIS. Drawing from the design strategies uncovered in these findings, designs for a SIS in the U.S. have been proposed in consideration of the controversial debate that has caused them to be rejected by politicians. This study counters prevailing wisdom in literature that designing for healthcare occurs exclusively in private, residential facilities. In fact, design is critical to the success of urban public health interventions, including SIS.
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Evan Wood, Mark W. Tyndall, Kathy Li, Elisa Lloyd-Smith, Will Small, Julio S.G. Montaner, Thomas Kerr
Canada Harm Reduction Injection Drug Users Supervised Injection Facilities
Do supervised injecting facilities attract higher-risk injection drug users?
BACKGROUND: In Western Europe and elsewhere, medically supervised safer injection facilities (SIFs) are increasingly being implemented for the prevention of health- and community-related harms among injection drug users (IDUs), although few evaluations have been conducted, and there have been questions regarding SIFs' ability to attract high-risk IDUs. We examined whether North America's first SIF was attracting IDUs who were at greatest risk of overdose and blood-borne disease infection.
METHODS: We examined data from a community-recruited cohort study of IDUs. The prevalence of SIF use was determined based on questionnaire data obtained after the SIF's opening, and we determined predictors of initiating future SIF use based on behavioral information obtained from questionnaire data obtained before the SIF's opening. Pearson's chi-square test was used to compare characteristics of IDUs who did and did not subsequently initiate SIF use.
RESULTS: Overall, 400 active injection drug users returned for follow-up between December 1, 2003 and May 1, 2004, among whom 178 (45%) reported ever using the SIF. When we examined behavioral data collected before the SIF's opening, those who initiated SIF use were more likely to be aged <30 years (odds ratio [OR]=1.6, 95% confidence interval [CI]=1.0-2.7], p=0.04); public injection drug users (OR=2.6, 95% CI=1.7-3.9, p<0.001); homeless or residing in unstable housing (OR=1.7, 95% CI=1.2-2.7, p=0.008); daily heroin users (OR=2.1, 95% CI=1.3-3.2, p=0.001); daily cocaine users (OR=1.6, 95% CI=1.1-2.5, p=0.025); and those who had recently had a nonfatal overdose (OR=2.7, 95% CI=1.2-6.1, p=0.016).
CONCLUSIONS: This study indicated that the SIF attracted IDUs who have been shown to be at elevated risk of blood-borne disease infection and overdose, and IDUs who were contributing to the public drug use problem and unsafe syringe disposal problems stemming from public injection drug use.
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Tara Marie Watson, Carol Strike, Gillian Kolla, Rebecca Penn, Ahmed M Bayoumi
Age Canada Harm Reduction Qualitative research Supervised Injection Facilities Youth
“Drugs don’t have age limits”: The challenge of setting age restrictions for supervised injection facilities
AIMS: People under age 18 who inject drugs represent a population at risk of health and social harms. Age restrictions at harm reduction programmes often formally exclude this population, but the reason behind such restrictions is lacking in the literature. To help fill this gap, we examine the perspectives of people who use drugs and various other stakeholders regarding whether supervised injection facilities (SIFs) should have age restrictions.
METHODS: Interviews and focus groups were conducted with a total of 95 people who use drugs and 141 other stakeholders (including police, fire and emergency services personnel, other city employees and officials, healthcare providers, residents and business representatives) in two Canadian cities without SIFs.
FINDINGS: We highlight the following thematic areas: mixed opinions regarding specific age restrictions; safety as a priority; different experiences and understandings of youth, agency and drug use; and ideas regarding maturity, “help” and other approaches. We note throughout that a familiar vulnerability–agency dichotomy often surfaced in the discussions.
CONCLUSIONS: This paper contributes new empirical insights regarding youth access to SIFs. We offer considerations that may inform discussions occurring in other jurisdictions debating SIF implementation and may help remove or clarify age-related policies for harm reduction programmes.
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M-J. S. Milloy, Thomas Kerr, Mark Tyndall, Julio Montaner, Evan Wood
Canada Harm Reduction Insite Overdose mortality Potentially averted deaths Supervised Injection Facility Vancouver
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.
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Mohammad Karamouzian, Carolyn Dohoo, Sara Forsting, Ryan McNeil, Thomas Kerr, Mark Lysyshyn
Canada Drug checking Drug consumption room Harm Reduction Insite Supervised Injection Facility Vancouver
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.
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Ehsan Jozaghi, Asheka Jackson
Canada Cost-benefit HIV Harm Reduction Saskatoon Supervised Injection Facility
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
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Heather Mann, Jennifer Walker, Lavinia Lau, Luc Lussier, Peter Kim
Canada Downtown Eastside Harm Reduction Overdose Prevention Site Overdose mortality Vancouver
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.
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Andrew Ivsins, , Cecilia Benoit, Karen Kobayashi, Susan Boyd
Assemblage theory Canada Downtown Eastside Enabling places Housing People Who Use Drugs Stigma Vancouver
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.
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Jade Boyd, Alexandra B. Collins, Samara Mayer, Lisa Maher, Thomas Kerr, Ryan McNeil
Canada Drug consumption rooms Ethnographic study Gendered violence Harm Reduction Intersectionality Overdose Prevention Sites Overdose mortality Risk Environment Supervised Consumption Sites
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.
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Jessica Hopkins
Canada Disease transmission Drug consumption rooms Feasibility HCV HIV Hamilton Harm Reduction Mobile Overdose mortality
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.
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Gillian Kolla, Kathleen S. Kenny, Molly Bannerman, Nick Boyce, Leigh Chapman, Zoë Dodd, Jen Ko, Sarah Ovens
Assisted injection Canada Drug Consumption Room Overdose Overdose Prevention Site Supervised Consumption Service Toronto
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.
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Thomas Kerr, Jo-Anne Stoltz, Mark Tyndall, Kathy Li, Ruth Zhang, Julio Montaner, Evan Wood
Canada HIV Overdose mortality Public Health Public Order Supervised injecting facilities Vancouver
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.
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Ryan McNeil, Laura B Dilley, Manal Guirguis-Younger, Stephen W Hwang, Will Small
Canada HIV/AIDS Harm Reduction Highly active antiretroviral therapy Palliative care Qualitative research Supervised Consumption Services
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.
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Geoff Bardwell, Carol Strike, Jason Altenberg, Lorraine Barnaby, Thomas Kerr
Canada Implementation context Police Supervised Consumption Services Supervised Injection Sites Surveillance Toronto
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
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Carol Strike, Jennifer A. Jairam, Gillian Kolla, Peggy Millson, Susan Shepherd, Benedikt Fischer, Tara Marie Watson, Ahmed M. Bayoumi
Adult Canada General population Ontario Public opinion Supervised Injection FacilitieS
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.
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Kora DeBeck, Thomas Kerr, Lorna Bird, Ruth Zhang, David Marsh, Mark Tyndall, Julio Montaner, Evan Wood
Aboriginal ancestry Addiction treatment Canada Injection cessation Supervised Injecting Facility Vancouver
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.
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Annie Foreman-Mackey, Ahmed M. Bayoumi, Miroslav Miskovic, Gillian Kolla, Carol Strike
Assisted injection Canada Community activism Harm Reduction Overdose Prevention Overdose Prevention Site Qualitative research Supervised Consumption Supervised Smoking Toronto
‘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.
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Gillian Kolla, Carol Strike
Canada Harm Reduction Naloxone Opioid overdose Peer workers Structural vulnerability Supervised Injection Services
‘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.
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Evan Wood, Thomas Kerr, Elisa Lloyd-Smith, Chris Buchner, David C Marsh, Julio SG Montaner, Mark W Tyndall
Canada Insite Methodology Methodology for evaluating Supervised injection Facility Vancouver
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.
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Silvina C. Mema, Gillian Frosst, Jessica Bridgeman, Hilary Drake, Corinne Dolman, Leslie Lappalainen, Trevor Corneil
British Columbia Canada Harm Reduction Mobile Supervised Consumption Services Overdose mortality Rural
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.
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Michael A. Irvine, Margot Kuo, Jane Buxton, Robert Balshaw, Michael Otterstatter, Laura Macdougall, M. J. Milloy, Aamir Bharmal, Bonnie Henry, Mark Tyndall, Daniel Coombs, Mark Gilbert
British Columbia Canada Combined intervention approach Opioid agonist Therapy Overdose Prevention Sites Overdose mortality Supervised Consumption Sites Take‐home Naloxone kits
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.
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M.-J. S. Milloy, Thomas Kerr, Richard Mathias, Ruth Zhang, Julio S. Montaner, Mark Tyndall, Evan Wood
Canada Injection Drug Users Insite Non-fatal overdose Overdose Supervised Injection Facility
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.
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R. Alan Wood, Evan Wood, Calvin Lai, Mark W. Tyndall, Julio S.G. Montaner, Thomas Kerr
Canada Illicit drug use Nurses Nursing interventions Patient education Supervised Injection Facility Vancouver Vein care
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.
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Canada Feasibility Study London Ontario Supervised Injection Services
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.
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Tobie Patterson, Aamir Bharmal, Shovita Padhi, Chris Buchner, Erin Gibson, Victoria Lee
Canada Drug consumption rooms Harm Reduction Overdose mortality Supervised Consumption Sites
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).
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.
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.
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Mary Clare Kennedy, Jade Boyd, Samara Mayer, Alexandra Collins, Thomas Kerr, Ryan McNeil
Canada Overdose Overdose Prevention Sites Peers People Who Use Drugs Rapid ethnography Supervised Consumption Facilities Supervised Injection Facilities Task shifting Vancouver
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.
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Kora DeBeck, Evan Wood, Ruth Zhang, Mark Tyndall, Julio Montaner, Thomas Kerr
Canada Drug consumption room Local Police Public Order Supervised Injection Facility Vancouver
Police and public health partnerships: Evidence from the evaluation of Vancouver's supervised injection facility
In various settings, drug market policing strategies have been found to have unintended negative effects on health service use among injection drug users (IDU). This has prompted calls for more effective coordination of policing and public health efforts. In Vancouver, Canada, a supervised injection facility (SIF) was established in 2003. We sought to determine if local police impacted utilization of the SIF. We used generalized estimating equations (GEE) to prospectively identify the prevalence and correlates of being referred by local police to Vancouver's SIF among IDU participating in the Scientific Evaluation of Supervised Injecting (SEOSI) cohort during the period of December 2003 to November 2005. Among 1090 SIF clients enrolled in SEOSI, 182 (16.7%) individuals reported having ever been referred to the SIF by local police. At baseline, 22 (2.0%) participants reported that they first learned of the SIF via police. In multivariate analyses, factors positively associated with being referred to the SIF by local police when injecting in public include: sex work (Adjusted Odds Ratio [AOR] = 1.80, 95%CI 1.28 – 2.53); daily cocaine injection (AOR = 1.54, 95%CI 1.14 – 2.08); and unsafe syringe disposal (AOR = 1.46, 95%CI 1.00 – 2.11). These findings indicate that local police are facilitating use of the SIF by IDU at high risk for various adverse health outcomes. We further found that police may be helping to address public order concerns by referring IDU who are more likely to discard used syringes in public spaces. Our study suggests that the SIF provides an opportunity to coordinate policing and public health efforts and thereby resolve some of the existing tensions between public order and health initiatives.
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Alexandra B. Collins, Jade Boyd, Samara Mayer, Al Fowler, Mary Clare Kennedy, Ricky N. Bluthenthal, Thomas Kerr, Ryan McNeil
Downtown Eastside Harm Reduction Overdose Overdose Prevention Sites Place-based policing Safe Consumption Site Vancouver
Policing space in the overdose crisis: A rapid ethnographic study of the impact of law enforcement practices on the effectiveness of overdose prevention sites
North America is in the midst of an overdose crisis. In some of the hardest hit areas of Canada, local responses have included the implementation of low-threshold drug consumption facilities, termed Overdose Prevention Sites (OPS). In Vancouver, Canada the crisis and response occur in an urban terrain that is simultaneously impacted by a housing crisis in which formerly ‘undesirable’ areas are rapidly gentrifying, leading to demands to more closely police areas at the epicenter of the overdose crisis. We examined the intersection of street-level policing and gentrification and how these practices re/made space in and around OPS in Vancouver's Downtown Eastside neighborhood. Between December 2016 and October 2017, qualitative interviews were conducted with 72 people who use drugs (PWUD) and over 200 h of ethnographic fieldwork were undertaken at OPS and surrounding areas. Data were analyzed thematically and interpreted by drawing on structural vulnerability and elements of social geography. While OPS were established within existing social-spatial practices of PWUD, gentrification strategies and associated police tactics created barriers to OPS services. Participants highlighted how fear of arrest and police engagement necessitated responding to overdoses alone, rather than engaging emergency services. Routine policing near OPS and the enforcement of area restrictions and warrant searches, often deterred participants from accessing particular sites. Further documented was an increase in the number of police present in the neighborhood the week of, and the week proceeding, the disbursement of income assistance cheques. Our findings demonstrate how some law enforcement practices, driven in part by ongoing gentrification efforts and buttressed by multiple forms of criminalization present in the lives of PWUD, limited access to needed overdose-related services. Moving away from place-based policing practices, including those driven by gentrification, will be necessary so as to not undermine the effectiveness of life-saving public health interventions amid an overdose crisis.
