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Austin T, Lavalley J, Parusel S, Collins AB, Olding M, Boyd J. Women who use drugs: engagement in practices of harm reduction care. Harm Reduct J 2023; 20:49. [PMID: 37055805 PMCID: PMC10100181 DOI: 10.1186/s12954-023-00775-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/28/2023] [Indexed: 04/15/2023] Open
Abstract
BACKGROUND Harm reduction services that employ or are operated by people who use drugs are an effective means of mitigating overdose risks and other drug-related harms. However, stereotypes portraying people who use criminalized drugs as incapable caregivers persist. This is especially true for women who use drugs, and to a greater extent racialized women, who are characterized as having diverged from traditional ideals of womanhood as a result of drug-user stigma and the intersections of gender- and class-based and racist stereotypes. In an effort to identify and understand how women who use drugs practise care through harm reduction, we explored the experiences of women accessing a low-threshold supervised consumption site exclusively for women (transgender and non-binary inclusive) in Vancouver, Canada. METHODS Data were drawn from research conducted from May 2017 to June 2018 exploring women's experiences accessing the supervised consumption site during an overdose crisis. Data included forty-five semistructured interviews with women recruited from the site, analysed thematically to explore practices of care through harm reduction. FINDINGS Participants reported engaging in both formal and informal care. Acts of care included interventions that both aligned with and deviated from conventional understandings of care practices, including overdose reversal and education, overdose supervision/care, and assisted injection. CONCLUSION The boundary between formal and informal harm reduction care is fluid. Women who use drugs engage in harm reduction across these borders with acts of care that align with or fill the gaps in current harm reduction services in order to meet the needs of drug-using communities, challenging negative stereotypes of women who use drugs. However, these caregiving practices can increase risks to care providers' physical, mental, and emotional health and wellness. Increased financial, social, and institutional supports, including safer supply, assisted injection, and community resources, are needed to better support women as they continue to engage in harm reduction care.
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Affiliation(s)
- Tamar Austin
- Birth Place Lab, UBC Midwifery, Faculty of Medicine, University Boulevard, Vancouver, BC, 3302-5950, Canada
- British Columbia Centre On Substance Use, St. Paul's Hospital, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
- Interdisciplinary Studies Graduate Program, University of British Columbia, Vancouver, BC, Canada
| | - Jennifer Lavalley
- British Columbia Centre On Substance Use, St. Paul's Hospital, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
- Interdisciplinary Studies Graduate Program, University of British Columbia, Vancouver, BC, Canada
| | - Sylvia Parusel
- British Columbia Centre On Substance Use, St. Paul's Hospital, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
| | - Alexandra B Collins
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Michelle Olding
- British Columbia Centre On Substance Use, St. Paul's Hospital, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada
- Interdisciplinary Studies Graduate Program, University of British Columbia, Vancouver, BC, Canada
| | - Jade Boyd
- British Columbia Centre On Substance Use, St. Paul's Hospital, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.
- Department of Medicine, University of British Columbia, St. Paul's Hospital, Burrard Street, Vancouver, BC, 608-1081, Canada.
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Michaud L, van der Meulen E, Guta A. Between Care and Control: Examining Surveillance Practices in Harm Reduction. CONTEMPORARY DRUG PROBLEMS 2023; 50:3-24. [PMID: 36733491 PMCID: PMC9885017 DOI: 10.1177/00914509221128598] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/08/2022] [Indexed: 02/05/2023]
Abstract
As harm reduction programs and services proliferate, people who use drugs (PWUD) are increasingly subjected to surveillance through the collection of their personal information, systematic observation, and other means. The data generated from these practices are frequently repurposed across various institutional sites for clinical, evaluative, epidemiological, and administrative uses. Rationales provided for increased surveillance include the more effective provision of care, service optimization, risk stratification, and efficiency in resource allocation. With this in mind, our reflective essay draws on empirical analysis of work within harm reduction services and movements to reflect critically on the impacts and implications of surveillance expansion. While we argue that many surveillance practices are not inherently problematic or harmful, the unchecked expansion of surveillance under a banner of health and harm reduction may contribute to decreased uptake of services, rationing and conditionalities tied to service access, the potential deepening of health disparities amongst some PWUD, and an overlay of health and criminal-legal systems. In this context, surveillance relies on the enlistment of a range of therapeutic actors and reflects the permeable boundary between care and control. We thus call for a broader critical dialogue within harm reduction on the problems and potential impacts posed by surveillance in service settings, the end to data sharing of health information with law enforcement and other criminal legal actors, and deference to the stated need among PWUD for meaningful anonymity when accessing harm reduction and health services.
