Assisted injection within supervised injection services: Uptake and client characteristics among people who require help injecting in a Canadian setting

Overdose prevention centres as spaces of safety, trust and inclusion: A causal pathway based on a realist review

ISSUES

Overdose prevention centres (OPC) are non-residential spaces where people can use illicit drugs (that they have obtained elsewhere) in the presence of staff who can intervene to prevent and manage any overdoses that occur. Many reviews of OPCs exist but they do not explain how OPCs work.

APPROACH

We carried out a realist review, using the RAMESES reporting standards. We systematically searched for and then thematically analysed 391 documents that provide information on the contexts, mechanisms and outcomes of OPCs.

KEY FINDINGS

Our retroductive analysis identified a causal pathway that highlights the feeling of safety - and the immediate outcome of not dying - as conditions of possibility for the people who use OPCs to build trust and experience social inclusion. The combination of safety, trust and social inclusion that is triggered by OPCs can - depending on the contexts in which they operate - generate other positive outcomes, which may include less risky drug use practices, reductions in blood borne viruses and injection-related infections and wounds, and access to housing. These outcomes are contingent on relevant contexts, including political and legal environments, which differ for women and people from racialised minorities.

CONCLUSIONS

OPCs can enable people who live with structural violence and vulnerability to develop feelings of safety and trust that help them stay alive and to build longer term trajectories of social inclusion, with potential to improve other aspects of their health and living conditions.

Characterizing Use of Supervised Consumption Services among Street-involved Youth and Young Adults in the Context of an Overdose Crisis

In response to an increase in overdose deaths, there was a rapid scale-up of supervised consumption services (SCS), including federally sanctioned SCS and low-barrier SCS known as overdose prevention sites (OPS), in Vancouver, Canada, beginning in December 2016. However, little is known about the use of such services among adolescents and young adults (AYA) in this context. We therefore sought to characterize factors associated with the use of federally sanctioned SCS and OPS among street-involved AYA who inject drugs in Vancouver during an overdose crisis. From December 2016 to March 2020, data were collected from a prospective cohort of street-involved AYA aged 14 to 26 at baseline. Using multivariable generalized estimating equation analyses, we identified factors associated with recent use of federally sanctioned SCS and OPS, respectively. Among 298 AYA who inject drugs, 172 (57.8%) and 149 (50.0%) reported using federally sanctioned SCS and OPS during the study period, respectively. In multivariable analyses, public injecting, negative police interactions, and residing or spending time ≥ weekly in the Downtown Eastside neighborhood were all positively associated with the use of federally sanctioned SCS and OPS, respectively. Additionally, ≥ daily unregulated opioid use and residential eviction were positively associated with federally sanctioned SCS use, while requiring help injecting was inversely associated. Self-identified female or non-binary gender was also positively associated with OPS use (all p < 0.05). Both federally sanctioned SCS and OPS successfully engaged AYA at heightened risk of adverse health outcomes. However, the lack of accommodation of AYA who require manual assistance with injecting at federally sanctioned SCS may be inhibiting service engagement.

Context and correlates of providing assistance with someone's first injection in the AIDS linked to the IntraVenous Experience cohort, Baltimore, MD

BACKGROUND

The social processes around initiating injection may be well-suited to intervention, yet there is substantial heterogeneity in the reported experiences of people who inject drugs (PWID) who assist with another individual's first drug injection. We aimed to describe the lifetime prevalence and context of providing initiation assistance among a cohort of PWID.

METHODS

Participants of the AIDS Linked to the IntraVenous Experience (ALIVE) cohort of PWID in Baltimore, Maryland (n=848) were surveyed during 2019-2020 about assisting with another person's first injection. Associations between factors related to injection risk and history of providing assistance were estimated using logistic regression models adjusted for sociodemographic and behavioral characteristics.

RESULTS

At baseline, participants were primarily male (66.1%), black (82.9%), aged a median of 42 years, and had been injecting a median of 18 years. Overall, 19% (n=157) of participants reported ever providing assistance for a median of 2 people (Interquartile Range: 1-4). Having hepatitis C infection (adjusted Odds Ratio [95% Confidence Interval]: 2.5 [1.4-4.6]), syringe sharing (2.2 [1.2-3.9]), and injecting ≥3 times per day (2.0 [1.2-3.4]) at study enrollment were associated with a history of assistance. Participants primarily assisted friends (58.0%), acquaintances (29.9%), and partners (21.7%). Common reasons for assisting were the other person's lack of injection knowledge (73.7%) or sharing drugs (44.9%). Additional reasons included to prevent injury.