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Kate Shannon, Tomiye Ishida, Robert Morgan, Arthur Bear, Megan Oleson, Thomas Kerr, Mark W. Tyndall
Canada Community impacts Crack cocaine Harm Reduction Public Health impacts Supervised Smoking Facilities Vancouver
Potential community and public health impacts of medically supervised safer smoking facilities for crack cocaine users
There is growing evidence of the public health and community harms associated with crack cocaine smoking, particularly the risk of blood-borne transmission through non-parenteral routes. In response, community advocates and policy makers in Vancouver, Canada are calling for an exemption from Health Canada to pilot a medically supervised safer smoking facility (SSF) for non-injection drug users (NIDU). Current reluctance on the part of health authorities is likely due to the lack of existing evidence surrounding the extent of related harm and potential uptake of such a facility among NIDUs in this setting. In November 2004, a feasibility study was conducted among 437 crack cocaine smokers. Univariate analyses were conducted to determine associations with willingness to use a SSF and logistic regression was used to adjust for potentially confounding variables (p < 0.05). Variables found to be independently associated with willingness to use a SSF included recent injection drug use (OR = 1.72, 95% CI: 1.09–2.70), having equipment confiscated or broken by police (OR = 1.96, 95% CI: 1.24–2.85), crack bingeing (OR = 2.16, 95% CI: 1.39–3.12), smoking crack in public places (OR = 2.48, 95% CI: 1.65–3.27), borrowing crack pipes (OR = 2.50, 95% CI: 1.86–3.40), and burns/ inhaled brillo due to rushing smoke in public places (OR = 4.37, 95% CI: 2.71–8.64). The results suggest a strong potential for a SSF to reduce the health related harms and address concerns of public order and open drug use among crack cocaine smokers should a facility be implemented in this setting.
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Courtney L. C. Collins, Thomas Kerr, Laura M. Kuyper, Kathy Li, Mark W. Tyndall, David C. Marsh, Julio S. Montaner, Evan Wood
Canada HCV HIV Harm Reduction Supervised Smoking Facility Vancouver
Potential uptake and correlates of willingness to use a supervised smoking facility for noninjection illicit drug use
Many cities are experiencing infectious disease epidemics and substantial community harms as a result of illicit drug use. Although medically supervised smoking facilities (SSFs) remain untested in North America, local health officials in Vancouver are considering to prepare a submission to Health Canada for an exemption to open Canada’s first SSF for evaluation. Reluctance of health policymakers to initiate a pilot study of SSFs may be due in part to outstanding questions regarding the potential uptake and community impacts of the intervention. This study was conducted to evaluate the prevalence and correlates of willingness to use an SSF among illicit drug smokers who are enrolled in the Vancouver Injection Drug Users Study. Participants who reported actively smoking cocaine, heroin, or methamphetamine who returned for follow-up between June 2002 and December 2002 were eligible for these analyses. Those who reported willingness to use an SSF were compared with those who were unwilling to use an SSF by using logistic regression analyses. Four hundred and forty-three participants were eligible for this study. Among respondents, 124 (27,99%) expressed willingness to attend an SSF. Variables that were independently associated with willingness to attend an SSF in multivariate analyses included sex-trade work (adjusted odds ratio [AOR]=1.85), crack pipe sharing (AOR=2.24), and residing in the city’s HIV epicentre (AOR=1.64). We found that participants who demonstrated a willingness to attend an SSF were more likely to be involved in the sex trade and share crack pipes. Although the impact of SSFs in North America can only be quantified by scientific evaluation, these data indicate a potential for public health and community benefits if SSFs were to become available.
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Elaine Hyshka, Tania Bubela, T. Cameron Wild
Canada Evidence-base Harm Reduction Illicit drug policy Injection Drug Use Law Supervised Injection Facilities
Prospects for scaling-up supervised injection facilities in Canada: the role of evidence in legal and political decision-making
BACKGROUND: North America's first supervised injection facility-Insite-opened in Vancouver in 2003 under a special federal legal exemption. Insite has faced significant political and legal opposition, which culminated in a recent Supreme Court of Canada ruling that ordered the federal Minister of Health to extend the facility's exemption and cited evidence that the facility is life-preserving and does not increase public disorder. Officials in several other cities have initiated or accelerated preparations for new facilities due to speculation that the ruling provides sufficient legal basis to expand supervised injection in Canada. However, a comprehensive assessment of the barriers and facilitators to supervised injection facility scale-up is lacking.
METHODS: This policy case study reviews a corpus of jurisprudence, legislation, scientific research and media texts to: describe the role of evidence in legal and political decision-making around Insite; analyze the implications of the Insite decision for new facilities; and discuss alternative avenues for supervised injection facility expansion.
RESULTS: The Insite decision does not simplify the path towards new supervised injection facilities, but nor does it does pose an insurmountable hurdle. Whether new facilities will be established depends largely upon how the Minister of Health interprets the ruling, the proponents' ability to demonstrate need and support from municipal and provincial governments and community members. Formally defining supervised injection as within nurses' scope of practice could further efforts to establish new facilities.
CONCLUSION: Additional court action may be required to establish a stable legal and policy basis for supervised injection facilities in Canada.
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Ayden Scheim, Beth Rachlis, Geoff Bardwell, Sanjana Mitra, Thomas Kerr
Canada London Ontario Public drug injecting
Public injecting among people who inject drugs in a mid-sized Canadian city
BACKGROUND: Harms associated with public drug injection in large cities are well-established, but little is known about challenges that public injecting may pose for smaller municipalities. We evaluated the prevalence and correlates of public injecting among a sample of people who inject drugs in London, a mid-sized city in southwestern Ontario.
METHODS: Between March and April 2016, a sample of people who injected drugs participated in a quantitative survey as part of the Ontario Integrated Supervised Injection Services Feasibility Study. Bivariable and multivariable logistic regression models estimated associations of sociodemographic characteristics, sociostructural exposures and drug use behaviours with regular public injecting (injecting in public ≥ 25% of the time over the previous 6 mo). We also described the locations and rationales provided for public injecting.
RESULTS: A total of 196 participants (38.3% female, median age 39 yr) provided complete data. Of the 196, 141 (71.9%) reported any public injecting in the previous 6 months, and 91 (46.4%) injected in public regularly. Homelessness or unstable housing (adjusted odds ratio [OR] 2.04, 95% confidence interval [CI] 1.01-4.12) and frequently injecting opioids (adjusted OR 2.27, 95% CI 1.17-4.42) or crystal methamphetamine (adjusted OR 2.38, 95% CI 1.18-4.79) daily were independently associated with regular public injection. Convenience (98 participants [69.5%]) and homelessness (56 [39.7%]) were the most commonly reported reasons for public injecting.
INTERPRETATION: As in large cities in Canada, public injecting in London is common and appears to be associated with unstable housing and high-intensity injecting. These results indicate an urgent need to create safer environments for people who inject drugs in London, including supervised injection, to reduce the negative individual and community impacts of public injecting.
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Michelle Firestone Cruz, Jayadeep Patra, Benedikt Fischer, Jürgen Rehm, Kate Kalousek
Canada Harm Reduction Heroin-assisted treatment Ontario Public opinion Public policy Supervised Injection Facility
Public opinion towards supervised injection facilities and heroin-assisted treatment in Ontario, Canada
In recent years, controversial interventions such as ‘heroin-assisted treatment’ (HAT) and ‘supervised injection facilities’ (SIFs) have been established in attempts to minimise the high morbidity and mortality consequences of illicit drug use. This paper examines public opinion towards HAT and SIF using data from the 2003 Centre for Addiction and Mental Health (CAMH) Monitor, a representative population survey conducted among adults residing in Ontario, Canada. Data relating specifically to SIFs and HAT were isolated from the main database (n = 885); agreement scores were collapsed to create a scale and analysed using independent sample t-tests and ANOVAs. Results revealed that 60 percent (n = 530) of the sample agreed that SIFs should be made available to injection drug users, while 40 percent (n = 355) disagreed. When asked about the provision of HAT, a similar pattern emerged. Variables significantly associated with positive opinions toward SIFs and HAT were: income; higher education; the use of cocaine or cannabis within the last 12 months; being in favour of cannabis decriminalisation; support of needle exchange in prison; view of illicit drug users as ill people; and agreement that drug users are in need of public support. Given the current political climate and the tentative position of SIFs and HAT in Canada, understanding the public's opinion is crucial for the feasibility and long-term sustainability of these interventions.
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Carol Strike, Nooshin Khobzi Rotondi, Tara Marie Watson, Gillian Kolla, Ahmed M. Bayoumi
Canada Ontario Public opinion Supervised Injection Facilities Supervised Smoking Facilities
Public opinions about supervised smoking facilities for crack cocaine and other stimulants
BACKGROUND: The purpose of this study was to estimate awareness and opinions about supervised smoking facilities (SSFs) for smoking crack cocaine and other stimulants and make comparisons with awareness and opinions about supervised injection facilities (SIFs) in Ontario, Canada.
METHODS: We used data from a 2009 telephone survey of a representative adult sample. The survey asked about awareness of, and level of support for, the implementation of SSFs and SIFs. Data were analysed using statistical models for complex survey data, which account for stratified sampling and incorporate sampling weights.
RESULTS: A total of 1035 participated in the survey. Significantly fewer had knowledge about SSFs (17.9 %) than about SIFs (57.6 %). Fewer strongly agreed with implementation of SSFs (19.6 %) than SIFs (28.3 %). Just over half (51.1 %) of participants somewhat agreed or disagreed, 15.7 % strongly agreed, and 10.6 % strongly disagreed with implementing both SSFs and SIFs.
CONCLUSIONS: Members of the public in Ontario had little knowledge of SSFs compared to SIFs. Recent federal government changes in Canada may provide the leadership environment necessary to ensure that innovative, evidence-based harm reduction programs such as SSFs are developed and implemented.
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Brandon DL Marshall, M-J Milloy, Evan Wood, Julio SG Montaner, Thomas Kerr
Canada Overdose mortality Reduction in Overdose Mortality Supervised Injecting Facilities Vanvouver
Reduction in overdose mortality after the opening of North America's first medically supervised safer injecting facility
BACKGROUND: Overdose from illicit drugs is a leading cause of premature mortality in North America. Internationally, more than 65 supervised injecting facilities (SIFs), where drug users can inject pre-obtained illicit drugs, have been opened as part of various strategies to reduce the harms associated with drug use. We sought to determine whether the opening of an SIF in Vancouver, BC, Canada, was associated with a reduction in overdose mortality.
METHODS: We examined population-based overdose mortality rates for the period before (Jan 1, 2001, to Sept 20, 2003) and after (Sept 21, 2003, to Dec 31, 2005) the opening of the Vancouver SIF. The location of death was determined from provincial coroner records. We compared overdose fatality rates within an a priori specified 500 m radius of the SIF and for the rest of the city.
FINDINGS: Of 290 decedents, 229 (79·0%) were male, and the median age at death was 40 years (IQR 32–48 years). A third (89, 30·7%) of deaths occurred in city blocks within 500 m of the SIF. The fatal overdose rate in this area decreased by 35·0% after the opening of the SIF, from 253·8 to 165·1 deaths per 100 000 person-years (p=0·048). By contrast, during the same period, the fatal overdose rate in the rest of the city decreased by only 9·3%, from 7·6 to 6·9 deaths per 100 000 person-years (p=0·490). There was a significant interaction of rate differences across strata (p=0·049).
INTERPRETATION: SIFs should be considered where injection drug use is prevalent, particularly in areas with high densities of overdose.
FUNDING: Vancouver Coastal Health, Canadian Institutes of Health Research, and the Michael Smith Foundation for Health Research.
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Mai-Lei Woo Kinshella, Tim Gauthier, Mark Lysyshyn
Atypical overdose presentations Canada Dyskinesia Fentanyl Insite Opioid overdose Rigidity Supervised Consumption Sites Supervised Injection Site Vancouver
Rigidity, dyskinesia and other atypical overdose presentations observed at a supervised injection site, Vancouver, Canada
OBJECTIVE: In midst of the overdose crisis, the clinical features of opioid overdoses seem to be changing. Understanding of the adverse effects of synthetic opioids such as fentanyl is currently limited to clinical settings. Insite, a supervised injection site in Vancouver, Canada, provides an opportunity to better understand illicit drug overdose presentations.
METHODS: A review of clinical records at Insite for October 2016 to April 2017 was undertaken to quantify atypical overdose presentations. Overdose reports were reviewed for the number of atypical opioid overdose presentations, temporal trends over the study period, concurrent symptoms, and interventions employed by staff.
RESULTS: Insite staff responded to 1581 overdoses during the study period, including 497 (31.4%) that did not fit a typical presentation for opioid overdoses. Of these, 485 fit into five categories of atypical features: muscle rigidity, dyskinesia, slow or irregular heart rate, confusion, and anisocoria. Muscle rigidity was the most common atypical presentation, observed in 240 (15.2%) of the overdose cases, followed by dyskinesia, observed in 150 (9.2%). Slow or irregular heart rate was observed in 69 (4.4%) cases, confusion in 24 (1.5%), and anisocoria in 2 (0.1%) of overall overdose cases.
DISCUSSION: The similarity of atypical overdose cases at Insite with anesthesiology case reports supports the understanding that the illicit drug supply is contaminated by fentanyl and other synthetic opioids. Atypical overdose presentations can affect clinical overdose response. The experience at Insite highlights the potential for supervised consumption sites to be innovative spaces for community learning and knowledge translation.
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Gillian Kolla, Carol Strike, Tara Marie Watson, Jennifer Jairam, Benedikt Fischer, Ahmed M. Bayoumi
Canada Drug Consumption Rooms Injection Drug Use NIMBY Ottawa Risk Supervised Consumption Facilities Toronto
Risk creating and risk reducing: Community perceptions of supervised consumption facilities for illicit drug use
Progressive public health authorities in high-income countries have advocated supervised consumption facilities, where people who use illicit drugs can consume them in a hygienic, supervised environment, as a way of reducing drug-related risks to both people who use drugs and communities. However, the planning of such facilities has often met with strong reactions from the local community. ‘Not in my backyard’ (NIMBY) type reactions are frequently encountered and public opinion polling is limited in its ability to provide detailed insights into the reasons why people support or oppose these facilities in Toronto and Ottawa. We explore perceptions of residents and business representatives to the proposed implementation of supervised consumption facilities, and examine their perceptions of risks from these facilities. We collected qualitative data from 2008–2010 using focus groups and interviews with 38 residents and 17 business representatives in these two large Canadian cities lacking supervised consumption facilities. We used thematic analysis to examine expressed benefits and risks regarding supervised consumption facilities amongst community members. These participants saw these facilities as potentially risk-reducing, but recognised that the facilities could also create risks for their communities. While community members accepted that facilities could have positive health effects, they expressed a level of concern regarding the risk of public nuisance associated with supervised consumption facilities that seemed unwarranted based on the existing evidence. Discussions on the risks involved in the establishment of supervised consumption facilities should move beyond a focus on the benefits to facility users, to exploring community-level benefits and risks, and integrate evidence regarding actual risk experiences from other locations. Similar approaches may apply to NIMBY concerns related to other contentious issues.