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Affiliation(s)
- Liam Michaud
- Socio-Legal Studies Graduate Program, York University, Toronto,
Ontario, Canada,Liam Michaud, Socio-Legal Studies Graduate
Program, York University, 4700 Keele St, Toronto, Ontario M3J 1P3, Canada.
| | - Emily van der Meulen
- Department of Criminology, Toronto Metropolitan University, Toronto,
Ontario, Canada
| | - Adrian Guta
- School of Social Work, University of Windsor, Windsor, Ontario,
Canada,Australian Research Centre in Sex, Health and Society, La Trobe
University, Melbourne, Victoria, Australia
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Olding M, Boyd J, Kerr T, Fowler A, McNeil R. (Re)situating expertise in community-based overdose response: Insights from an ethnographic study of overdose prevention sites (OPS) in Vancouver, Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 111:103929. [PMID: 36529032 PMCID: PMC10184134 DOI: 10.1016/j.drugpo.2022.103929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/20/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022]
Abstract
Overdose Prevention Sites (OPS) are low-barrier services where people may use illicit drugs under the monitoring of staff trained to provide life-saving care in the event of an overdose. In British Columbia (BC), Canada, OPS have been rapidly scaled-up as a community-based response to the overdose crisis and are staffed primarily by community members who are also people who use drugs (PWUD). While it is known that PWUD perform vital roles in OPS and other community-based overdose interventions, the expertise and expert knowledge of PWUD in this work remains under-theorised. This study draws on 20 months of ethnographic fieldwork in Vancouver, BC (July 2018 to March 2020), to explore how OPS responders who are PWUD developed and enacted expertise in overdose response. Ethnographic fieldwork focused on four OPS located in Vancouver's Downtown Eastside (DTES) and Downtown South neighbourhoods. Methods included 100 hours of observation in the sites and surrounding areas, three site-specific focus groups with OPS responders (n=20), and semi-structured interviews with OPS responders (n=14) and service users (n=23). Data was analysed with the aim of characterizing the knowledge underpinning responders' expertise, and the arrangements which allow for the formation and enactment of expertise. We found that OPS responders' expertise was grounded in experiential knowledge acquired through their positionality as PWUD and members of a broader community of activists engaged in mutual aid. Responders became skilled in overdose response through frequent practice and drew on their experiential and embodied knowledge of overdose to provide care that was both technically proficient and responsive to the broader needs of PWUD (e.g. protection from criminalization and stigmatizing treatment). Responders emphasized that the spatial arrangements of OPS supported the development of expertise by facilitating more specialized and comprehensive overdose care. OPS became sites of collective expertise around overdose management as responder teams developed shared understandings of overdose management, including processes for managing uncertainty, delegating team responsibilities, and sharing decision-making. This research re-situates theoretical understandings of expertise in community-based overdose response with implications for overdose prevention interventions. Findings underscore the experiential and embodied expertise of PWUD as community-based responders; the importance of supportive environments and team-based approaches for overdose response; and the benefits of community-driven training that extends beyond technical skills of overdose identification and naloxone administration.
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Affiliation(s)
- Michelle Olding
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 1Y6, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Jade Boyd
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 1Y6, Canada; Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 1Y6, Canada; Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Al Fowler
- East Vancouver Activist, Vancouver, BC, Canada
| | - Ryan McNeil
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 1Y6, Canada; Yale School of Medicine, New Haven, CT, United States.
