The Sydney Medically Supervised Injecting Centre: reducing harm associated with heroin overdose

Evolving trends in drug overdose mortality in the USA from 2000 to 2020: an age-period-cohort analysis

Background

Drug overdose deaths in the USA have increased rapidly in the past 20 years, and understanding patterns and trends in mortality is essential to develop policy responses. This study aimed to determine whether cohort patterns in mortality due to drug overdose have changed in the past two decades and assess these patterns by race and sex.

Methods

The national records of accidental drug overdose death were extracted from Centers for Disease Control and Prevention, National Center for Health Statistics Mortality Data for 2000-2020. Age-period-cohort analysis was performed to examine independent effects of age, period and birth cohort on accidental drug overdose mortality.

Findings

The number of accidental drug overdose deaths increased by 622% between 2000 and 2020, and age-standardized mortality rates increased nearly four-fold in both men and women. Age-period-cohort decomposition found rapid increases in mortality since 2012 in men and women, with higher mortality risk in cohorts born after 1990. The fastest increase occurred in Black Americans since 2012, and Americans of all races born after 1975 had significantly higher mortality risk, with mortality risk increasing rapidly in more recent cohorts. The peak of mortality has shifted from the 40-59 age group to the 30-40 year age group in the past decade.

Interpretation

The burden of drug overdose mortality has shifted to younger Americans, and a new generation of Americans are at significantly higher and rapidly increasing risk of overdose death. Urgent action is needed to prevent an entire generation of young people being consigned to decades of preventable mortality.

Funding

None.

The Nation's First Publicly Recognized Overdose Prevention Centers: Lessons Learned in New York City

In November of 2021, multiple factors converged to create a window of opportunity to open overdose prevention centers (OPCs) at two existing syringe service programs (SSPs) in New York City (NYC). Political will exists in NYC, particularly toward the end of the de Blasio administration's term, and the NYC Health Department worked to garner additional support from local and state elected officials given the dire need to address the overdose crisis. This coincided with readiness on the part of one of the NYC SSP providers, OnPoint NYC, to open and operate OPC services. Legal risks were assessed by both the city and the provider. This case study outlines the sequence of events that resulted in NYC supporting OnPoint to open the first two publicly recognized OPCs in the nation, including lessons learned to inform other jurisdictions considering offering such services.

(Re)situating expertise in community-based overdose response: Insights from an ethnographic study of overdose prevention sites (OPS) in Vancouver, Canada

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.

Harm reduction in the hospital: An overdose prevention site (OPS) at a Canadian hospital

BACKGROUND

Substance use management in hospitals can be challenging. In response, a Canadian hospital opened an overdose prevention site (OPS) where community members and hospital inpatients can inject pre-obtained illicit drugs under supervision. This study aims to: (1) describe program utilization patterns; (2) characterize OPS visits; and (3) evaluate overdose events and related outcomes.

METHODS

A retrospective chart review was completed at one hospital in Vancouver, Canada. All community members and hospital inpatients who visited the OPS between May 2018 and July 2019 were included. Client measures included: hospital inpatient status, use of intravenous access line for drug injection, and substances used. Program measures included: number of visits (daily/monthly), overdose (fatal/non-fatal) events and overdose-related outcomes.

RESULTS

Overall, 11,673 OPS visits were recorded. Monthly visits increased from 306 to 1198 between May 2018 and July 2019 respectively. On average, 26 visits occurred daily. Among all visits, 20% reported being a hospital inpatient, and 5% reported using a hospital intravenous access line for drug injection. Opioids (56%) and stimulants (24%) were the most common substances used. Overall 39 overdose events occurred - 82% required naloxone reversal, 28% required transfer to the hospital's emergency department and none were fatal. Overdose events were more common among hospital inpatients compared to community clients (6.6 vs 2.2 per 1000 visits respectively; p value = 0.046).

CONCLUSIONS

This unique OPS is an example of a hospital-based harm reduction initiative. Use of the site increased over time among both groups with no fatal overdose events occurring.

Harm Reduction Policy Support among Students at Two U.S. Universities

Background: The U.S. is undergoing an opioid overdose crisis. Harm reduction (HR) policies are associated with decreased overdose deaths and incidence of communicable diseases, yet legality of HR policies differs across U.S. jurisdictions. College student perceptions of HR policies are underexplored, even though their voting behavior has increased in recent years. We sought to compare their support of different HR policies and to explore relationships between demographic characteristics and support for HR policies. Methods: We collected cross-sectional, convenience sample survey data from undergraduate students at two large public universities, one in the Midwest and one in the Southeast, during Fall 2018/Spring 2019. We analyzed data using descriptive statistics and logistic regressions. Results: The final sample included 1,263 respondents. Good Samaritan laws (n = 833, 66%) and naloxone distribution (n = 476, 37.7%) were most commonly supported, while heroin maintenance treatment (n = 232, 18.4%) and heroin decriminalization (n = 208, 16.5%) were least supported. Democrat/liberal or less religious/spiritual respondents supported HR policies more than their Republican/conservative or religious/spiritual counterparts. Midwestern students were more likely to support syringe services programs. Conclusion: HR education initiatives could target religious and/or Republican/conservative students, as they have lower HR support. Among HR policies, Good Samaritan policies may be easiest to pass in college communities.