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Evan Wood, Mark W. Tyndall, Jo-Anne Stoltz, Will Small, Ruth Zhang, Jacqueline O’Connell, Julio S.G. Montaner, Thomas Kerr
Canada HIV incidence Injection Drug Users Supervised Injecting Facility Vancouver
Safer injecting education for HIV prevention within a medically supervised safer injecting facility
BACKGROUND: Requiring help injecting has recently been independently associated with syringe sharing and HIV incidence among injection drug users (IDUs) in Vancouver. We examined IDUs who were receiving safer injecting education within a supervised injecting facility (SIF) in Vancouver.
METHODS: The Scientific Evaluation of Supervised Injecting (SEOSI) cohort is based on a representative sample of SIF users. We examined the prevalence and correlates of receiving safer injecting education within the SIF using univariate and logistic regression analyses.
RESULTS: Between May 31, 2003 and Oct 22, 2004, 874 individuals of the SEOSI cohort have completed the baseline questionnaire, among whom 293 (33.5%) received safer injecting education. In multivariate analyses, requiring help with an injection in the last 6 months (OR = 2.20 [95% CI: 1.62–2.98]) and sex-trade involvement in the last 6 months (OR = 1.54 [1.09–2.16]) were independently associated with receiving safer injecting education within the SIF.
CONCLUSIONS: Since requiring help injecting has previously been associated with HIV incidence, it is encouraging that this risk factor was associated with receiving safer injecting education within the SIF. Nevertheless, prospective evaluation is necessary to examine if receiving safer injecting education is associated with reduced HIV risk behaviour and blood-borne disease incidence.
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Robert S. Broadhead, Thomas H. Kerr, Jean-Paul C. Grund, Frederick L. Altice
Canada Harm Reduction Public Policy Safer Injection Facilities
Safer Injection Facilities in North America: Their Place in Public Policy and Health Initiatives
The continuing threat posed by HIV, HCV, drug overdose, and other injection-related health problems in both the United States and Canada indicates the need for further development of innovative interventions for drug injectors, for reducing disease and mortality rates, and for enrolling injectors into drug treatment and other health care programs. Governmentally sanctioned “safer injection facilities” (SIFs) are a service that many countries around the world have added to the array of public health programs they offer injectors. In addition to needle exchange programs, street-outreach and other services, SIFs are clearly additions to much larger comprehensive public health initiatives that municipalities pursue in many countries. A survey of the existing research literature, plus the authors' ethnographic observations of 18 SIFs operating in western Europe and one SIF that was recently opened in Sydney, Australia, suggest that SIFs target several problems that needle exchange, street-outreach, and other conventional services fall short in addressing: (1) reducing rates of drug injection and related-risks in public spaces; (2) placing injectors in more direct and timely contact with medical care, drug treatment, counseling, and other social services; (3) reducing the volume of injectors' discarded litter in, and expropriation of, public spaces. In light of the evidence, the time has come for more municipalities within North America to begin considering the place of SIFs in public policy and health initiatives, and to provide support for controlled field trials and demonstration projects of SIFs operating in injection drug-using communities.
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Melissa McCann, Sameena Vadivelu
Canada Evaluation London Ontario Overdose Prevention Site
Saving Lives. Changing Lives. Summary Report on the findings from an Evaluation of London’s Temporary Overdose Prevention Site (TOPS), Ontario
Middlesex-London, Ontario, along with many other Canadian communities is experiencing an opioid crisis that has taken the lives of many people in our community. At the same time, there are increased rates of HIV infection and infectious endocarditis in people who use injection drugs (PWUD). Together, this overlapping drug and infectious disease crisis has drawn attention to a complex public health issue requiring the attention of local public health authorities and community partners.
In December 2017, to assist communities with this public health need, the Ministry of Health and Long-Term Care (MOHLTC) introduced a strategy: the establishment of Overdose Prevention Sites (OPS). Communities in need could apply to the MOHLTC to obtain approval and funding to establish an OPS. These sites are a low barrier, time-limited service for people to consume drugs in a supervised environment and facilitate connections to other health and social services. With the support of community partners, the Middlesex-London Health Unit and Regional HIV/AIDS Connection (RHAC) opened Ontario’s first legally sanctioned Temporary Overdose Prevention Site (TOPS) at 186 King Street on February 12, 2018.
In the summer of 2018, a process and outcome evaluation was conducted to capture lessons learned in the first six months of operation, and to document the site’s progress in meeting its intended outcomes.
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Evan Wood, Mark W. Tyndall, Julio S. Montaner, Thomas Kerr
Canada Evaluation Insite Supervised Injecting Facility Vancouver
Summary of findings from the evaluation of a pilot medically supervised safer injecting facility
In many cities, infectious disease and overdose epidemics are occurring among illicit injection drug users (IDUs). To reduce these concerns, Vancouver opened a supervised safer injecting facility in September 2003. Within the facility, people inject pre-obtained illicit drugs under the supervision of medical staff. The program was granted a legal exemption by the Canadian government on the condition that a 3-year scientific evaluation of its impacts be conducted. In this review, we summarize the findings from evaluations in those 3 years, including characteristics of IDUs at the facility, public injection drug use and publicly discarded syringes, HIV risk behaviour, use of addiction treatment services and other community resources, and drug-related crime rates. Vancouver's safer injecting facility has been associated with an array of community and public health benefits without evidence of adverse impacts. These findings should be useful to other cities considering supervised injecting facilities and to governments considering regulating their use.
Many cities are experiencing infectious disease and overdose epidemics as a result of illicit injection drug use, an activity that is also associated with a number of negative community impacts, including public drug use. Despite these harms, innovative public health programs for reducing health and community concerns remain highly controversial in North America and other settings where HIV infection is spreading rapidly among injection drug users (IDUs).
In Canada, Vancouver has been an epicentre of drug-related harm during the last decade. In response, the affected community began advocating a medically supervised safer injecting facility where IDUs could inject pre-obtained drugs under the supervision of medical staff.11 Within the facility, IDUs are typically provided with sterile syringes and emergency care in the event of overdose, as well as primary care services and referral to addiction treatment. Such facilities exist in more than 2 dozen European cities and, more recently, in Sydney, Australia.
Vancouver's safer injecting facility was opened in September 2003 as a pilot study. The legal exemption by the federal government that allowed operation of the facility was limited to 3 years and was granted on the condition that an external 3-year scientific evaluation of its impacts be conducted. Given the controversial nature of the program, stakeholders agreed that all findings from the evaluation, including this report, should be externally peer-reviewed and published in the medical literature before dissemination. In this review we report on the 3 years' findings.
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Medicine Hat Coalition on Supervised Consumption
Alberta Canada Drug consumption rooms Evidence-base Harm Reduction Supervised Consumption Services
Supervised Consumption: A Report to the Community of Medicine Hat
In 2016-2017, Medicine Hat experienced 10 opioid-related overdose deaths, and the South Zone had the highest rate of emergency room visits related to opioids (23% higher than the provincial average). Additionally, Medicine Hat experienced 61 EMS calls related to opioid overdose in 2016 (Alberta Health, 2017).
In 2016, Alberta Health announced funding to support the assessment of the need for and development of supervised consumption services (SCS) across the province. The Medicine Hat Coalition on Supervised Consumption Services (MHCSC) was formed to guide the needs assessment and program planning in our city. The MHCSC includes representatives from nine organizations including Alberta Health Services, the City of Medicine Hat, Medicine Hat Police Service, Medicine Hat College, the University of Calgary and numerous community-based organizations and service providers. In 2017, the MHCSC did a research study involving a survey with 185 people who use substances, follow-up interviews with 10 people and focus groups with employees working directly with people who use substances in Medicine Hat.
This report summarizes findings from our needs assessment and research. The purpose is to describe the current state of Medicine Hat’s opioid crisis and offer recommendations for evidence-based interventions to address it. Our goal is to provide information to help demystify and debunk myths associated with drug use, harm reduction and supervised consumption services more specifically.
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Stacey Bourque, Em M. Pijl, Erin Mason, Jill Manning, Takara Motz
Canada Harm Reduction Inhalation Safer smoking room Supervised Consumption Site Supervised Inhalation Site
Supervised inhalation is an important part of supervised consumption services
SETTING: The first regulated supervised inhalation site (safer smoking room) in North America has opened in Lethbridge, Alberta, as part of a supervised consumption site addressing all routes of consumption. When designing the service, we felt it was important to accommodate not just injection drug use but also inhalation because it is not the method of drug use that kills but the drug itself, all people who use drugs deserve service regardless of their mode of use, and people who use drugs should have the opportunity to use the method with the lowest risk.
INTERVENTION: We received approval from Health Canada to offer supervised inhalation services in addition to supervised injection services. Based on a European model, we worked with a local commercial heating, cooling, and ventilation (HVAC) company to create rooms with ventilation systems that complied with Canadian health and safety regulations.
OUTCOME: People who use drugs by inhalation have repeatedly told us that they want to use indoors and will do so given the option. Since opening the supervised consumption service at the end of February 2018, the response has been overwhelming and both of the inhalation rooms are constantly in use.
IMPLICATIONS: Supervised inhalation services provide an alternative to public drug use and an opportunity for people who use drugs to engage with harm reduction services. Other supervised consumption services in Canada may also wish to pursue exemptions for this service.
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Thomas Kerr, Sanjana Mitra, Mary Clare Kennedy, Ryan McNeil
Canada Drug consumption rooms Harm Reduction Insite Montreal Ottawa Overdose Prevention Sites Overdose mortality Supervised injection facilities Toronto
Supervised injection facilities in Canada: past, present, and future
Canada has long contended with harms arising from injection drug use. In response to epidemics of HIV infection and overdose in Vancouver in the mid-1990s, a range of actors advocated for the creation of supervised injection facilities (SIFs), and after several unsanctioned SIFs operated briefly and closed, Canada’s first sanctioned SIF opened in 2003. However, while a large body of evidence highlights the successes of this SIF in reducing the health and social harms associated with injection drug use, extraordinary efforts were needed to preserve it, and continued activism by local people who inject drugs (PWID) and healthcare providers was needed to promote further innovation and address gaps in SIF service delivery. A growing acceptance of SIFs and increasing concern about overdose have since prompted a rapid escalation in efforts to establish SIFs in cities across Canada. While much progress has been made in that regard, there is a pressing need to create a more enabling environment for SIFs through amendment of federal legislation. Further innovation in SIF programming should also be encouraged through the creation of SIFs that accommodate assisted injecting, the inhalation of drugs. As well, peer-run, mobile, and hospital-based SIFs also constitute next steps needed to optimize the impact of this form of harm reduction intervention.
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Mary Clare Kennedy, Kanna Hayashi, M-J Milloy, Evan Wood, Thomas Kerr
All-cause mortality Canada People Who Inject Drugs Supervised Injection Facilities Vancouver
Supervised injection facility use and all-cause mortality among people who inject drugs in Vancouver, Canada: A cohort study
BACKGROUND: People who inject drugs (PWID) experience elevated rates of premature mortality. Although previous studies have demonstrated the role of supervised injection facilities (SIFs) in reducing various harms associated with injection drug use, including accidental overdose death, the possible impact of SIF use on all-cause mortality is unknown. Therefore, we examined the relationship between frequent SIF use and all-cause mortality among PWID in Vancouver, Canada.
METHODS AND FINDINGS: Data were derived from 2 prospective cohort studies of PWID in Vancouver, Canada, between December 2006 and June 2017. Every 6 months, participants completed questionnaires that elicited information regarding sociodemographic characteristics, substance use patterns, social-structural exposures, and use of health services including SIFs. These data were confidentially linked to the provincial vital statistics database to ascertain mortality rates and causes of death. We used multivariable extended Cox regression analyses to estimate the independent association between frequent (i.e., at least weekly) SIF use and all-cause mortality. Of 811 participants, 278 (34.3%) were women, and the median age was 39 years (IQR 33–46) at baseline. In total, 432 (53.3%) participants reported frequent SIF use at baseline, and 379 (46.7%) did not. At baseline, frequent SIF users were on average younger than nonfrequent users, and a higher proportion of frequent SIF users than nonfrequent users were unstably housed, resided in the Downtown Eastside neighbourhood, injected in public, had a recent non-fatal overdose, used prescription opioids at least daily, injected heroin at least daily, injected cocaine at least daily, and injected crystal methamphetamine at least daily. A lower proportion of frequent SIF users than nonfrequent users were HIV positive and enrolled in addiction treatment at baseline. The median duration of follow-up among study participants was 72 months (IQR 24–123). In total, 112 participants (13.8%) died during the study period, yielding a crude mortality rate of 22.7 (95% CI 18.7–27.4) deaths per 1,000 person-years. The median years of potential life lost per death was 34 (IQR 27–42) years. In a time-updated multivariable model, frequent SIF use was inversely associated with risk of all-cause mortality after adjusting for potential confounders, including age, sex, HIV seropositivity, unstable housing, at least daily cocaine injection, public injection, incarceration, enrolment in addiction treatment, and calendar year of interview (adjusted hazard ratio 0.46, 95% CI 0.26–0.80, p = 0.006). The main study limitations are the limited generalizability of findings due to non-random sampling, the potential for reporting biases due to reliance on some self-reported information, and the possibility that residual confounding influenced findings.
CONCLUSIONS: We observed a high burden of premature mortality among a community-recruited cohort of PWID. Frequent SIF use was associated with a lower risk of death, independent of relevant confounders. These findings support efforts to enhance access to SIFs as a strategy to reduce mortality among PWID. Further analyses of individual-level data are needed to determine estimates of, and potential causal pathways underlying, associations between SIF use and specific causes of death.