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Mitra S, Kolla G, Bardwell G, Wang R, Sniderman R, Mason K, Werb D, Scheim A. Requiring help injecting among people who inject drugs in Toronto, Canada: Characterising the need to address sociodemographic disparities and substance-use specific patterns. Drug Alcohol Rev 2022; 41:1062-1070. [PMID: 35577755 DOI: 10.1111/dar.13473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 03/09/2022] [Accepted: 03/26/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Those requiring help injecting are at an elevated risk of injection-related injury and blood-borne infections and are thus a priority group for harm reduction programs. As supervised consumption services (SCS) are scaled-up across Canada, information on those who require help injecting is necessary to inform equitable service uptake. We characterised the sociodemographic, structural and drug use correlates of needing help injecting among a cohort of people who inject drugs in Toronto, Canada. METHODS A cross-sectional baseline survey was administered between November 2018 and March 2020. Unadjusted and multivariable logistic regression models examined associations with requiring help injecting in the past 6 months. A gender-stratified sub-analysis described characteristics of receiving help among those requiring it. RESULTS Of 701 participants (31.0% cisgender women), 294 (41.9%) needed recent help injecting. In unadjusted analyses, being a racialised, non-Indigenous person (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.13-2.86) or a cisgender woman (OR 1.72, 95% CI 1.24-2.39) were associated with needing help. In multivariable analyses, requiring assistance was associated with needing frequent help preparing drugs (adjusted OR [AOR] 9.52, 95% CI 4.78-21.28), fewer years since first injection (AOR for 1 year increase: 0.97, 95% CI 0.95-0.99) and injecting stimulants. Among those who required help, cisgender women reported needing assistance more often than cisgender men (P = 0.009). DISCUSSION AND CONCLUSIONS Over two-fifths of the sample required help injecting; requiring assistance was associated with sociodemographic indicators and substance use-specific patterns. Findings highlight the need to scale-up educational resources for those who receive or provide help injecting, as well as SCS that accommodate onsite injection assistance.
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Affiliation(s)
- Sanjana Mitra
- Interdisciplinary Graduate Studies Program, University of British Columbia, Vancouver, Canada.,British Columbia Centre on Substance Use, Vancouver, Canada
| | - Gillian Kolla
- Canadian Institute for Substance Use Research, University of Victoria, Victoria, Canada
| | - Geoff Bardwell
- British Columbia Centre on Substance Use, Vancouver, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, Vancouver, Canada
| | - Rick Wang
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
| | - Ruby Sniderman
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Canada
| | - Kate Mason
- South Riverdale Community Health Centre, Toronto, Canada
| | - Dan Werb
- Centre on Drug Policy Evaluation, Unity Health Toronto, Toronto, Canada.,University of California San Diego School of Medicine, La Jolla, USA
| | - Ayden Scheim
- Dornsife School of Public Health, Drexel University, Philadelphia, USA.,Centre on Drug Policy Evaluation, Unity Health Toronto, Toronto, Canada
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Kennedy MC, Hayashi K, Milloy MJ, Compton M, Kerr T. Health impacts of a scale-up of supervised injection services in a Canadian setting: an interrupted time series analysis. Addiction 2022; 117:986-997. [PMID: 34854162 PMCID: PMC8904318 DOI: 10.1111/add.15717] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 09/20/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIMS In response to a dramatic rise in overdose deaths due to injection drug use, there was a rapid scale-up of low-threshold supervised injection services (SIS), termed 'overdose prevention sites' (OPS), in Vancouver, Canada in December 2016. We measured the potential impact of this intervention on SIS use and related health outcomes among people who inject drugs (PWID). DESIGN Segmented regression analyses of interrupted time series data from two community-recruited prospective cohorts of PWID from January 2015 to November 2018 were used to measure the impact of the OPS scale-up on changes in SIS use, public injection, syringe sharing and addiction treatment participation, controlling for pre-existing secular trends. SETTING Vancouver, Canada. PARTICIPANTS Of 745 PWID, 292 (39.7%) were women, 441 (59.6%) self-reported white ancestry and the median age was 47 years (interquartile range = 38, 53) at baseline. MEASUREMENTS Immediate (i.e. step level) and gradual (i.e. slope) changes in the monthly proportion of participants who self-reported past 6-month SIS use, public injection, syringe sharing and participation in any form of addiction treatment. FINDINGS Post OPS expansion, the monthly prevalence of SIS use immediately increased by an estimated 6.4% [95% confidence interval (CI) = 1.7, 11.2] and subsequently further increased by an estimated 0.7% (95% CI = 0.3, 1.1) per month. The monthly prevalence of addiction treatment participation immediately increased by an estimated 4.5% (95% CI = 0.5, 8.5) following the OPS expansion, while public injection and syringe sharing were estimated to immediately decrease by 5.5% (95% CI = 0.9, 10.0) and 2.5% (95% CI = 0.5, 4.6), respectively. Findings were inconclusive as to whether or not an association was present between the intervention and subsequent gradual changes in public injection, syringe sharing and addiction treatment participation. CONCLUSIONS Scaling-up overdose prevention sites in Vancouver, Canada in December 2016 was associated with immediate and continued gradual increases in supervised injection service engagement and immediate increases in related health benefits.
