The U.S. government has struggled to control the most recent waves of the opioid epidemic that have killed more than 400,000 people since 2010 (PDF, 198 KB). External link Other countries have decided to give people misusing intravenous drugs ownership over at least one aspect of their addiction: location.
People use opioids “wherever they can,” said Kathleen Woodruff External link DNP, ANP-BC, clinical assistant professor at USC Suzanne Dworak-Peck School of Social Work Department of Nursing. “The street, abandoned buildings ... they will find a place to use.”
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
The planning study provides Official Plan policy and zoning recommendations for consumption and treatment services and/or other similar services. The planning study reviews Federal and Provincial criteria for the siting of consumption and treatment services, along with other land use compatibility considerations.
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.
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.
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.
hospitalizations, ambulance calls, or disease.
Bottom line: Best evidence from cohort and modeling studies suggests that SISs are associated with lower overdose mortality (88 fewer overdose deaths per 100 000 person-years [PYs]), 67% fewer ambulance calls for treating overdoses, and a decrease in HIV infections. Effects on hospitalizations are unknown.
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.
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.
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.
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
drugs? Will introducing the services attract more people to use narcotics? Will supervised consumption services attract people who sell drugs? Why aren’t we putting more resources into prevention and treatment? What is the status of the application to Health Canada to provide Supervised
Consumption Services at Sheldon M. Chumir Health Centre? ...
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.
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.
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.
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.
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.
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.
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
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.
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.
Methods: The analyses examined the impact of Insite's programs for a single year. Mathematical models were used to calculate the number of additional HIV infections that would be expected if Insite were closed. The life-time HIV-related medical costs associated with these additional infections were compared to the annual operating costs of the Insite facility.
Results: If Insite were closed, the annual number of incident HIV infections among Vancouver IDU would be expected to increase from 179.3 to 262.8. These 83.5 preventable infections are associated with $17.6 million (Canadian) in life-time HIV-related medical care costs, greatly exceeding Insite's operating costs, which are approximately $3 million per year.
Conclusions: Insite's safe injection facility and syringe exchange program substantially reduce the incidence of HIV infection within Vancouver's IDU community. The associated savings in averted HIV-related medical care costs are more than sufficient to offset Insite's operating costs.
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.
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.
Initiated in September 2017, this teleconference network serves as a forum for current and prospective service providers to share information and promising practices related to SCS and OPS. To date, more than 60 individuals from 20 Canadian cities have participated. The teleconference network seeks to assist communities in building their capacity to offer SCS/OPS by sharing challenges and innovations among service providers.
This webinar engage participants in a discussion with experts on key themes related to the development of an SCS or an OPS.
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.
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.
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.
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.
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.
The OPS is a welcoming, safe, and supportive environment for PWID.
and community within this dark time. We are committed to meeting people where they are at and helping to make their lives better in any way we can.
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.
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.
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.
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.
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.
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.
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.
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.
• providing information to Londoners about Supervised Consumption Facilities and local need
• Obtaining feedback on perceived benefits and concerns, recommendations to address concerns and site location suggestions and considerations
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.
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.
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.
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.
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.
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.
The main emphasis of the country mission was, however, on the prevention and control of HIV.
The country visit was conducted in Helsinki over three days and consisted of meetings with several institutions and organisations. In addition to representatives from the Ministry of Social Affairs and Health, meetings included representatives from the National Institute for Health and Welfare, the Criminal Sanctions Agency and various nongovernmental organisations.
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.
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.
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.
Refusant les expériences en Espagne, Suisse, Allemagne ou Canada, et balayant les études scientifiques, le précédent gouvernement avait dit « non » aux salles d'injection. Malgré ce refus, des villes de droite comme de gauche – Bordeaux, Nancy, Strasbourg, Marseille ou Paris – ont préparé la mise en place de ces salles en attendant des jours meilleurs.
Ce livre revient sur ces années où les usagers de drogues illicites ont été des boucs émissaires. Il est un cri d’espoir et un appel pour une politique des drogues plus humaine et plus efficace, fondée sur la régulation des usages.
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.
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.
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.
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.
This briefing paper provides a short summary of the background, history and objectives of DCRs, and analyses available evidence regarding their impact. The second part of the briefing paper consists of an overview of the various DCRs in different countries, with a particular focus on the concepts used to develop these facilities with regard to the local political, cultural and social situation of each country.