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Mary Clare Kennedy, Kanna Hayashi, M-J Milloy, Jade Boyd, Evan Wood, Thomas Kerr
Canada Injection Drug Use Prospective cohort Supervised Injection Facilities Violence
Supervised injection facility use and exposure to violence among a cohort of people who inject drugs: A gender-based analysis
BACKGROUND: Supervised injection facilities (SIFs) have been established in many settings, in part to reduce risks associated with injecting in public, including exposure to violence. However, the relationship between SIF use and experiencing violence has not yet been thoroughly evaluated. We sought to longitudinally examine the gender-specific relationship between SIF use and exposure to violence among people who inject drugs (PWID) in a Canadian setting.
METHODS: Data were drawn from two prospective cohort studies of PWID in Vancouver, Canada, between December 2005 and December 2016. Semi-annually, participants completed questionnaires that elicited data concerning sociodemographic characteristics, behavioural patterns, violent encounters and health service utilization. We used multivariable generalized estimating equations (GEE) to estimate the independent association between exclusively injecting drugs at a SIF and experiencing physical or sexual violence among men and women PWID, respectively.
RESULTS: Of 1930 PWID followed for a median of four years, 679 (35.2%) were women and the median age was 41 years at baseline. In total, 353 (52.0%) women and 694 (55.5%) men reported experiencing at least one incident of violence during follow-up. In multivariable analyses, exclusive SIF use was associated with decreased odds of experiencing violence among men after adjusting for potential confounders (Adjusted Odds Ratio [AOR] = 0.64; 95% confidence interval [CI]: 0.46–0.89). Exclusive SIF use was not significantly associated with experiencing violence among women in adjusted analyses (AOR = 0.97; 95% CI: 0.57–1.66).
CONCLUSION: In light of the recent expansion of SIFs in Canada, our finding of a protective association between exclusive SIF use and exposure to violence among men is encouraging. The fact that we did not observe a significant association between SIF use and experiencing violence among women highlights the need for social-structural interventions that are more responsive to the specific needs of women PWID in relation to violence prevention.
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Mary Clare Kennedy, David C. Klassen, Huiru Dong, M-J S. Milloy, Kanna Hayashi
Canada Long-term patterns of utilization People Who Inject Drugs Supervised Injection Facility Vancouver
Supervised Injection Facility Utilization Patterns: A Prospective Cohort Study in Vancouver, Canada
INTRODUCTION: Although the health and community benefits of supervised injection facilities are well documented, little is known about long-term patterns of utilization of this form of health service. The present study seeks to longitudinally characterize discontinuation of use of a supervised injection facility in Vancouver, Canada.
METHODS: Data were drawn from 2 community-recruited prospective cohorts of people who inject drugs between December 2005 and December 2016. In 2018, extended Cox regression for recurrent events was used to examine factors associated with time to cessation of supervised injection facility use during periods of active injection.
RESULTS: Of 1,336 people who inject drugs that were followed for a median of 50 months, 847 (63.4%) participants reported 1,663 6-month periods of supervised injection facility use cessation while actively injecting drugs (incidence density of 26.6 events per 100 person-years). An additional 2,282 (57.8%) of the total 3,945 6-month periods of supervised injection facility use cessation occurred during periods of injection cessation. In multivariable analyses, enrollment in methadone maintenance therapy (adjusted hazard ratio=1.41) and HIV seropositivity (adjusted hazard ratio=1.23) were positively associated with supervised injection facility use cessation during periods of active injection, whereas homelessness (adjusted hazard ratio=0.59), at least daily heroin injection (adjusted hazard ratio=0.70), binge injection (adjusted hazard ratio=0.68), public injection (adjusted hazard ratio=0.67), nonfatal overdose (adjusted hazard ratio=0.73), difficulty accessing addiction treatment (adjusted hazard ratio=0.69), and incarceration (adjusted hazard ratio=0.70) were inversely associated with this outcome (all p<0.05). The most commonly reported reasons for supervised injection facility use cessation were injection drug use cessation (42.3%) and a preference for injecting at home (30.7%).
CONCLUSIONS: These findings suggest that this supervised injection facility successfully retains people who inject drugs at elevated risk of drug-related harms and indicate that many supervised injection facility clients neither use this service nor inject drugs perpetually.
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Noam Katz, Lynne Leonard, Lorne Wiesenfeld, Jeffrey J. Perry, Venkatesh Thiruganasambandamoorthy, Lisa Calder
Canada Drug consumption rooms Emergency physicians Harm Reduction Supervised Injection Facilities
Support of supervised injection facilities by emergency physicians in Canada
Despite evidence supporting the implementation of supervised injection facilities (SIFs) by multiple stakeholders, no evaluation of emergency physicians’ attitudes has ever been documented towards such facilities in Canada or internationally. The primary goal of our study was to determine the opinions and perceptions of emergency physicians regarding the implementation of SIFs in Canada.
We conducted a national electronic survey of staff and resident emergency physicians in Canada using an iteratively designed survey tool in consultation with content experts. Invitations to complete the survey were sent via email by the Canadian Association of Emergency Physicians. Inclusion criteria required respondents to have treated an adult patient in a Canadian emergency department within the preceding 6 months. The primary measure was the proportion of respondents who would support, not support or were unsure of supporting SIFs in their community with the secondary measure being the likelihood of respondents to refer patients to a SIF if available.
We received 280 responses out of 1353 eligible physicians (20.7%), with the analysis conducted on 250 responses that met inclusion criteria (18.5%). The majority of respondents stated they would support the implementation of SIFs in their community (N = 172; 74.5%) while 10.8% (N = 25) would not and 14.7% (N = 34) did not know. The majority of respondents said they would refer their patients to SIFs (N = 198; 84.6%), with 4.3% (N = 10) who would not and 11.1% (N = 26) who were unsure.
The findings from our study demonstrate that the majority of emergency physician respondents in Canada support the implementation of such sites (74.5%) while 84.6% of respondents would refer patients from the emergency department to such sites if they did exist. Given that many Canadian cities are actively pursuing the creation of SIFs or imminently opening such sites, it appears that our sample population of emergency physicians would both support this approach and would utilize such facilities in an effort to improve patient-centered outcomes for this often marginalized population.
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Evan Wood, Thomas Kerr, Mark W. Tyndall, Julio S.G. Montaner
Addiction Best evidence Canada Health Policy Peer review Political interference Scientific process Supervised Injecting Facility
The Canadian government's treatment of scientific process and evidence: Inside the evaluation of North America's first supervised injecting facility
Although the recommendations of scientific review bodies have traditionally been free of political interference in Canada, there have recently been growing concerns raised about Canada's new federal government's treatment of scientific processes and evidence. This concern is relevant to the scientific evaluation of Canada's first medically supervised safer injecting facility (SIF), which opened in Vancouver in 2003, where illicit injection drug users can inject pre-obtained illicit drugs under the supervision of nurses. This commentary describes what may be a serious breach of international scientific standards relating to the Canadian government's handling of the SIF's scientific evaluation, and the circumstances which eventually led to a moratorium on SIF trials in other Canadian cities. Although the primary focus of this discussion should remain on the health of the people using the SIF, it is hoped that the publication of the information contained in this report will lead to greater public scrutiny of the Canadian government's handling of addiction research and drug policy, and provide lessons for researchers, drug policy-makers, and affected communities in other settings.
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Marie Jauffret-Roustide, Isabelle Cailbault
Acceptability Controversy analysis Drug Policy Drug consumption rooms France Harm Reduction Paris
Drug consumption rooms: Comparing times, spaces and actors in issues of social acceptability in French public debate
BACKGROUND:In October 2016, the first French drug consumption room (DCR) opened in Paris. We propose to examine the process through which this issue has been framed as a matter of public concern, after being ignored for almost 20 years. Our analysis of the controversy on DCRs investigates how public conversations on harm reduction evolve according to the time period (from the 1990s to the present), scale of discourse (local vs. national), and involved actors (politicians, professionals, local residents, and drug users).
METHODOLOGY: Our methodology includes analyses of media content: we reviewed 1735 articles published between 1990 and 2017. Our theoretical approach is in line with the sociology “des épreuves” derived from pragmatic sociology and controversy analysis. This approach goes beyond interactionism by attempting to place situations back into broader sociological realities. We also pay special attention to governance, a political lens that focuses on local aspects of negotiations and on the implication of a variety of actors.
RESULTS: While the current debate on DCRs in France draws on constraints and resources already present in the harm reduction debate of the 1980s, it also repositions itself by avoiding moral argumentation and featuring less confrontation in the professional sphere. Today, we can see that the center of this tense debate has shifted from the professional sphere to the political and residential spheres. Most often, residents advance concerns that are not directly related to drug users themselves, but that derive from their apprehension of living in a displaced and stranded neighborhood. The public conversation leaves little room for drug users, even though they are the primary stakeholders of harm reduction and play a crucial role in DCR advocacy.
CONCLUSION: Our work reveals that the controversy about DCR is the product of complex interactions between different kinds of actors harm reduction professionals, political actors at the local and national levels, local residents, and drug users. Comparing different instances of public debate reveals the specific limitations and potentials for change in French drug policy.
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Tristan Duncan, Cameron Duff, Bernadette Sebar, Jessica Lee
Drug consumption rooms Frankfurt Germany Harm Reduction Pleasure Post-humanism
‘Enjoying the kick’: Locating pleasure within the drug consumption room
BACKGROUND: Harm reduction policy and praxis has long struggled to accommodate the pleasures of alcohol and other drug use. Whilst scholars have consistently highlighted this struggle, how pleasure might come to practically inform the design and delivery of harm reduction policies and programs remains less clear. The present paper seeks to move beyond conceptual critiques of harm reduction’s ‘pleasure oversight’ to more focused empirical analysis of how flows of pleasure emerge, circulate and, importantly, may be reoriented in the course of harm reduction practice.
METHODS: We ground our analysis in the context of detailed ethnographic research in a drug consumption room in Frankfurt, Germany. Drawing on recent strands of post-humanist thought, the paper deploys the concept of the ‘consumption event’ to uncover the manner in which these facilities mediate the practice and embodied experience of drug use and incite or limit bodily potentials for intoxication and pleasure.
RESULTS: Through the analysis, we mapped a diversity of pleasures as they emerged and circulated through events of consumption at the consumption room. Beyond the pleasurable intensities of intoxication’s kick, these pleasures were expressed in a range of novel capacities, practices and drug using bodies. In each instance, pleasure could not be reduced to a simple, linear product of drug use. Rather, it arose for our participants through distinctive social and affective transformations enabled through events of consumption at the consumption room and the generative force of actors and associations of which these events were composed.
CONCLUSION: Our research suggests that the drug consumption room serves as a conduit through which its clients can potentially enact more pleasurable, productive and positive relations to both themselves and their drug use. Acknowledging the centrality of pleasure to client engagement with these facilities, the paper concludes by drawing out the implications of these findings for the design and delivery of consumption room services.