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Affiliation(s)
- Mary Clare Kennedy
- British Columbia Centre on Substance Use, Vancouver, BC, Canada,Department of Medicine, University of British Columbia, St Paul’s Hospital, Vancouver, BC, Canada
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, Vancouver, BC, Canada,Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, Vancouver, BC, Canada,Department of Medicine, University of British Columbia, St Paul’s Hospital, Vancouver, BC, Canada
| | | | - Thomas Kerr
- British Columbia Centre on Substance Use, Vancouver, BC, Canada,Department of Medicine, University of British Columbia, St Paul’s Hospital, Vancouver, BC, Canada
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Fischer B, O’Keefe-Markman C, Lee A(MH, Daldegan-Bueno D. 'Resurgent', 'twin' or 'silent' epidemic? A select data overview and observations on increasing psycho-stimulant use and harms in North America. Subst Abuse Treat Prev Policy 2021; 16:17. [PMID: 33588896 PMCID: PMC7883758 DOI: 10.1186/s13011-021-00350-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2021] [Indexed: 01/16/2023] Open
Abstract
In the early 2000s, increasing prevalence of psycho-stimulant (e.g., crack/cocaine, methamphetamine) use and related harms, including severe adverse health outcomes, was observed among - mostly marginalized - populations of persons using illicit drugs in North America, underscoring an urgent need for interventions options towards improved prevention and treatment. By about 2010, however, the 'opioid crisis', featuring unprecedented use and public health burden, had accelerated into full force in North America, largely muting attention to the psycho-stimulant issue until recently. Recent surveillance data on drug use and related mortality/morbidity from the present decade has documented a marked resurgence of psycho-stimulant use and harms especially in at-risk populations, commonly in direct combination with opioids, across North America, resulting in a 'twin epidemic' comprised of opioids and psycho-stimulants We briefly review select epidemiological data indicators for these developments from the United States and Canada; in the latter jurisdiction, related evidence has been less prevalent and systematic but corroborating the same trends. Evidently, the (widely ongoing) focus on the 'opioid epidemic' as a 'mono-type' drug problem has become an anachronism that requires urgent and appropriate correction. We then briefly consider existing, evidence-based options for - prevention and treatment - interventions targeting psycho-stimulant use and harms, which are substantially more limited and/or less efficacious than those available for problematic opioid use, while presenting major gaps and challenges. The observed resurgence of psycho-stimulants may, indirectly, relate to recent efforts towards curtailing (medical) opioid availability, thereby accelerating demand and supply for both illicit opioids and psycho-stimulants. The presently unfolding 'twin epidemic' of opioids and psycho-stimulants, combined with limited intervention resources, presents an acute challenge for public health and may crucially undermine actively extensive efforts to reduce opioid-related health harms in North America.