Perceptions of Syringe Service Programs and Supervised Use Sites Among a Sample of Registered Voters in a US State

CONTEXT

The decision to initiate a syringe service program or expand to a supervised use site is often influenced by local public support or opposition.

OBJECTIVE

The purpose of this study was to better understand public attitudes to local syringe service programs to inform the possibility of expanding services.

DESIGN, SETTING, AND PARTICIPANTS

We surveyed a sample of registered voters (n = 690) in the 8 counties in the state of Colorado with existing syringe service programs.

MAIN OUTCOME MEASURES

Respondents were asked about their awareness of and attitudes toward syringe service programs and supervised use sites.

RESULTS

More than three-fourths of respondents reported they were familiar with syringe service programs, but only a quarter knew they were legal, despite all survey respondents living near an operating program. Nearly one in 3 respondents thought a syringe service program or a supervised use site makes a community better, and a majority (57%) thought supervised use sites should be legal in their state. There were significant differences in attitudes toward the benefits and risks of syringe service programs by political party affiliation.

CONCLUSION

Understanding the level of community knowledge and support for syringe service programs, as well as the reasons for opposition, can be helpful in addressing community concerns when seeking to initiate or expand services.

Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical Features and Implications for Health Care and Public Responses: A Scientific Statement From the American Heart Association

Opioid overdose is the leading cause of death for Americans 25 to 64 years of age, and opioid use disorder affects >2 million Americans. The epidemiology of opioid-associated out-of-hospital cardiac arrest in the United States is changing rapidly, with exponential increases in death resulting from synthetic opioids and linear increases in heroin deaths more than offsetting modest reductions in deaths from prescription opioids. The pathophysiology of polysubstance toxidromes involving opioids, asphyxial death, and prolonged hypoxemia leading to global ischemia (cardiac arrest) differs from that of sudden cardiac arrest. People who use opioids may also develop bacteremia, central nervous system vasculitis and leukoencephalopathy, torsades de pointes, pulmonary vasculopathy, and pulmonary edema. Emergency management of opioid poisoning requires recognition by the lay public or emergency dispatchers, prompt emergency response, and effective ventilation coupled to compressions in the setting of opioid-associated out-of-hospital cardiac arrest. Effective ventilation is challenging to teach, whereas naloxone, an opioid antagonist, can be administered by emergency medical personnel, trained laypeople, and the general public with dispatcher instruction to prevent cardiac arrest. Opioid education and naloxone distributions programs have been developed to teach people who are likely to encounter a person with opioid poisoning how to administer naloxone, deliver high-quality compressions, and perform rescue breathing. Current American Heart Association recommendations call for laypeople and others who cannot reliably establish the presence of a pulse to initiate cardiopulmonary resuscitation in any individual who is unconscious and not breathing normally; if opioid overdose is suspected, naloxone should also be administered. Secondary prevention, including counseling, opioid overdose education with take-home naloxone, and medication for opioid use disorder, is important to prevent recurrent opioid overdose.

Supervised consumption service use and recent non-fatal overdose among people who inject drugs in Toronto, Canada

BACKGROUND

Aiming to reducing overdose mortality, over 40 supervised drug consumption services (SCS) presently operate in Canada. Arguments against SCS include the potential for increased non-fatal overdoses mediated by risk compensation. This study estimates associations between SCS use and recent non-fatal overdose among people who inject drugs (PWID).

METHODS

We analyzed cross-sectional baseline data collected between November 2018 and March 2020 from a cohort of adult PWID in Toronto, Canada. Recent non-fatal overdose was self-reported over the previous six months. The primary exposure was frequency of SCS use, self-reported as the proportion of injections performed at an SCS (all or most [75-100%], some [26-74%], few [≤25%], or none) in the previous six months. The prevalence of recent overdose was compared between all unique pairs of groups based on their frequency of SCS use and expressed as covariate-adjusted prevalence ratios (PR) estimated using modified Poisson regression.