CONCLUSION

PWID with a history of assisting with another person's first injection exhibited heightened vulnerability to infections and more frequent substance use. Expanding implementation of interventions with an emphasis on harm reduction is needed.

Difficulty accessing supervised consumption services during the COVID-19 pandemic among people who use drugs in Vancouver, Canada

BACKGROUND

The overdose crisis in Canada has worsened since the emergence of the COVID-19 pandemic. Although this trend is thought to be driven in part by closures or reduced capacity of supervised consumption services (SCS), little is known about the factors that may impede access to such services during the COVID-19 pandemic among people who use drugs. This study sought to characterize the prevalence and correlates of having difficulty accessing SCS during the COVID-19 pandemic among people who use drugs in Vancouver, Canada.

METHODS

Cross-sectional data from two open prospective cohorts of people who use drugs were collected via phone or videoconferencing interviews conducted between July 2020 and November 2020. Multivariable logistic regression analyses were used to examine factors associated with experiencing difficulty accessing SCS.

RESULTS

Among the 428 people who use drugs who participated in the study, 223 (54.7%) self-identified as men and the median age was 51 years (1st to 3rd quartile: 42-58). A total of 58 (13.6%) participants reported experiencing difficulty accessing SCS. In a multivariable analysis, factors positively associated with difficulty accessing SCS included daily crystal methamphetamine use (Adjusted odds ratio [AOR] = 2.60; 95% confidence interval [CI] 1.28-5.30), active injection drug use (AOR = 4.06; 95% CI 1.38-11.90), recent non-fatal overdose (AOR = 2.45; 95% CI 1.24-4.85), and unstable housing (AOR = 2.14; 95% CI 1.08-4.23). Age was inversely associated with the outcome (AOR = 0.96; 95% CI 0.93-0.99) in multivariable analyses. The most commonly reported reasons for experiencing difficulty accessing SCS were: COVID-19-related site closure or shortened hours (42.9%) and having to wait too long to use a site (39.3%).

CONCLUSIONS

We found that people who use drugs with markers of structural vulnerability and drug-related risk were more likely to experience difficulty accessing SCS during the COVID-19 pandemic. These findings point to the need for strategies to support access to such services as part of pandemic response efforts.

Requiring help injecting among people who inject drugs in Toronto, Canada: Characterising the need to address sociodemographic disparities and substance-use specific patterns

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.

Health impacts of a scale-up of supervised injection services in a Canadian setting: an interrupted time series analysis

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.

"With a PICC line, you never miss": The role of peripherally inserted central catheters in hospital care for people living with HIV/HCV who use drugs

BACKGROUND

People who use drugs (PWUD), and especially those who inject drugs, are at increased risk of acquiring bloodborne infections (e.g., HIV and HCV), experiencing drug-related harms (e.g., abscesses and overdose), and being hospitalized and requiring inpatient parenteral antibiotic therapy delivered through a peripherally inserted central catheter (PICC). The use of PICC lines with PWUD is understood to be a source of tension in hospital settings but has not been well researched. Drawing on theoretical and analytic insights from "new materialism," we consider the assemblage of sociomaterial elements that inform the use of PICCs.

METHODS

This paper draws on n = 50 interviews conducted across two related qualitative research projects within a program of research about the impact of substance use on hospital admissions from the perspective of healthcare providers (HCPs) and people living with HIV/HCV who use drugs. This paper focuses on data about PICC lines collected in both studies.

RESULTS

The decision to provide, maintain, or remove a PICC is based on a complex assemblage of factors (e.g., infections, bodies, drugs, memories, relations, spaces, temporalities, and contingencies) beyond whether parenteral intravenous antibiotic therapy is clinically indicated. HCPs expressed concerns about the risk posed by past, current, and future drug use, and contact with non-clinical spaces (e.g., patient's homes and the surrounding community), with some opting for second-line treatments and removing PICCs. The majority of PWUD described being subjected to threats of discharge and increased monitoring despite being too ill to use their PICC lines during past hospital admissions. A subset of PWUD reported using their PICC lines to inject drugs as a harm reduction strategy, and a subset of HCPs reported providing harm reduction-centred care.

CONCLUSION

Our analysis has implications for theorizing the role of PICC lines in the care of PWUD and identifies practical guidance for engaging them in productive and non-judgemental discussions about the risks of injecting into a PICC line, how to do it safely, and about medically supported alternatives.