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Affiliation(s)
- Benedikt Fischer
- Schools of Population Health and Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Rd, Grafton, Auckland, 1023 New Zealand
- Centre for Applied Research in Mental Health and Addiction, Faculty of Health Sciences, Simon Fraser University, 515 W. Hastings Street, Vancouver, BC V6B 5K3 Canada
- Department of Psychiatry, University of Toronto, 250 College Street, 8th floor, Toronto, M5T 1R8 Canada
- Department of Psychiatry, Federal University of São Paulo, R. Dr. Ovídio Pires de Campos, 785, São Paulo, SP 05403-903 Brazil
| | - Caroline O’Keefe-Markman
- Centre for Applied Research in Mental Health and Addiction, Faculty of Health Sciences, Simon Fraser University, 515 W. Hastings Street, Vancouver, BC V6B 5K3 Canada
| | - Angelica (Min-Hye) Lee
- Centre for Applied Research in Mental Health and Addiction, Faculty of Health Sciences, Simon Fraser University, 515 W. Hastings Street, Vancouver, BC V6B 5K3 Canada
| | - Dimitri Daldegan-Bueno
- Schools of Population Health and Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Rd, Grafton, Auckland, 1023 New Zealand
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Pijl E, Oosterbroek T, Motz T, Mason E, Hamilton K. Peer-assisted injection as a harm reduction measure in a supervised consumption service: a qualitative study of client experiences. Harm Reduct J 2021; 18:5. [PMID: 33407575 PMCID: PMC7788836 DOI: 10.1186/s12954-020-00455-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 12/10/2020] [Indexed: 11/25/2022] Open
Abstract
Background Peer assistance is an emerging area of study in injection drug use. When Canada’s first supervised consumption site (SCS) opened in 2003 in Vancouver, Canada, clients were prohibited from injecting their peers; only recently has this practise been introduced as a harm reduction measure at these sites. In 2018, Health Canada granted federal exemption to allow peer-assisted injection at certain SCS sites, under the Controlled Drugs and Substances Act. Literature pertaining to peer-assisted injection addresses several topics: interpersonal relationships between the injection provider and recipient; the role of pragmatism; trust and expertise; and gender relations. Methods In this qualitative study, participants (n = 16) were recruited to be interviewed about their experiences in a peer-assisted injection program (PAIP) at one SCS regulated by Health Canada. Interview data were transcribed and thematically analyzed. Quantitative administrative data were used to provide context and to describe the study population, comprised of people in the PAIP (n = 248). Results PAIP clients made up 17.4% of all SCS clients. PAIP clients were more likely to be female and Indigenous. Injection providers expressed being moved by compassion to help others inject. While their desire to assist was pragmatic, they felt a significant burden of responsibility for the outcomes. Other prominent factors related to the injection provider-recipient relationship were social connection, trust, safety, social capital, and reciprocity. Participants also made suggestions for improving the PAIP which included adding more inhalation rooms so that if someone was unable to inject they could smoke in a safe place instead. Additionally, being required by law to divide drugs outside of the SCS, prior to preparing and using in the site, created unsafe conditions for clients. Conclusions Regular use of the SCS, and access to its resources, enabled participants to lower their risk through smoking and to practice lower-risk injections. At the federal level, there is considerable room to advocate for allowing clients to divide drugs safely within the SCS, and to increase capacity for safer alternatives such as inhalation.
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Affiliation(s)
- Em Pijl
- Faculty of Health Sciences, University of Lethbridge, Lethbridge, Canada.
| | - Tracy Oosterbroek
- Faculty of Health Sciences, University of Lethbridge, Lethbridge, Canada
| | | | | | - Keltie Hamilton
- Faculty of Health Sciences, University of Lethbridge, Lethbridge, Canada
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Xavier J, Rudzinski K, Guta A, Carusone SC, Strike C. Rules and Eligibility Criteria for Supervised Consumption Services Feasibility Studies - A Scoping Review. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 88:103040. [PMID: 33220597 DOI: 10.1016/j.drugpo.2020.103040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 10/29/2020] [Accepted: 11/01/2020] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Supervised consumption services (SCS) reduce HIV risks and overdose for people who use drugs (PWUD) and are known to have wide-ranging public health benefits. Feasibility studies are often conducted as part of program/implementation development. We conducted a scoping review of SCS feasibility/pre-implementation studies to answer: what is known about stakeholders' opinions of SCS rules and eligibility criteria? METHODS Using the PRISMA-ScR guidelines, we searched Medline, PsychINFO, Embase, CINAHL, and SCOPUS databases for: (a) empirical research, (b) reported in English, (c) focused on SCS, (d) pre-implementation feasibility studies (research conducted prior to implementation of SCS in a given context), (e) examining SCS operational rules and eligibility criteria. Abstracts were reviewed to verify appropriateness; full articles/reports were retrieved; data were extracted and charted. RESULTS Of the 1,268 data sources identified/reviewed, 19 sources, were included. Manuscripts showed the following criteria that might be considered when determining who can and cannot use SCS: age, pregnancy status, and opioid substitution treatment status. To govern behaviours at SCS, manuscripts focused on: acceptable modes of drug consumption, assisted injections, sharing drugs on-site, pill injecting, and mandatory hand washing, etc. Stakeholders generally agreed that; eligibility restrictions and site rules should be minimal to establish low-barrier services. SCS are often forced to contend with the tension between adhering to a medical or public health model and creating low-barrier services. SCS rules are at the center of this intersection because rules and eligibility criteria implemented to mirror other health services may not align with the needs of PWUD. CONCLUSION Given the public health significance of SCS, establishing best practices for service delivery is critical for increasing access and addressing implementation issues. Future research should examine other operational elements of SCS, such as design elements, staffing models, and ancillary services. Additional research should also focus on supervised smoking services.