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Freya Vander Laenen, Pablo Nicaise, Tom Decorte, Jessica De Maeyer, Brice De Ruyver, Pierre Smith, Louis Favril
Belgium Drug consumption rooms Feasibility Harm Reduction
Feasibility study on drug consumption rooms in Belgium - Étude de faisabilité de salles de consommation à moindre risque en Belgique
[English version below] Les usagers de drogues illicites (UDI) font l'expérience d'un vaste ensemble de dommages liés à cette consommation de drogues. Dans le monde entier, les Etats ont, depuis de nombreuses années, développé diverses options politiques en matière de drogues qui visent à réduire de tels dommages, lesdites politiques de Réduction des risques (Csete et al., 2016; Strang et al., 2012). Cette composante désigne les politiques, les programmes et les pratiques visant principalement la réduction des conséquences négatives connexes à l'usage de drogues psychoactives, légales ou illégales, sur les plans sanitaire, social et économique, sans pour autant viser la réduction de la consommation elle-même. La Réduction des Risques est basée sur un modèle de santé publique dont l'objectif premier est d'améliorer l'état de santé et de bien-être des usagers de drogues tout en réduisant les dommages pour la population et la société. Il s'agit donc d'un complément aux approches qui visent la prévention et la réduction de l'usage de drogues en général (EMCDDA, 2010). Des organisations internationales considèrent les interventions de Réduction des risques comme des good practices. Celles-ci incluent les traitements de substitution aux opiacés, les programmes d'échange et d'accès aux seringues et aux aiguilles, ou les traitements par délivrance d'héroïne contrôlée. L'une des interventions spécifiques de Réduction des Risques sont les salles de consommation à moindre risque (SMCR), que l'on définit comme des lieux reconnus légalement, offrant un environnement hygiéniquement sûr, où des individus peuvent consommer les drogues qu'ils ont obtenues préalablement, sans jugement moral, et sous la supervision d'un personnel qualifié. Bien que les SMCR peuvent varient quant à leurs procédures opérationnelles et leurs modèles de fonctionnement, leurs objectifs sont similaires. La finalité générale des SMCR est d'entrer en contact avec les populations d'UDI les plus à risque et de répondre à leurs problèmes, principalement les usagers injecteurs et ceux qui consomment en public. Pour cette population, les SMCR visent à réduire les risques de transmission d'infections, ainsi qu'à diminuer les problèmes de morbidité et de mortalité liés aux overdoses et aux autres dommages associés à l'usage de drogues en milieu non-hygiénique ou peu sûr. En plus de ces objectifs sanitaires, les SMCR visent également à réduire les nuisances liées à l'usage de drogues dans des lieux publics et de diminuer la présence de seringues et d'aiguilles usagées sur la voie publique, ainsi que d'autres problèmes d'ordre public en relation avec les scènes ouvertes de consommation de drogues. Ainsi, les SMCR visent à diminuer les conséquences négatives de l'usage de drogues illicites, tant au plan individuel que social. DRUGROOM │ 4 De tels services de Réduction des Risques sont opérationnels depuis 1986. En 2017, l'Europe compte 90 SMCR officielles dans huit pays: au Danemark, en Norvège, en Espagne, en Suisse, et dans les quatre pays voisins de la Belgique: en France, en Allemagne, au Luxembourg et aux Pays-Bas. Des preuves scientifiques substantielles ont été obtenues au cours des trente dernières années à propos de l'efficacité des SMCR. Malgré des différences opérationnelles, on a montré des effets positifs des SMCR tant pour les UDI que pour la population générale, en particulier lorsqu'elles sont intégrées dans le tissu des autres services d'assistance locale. En outre, la fréquentation et l'utilisation des SMCR ont été associées à une réduction significative des accidents par overdose et des problèmes liés à l'échange de seringues usagées, des blessures par injection, sans pour autant engendrer une augmentation du nombre d'UDI et sans affecter les taux de rechute. Les SMCR constituent aussi un point d'entrée important vers les services de soins et autres services sociaux pour usagers de drogues. Sur le plan social, la mise en place de SMCR a permis d'améliorer l'ordre public en réduisant la présence de déchets liés à l'injection sans pour autant avoir augmenté la criminalité associée à l'usage de drogues. Ainsi, les SMCR ont été évaluées comme ayant atteint leurs objectifs de santé et de sécurité publique, et trouvent donc leur place dans l'ensemble des services destinés aux UDI (Kennedy, Karamouzian, & Kerr, 2017; Potier et al., 2014). Cependant, malgré l'abondance de preuves scientifiques, la mise en place de SMCR reste un sujet très controversé, bien que ce soit à l'agenda politique d'un grand nombre de pays dans le monde (par ex. en Irlande, en Ecosse, ou aux Etats-Unis). Pourtant, à ce jour, il n'existe pas de SMCR en Belgique. La Cellule Générale de Politique Drogues a publié un document de travail en 2016 à ce sujet (CGPD, 2016). Ce document s'interroge sur la faisabilité et les conditions préalables à remplir pour la mise en place de SMCR en Belgique, avec une attention spécifique aux besoins et aux aspects organisationnels, budgétaires et légaux. Une des sept conclusions finales du document était qu'une étude de faisabilité était nécessaire si l'on voulait mettre en place de telles SMCR. C'est donc dans ce contexte que la Politique Scientifique Fédérale (BELSPO) a commandité, pour la première fois, une recherche évaluant cette faisabilité en Belgique. ----------------------------------- People who use illicit drugs (PWUD) experience a wide range of drug-related harms. Worldwide, countries have been converging on a core of drug policy options aimed at reducing these drug-related harms for many years, including harm reduction (Csete et al., 2016; Strang et al., 2012). This latter component, harm reduction, refers to policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs, without necessarily reducing drug consumption. Harm reduction is grounded within a public health model, which primarily aims to improve the health and well-being of drug users alongside reducing community and societal level harms, and complements approaches that seek to prevent or reduce the overall level of drug use (EMCDDA, 2010). International bodies identify harm reduction interventions as good practices, including opioid substitution treatment, needle and syringe (exchange) programmes, and heroin-assisted treatment (EMCDDA, 2010). One specific intervention includes drug consumption rooms1 (DCRs), defined as legally sanctioned facilities offering a hygienic environment where individuals can use pre-obtained drugs in a non-judgemental environment and under supervision of trained staff. Although DCRs vary in operational procedures and design, the aims of DCRs are similar across sites. The overall rationale for DCRs is reach out to, and address the problems of, specific high-risk populations of PWUD, especially injectors and those who consume in public. For this group, DCRs aim to reduce the risk of transmission of blood-borne infections, to reduce the likelihood of morbidity and mortality resulting from overdose, and to help people who use drugs avoid other harms associated with drug consumption under unhygienic or unsafe conditions. In addition to these health-oriented goals, DCRs also aim to contribute to a reduction in drug use in public places and the presence of discarded needles and other related public order problems linked with open drug scenes. In sum, DCRs aim to reduce both individual-level and public-level harms associated with illicit drug use. These harm reduction facilities have been operating since 1986; anno 2017, Europe counted 90 official DCRs in eight countries: Denmark, Norway, Spain, Switzerland, and Belgium’s four neighbouring countries: France, Germany, Luxembourg, and the Netherlands (EMCDDA, 2017). A substantial body of scientific evidence has accumulated over the past three decades to support the effectiveness of DCRs; although heterogeneous in design and operation, DCRs have demonstrated that they can 1 The term ‘drug consumption room’ is often used interchangeably with supervised injection facility (SIF), safe injection site (SIS), and medically supervised injection centre (MSIC). DRUGROOM │ 4 produce beneficial effects, both for PWUD and for the community, particularly when they are part of a wider continuum of local interventions. Moreover, (frequent) DCR use has been associated with reductions in overdose-related harms, syringe sharing and injection-related injuries, without increasing either the number of local PWUD or rates of relapse. DCRs also serve as important entry points to external drug treatment and other health and social services for PWUD. At the community level, the establishment of DCRs has contributed to improvements in public order through reductions in public drug use and publicly-discarded injection-related litter, and has not been associated with increases in drug-related crime. Collectively, the available evidence suggests that DCRs are effectively meeting their primary public health and order objectives and therefore supports their role within a continuum of services for PWUD (Kennedy, Karamouzian, & Kerr, 2017; Potier et al., 2014). Despite this abundance of evidence, implementation of DCRs remains highly controversial. Yet, the debate about implementing new DCRs remains high on the political agenda in a number of countries worldwide (e.g., Ireland, Scotland, United States). To date, Belgium does not offer a DCR to its drug using population. The General Drugs Policy Cell published a working paper in 2016 devoted to the topic of DCRs in Belgium (ACD, 2016). They sought to investigate the feasibility and preconditions for the implementation of DCRs in Belgium, with specific attention to needs, and organisational, budgetary and legal aspects. One of the seven final conclusions was that, if one wishes to implement a DCR, a prior feasibility study is essential. Against this background, the Belgian Science Policy Office (BELSPO) commissioned a first-ever study to assess the feasibility of DCRs in Belgium.
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V. Clergue-Duval, G. Cleirec, V. Taroni, J. Azuar
France Médecins généralistes Opinion Ordre public Paris Réduction des risques Salles de consommation à moindre risque
Salle de consommation à moindre risque : les généralistes majoritairement favorables à l'expérimentation
Contexte : L’ouverture de la première salle de consommation à moindre risque (SCMR) en France a eu lieu en octobre 2016 à Paris dans le Xe arrondissement. Les médecins généralistes libéraux (MG) du nord de Paris sont concernés en tant qu’acteurs du territoire de soins.
Objectif : Recueillir l’opinion des MG libéraux du nord de Paris sur l’expérimentation de la SCMR.
Méthode : Tous les MG libéraux des IXe, Xe, XVIIIe et XIXe arrondissements de Paris ont été contactés par téléphone, et un questionnaire a été adressé à ceux qui l’acceptaient.
Résultats : Cent onze MG ont répondu (âge médian 57 ans, 36 % de femmes, 57,3 % en cabinet individuel), soit 33,5 %. Une majorité des avis exprimés (61,5 %) étaient favorables à l’ouverture de la SCMR (p = 0,036), avec des réserves pour 39,3 % d’entre eux. 18 % de l’échantillon était sans opinion sur la question. En analyse multivariée, les facteurs significativement associés à un avis favorable étaient l’âge inférieur à 50 ans et le fait d’être prescripteur de traitements de substitution aux opiacés. Les principales réserves exprimées concernaient la sécurité des quartiers environnants.
Conclusion : Les MG étaient donc majoritairement favorables à une expérimentation de qualité de la SCMR sur leur territoire, notamment ceux formés à la réduction des risques depuis les années 1990. Cependant, ils étaient en attente des résultats de son évaluation concrète. Ces résultats méritent d’être réévalués plusieurs mois après l’ouverture de la SCMR.
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Carrie Lingle
Critical Review Drug consumption rooms Harm Reduction International Methodology
A Critical Review of the effectiveness of Safe Injection Facilities as a Harm Reduction strategy
Injection drug use is associated with several public health issues, primarily the spread of serious blood-borne diseases such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV). Injections drug users often participate in risky behaviors such as the sharing of drug paraphernalia. Blood-borne diseases such as HIV and HCV are very easily transmitted between injection drug users through shared drug paraphernalia. In the United States, over one million people are infected with HIV, and one third of these infections are related to injection drug use in some manner.
There are many traditional interventions and programs currently being implemented in an attempt to address the public health issues associated with injection drug use; however, a controversial intervention focused on harm reduction is the focus of this paper. Safe injection facilities are relatively new interventions aimed at reaching high-risk injection drug users. These facilities provide a safe place in which injection drug users can take their own drugs and inject them under the supervision of medical staff. The benefits of this type of intervention are many. Injection drug users are able to inject in a safe environment in which they do not feel rushed, easy access to clean drug paraphernalia to use for injections, and trained medical staff are able to respond to overdose situations in a rapid manner. Safe injection facilities have an excellent record of reducing overdose deaths, in some cases to zero. There is potential for safe injection facilities to be of great public health significance in helping to control the spread of diseases and improving the quality of life for drug users.
Safe injection facilities are common in Europe, but are viewed with great hesitation and concern in North America and some other countries. This paper is a critical review of the literature, examining studies conducted on the various issues surrounding safe injection facilities, and their potential role as an important public health intervention.
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Mehmet Zülfü Öner
Drug Addiction Drug Policy Drug consumption rooms Harm Reduction International
An Overview Of Drug Consumption Rooms
In response to growing concerns about the public health and public order problems related to drug use, countries use a comprehensive approach to the drug problem, which includes prevention, harm reduction, treatment, and enforcement. Harm reduction encompasses interventions, programmes and policies that seek to reduce the health, social and economic harms of drug use to individuals, communities and societies. Drug consumption rooms are an example of a harm reduction programme and are a component of some drug strategies in some countries.
Drug consumption rooms (DCRs) are legally sanctioned public health facilities that offer a hygienic environment where people can use drugs under the supervision of trained staff. The overall rationale for consumption rooms is to reach and address the problems of specific, high-risk populations of drug users, especially injectors and those who consume in public. Drug consumption rooms aim to reduce the risk of transmission of blood-borne infections, in particular HIV (Human Immunodeficiency Virus) and hepatitis; to reduce the likelihood of illness and death resulting from overdose; and to help people who use drugs avoid other harms associated with drug consumption under unhygienic or unsafe conditions.
This article looks at the experiences with drug consumption rooms describes the general features and analyzes them from a historical point of view. This article also explores the position of these rooms in international law.
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Tara Marie Watson, Carol Strike, Gillian Kolla, Rebecca Penn, Jennifer Jairam, Shaun Hopkins, Janine Luce, Naushaba Degani, Peggy Millson, Ahmed Bayoumi
Crack cocaine Drug consumption rooms Harm Reduction International Stakeholders Supervised Consumption Facility Supervised Injecting Facility Supervised Smoking Facility
Design considerations for supervised consumption facilities (SCFs): Preferences for facilities where people can inject and smoke drugs
BACKGROUND: Supervised consumption facilities (SCFs) aim to improve the health and well-being of people who use drugs by offering safer and more hygienic alternatives to the risk environments where people typically use drugs in the community. People who smoke crack cocaine may be willing to use supervised smoking facilities (SSFs), but their facility design preferences and the views of other stakeholders have not been previously investigated in detail.
METHODS: We consulted with people who use drugs and other stakeholders including police, fire and ambulance service personnel, other city employees and city officials, healthcare providers, residents, and business owners (N = 236) in two Canadian cities without SCFs and asked how facilities ought to be designed. All consultations were audio-recorded and transcribed. Thematic analyses were used to describe the knowledge and opinions of stakeholders.
RESULTS: People who use drugs see SSFs as offering public health and safety benefits, while other stakeholders were more sceptical about the need for SSFs. People who use drugs provided insights into how a facility might be designed to accommodate supervised injection and supervised smoking. Their strongest preference would allow both methods of drug use within the same facility with some form of physical separation between the two based on different highs, comfort regarding exposure to different methods of drug administration, and concerns about behaviours often associated with smoking crack cocaine. Other stakeholders raised a number of SSF implementation challenges worthy of consideration.
CONCLUSION: Decision-makers in cities considering SCF or SSF implementation should consider the opinions and preferences of potential clients to ensure that facilities will attract, retain, and engage people who use drugs.
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Vendula Belackova, Allison M. Salmon, Eberhard Schatz, Marianne Jauncey
Drug Consumption Rooms Hepatitis C support services Hepatitis C testing Hepatitis C treatment International People Who Inject Drugs Supervised Injecting Facilities
Drug consumption rooms (DCRs) as a setting to address hepatitis C – findings from an international online survey
BACKGROUND: Prevalence of Hepatitis C Virus (HCV) among people who inject drugs (PWID) is high. Risky injecting behaviours have been found to decrease in drug consumption rooms (DCRs) and supervised injecting facilities (SIFs), yet HCV prevention and treatment in these settings have not been extensively explored.
METHODS: To determine the range and scope of HCV prevention and treatment options in these services, we assessed DCR/SIF operational features, their clients’ characteristics and the HCV-related services they provide. A comprehensive online survey was sent to the managers of the 91 DCRs/SIFs that were operating globally as of September 2016. A descriptive cross-country analysis of the main DCR/SIF characteristics was conducted and bivariate logistic models were used to assess factors associated with enhanced HCV service provision.
RESULTS: Forty-nine valid responses were retrieved from DCRs/SIFs in all countries where they were established at the time of the survey (Australia, Canada, Denmark, France, Germany, Luxembourg, Netherlands, Norway, Spain and Switzerland). Internationally, the operational capacities of DCRs/SIFs varied in terms of funding, location, size and staffing, but their clients all shared common features of vulnerability and marginalisation. Estimated HCV prevalence rates were around 60%. Among a range of health and social services and referrals to other programs, most DCRs/SIFs provided HCV testing onsite (65%) and/or offered liver monitoring or disease management (54%). HCV treatment onsite was offered or was planned to be offered by 21% of DCRs/SIFs. HCV testing onsite was associated with provision of other services addressing blood-borne diseases and HCV treatment was linked to the provision of OST. HCV disease management was associated with employing a nurse at a DCR/SIF and HCV treatment was associated with employing a medical doctor.
CONCLUSIONS: DCRs/SIFs offer easy-to-access HCV-related services for PWID. The availability of onsite medical professionals and provision of support and education to non-medical staff are key to enhanced provision of HCV-related services in DCRs/SIFs. Funding and support for HCV treatment at the community level, via low-threshold services such as DCRs/SIFs, are worthy of action.