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.
Module 4 contains a prefatory note which outlines the rationale for and benefits of supervised drug consumption facilities and which describes relevant international laws and policies, including human rights obligations. Module 4 provides model law that can be put in place to make such facilities effective interventions in protecting the health and well-being of individuals who use drugs, advancing public health more generally, and benefiting communities affected by public drug use. Module 4 concludes with a list of recommended resources.
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.
Recent Findings Consistent evidence demonstrates that SCFs mitigate overdose-related harms and unsafe drug use behaviours, as well as facilitate uptake of addiction treatment and other health services among people who use drugs (PWUD).
Further, SCFs have been associated with improvements in public order without increasing drug-related crime. SCFs have also been shown to be cost-effective.
Summary This systematic review suggests that SCFs are effectively meeting their primary public health and order objectives and therefore supports their role within a continuum of services for PWUD. Additional studies are needed to better understand the potential long-term health impacts of SCFs and how innovations in SCF programming may help to optimize the effectiveness of this intervention.
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.
Ce rapport de synthèse présente le contexte, l’histoire et les objectifs des SCMR et analyse les preuves disponibles quant à leur impact. La deuxième partie de ce rapport fournit un aperçu des SCMR dans différents pays, avec un accent particulier placé sur les concepts utilisés pour développer ces espaces en fonction du contexte politique, culturel et social de chaque pays.
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.
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.
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.
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.
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.
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.
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).
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.
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
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.
METHODS: IDUs were recruited in San Francisco using targeted sampling and interviewed using a quantitative survey (N=602). We assessed the prevalence of willingness to use a SIF as well as correlates of willingness among this group.
RESULTATS: Eighty-five percent of IDUs reported that they would use a SIF, three quarters of whom would use it at least three days per week. In multivariate analysis, having injected in public and having injected speedballs were associated with intent to use a SIF. The majority of IDUs reported acceptability of many potential rules and regulations of a pilot SIF, except video surveillance, and being required to show identification.
CONCLUSIONS: Building on the success of SIFs in various international settings, IDUs in San Francisco appear interested in using a SIF should one be implemented.
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.
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.
Research indicates that safer consumption spaces are effective at reducing overdose fatalities, hospitalizations, infectious disease transmission, while also increasing initiation and retention in health care (which leads to better long-term substance use treatment outcomes). They are also cost effective.
The report offers strategies for extending funding and advocating for legally sanctioned safer consumption spaces in a manner that focuses on the leadership and needs of people who use drugs.
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.
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.
1. That the MMS perform an internal evidence-based study of the ethical, legal, and liability considerations and feasibility of a medically-supervised injection facility (MSIF) in Massachusetts.
2. That at the conclusion of an internal study of medically-supervised injection facilities (MSIF), the Board of Trustees will report back to the House of Delegates, no later than A-17, with recommendations for an MMS advocacy position on MSIF.
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.
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.
Methods: We estimate the benefits by utilizing local health data and data on the impact of existing SIFs in models for six outcomes: prevented human immunodeficiency virus transmission, Hepatitis C virus transmission, skin and softtissue infection, overdose mortality, and overdose-related medical care and increased medication-assisted treatment for opioid dependence.
Results: We predict that for an annual cost of $1.8 million, a single SIF would generate $7.8 million in savings, preventing 3.7 HIV infections, 21 Hepatitis C infections, 374 days in the hospital for skin and soft-tissue infection, 5.9 overdose deaths, 108 overdose-related ambulance calls, 78 emergency room visits, and 27 hospitalizations, while bringing 121 additional people into treatment.
Conclusions: We conclude that a SIF would be both extremely cost-effective and a significant public health and economic benefit to Baltimore City.
METHODS: We conducted a freelisting exercise with PWID (n=42) and healthcare providers (n=20) at a syringe exchange program (SEP) that provides comprehensive clinical and social services in Philadelphia to inform in-depth semi-structured interviews with PWID (n=19) at the same location.