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Affiliation(s)
- Jessica Xavier
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, M5T 3M7, Canada
| | - Katherine Rudzinski
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, M5T 3M7, Canada
| | - Adrian Guta
- School of Social Work, University of Windsor, 167 Ferry Street, Windsor, ON, N9A 0C5, Canada
| | - Soo Chan Carusone
- Casey House, 119 Isabella St, Toronto, ON, M4Y 1P2, Canada; Department of Health Research Methodology, Evidence, and Impact, McMaster University, 1280 Main Street West 2C Area, Hamilton, ON, L8S 4K, Canada
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, M5T 3M7, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria St, Toronto, ON M5B 1T8, Canada.
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Kennedy MC, Milloy MJ, Hayashi K, Holliday E, Wood E, Kerr T. Assisted injection within supervised injection services: Uptake and client characteristics among people who require help injecting in a Canadian setting. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 86:102967. [PMID: 33039705 PMCID: PMC8026755 DOI: 10.1016/j.drugpo.2020.102967] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/18/2020] [Accepted: 09/24/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND People who require help injecting illicit drugs experience elevated rates of a range of health-related harms, including overdose and acquisition of blood-borne pathogens. In response, some supervised injection services (SIS) in Canada have begun to permit clients to be physically injected by fellow clients or staff members. However, little is known about uptake and characteristics of clients who engage in this practice. We therefore sought to examine factors associated with receiving injection assistance at SIS among people who require help injecting drugs in Vancouver, Canada. METHODS Data were drawn from two community-recruited prospective cohort studies of people who inject drugs (PWID). We used multivariable generalized estimating equation (GEE) analyses with time-updated covariates to identify factors associated with self-reported receipt of injection assistance at SIS. RESULTS Between June 2017 and December 2018, 319 individuals who reported having recently required help injecting were included in the study. Of these, 160 (51.0%) were women and the median age was 42 years at baseline. In total, 54 (16.9%) participants reported receiving injection assistance at a SIS at least once over an average of 3.3 months of follow-up. In multivariable GEE analyses, recent homelessness (Adjusted Odds Ratio [AOR] = 2.04; 95% confidence interval [CI]: 1.13 - 3.66), fentanyl injection (AOR = 3.45; 95% CI: 1.42 - 8.41), non-fatal overdose (AOR = 1.86; 95% CI: 1.02 - 3.38) and enrolment in methadone maintenance therapy (AOR = 1.89; 95% CI: 1.03 - 3.47) were associated with increased odds of receiving injection assistance at SIS. CONCLUSION Although uptake of assisted injection at SIS was relatively low among this sample of people who require help injecting, this practice was associated with several indicators of structural vulnerability and drug-related risk. These findings suggest that accommodating assisted injection within SIS may be providing opportunities to engage and reduce harms among higher-risk subpopulations of PWID in this setting.
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Affiliation(s)
- Mary Clare Kennedy
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, CANADA, V6Z 2A9; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6.