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Benedikt Fischer, Sarah Turnbull, Blake Poland, Emma Haydon
Exclusion Governmentality Harm Reduction International Public Order Supervised Injection Sites Urban Health
Drug use, risk and urban order: examining supervised injection sites (SISs) as ‘governmentality’
This paper problematises the emergence and functioning of the recent phenomenon of ‘supervised injection sites’ (SISs) as a case study of post-welfarist governmentality. We propose that SISs arose as an unprecedented intervention in the late 20th century to deal with the increasing challenge of ‘urban drug scenes’ towards public order interests ‘entrepreneurial city’. Under predominant discourses of ‘public health’ and ‘harm reduction’, SISs became possible within a wide variety of political interests as a technology for purifying public spaces of ‘disorderly’ drug users to present the ‘new city’ as an attractive consumption space. Thus, SISs can be meaningfully understood as one element of socio-spatial ‘exclusion’ of marginalised populations from urban cores to ghettoised, peripheral spaces, even as they more benignly seek to better meet the unique needs of drug user populations. Further, the inner workings of SISs illustrate these facilities as powerful surveillance and discipline sites, defining the drug user as an agent of omnipresent risk being responsibilized in the care of the self and body, but also multiple aspects of behaviour and lifestyle reaching beyond drug use; thus construing the drug user as a ‘normalised’ citizen/consumer. We suggest that pressures to answer to powerful interests promoting ‘order’ are concretised as practices of ‘risk management’ ‘on the shop floor’, raising serious questions about the extent to which the ability to meet user needs is compromised in the interest of social control, surveillance, ‘management’, ‘education’, and ‘rehabilitation’, particularly in the current socio-political context (characterised as it is by a persistence, and indeed concomitant hardening, of repressive measures ‘on the street’).
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Marilou Gagnon, Tim Gauthier, Elena Adán, Andy Bänninger, Luc Cormier, Jennifer Kathleen Gregg, Sara Gill, Kirsten Horsburgh, Peter Kreutzmann, Julie Latimer, Gurvan Le Bourhis, Christi...
Addiction Consensus Drug Consumption Rooms Harm Reduction International Nurses Nursing role Supervised Consumption Sites
International Consensus Statement on the Role of Nurses in Supervised Consumption Sites
BACKGROUND AND OBJECTIVE: Supervised consumption sites (SCS) have been implemented in Europe, North America and Australia, reaching a total of 158 sites worldwide. In addition to reducing harms and preventing overdoses and overdose deaths, SCS act as a point of service for people who use drugs to access much needed health care services. Registered nurses who work in SCS provide care, support, education, and resources to reduce health risks and improve health. It has been clearly established that these interventions fall within the legislated scope of practice of registered nurses but the actual role of nurses in SCS remains poorly defined and understood, especially by decision-makers, employers, health care providers, and the broader community.
MATERIAL AND METHODS: To address this significant practice, policy and research gap, a consensus statement was developed based on information generated by 17 content experts from 10 countries namely, Canada, Spain, Australia, France, Denmark, Norway, Ireland, Switzerland, Germany, and Scotland. The statement was developed from “the ground up” by gathering information on three content areas: nursing practice in SCS, training, and needs. This information was summarized, and then submitted to two rounds of voting using a modified Delphi method to build consensus.
RESULTS: The final content of the consensus statement is comprised of five sections: 1) Philosophy of care, 2) Framework, 3) Nursing role, 4) Training requirements, and 5) Needs of nurses.
CONCLUSION: This consensus statement is a first step toward a better understanding of the role of nurses in SCS. There is an immense responsibility on nurses in this setting, as the majority of people who access SCS face many barriers in accessing other health and social services, even when their need for those services may be critical. For these reasons, it is essential to better prepare nurses for these realities. It is our hope that this first international consensus statement can serve as a foundation to guide practice, policy, research, and operational decisions in SCS.
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Vendula Belackova, Allison M. Salmon, Eberhard Schatz, Marianne Jauncey
Drug consumption rooms HCV International Supervised Injecting Facilities
Online census of Drug Consumption Rooms (DCRs) as a setting to address HCV: current practice and future capacity
Drug consumption rooms (DCRs) and supervised injecting facilities (SIFs) target the most vulnerable people who use drugs (PWUD) – particularly people who use opioids, people who inject drugs (PWID), people who use drugs heavily or high-risk drug users (HRDI). While decreases in risky injecting behaviours are an outcome of DCR use, HCV prevention and treatment in these settings haven’t been adequately described. There are no international DCR standards for HCV practice and surveys are yet to address HCV prevention, treatment or sero-prevalence status of DCR clients. This online survey provides a ‘snapshot’ of DCR clients’ HCV status; approaches to HCV in DCRs, and what DCRs need to expand these services.
Fifty-one responses were collected from representatives of the 92 operating DCRs in Australia, Canada, Denmark, France, Germany, Luxembourg, Netherlands, Norway, Spain and Switzerland participated in the survey; thus over half of the DCRs were directly represented (55 %) and several respondents had filled the survey on behalf of several DCR’s within their organisation. All countries where DCRs are operated were represented.
An estimated mean 71% of SIF/DCR clients had been tested for HCV and about 58% were HCV positive. Most DCRs provided HCV testing onsite (67%); of these majority tested via blood samples (65%) and several used finger prick (31%) or saliva (31%). Several DCRs referred to offsite HCV testing (75%). Only four European DRCs provided HCV treatment onsite at the time of the survey; twowere providing DAAs (“new treatment”) and two were providing both interferon and DAAs treatments. The majority of SIFs/DCRs referred clients offsite for treatment (96%). Several offered disease self-management support (50%) or monitoring liver health (24%). Overall, DCRs reported that HCV support (94%), new treatments (92%) or treatment with interferon (50%) were available for their clients at other services.
To provide further HCV-related services, DCR indicated that they need more staff time (51%) and staff training (45%), that they would have to expand staff qualifications (30%) and that further funding for equipment and services would be needed (38%). A change in national HCV treatment guidelines for active drug users was also identified as a need (23%). When it comes any additional funding, the respondents indicated they would use it on employing additional medical staff (52%), develop client education (52%) or on additional staff training (46%).
DCR involvement in HCV prevention and treatment is crucial. SIFs/DCRs should to be supported to provide an entry point to HCV treatment as they are working on the frontline with the most marginalised PWID and are capable of removing barriers to HCV treatment in this population. Also, options for colocation of HCV services at DCRs or provision of HCV treatment onsite should be considered.
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Tom May, Trevor Bennett, Katy Holloway
International RETRACTED
RETRACTED: The impact of medically supervised injection centres on drug-related harms: A meta-analysis
This article has been retracted at the request of the Editor-in-Chief of the International Journal of Drug Policy.
In light of two critical reviews received by the International Journal of Drug Policy after publication (available on request), and additional commissioned independent assessments, the International Journal of Drug Policy has retracted the following paper from publication: May, T., Bennett, T. and Holloway, K. (2018) The impact of medically supervised injection centres on drug-related harms: A meta-analysis, 59: 98-107.
This action is supported by the authors’ acknowledgement of methodological weaknesses linked to the pooling of diverse outcomes into a single composite measure (authors’ response to critical reviews also available on request from the Editor). The authors have acknowledged that these analyses should not have been undertaken in this way and resulted from honest human error in the use of methods. Accordingly, the authors acknowledge that the combined effect size reported in the original paper should be discounted. Given that the composite measure was a key finding reported by the original paper, the decision to retract the paper from publication had been made, including with the consent of the authors. The journal acknowledges that the peer review process did not pick up on the specific methodological weaknesses identified post publication. The International Journal of Drug Policy takes its peer review process extremely seriously. It is for this reason that the International Journal of Drug Policy commissioned an independent assessment of the original paper in addition to the original peer review reports in order to assess whether to retract the paper.
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BACKGROUND: Medically Supervised Injection Centres (MSICs) are legally-sanctioned facilities where users can consume pre-obtained drugs under medical supervision. Although there is a substantial body of research exploring their effectiveness, there have been few attempts to quantify outcomes across studies. In order to determine the impact of the body of research as a whole, outcomes from studies were synthesised using meta-analysis.
METHODS: Literature sources were identified through searches in four bibliographic databases. Inclusion in the final review was dependent on the study meeting certain eligibility criteria, including a minimum of pre-test, post-test, control group designs. Data were extracted and pooled in a meta-analysis using both fixed and random effects methods.
RESULTS: Eight studies met the inclusion criteria. Overall, MSICs had a significant, but small, positive effect on outcomes based on the fixed effect analysis and no effect based on random effect analysis. The results of the independent outcome analyses showed that MSICs had a significant favourable result in relation to drug-related crime and a significant unfavourable result in relation to problematic heroin use or injection. MSICs were found to have no effect on overdose mortality or syringe/equipment sharing.
CONCLUSION: Whilst the effectiveness of the early versions of MSICs remains uncertain, this should not rule out continuing to test and develop MSICs in locations where public injecting and other drug-related harms are a major problem. It is important, however, that evaluation research publishes replicable data to enable future meta-analyses and to expand the body of knowledge in the field.
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Drug consumption rooms HCV HIV Harm Reduction International Overdose mortality Poster
Scientific and programmatic implications of safer injection facilities for persons who inject drugs illicitly
Background: Persons who inject drugs (PWID), particularly those who inject in streets, alleys, and parks, use needles and syringes used by others, or use unclean drug-preparation equipment (cotton, cookers, or water) are at risk for HIV, HBV, and HCV infections. To reduce risk for infectious diseases and improve health outcomes, cities in Australia, Canada, Germany, Luxembourg, Netherlands, Norway, Spain, and Switzerland established safer injection facilities (SIFs) following establishment of legal support. SIFs provide clean injection environments, sterile injection equipment, and clean drug-preparation equipment at the time of injection.
Method: We reviewed and summarized the published scientific evidence (PubMed, EMBASE, PsychInfo) and appraised the programmatic implications of SIFs.
Results: At SIFs, persons can more safely inject drugs that they have purchased outside of the facility. SIF management and staff do not assist in
injection. SIFs safely dispose of used equipment and provide on-site counseling, referral to addiction treatment and health services, and overdose emergency assistance. SIFs limit transmission of HIV, viral hepatitis, and bacterial infections, reduce overdose mortality, prevent accidental needlestick injuries to community members, reduce public nuisance and litter, and improve health outcomes and public safety. As cost-saving and costeffective interventions, SIFs offer unique and complementary benefits, as compared to other effective interventions (prevention and treatment of drug abuse, syringe exchange programs, non-prescription pharmacy sale of sterile injection equipment, safe disposal programs for used equipment, community overdose prevention programs, prevention and treatment of infectious diseases) which often are not available to all persons who use drugs. Through collaboration with community members, law enforcement officers, persons who inject drugs, service providers, and public health scientists and practitioners, SIFs can meet needs of users and communities.
Conclusions: SIF services, within a multipronged intervention approach, address complex social and public health consequences of injection drug use and ameliorate the negative effects of injection drug use on users and communities.
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Jonathan P. Caulkins, Bryce Pardo, Beau Kilme
Causal evidence International Supervised Consumption Sites
Supervised consumption sites: a nuanced assessment of the causal evidence
BACKGROUND AND AIMS: Supervised consumption sites (SCS) operate in more than 10 countries. SCS have mostly emerged as a bottom‐up response to crises, first to HIV/AIDS and now overdose deaths, in ways that make rigorous evaluation difficult. Opinions vary about how much favorable evidence must accumulate before implementation. Our aim was to assess the nature and quality of evidence on the consequences of implementing SCS.
METHODS: We reviewed the higher‐quality SCS literature, focusing on articles evaluating natural experiments and mathematical modeling studies that estimate costs and benefits. We discuss the evidence through the lens of three types of decision‐makers and from three intellectual perspectives.
RESULTS: Millions of drug use episodes have been supervised at SCS with no reported overdose deaths; however, uncertainties remain concerning the magnitude of the population‐level effects. The published literature on SCS is large and almost unanimous in its support, but limited in nature and the number of sites evaluated. It can also overlook four key distinctions: (1) between outcomes that occur within the facility and possible spillover effects on behavior outside the SCS; (2) between effects of supervising consumption and the effects of other services offered, such as syringe or naloxone distribution; (3) between association and causation; and (4) between effectiveness and the cost‐effectiveness of SCS compared to other interventions.
CONCLUSIONS: The causal evidence for favorable outcomes of supervised consumption sites is minimal, but there appears to be little basis for concern about adverse effects. This raises the question of how context and priors can affect how high the bar is set when deciding whether to endorse supervised consumption sites. The literature also understates distinctions and nuances that need to be appreciated to gain a rich understanding of how a range of stakeholders should interpret and apply that evidence to a variety of decisions.
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Chloé Potier, Vincent Laprevote, Françoise Dubois-Arber, Olivier Cottencin, Benjamin Rolland
Drug Consumption Rooms Harm Reduction International Supervised Injection Services Systematic review
Supervised injection services: what has been demonstrated? A systematic literature review
BACKGROUND: Supervised injection services (SISs) have been developed to promote safer drug injection practices, enhance health-related behaviors among people who inject drugs (PWID), and connect PWID with external health and social services. Nevertheless, SISs have also been accused of fostering drug use and drug trafficking.
AIMS: To systematically collect and synthesize the currently available evidence regarding SIS-induced benefits and harm.
METHODS: A systematic review was performed via the PubMed, Web of Science, and ScienceDirect databases using the keyword algorithm [(“SUPERVISED” OR “SAFER”) AND (“INJECTION” OR “INJECTING” OR “SHOOTING” OR “CONSUMPTION”) AND (“FACILITY” OR “FACILITIES” OR “ROOM” OR “GALLERY” OR “CENTRE” OR “SITE”)].
RESULTS: Seventy-five relevant articles were found. All studies converged to find that SISs were efficacious in attracting the most marginalized PWID, promoting safer injection conditions, enhancing access to primary health care, and reducing the overdose frequency. SISs were not found to increase drug injecting, drug trafficking or crime in the surrounding environments. SISs were found to be associated with reduced levels of public drug injections and dropped syringes. Of the articles, 85% originated from Vancouver or Sydney.