RESULTS: Participants expressed support for a potential SIF as a valuable public health intervention. They suggested that an SIF would improve PWID health while reducing the public disorder associated with injecting drugs in public. The latter was especially important to participants without stable housing, whose decision to inject furtively in secluded places was often motivated by desire not to upset community members, and particularly children. These participants acknowledged that such seclusion elevated the risk of fatal overdose. Despite similarly positive perceptions about an SIF, participants with stable housing reported that they would prefer to continue injecting at home.
CONCLUSION: Results both confirm and extend prior research about PWID and SIFs. Participants expressed support for SIFs as in prior survey research in the U.S. and in other countries. Facility location and housing status were identified as important determinants of facility use. Results extend prior research by illuminating PWID perceptions in the U.S. including motivations grounded in concern for public order.
METHODS: Semi-structured qualitative interviews were conducted with 15 SIEs recruited through convenience sampling throughout NYC. Participants were provided with peer-reviewed scientific evidence prior to discussing SIFs. Data were analysed using a hybrid deductive and inductive approach.
RESULTS: Most SIEs had encountered drug use (93%, n = 14/15) and syringes (73%, n = 11/15) in their business bathrooms and three had encountered unresponsive individuals. Nearly all workers (93%, n = 14/15) were supportive of SIFs and believed SIFs would reduce injection drug use in their business bathrooms. Participants also believed that ‘not in my backyard’ arguments from community boards may impede SIF operation.
CONCLUSIONS: Service industry employees are critical stakeholders due to their exposure to occupational health hazards related to public injection. Those interviewed were amenable to SIF operation as a form of occupational harm reduction and their experiences provide an important dimension to the political debate surrounding SIFs.
METHODS: Our study describes the relationship between place of drug use and health outcomes through the analysis of associations between frequent public drug use and drug-related arrest, overdose, and reuse of injection equipment. We analysed data from a cross-sectional, observational study of individuals who utilize syringe exchange services in 8 U.S. cities. Using regression analysis, we assessed associations between public drug use, demographic characteristics, and health risks.
RESULTS: Half (48%) of the respondents (N = 575) reported that at least one of their top two most frequent places of drug use is a public place. Street homelessness (AOR = 17.44), unstable housing (AOR = 3.43) and being under age 30 (AOR = 1.85) were independently associated with increased odds of frequent public drug use. Frequent public drug use was associated with increased odds of past-year arrest for drug-related offenses (AOR = 1.87).
CONCLUSION: Public drug use is associated with negative health and social outcomes. Increased access to harm reduction services, housing, and supervised consumption sites (SCS) interventions and a shift away from punitive approaches to drug use may reduce the some of the harms associated with public drug use.
The report reviews key issues related to safe consumption sites, and lists some of the best practices and lessons learned for advocacy and educating people around SCSs to teach the value and benefits these sites provide to people who use drugs and the communities where they live.
- Describe literature related to supervised consumption facilities as harm-reduction strategies in addressing overdose deaths, infections and community harms from heroin and other opioid use.
- Apply estimates of outcomes from other communities to the City of Philadelphia’s data, where data are available, to approximate the possible impact of a supervised consumption facility located where deaths from overdose have been most likely to occur.
As the nation grapples with how to effectively respond to these epidemics, NASTAD urges policymakers, public health and safety leaders, and impacted communities to embrace a comprehensive approach to end these intersecting epidemics. As one element of a comprehensive strategy, NASTAD supports Supervised Injection Facilities (SIFs) as an important, evidence-based, intervention. These programs operate with legal sanction in 11 countries and number well over 100 worldwide. SIFs have been shown to reduce HCV/HIV transmission risks and link participants to testing, infectious disease treatment, medication-assisted treatment, and physical and behavioral health services. Studies of SIFs have shown that they do not lead to increases in drug use, frequency of injection, or levels of drug-related crime while effectively reducing overdose death and occurrence.
We recognize that stakeholders may have differing roles in these efforts. Herein, we outline potential avenues to support these lifesaving programs and opportunities for engagement and education among various stakeholder groups.
highest in the nation. Public injecting is also an ongoing concern. Just in Denver in 2018 alone, at least 25 people passed away from overdose in public locations such as parks, alleys, parking lots, and business restrooms. These deaths were unnecessary and preventable.