| | - M-J Milloy
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, CANADA, V6Z 2A9; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, CANADA, V6Z 2A9; Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, BC, CANADA, V5A 1S6
| | - Elizabeth Holliday
- Vancouver Coastal Health, 2775 Laurel Street, Vancouver, BC, CANADA V5Z 1M9
| | - Evan Wood
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, CANADA, V6Z 2A9; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, CANADA, V6Z 2A9; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
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Russell C, Imtiaz S, Ali F, Elton-Marshall T, Rehm J. 'Small communities, large oversight': The impact of recent legislative changes concerning supervised consumption services on small communities in Ontario, Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 82:102822. [PMID: 32563756 DOI: 10.1016/j.drugpo.2020.102822] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 01/10/2023]
Abstract
The opioid epidemic continues to exert a large toll on public health across Canada, with the province of Ontario specifically experiencing exceptionally high opioid-related hospitalizations and overdoses in 2019. As a key evidence-based public health intervention to reduce these harms, over the past few years supervised consumption services (SCS), including temporary and flexible unsanctioned models, have been implemented in select cities across the province. However, in March 2019, the newly elected Ontario provincial government replaced SCS regulations with a 'streamlined' model that introduced additional bureaucratic and administrative requirements for application approval and funding, while placing a cap on the number of sites allowed. Only a select few sites were approved, despite the ability of numerous cities across the province to demonstrate a need for SCS in their community. Importantly, many small communities throughout Ontario have been experiencing opioid-related harms at rates which far outpace those of larger cities. Several of these communities have been actively working towards securing SCS sites, but have been unable to do so as they do not have the resources to meet stringent application requirements. These regulatory changes therefore hinder the feasibility of small communities to implement necessary and life-saving SCS, which will affect lives. This is a major oversight.
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Affiliation(s)
- Cayley Russell
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), 33 Russell St., Toronto, Ontario, Canada, M5S 2S1.
| | - Sameer Imtiaz
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), 33 Russell St., Toronto, Ontario, Canada, M5S 2S1
| | - Farihah Ali
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), 33 Russell St., Toronto, Ontario, Canada, M5S 2S1
| | - Tara Elton-Marshall
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), 33 Russell St., Toronto, Ontario, Canada, M5S 2S1; Dalla School of Public Health, University of Toronto, 155 College St., Toronto, Ontario, Canada, M5T 3M7; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, 1151 Richmond St., London, Ontario, Canada, M6A 5C1
| | - Jürgen Rehm
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), 33 Russell St., Toronto, Ontario, Canada, M5S 2S1; Dalla School of Public Health, University of Toronto, 155 College St., Toronto, Ontario, Canada, M5T 3M7; Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), 250 College St., Toronto, Ontario, Canada, M5T 1R8; Department of Psychiatry, University of Toronto, 1 King's College Circle, Toronto, Ontario, Canada, M5S 1A8; Institute of Medical Science (IMS), University of Toronto, 1 King's College Circle, Toronto, Ontario, Canada, M5S 1A8; Institut für Klinische Psychologie und Psychotherapie, Technische Universität Dresden, Chemnitzer Str. 46, 01187 Dresden, Germany; Department of International Health Projects, Institute for Leadership and Health Management, I.M. Sechenov First Moscow State Medical University, Bol'shaya Pirogovskaya Ulitsa, 19с1, Moscow, Russian Federation 119146
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Kolla G, Strike C. Practices of care among people who buy, use, and sell drugs in community settings. Harm Reduct J 2020; 17:27. [PMID: 32381011 PMCID: PMC7206732 DOI: 10.1186/s12954-020-00372-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 04/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Popular perception of people who sell drugs is negative, with drug selling framed as predatory and morally reprehensible. In contrast, people who use drugs (PWUD) often describe positive perceptions of the people who sell them drugs. The "Satellite Sites" program in Toronto, Canada, provides harm reduction services in the community spaces where people gather to buy, use, and sell drugs. This program hires PWUD-who may move into and out of drug selling-as harm reduction workers. In this paper, we examine the integration of people who sell drugs directly into harm reduction service provision, and their practices of care with other PWUD in their community. METHODS Data collection included participant observation within the Satellite Sites over a 7-month period in 2016-2017, complemented by 20 semi-structured interviews with Satellite Site workers, clients, and program supervisors. Thematic analysis was used to examine practices of care emerging from the activities of Satellite Site workers, including those circulating around drug selling and sharing behaviors. RESULTS Satellite Site workers engage in a variety of practices of care with PWUD accessing their sites. Distribution of harm reduction equipment is more easily visible as a practice of care because it conforms to normative framings of care. Criminalization, coupled with negative framings of drug selling as predatory, contributes to the difficultly in examining acts of mutual aid and care that surround drug selling as practices of care. By taking seriously the importance for PWUD of procuring good quality drugs, a wider variety of practices of care are made visible. These additional practices of care include assistance in buying drugs, information on drug potency, and refusal to sell drugs that are perceived to be too strong. CONCLUSION Our results suggest a potential for harm reduction programs to incorporate some people who sell drugs into programming. Taking practices of care seriously may remove some barriers to integration of people who sell drugs into harm reduction programming, and assist in the development of more pertinent interventions that understand the key role of drug buying and selling within the lives of PWUD.