CONCLUSION: SISs have largely fulfilled their initial objectives without enhancing drug use or drug trafficking. Almost all of the studies found in this review were performed in Canada or Australia, whereas the majority of SISs are located in Europe. The implementation of new SISs in places with high rates of injection drug use and associated harms appears to be supported by evidence.
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Rebecca Jesseman, Karen Palmer
Bibliography Drug consumption rooms Harm Reduction Injection Drug Use Insite International Medically Supervised Injecting Centre Safe Injection Site Supervised Consumption Facilities Supervised Drug Consumption
Supervised Injection Sites - Injection Drug Use: A Bibliography
The Canadian Centre on Substance Use and Addiction (CCSA) produces this document to provide a central reference resource for peer-reviewed and grey literature publications presenting or analyzing research on the operation and impact of supervised consumption sites that provide services for injection drug use. CCSA regularly monitors peer-reviewed and grey literature for relevant new publications on this topic and adds them to this document. References are provided in the language of the original article.
This bibliography was first published in May 2009 and has been updated on an annual basis since then. It is intended as a resource for those interested in gaining an overview of recent literature on the topic. It was generated using variations on the term “injection facilities,” as well as searches related to targeted Canadian and Australian locations (specifically, Vancouver’s InSite and Sydney’s Medically Supervised Injecting Centre). Additional sources were identified through referrals from researchers in the field and reviews of reference lists.
For the current edition of this bibliography, 40 references have been added, identified through searches with date limits from June 1, 2016, to August 31, 2017. Additional web-based scans and searches were conducted in early September 2017. Literature searches were conducted in PubMed, PsycNET, EBSCO (MEDLINE Complete, and Psychology and Behavioral Sciences Collection) and Google Scholar. Grey literature was identified through Google searches and targeted website scanning. Four key phrases were used to conduct the searches: “supervised injection,” “injection facilities,” “safe injection” and “drug consumption rooms.” The Appendix provides additional details about the search strategy.
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Jaime Arredondo-Sánchez Lira, Clara Fleiz-Bautista, Pieter Baker, Jorge A. Villatoro-Velázquez, Mario Domínguez-García, Leo Beletsky
Attitudes Drug Policy Harm Reduction Heroin Mexico Safe Consumption Site Tijuana
Attitudes towards safe consumption sites among police and people with lived experience in Tijuana, Mexico: initial report from the field
INTRODUCTION: Mexico northern border has high levels of heroin use. For more than 10 years, the country has implemented several harm reduction interventions to reduce the risks associated with drug use. New strategies such as Safe Consumption Sites (SCS) must be considered as a next step to service vulnerable populations and increase their health outcomes.
OBJECTIVE: This report seeks to measure and compare attitudes on a potential SCS intervention in Tijuana among police and people with lived experience (PLE) in heroin use in the city.
METHOD: Two parallel studies on police practices and everyday experiences of heroin users in Tijuana were able to ask similar questions about attitudes toward SCS and its implementation in the city. They conducted quantitative interviews with 771 active police officers and 200 PLE while in rehabilitation services.
RESULTS: Both groups showed a high personal support for SCS of nearly 82% and a perceived implementation success around 80%. Officers reported 58.9% peer support for SCS while PLE 79%. Around 76% of both groups agreed that a SCS would help to improve their personal health. Finally, 86.2% of the officers would refer people to a SCS while 62.5% of PLE would use the service.
DISCUSSION AND CONCLUSIONS: The strong positive attitudes from police officers and PLE towards SCS in the city of Tijuana reported in both studies indicate the possibility of a successful implementation of a SCS. This intervention would represent an innovative way to protect PLE from police harassment and victimization, helping reduce HIV and HCV risk behaviors while improving community health.
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Sandra Solai, Françoise Dubois-Arber, Fabienne Benninghoff, Lazare Benaroyo
Ethics Geneva Harm Reduction Supervised Consumption Room Switzerland
Ethical reflections emerging during the activity of a low threshold facility with supervised drug consumption room in Geneva, Switzerland
A drug consumption room (DCR), ‘Quai 9’, opened in Geneva, Switzerland in 2001. As part of its evaluation, a study of situations which presented staff with ethical conflicts in their day to day work was undertaken in 2003. Problem situations were identified via an open ended questionnaire and non-participatory observations. The nature of the ethical conflicts encountered in the identified situations was discussed in a staff focus group and analysed using an ethical framework based on three levels of norms (personal, professional, institutional) adapted from a clinical setting. In a second focus group, an applied analysis, using the same level of norms from the first focus group, was presented to the staff to assist them dealing with ethical conflicts. Situations associated with ethical conflicts for staff were assisting clients to inject, client refusal to seek treatment in spite of poor health, new injectors, prohibition of access to minors, pregnant clients, client self mutilation, and non-participation in proposed activities. The study showed that despite Quai 9's clear objectives, expressed philosophy, and operational rules, the staff were frequently exposed to ethically conflicting situations. However, open and structured discussion of these situations using an ethical framework which allowed the identification of different norms and discussion of their respective importance in order to reach a common decision was feasible and useful in a DCR setting.
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Liz McCulloch
Cost-benefit Disease transmission Drug consumption rooms Europe Evidence-base Glasgow HCV HIV Harm Reduction Ireland
An investigation into the feasibility of establishing Drug Consumption Rooms
The time is right to look at new ways of reducing mortality among people who use illicit drugs. Across the UK, we are seeing record levels of drug-related deaths. These deaths often occur among people who use heroin, as well as alcohol and tobacco. The appearance of synthetic opioids like fentanyl and carfentanil in the UK drug markets threatens to cause even more harm.Many of the most vulnerable people are not well served by existing models of treatment. So we need new ways of engaging these people in services that can save their lives. The need for drug consumption rooms is urgent.
As this report shows, providing facilities where people can use illicitly purchased heroin under the supervision of trained staff has saved many lives in the countries where they already exist. There has never been a death from overdose in a drug consumption room. Although many overdose events have occurred, the presence of trained staff and swift delivery of oxygen and naloxone prevents death. Such facilities do not increase drug use or crime in their neighbourhoods. Rather, they reduce risks related to public injecting and discarded needles. They form a valuable part of the mix of interventions that are required to reduce deaths. This also includes opioid substitution therapy of optimal dosage and duration, wider provision of naloxone, heroin-assisted treatment and investment in welfare, social and mental health services.
The legal barriers to the establishment of drug consumption rooms have been reduced by acknowledgement at UN and UK government level that they can form a legitimate part of local responses to drug-related harms. But the Scottish Lord Advocate’s recent advice shows that a clearer legal framework will need to be provided. In the meanwhile, as this report explains, it is still possible for local areas to develop a discretionary model that enables the establishment of drug consumption rooms in places which have a high concentration of injecting drug use. The longer we wait to set them up, the more people will die preventable deaths.
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Rob Barker-Williams
Calgary Canada Copenhagen Denmark Drug consumption rooms Dublin Germany Glasgow Hamburg Harm Reduction
Drug Consumption Rooms: A Welsh Response
Drug Consumption Rooms (DCRs) can go by multiple names including: Medically Supervised Injecting Centres (MSIC); Supervised Injecting Facilities; Supervised Injecting Services; Community Health Engagement Locations (CHELs); and what they intend to be called in Wales, Enhanced Harm Reduction Centres (EHRCs). For the simplicity of this report, I will only use the DCR terminology, that will encapsulate all the other names. DCRs have been a part of the harm reduction movement within the substance use field since the mid 1980’s with the first such facility opening in Bern, Switzerland in 1986. Of the 123 DCRs that are currently operational worldwide, the majority are based within Europe. Australia and Canada are the hosts to DCRs outside of Europe. Closer to home, discussions regarding establishing a DCR in both Dublin and Glasgow are ongoing.
Within a DCR, people can use illicit drugs under the supervision of trained staff. The way these drugs can be administered depends on the model of the DCR; some facilities only allow injecting whereas others also provide areas for inhalation of substances. Different services may be available at other DCRs, with further explanation in section 7.1 but all DCRs provide clean equipment for people to administer their substances (e.g. needles, syringes, cookers etc). Most DCRs also provide naloxone on site (legislation permitting).
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Kirsten M.A. Trayner, Andrew McAuley, Norah E. Palmateer, David J. Goldberg, Samantha J. Shepherd, Rory N. Gunson, Emily J. Tweed, Saket Priyadarshi, Catriona Milosevic, Sharon J. Hutch...
Drug-related harms Glasgow HIV Harm Reduction People Who Inject Drugs Public injecting Scotland UK
Increased risk of HIV and other drug-related harms associated with injecting in public places: national bio-behavioural survey of people who inject drugs
BACKGROUND: Whilst injecting drugs in public places is considered a proxy for high risk behaviour among people who inject drugs (PWID), studies quantifying its relationship with multiple drug-related harms are lacking and none have examined this in the context of an ongoing HIV outbreak (located in Glasgow, Scotland). We aimed to: 1) estimate the prevalence of public injecting in Scotland and associated risk factors; and 2) estimate the association between public injecting and HIV, current HCV, overdose, and skin and soft tissue infections (SSTI).
METHODS: Cross-sectional, bio-behavioural survey (including dried blood spot testing to determine HIV and HCV infection) of 1469 current PWID (injected in last 6 months) recruited by independent interviewers from 139 harm reduction services across Scotland during 2017–18. Primary outcomes were: injecting in a public place (yes/no); HIV infection; current HCV infection; self-reported overdose in the last year (yes/no) and SSTI the last year (yes/no). Multi-variable logistic regression was used to determine factors associated with public injecting and to estimate the association between public injecting and drug-related harms (HIV, current HCV, overdose and SSTI).
RESULTS: Prevalence of public injecting was 16% overall in Scotland and 47% in Glasgow city centre. Factors associated with increased odds of public injecting were: recruitment in Glasgow city centre (aOR=5.45, 95% CI 3.48–8.54, p<0.001), homelessness (aOR=3.68, 95% CI 2.61–5.19, p<0.001), high alcohol consumption (aOR=2.42, 95% CI 1.69–3.44, p<0.001), high injection frequency (≥4 per day) (aOR=3.16, 95% CI 1.93–5.18, p<0.001) and cocaine injecting (aOR=1.46, 95% CI 1.00 to 2.13, p = 0.046). Odds were lower for those receiving opiate substitution therapy (OST) (aOR=0.37, 95% CI 0.24 to 0.56, p<0.001) and older age (per year increase) (aOR=0.97, 95% CI 0.95 to 0.99, p = 0.013). Public injecting was associated with an increased risk of HIV infection (aOR=2.11, 95% CI 1.13–3.92, p = 0.019), current HCV infection (aOR=1.49, 95% CI 1.01–2.19, p = 0.043), overdose (aOR=1.59, 95% CI 1.27–2.01, p<0.001) and SSTI (aOR=1.42, 95% CI 1.17–1.73, p<0.001).
CONCLUSIONS: These findings highlight the need to address the additional harms observed among people who inject in public places and provide evidence to inform proposals in the UK and elsewhere to introduce facilities that offer safer drug consumption environments.
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Jarryd Bartle
Drug Consumption Rooms Evidence-base Harm Reduction Overdose Prevention Centres Safe Injecting Rooms UK
Room for improvement: How drug consumption rooms save lives
Supervised drug consumption rooms (sometimes referred to as ‘safe injecting rooms’ or ‘overdose prevention centres’) allow people who use illicit drugs to consume substances whilst under the supervision of trained staff.
Drug consumption facilities aim to reduce risks of disease transmission, overdose and public nuisance whilst also providing a location for people who have substance dependence to access treatment, employment, and housing support services.
The UK currently does not have any supervised drug consumption rooms, although proposals for facilities have been made by local agencies in West Midlands, North Wales, Southampton, Glasgow, and Bristol. In 2016, the UK Advisory Council on the Misuse of Drugs recommended that consideration be given to the potential of drug consumption rooms within areas of high injecting drug use in order to reduce drug related deaths. The government response was that no plans existed to introduce drug consumption rooms in the UK.
A 2018 survey of injecting drug users in the UK found that a large majority (89%) expressed willingness to use a drug consumption room and accepted the need for rules within such facilities such as no drug sharing (84.3%), no assistance with injecting (81.8%), compulsory supervision (76.7%) and compulsory hand washing (92.1%).
The following paper will outline the need for drug consumption rooms in the UK, evidence supporting their use and considerations for implementation at a local level
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Amanda M. Atkinson, Andrew McAuley, Kirsten M.A. Trayner, Harry R. Sumnall
Agenda setting Drug Consumption Rooms Glasgow Harm Reduction News media Policy making Problematization UK
‘We are still obsessed by this idea of abstinence’: A critical analysis of UK news media representations of proposals to introduce drug consumption rooms in Glasgow, UK

BACKGROUND: Drug consumptions rooms (DCRs) are a well-established and evidence-based harm reduction response to drug use. Recently, a consortium led by health services in Glasgow, United Kingdom (UK), proposed piloting a DCR. In this article, we examine how the proposals were represented in news media reporting, and the possible effects of such reporting.

METHODS: A quantitative content and qualitative thematic analysis of UK news media (n = 174 articles) representations of the proposals to introduce DCRs in the city of Glasgow, UK, was conducted. Analysis was informed by Bacchi’s (2009, 2012, 2017). approach to policy analysis, ‘What's the problem represented to be?’

FINDINGS: Competing representations of the ‘problem’ of injecting drug use (IDU) were contested by a range of actors with different political visions. The applicability of the ‘evidence base’, potential benefits of DCRs to both users and the public, and the associated economic costs, were presented in differing ways depending on the underlying assumptions and presumptions of the arguments constructed (e.g. harm reduction vs recovery). As a result, a number of conflicting subject positions were presented that may have implications for the way that people who inject drugs (PWID) see themselves, and how they are viewed and treated by society. Whilst proponents positioned DCRs within a discourse of public health, an underlying rhetoric of abstinence and recovery underpinned the arguments against DCRs. It was this latter discourse that underpinned the UK Government’s rejection of the proposals, which the Scottish Government were prevented from overruling within the political constraints of their devolved powers, with the lived effect of people who use drugs (PWUD) being denied access to public health services that mitigate harm.