Along with the risk of overdose, unsafe injection practices are associated with blood-borne disease transmission and skin and soft tissue infection (SSTI)—also extremely costly, yet preventable, concerns. Injection drug use is the primary cause of new hepatitis C virus (HCV) infections in Colorado, with half of all reported cases occurring among people who inject drugs (PWID). In the past year, more than half of all PWID in the city of Denver experienced a skin or soft tissue infection, requiring them to utilize emergency rooms and hospital beds.
Prevention and treatment are important aspects of our public health infrastructure, but they are not enough. By enhancing harm reduction services that directly address the risks associated with continued drug use, we can better mitigate some of the most costly problems and improve access to effective public health resources that would better protect our communities.
Recognizing that laws shape health interventions targeting drug users, we analyzed the legal environment for publicly authorized SIFs in the United States. Although states and some municipalities have the power to authorize SIFs under state law, federal authorities could still interfere with these facilities under the Controlled Substances Act. A state- or locally-authorized SIF could proceed free of legal uncertainty only if federal authorities explicitly authorized it or decided 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.
METHODS: We utilized local estimates and other data sources deemed appropriate for our setting to implement a mathematical model that assesses the impact of a hypothetical SIF on overdose deaths, non-fatal overdose health service utilization, skin and soft tissue infections, bacterial infections, viral infections, and enrollment in medication assisted treatment (MAT). We estimated the costs and savings that would occur on an annual basis for a small-scale pilot site given current overdose rates, as well as three other scenarios of varying scale and underlying overdose rates.
RESULTS: Assuming current overdose rates, a hypothetical Seattle SIF in a pilot phase is projected to annually reverse 167 overdoses and prevent 6 overdose deaths, 45 hospitalizations, 90 emergency department visits, and 92 emergency medical service deployments. Additionally, the site would facilitate the enrollment of 41 SIF clients in medication assisted treatment programs. These health benefits correspond to a monetary value of $5,156,019. The annual estimated cost of running the SIF is $1,222,332. The corresponding cost-benefit ratio suggests that the pilot SIF would generate $4.22 for every dollar spent on SIF operational costs. The pilot SIF is projected to save the healthcare system $534,453. If Seattle experienced elevated overdose rates and Seattle SIF program were scaled up, the health benefits and financial value would be considerably greater.
CONCLUSION: This analysis suggests that a SIF program in Seattle would save lives and result in considerable health benefits and cost savings.
METHODS: A cross-sectional survey of a convenience sample of 237 people who inject drugs and utilize Boston's needle exchange program (NEP). The drop-in NEP provides myriad harm reduction services and referrals to addiction treatment. The survey was mostly self-administered (92%).
RESULTS: Results showed positive willingness to use a SIF was independently associated with use of heroin as main substance (odds ratio [OR]: 5.47; 95% confidence interval [CI]: 1.9–15.4; P = .0004), public injection (OR: 5.09; 95% CI: 1.8–14.3; P = .002), history of seeking substance use disorder (SUD) treatment (OR: 4.99; 95% CI: 1.2–21.1; P = .05), having heard of SIF (OR: 4.80; 95% CI: 1.6–14.8; P = .004), Hispanic ethnicity (OR: 4.22; 95% CI: 0.9–18.8; P = .04), frequent NEP use (OR: 4.18; 95% CI: 1.2–14.7; P = .02), current desire for SUD treatment (OR: 4.15; 95% CI: 1.2–14.7; P = .03), hepatitis C diagnosis (OR: 3.68; 95% CI: 1.2–10.1; P = .02), posttraumatic stress disorder (PTSD) diagnosis (OR: 3.27; 95% CI: 1.3–8.4; P = .01), report of at least 1 chronic medical diagnosis (hepatitis C, human immunodeficiency virus [HIV], hypertension, or diabetes) (OR: 3.27; 95% CI: 1.2–8.9; P = .02), and comorbid medical and mental health diagnoses (OR: 2.93; 95% CI: 1.2–7.4; P = .02).
CONCLUSIONS: Most respondents (91.4%) reported willingness to use a SIF. Respondents with substance use behavior reflecting high risk for overdose were significantly more likely to be willing to use a SIF. Respondents with behaviors that contribute to public health burden of injection drug use were also significantly more likely to be willing to use a SIF. Results indicate that this intervention would be well utilized by individuals who could most benefit from the model. As part of a broader public health approach, SIFs should be considered to reduce opioid overdose mortality, decrease public health burden of the opioid crisis, and promote access to addiction treatment and medical care.