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Affiliation(s)
- Gillian Kolla
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, M5T 3 M7, Canada.
| | - Carol Strike
- Dalla Lana School of Public Health, University of Toronto, 155 College St., Toronto, ON, M5T 3 M7, Canada
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Kennedy MC, Hayashi K, Milloy MJ, Boyd J, Wood E, Kerr T. Supervised injection facility use and exposure to violence among a cohort of people who inject drugs: A gender-based analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 78:102692. [PMID: 32200269 DOI: 10.1016/j.drugpo.2020.102692] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/27/2020] [Accepted: 01/27/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Supervised injection facilities (SIFs) have been established in many settings, in part to reduce risks associated with injecting in public, including exposure to violence. However, the relationship between SIF use and experiencing violence has not yet been thoroughly evaluated. We sought to longitudinally examine the gender-specific relationship between SIF use and exposure to violence among people who inject drugs (PWID) in a Canadian setting. METHODS Data were drawn from two prospective cohort studies of PWID in Vancouver, Canada, between December 2005 and December 2016. Semi-annually, participants completed questionnaires that elicited data concerning sociodemographic characteristics, behavioural patterns, violent encounters and health service utilization. We used multivariable generalized estimating equations (GEE) to estimate the independent association between exclusively injecting drugs at a SIF and experiencing physical or sexual violence among men and women PWID, respectively. RESULTS Of 1930 PWID followed for a median of four years, 679 (35.2%) were women and the median age was 41 years at baseline. In total, 353 (52.0%) women and 694 (55.5%) men reported experiencing at least one incident of violence during follow-up. In multivariable analyses, exclusive SIF use was associated with decreased odds of experiencing violence among men after adjusting for potential confounders (Adjusted Odds Ratio [AOR] = 0.64; 95% confidence interval [CI]: 0.46-0.89). Exclusive SIF use was not significantly associated with experiencing violence among women in adjusted analyses (AOR = 0.97; 95% CI: 0.57-1.66). CONCLUSION In light of the recent expansion of SIFs in Canada, our finding of a protective association between exclusive SIF use and exposure to violence among men is encouraging. The fact that we did not observe a significant association between SIF use and experiencing violence among women highlights the need for social-structural interventions that are more responsive to the specific needs of women PWID in relation to violence prevention.
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Affiliation(s)
- Mary Clare Kennedy
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada.
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Faculty of Health Sciences, Simon Fraser University, Blusson Hall, Room 11300, 8888 University Drive, Burnaby, BC V5A 1S6, Canada
| | - M-J Milloy
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada
| | - Jade Boyd
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada
| | - Evan Wood
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 400-1045 Howe Street, Vancouver, BC V6Z 2A9, Canada
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Critical studies of harm reduction: Overdose response in uncertain political times. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 76:102615. [PMID: 31837567 DOI: 10.1016/j.drugpo.2019.102615] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 11/14/2019] [Accepted: 12/02/2019] [Indexed: 12/20/2022]
Abstract
North America continues to witness escalating rates of opioid overdose deaths. Scale-up of existing and innovative life-saving services - such as overdose prevention sites (OPS) as well as sanctioned and unsanctioned supervised consumption sites - is urgently needed. Is there a place for critical theory-informed studies of harm reduction during times of drug policy failures and overdose crisis? There are different approaches to consider from the critical literature, such as those that, for example, interrogate the basic principles of harm reduction or those that critique the lack of pleasure in the discourses surrounding drug use. Influenced by such work, we examine the development of OPS in Canada, with a focus on recent experiences from the province of Ontario, as an important example of the impacts associated with moving from grassroots harm reduction to institutionalised policy and practice. Services appear to be most innovative, dynamic, and inclusive when people with lived experience, allies, and service providers are directly responding to fast-changing drug use patterns and crises on the ground, before services become formally bureaucratised. We suggest a continuing need to both critically theorise harm reduction and to build strong community relationships in harm reduction work, in efforts to overcome political moves that impede collaboration with and inclusiveness of people who use drugs.
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