CONCLUSION: We conclude that attempts to introduce and gain public and political support for harm reduction responses such as DCRs through the news media face challenges within the historical and political context of prohibitionist UK drugs policy.

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Colleen L. Barry, Susan G. Sherman, Elizabeth Stone, Alene Kennedy-Hendricks, Jeff Niederdeppe, Sarah Linden, Emma E. McGinty
Harm Reduction Public opinion Safe Consumption Sites USA
Arguments supporting and opposing legalization of safe consumption sites in the U.S.
BACKGROUND: Safe consumption sites are spaces where people can legally use pre-obtained drugs under medical supervision and are currently in operation in Canada, Australia and Western Europe. These sites are effective in reducing opioid overdose mortality and other harms associated with opioid use, such as HIV infection, and increasing drug treatment entry. Various U.S. communities are considering establishing safe consumption sites, however, only 29% of U.S. adults support their legalization. This purpose of this study is to assess what types of arguments resonate with the public in support of and opposition to legalizing safe consumption sites to combat the opioid epidemic.
METHODS: A public opinion survey of U.S. adults in July-August 2017 (N = 1004) used a probability-based sample of respondents from a large, nationally representative online panel. The survey examined the public’s perception of the strength of common arguments offered in support of and opposition to legalizing safe consumption sites. Arguments were identified through a detailed scan of news media coverage, public reports, and advocacy materials.
RESULTS: The national sample of U.S. adults rated all arguments opposing legalization of safe consumption sites as stronger than any of the arguments supporting legalization. The most highly rated opposing arguments were that public funds were better spent on addiction treatment, and that sites were allowing illegal activity and encouraging people to use drugs. The highest rated arguments supporting legalization were that safe consumption sites were a better alternative than arresting people for using drugs, they would reduce HIV and hepatitis C by encouraging safe injection practices, and that they would lower emergency department admission and hospitalization costs.
CONCLUSION: Legalization of this evidence-based harm reduction approach in U.S. communities will be difficult to advance without public education to confront persistent myths that safe consumption sites encourage drug use and do not facilitate treatment access.
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Bryce Pardo, Jonathan P. Caulkins, Beau Kilmer
Evidence-base Harm Reduction Overdose mortality Supervised Consumption Sites USA
Assessing the Evidence on Supervised Drug Consumption Sites
Current levels of opioid-related morbidity and mortality in the United States are staggering. Data for 2017 indicate that there were more than 47,000 opioid-involved overdose deaths (roughly similar to deaths from AIDS at its peak in 1995), and 1 in 8 adults now report having had a family member or close friend die from opioids. There has been a near universal call from blue-ribbon commissions and expert panels for increasing access to Food and Drug Administration-approved medications for those with an opioid use disorder; however, jurisdictions addressing opioid use disorder and overdose may wish to consider additional interventions beyond increasing access to these medications. Two interventions that are implemented in some other countries but not in the United States are heroin-assisted treatment (HAT) and supervised consumption sites (SCSs). Given the severity of the opioid crisis, there is urgency to evaluate tools that might reduce its impact and save lives. This working paper is part of a series of reports assessing the evidence on and arguments made about HAT and SCSs and examining some of the issues associated with implementing them in the United States. The target audiences include decision makers in rural and urban areas grappling with opioids as well as researchers and journalists. This working paper assesses evidence on and arguments made about SCSs. It also offers a descriptive assessment of SCSs and the logic model behind their implementation. The other parts of this series of reports include: (1) a summary report of all the components of the research study; (2) a review of the HAT literature; (3) a report on key informant views on the acceptability and feasibility of implementing HAT and SCSs in selected U.S. jurisdictions heavily affected by the opioid crisis and (4) a report on international experience with the implementation of HAT and SCSs.
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Barrot H. Lambdin, Ricky N. Bluthenthal, Jon E. Zibbell, Lynn Wenger, Kelsey Simpson, Alex H. Kral
California Fentanyl HCV HIV Harm Reduction Injection frequency Supervised Consumption Services Syringe sharing USA
Associations between perceived illicit fentanyl use and infectious disease risks among people who inject drugs
BACKGROUND: Over the last several years, fentanyl has been introduced into the illicit drug supply in the United States. While the impact of fentanyl on overdose fatalities is clear, the increase in fentanyl use may also be affecting drug use practices with implications for infectious disease transmission. We conducted a cross-sectional survey to explore associations of perceived illicit fentanyl use with opioid use frequency, injection frequency and syringe sharing among people who inject drugs in two California cities.
METHODS: People who inject drugs (PWID) were recruited from community settings in Los Angeles and San Francisco, CA from June 2017 to September 2018. Multivariable logistic regression was used to explore adjusted associations between perceived illicit fentanyl use and high frequency opioid use, high frequency injection and syringe sharing.
RESULTS: Among the 395 study participants, the median age of participants was 44 years; 74% of participants were cisgender male; 73% reported to be homeless; 61% lived in San Francisco and 39% in Los Angeles. The prevalence of perceived illicit fentanyl use in the past six months was 50.4% (95% confidence interval (CI): 45.4%-55.3%) among PWID. Findings from our adjusted logistic regression models suggested that people reporting perceived illicit fentanyl use had a greater odds of high frequency opioid use (adjusted odds ratio (aOR) = 2.36; 95% CI: 1.43–3.91; p = 0.001), high frequency injection (aOR = 1.84; 95% CI: 1.08–3.13; p = 0.03) and receptive syringe sharing (aOR = 2.16; 95% CI: 1.06–4.36; p = 0.03), as compared to people using heroin and other street drugs but not fentanyl.
CONCLUSION: People reporting perceived illicit fentanyl use were at increased risk for injection-related infectious disease risks. Actions must be taken to reduce these risks, including improved access to syringe service programs and opioid treatment and consideration of innovative approaches, such as supervised consumption services.
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Peter A. Clark, Marvin J. Lee, Sonul Gulati, Arun Minupuri, Pavan Patel, Shengnan Zheng, Samuel A. Schadt, John Dubensky, Matthew DiMeglio, Siddardth Umapathy, Olivia Nguyen, Priscilla...
Canada Comprehensive User Engagement Sites Harm Reduction Insite Philadephia Safe Injection Facilities USA Vancouver
Comprehensive User Engagement Sites (CUES) in Philadelphia: A Constructive Proposal
This paper is a study about Philadelphia’s comprehensive user engagement sites (CUESs) as the authors address and examine issues related to the upcoming implementation of a CUES while seeking solutions for its disputed questions and plans. Beginning with the federal drug schedules, the authors visit some of the medical and public health issues vis-à-vis safe injection facilities (SIFs). Insite, a successful Canadian SIF, has been thoroughly researched as it represents a paradigm for which a Philadelphia CUES can expand upon. Also, the existing criticisms against SIFs are revisited while critically unpackaged and responded to in favor of the establishment. In the main section, the authors propose the layout and services of the upcoming CUES, much of which would be in congruent to Vancouver’s Insite. On the other hand, the CUES would be distinct from Insite, as the authors emphasize, in that it will offer an information center run by individuals in recovery and place additional emphasis on early education for young healthcare professionals by providing them a platform to work at the site. The paper will also briefly investigate the implementation of a CUES site under an ethical scope of the Harm Reduction Theory. Lastly, the authors recommend some strategic plans that the Philadelphia City government may consider employing at this crucial stage.
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Brett Wolfson-Stofko, Alex S. Bennett, Luther Elliott, Ric Curtis
Bathrooms Drug consumption rooms Harm Reduction New York Overdose mortality Public Order Public injection Supervised Injection Facilities USA
Drug use in business bathrooms: An exploratory study of manager encounters in New York City
Background: Though public bathroom drug injection has been documented from the perspective of people who inject drugs, no research has explored the experiences of the business managers who oversee their business bathrooms and respond to drug use. These managers, by default, are first-responders in the event of a drug overdose and thus of intrinsic interest during the current epidemic of opioid-related overdoses in the United States. This exploratory study assists in elucidating the experiences that New York City business managers have with people who inject drugs, their paraphernalia, and their overdoses.
Methods: A survey instrument was designed to collect data on manager encounters with drug use occurring in their business bathrooms. Recruitment was guided by convenience and purposive approaches.
Results: More than half of managers interviewed (58%, n = 50/86) encountered drug use in their business bathrooms, more than a third (34%) of these managers also found syringes, and the vast majority (90%) of managers had received no overdose recognition or naloxone training. Seven managers encountered unresponsive individuals who required emergency assistance.
Conclusion: The results from this study underscore the need for additional research on the experiences that community stakeholders have with public injection as well as educational outreach efforts among business managers. This research also suggests that there is need for a national dialogue about potential interventions, including expanded overdose recognition and naloxone training and supervised injection facilities (SIF)/drug consumption rooms (DCR), that could reduce public injection and its associated health risks.
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Alene Kennedy-Hendricks, Jenna Bluestein, Alex H. Kral, Colleen L. Barry, Susan G. Sherman
Drug Policy Harm Reduction Overdose mortality People Who Use Drugs Safe Consumption Sites USA
Establishing Sanctioned Safe Consumption Sites in the United States: Five Jurisdictions Moving the Policy Agenda Forward
OBJECTIVE: Safe consumption sites enable use of preobtained drugs in hygienic settings where trained staff are available to respond to overdoses and connect individuals with health and social services. This study examined efforts to advance policies to establish safe consumption sites in the United States, where no sanctioned sites exist.
METHODS: Between April and July 2018, the authors conducted 25 telephone interviews with a purposive sample of key informants in five communities considering safe consumption site implementation. Participants included organizers and advocates, government officials, and personnel with social service and health organizations. Interview notes were analyzed by using hybrid inductive-deductive coding.
RESULTS: Key strategies for organizing support for safe consumption sites included involving people who use drugs, engaging diverse partners, supporting allies in related causes, and using various tactics to garner support from policy makers. Major barriers to adoption included identifying the right locations, uncertainty about the federal response, mistrust arising from racial injustice in drug policy, and financing. Participants identified facilitators of progress toward safe consumption site adoption, such as building on existing harm reduction programs, securing political champions, and exposing community officials to programs operating internationally.
CONCLUSIONS: A window of opportunity may be opening to advance policy related to safe consumption sites; whether sanctioned sites become part of the broader policy strategy for addressing drug use and overdose in the United States will depend on the experiences of the first sites. Organizing around this issue may facilitate engagement among people who use drugs in broader conversations about drug policy.
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Czarina N. Behrends, Denise Paone, Michelle L. Nolan, Ellenie Tuazon, Sean M. Murphy, Shashi N. Kapadia, Philip J. Jeng, Ahmed M. Bayoumi, Hillary V. Kunins, Bruce R. Schackman
Economic evaluation Healthcare system costs Healthcare utilization New York City Opioid overdose Supervised Injection Facilities USA
Estimated impact of supervised injection facilities on overdose fatalities and healthcare costs in New York City
BACKGROUND: The opioid epidemic in the United States has resulted in over 42,000 U.S. opioid overdose fatalities in 2016 alone. In New York City (NYC) opioid overdoses have reached a record high, increasing from 13.6 overdose deaths/100,000 to 19.9/100,000 from 2015 to 2016. Supervised injection facilities (SIFs) provide a hygienic, safe environment in which pre-obtained drugs can be consumed under clinical supervision to quickly reverse opioid overdoses. While SIFs have been implemented worldwide, none have been implemented to date in the United States. This study estimates the potential impact on opioid overdose fatalities and healthcare system costs of implementing SIFs in NYC.
METHODS: A deterministic model was used to project the number of fatal opioid overdoses avoided by implementing SIFs in NYC. Model inputs were from 2015 to 2016 NYC provisional overdose data (N = 1852) and the literature. Healthcare utilization and costs were estimated for fatal overdoses that would have been avoided from implementing one or more SIFs.
RESULTS: One optimally placed SIF is estimated to prevent 19–37 opioid overdose fatalities annually, representing a 6–12% decrease in opioid overdose mortality for that neighborhood; four optimally placed SIFs are estimated to prevent 68–131 opioid overdose fatalities. Opioid overdoses cost the NYC healthcare system an estimated $41 million per year for emergency medical services, emergency department visits, and hospitalizations. Implementing one SIF is estimated to save $0.8–$1.6 million, and four SIFs saves $2.9–$5.7 million in annual healthcare costs from opioid overdoses.
CONCLUSIONS: Implementing SIFs in NYC would save lives and healthcare system costs, although their overall impact may be limited depending on the geographic characteristic of the local opioid epidemic. In cities with geographically dispersed opioid epidemics such as NYC, multiple SIFs will be required to have a sizeable impact on the total number of opioid overdose fatalities occurring each year.
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Scott Burris, Evan D. Anderson, Leo Beletsky, Corey S. David
Drug consumption rooms Harm Reduction Law Police power Public Health Supervised Injection Facility USA
Federalism, Policy Learning, and local innovation in Public Health: The case of the Supervised Injection Facility
Evidence from international evaluations suggests that safe injection facilities (SIFs) may represent a medically effective and economically efficient strategy for reducing the incidence and harms of injection drug use among the chronically homeless and otherwise marginalized people. The success of such facilities in other countries has amplified calls for their introduction in the United States where injection drug use among the most difficult to reach groups continues to be an intractable source of numerous individual and public health harms as well as a major financial burden for certain municipalities.
In recognition of the fact that even evidence-based health interventions may fall under the ambit of laws targeting drugs and drug users, we analyzed the legal environment for publicly authorized SIFs in the United States. Our conclusions suggest that states and some municipalities have the power to authorize SIFs under their longstanding powers to protect the public’s health, but that federal authorities could still interfere with these facilities under the possession and “Crack House Statute” provisions of the Controlled Substances Act (CSA).
We analyze the applicability of these provisions and discuss possible defenses rooted in statutory interpretation, preemption and the Commerce Clause. We conclude that plausible legal arguments exist that those operating an SIF should not (and perhaps can not) be convicted under the auspices of the CSA. However, state- or locally-authorized SIFs can proceed free of legal uncertainty only if federal authorities explicitly authorize them or decide not to interfere. Given legal uncertainty and the similar experience with syringe exchange programs, we recommend a process of sustained health research, strategic advocacy, and political deliberation.
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