Methods: Twenty three qualitative interviews were conducted with people who used the underground facility, staff, and volunteers to examine the impact of the facility on peoples’ lives, including the impact of lack of formal legal sanction on service provision.
Results: Participants reported that having a safe space to inject drugs had led to less injections in public spaces, greater ability to practice hygienic injecting practices, and greater protection from fatal overdose. Constructive aspects of being ‘underground’ included the ability to shape rules and procedures around user need rather than to meet political concerns, and the rapid deployment of the project, based on immediate need. Limitations associated with being underground included restrictions in the size and diversity of the population served by the site, and reduced ability to closely link the service to drug treatment and other health and social services.
Conclusion: Unsanctioned supervised injection facilities can provide a rapid and user-driven response to urgent public health needs. This work draws attention to the need to ensure such services remain focused on user-defined need rather than external political concerns in jurisdictions where supervised injection facilities acquire local legal sanction.
Methods: Between January 2015 and February 2016, youth with recent NMPO use were recruited to participate in the Rhode Island Young Adult Prescription Drug Study (RAPiDS). We explored factors associated with willingness to use a SIF among participants who had injected drugs or were at risk of initiating injection drug use (defined as having a sex partner who injects drugs or having a close friend who injects).
Results: Among 54 eligible participants, the median age was 26 (IQR = 24-28), 70.4% were male, and 74.1% were white. Among all participants, when asked if they would use a SIF, 63.0% answered “Yes”, 31.5% answered “No”, and 5. 6% were unsure. Among the 31 participants reporting injection drug use in the last six months, 27 (87.1%) reported willingness to use a SIF; 15 of the 19 (78.9%) who injected less than daily reported willingness, while all 12 (100.0%) of the participants who injected daily reported willingness. Compared to participants who were unwilling or were unsure, participants willing to use a SIF were also more likely to have been homeless in the last six months, have accidentally overdosed, have used heroin, have used fentanyl non-medically, and typically use prescription opioids alone.
Conclusions: Among young adults who use prescription opioids non-medically and inject drugs or are at risk of initiating injection drug use, more than six in ten reported willingness to use a SIF. Established risk factors for overdose, including homelessness, history of overdose, daily injection drug use, heroin use, and fentanyl misuse, were associated with higher SIF acceptability, indicating that young people at the highest risk of overdose might ultimately be the same individuals to use the facility. Supervised injection facilities merit consideration to reduce overdose mortality in the USA.
Safe consumption spaces (SCS) are evidence-based interventions that reduce drug-related morbidity and mortality operating in many countries. However, SCS are yet to be widely implemented in the USA despite the escalating overdose epidemic. The aim of this multi-city study was to identify the factors associated with willingness to use a SCS among people who use drugs (PWUD) in Baltimore, Providence, and Boston, stratified by injection drug use status. Our secondary aim was to characterize the anticipated barriers to accessing SCS if they were to be implemented in these cities. PWUD were invited to complete a cross-sectional survey in 2017. The analysis was restricted to 326 opioid users (i.e., heroin, fentanyl, and non-medical opioid pill use). The majority (77%) of participants expressed willingness to use a SCS (Baltimore, 78%; Providence, 68%; Boston. 84%). Most respondents were male (59%), older than 35 years (76%), non-white (64%), relied on public/semi-public settings to inject (60%), had a history of overdose (64%), and recently suspected fentanyl contamination of their drugs (73%). A quarter (26%) preferred drugs containing fentanyl. Among injectors, female gender, racial minority status, suspicion of drugs containing fentanyl, and drug use in public/semi-public settings were associated with higher willingness to use a SCS; prior arrest was associated with lower willingness. Among non-injectors, racial minority status, preference for fentanyl, and drug use in public/semi-public settings were associated with higher willingness, whereas recent overdose held a negative association. The most commonly anticipated barriers to accessing a SCS in the future were concerns around arrest (38%), privacy (34%), confidentiality/trust/safety (25%), and cost/time/transportation (16%). These data provide evidence of high SCS acceptability among high-risk PWUD in the USA, including those who prefer street fentanyl. As SCS are implemented in the USA, targeted engagement efforts may be required to reach individuals exposed to the criminal justice system.