RESULTS

Among 701 PWID (median [IQR] age, 40 [33 to 49]; 64.3% cisgender men; 56.8% injecting daily), most reported SCS use (all/most, 26.2%; some, 30.9%; few, 29.4%) versus no use (13.5%), with 38.6% reporting a recent overdose. From adjusted regression analyses, more frequent SCS use was not statistically significantly associated with overdose when compared to either no SCS use or less frequent use. Associations between SCS use frequency and overdose were notably smaller among SCS clients compared to associations between SCS clients and non-users (e.g., all/most versus none: PR, 1.43 [95% CI, 0.93 to 2.21]; all/most versus some: PR, 0.94 [95% CI, 0.75 to 1.17]; all/most versus few: PR, 1.15 [95% CI, 0.89 to 1.48]).

CONCLUSION

Findings did not indicate statistically significant associations between SCS use frequency and recent non-fatal overdose, particularly among SCS clients who may be more comparable. Nevertheless, overdose was common, underscoring the need to prevent non-fatal overdose and associated morbidity.

Anticipated use of a supervised drug consumption site among syringe services program clients in King County, Washington: Assessing the role of opioid overdose and injection behavior

BACKGROUND

US jurisdictions are considering implementing supervised drug consumption sites (SCSs) to combat the overdose epidemic. No sanctioned SCS exists in the US, but King County, Washington has proposed Community Health Engagement Locations (CHELs), which would include supervised drug consumption. We assessed characteristics of people engaged in syringe services programs (SSPs) who anticipated SCS use.

METHODS

We estimated prevalence of anticipated SCS use in a 2017 cross-sectional sample of King County SSP participants (N = 377). We used Poisson regression with robust standard errors to estimate likelihood of anticipated SCS use by overdose history (experienced, witnessed only, neither), public injection frequency (always, some/most times, never), drug use behaviors, and sociodemographic characteristics.

RESULTS

The sample was primarily male (66.8 %), white (69.5 %), and averaged 37 years old. Almost two-thirds of participants witnessed or experienced an overdose in the past year (43.2 % witnessed only; 19.6 % experienced overdose). Four in five SSP participants (83.0 %) anticipated any SCS use. Anticipated SCS use was higher among participants who experienced an overdose (risk ratio [RR] = 1.14, 95 % CI = 1.04, 1.24) than those with no overdose experience. In multivariable analyses, anticipated SCS use was higher among people reporting injecting publicly (e.g., always vs. never: aRR = 1.26, 95 % CI = 1.11, 1.43), and lower among people primarily using methamphetamine (aRR = 0.80, 95 % CI = 0.67, 0.96) compared to people primarily using opioids.

CONCLUSIONS

In King County, SCS services would be used by people at high risk of overdose, including SSP participants reporting injecting in public. SCSs could be an important step to promote health and safety across communities.

Effect of Intranasal vs Intramuscular Naloxone on Opioid Overdose: A Randomized Clinical Trial

IMPORTANCE

Previous unblinded clinical trials suggested that the intranasal route of naloxone hydrochloride was inferior to the widely used intramuscular route for the reversal of opioid overdose.

OBJECTIVE

To test whether a dose of naloxone administered intranasally is as effective as the same dose of intramuscularly administered naloxone in reversing opioid overdose.

DESIGN, SETTING, AND PARTICIPANTS

A double-blind, double-dummy randomized clinical trial was conducted at the Uniting Medically Supervised Injecting Centre in Sydney, Australia. Clients of the center were recruited to participate from February 1, 2012, to January 3, 2017. Eligible clients were aged 18 years or older with a history of injecting drug use (n = 197). Intention-to-treat analysis was performed for all participants who received both intranasal and intramuscular modes of treatment (active or placebo).

INTERVENTIONS

Clients were randomized to receive 1 of 2 treatments: (1) intranasal administration of naloxone hydrochloride 800 μg per 1 mL and intramuscular administration of placebo 1 mL or (2) intramuscular administration of naloxone hydrochloride 800 μg per 1 mL and intranasal administration of placebo 1 mL.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was the need for a rescue dose of intramuscular naloxone hydrochloride (800 μg) 10 minutes after the initial treatment. Secondary outcome measures included time to adequate respiratory rate greater than or equal to 10 breaths per minute and time to Glasgow Coma Scale score greater than or equal to 13.

RESULTS

A total of 197 clients (173 [87.8%] male; mean [SD] age, 34.0 [7.82] years) completed the trial, of whom 93 (47.2%) were randomized to intramuscular naloxone dose and 104 (52.8%) to intranasal naloxone dose. Clients randomized to intramuscular naloxone administration were less likely to require a rescue dose of naloxone compared with clients randomized to intranasal naloxone administration (8 [8.6%] vs 24 [23.1%]; odds ratio, 0.35; 95% CI, 0.15-0.66; P = .002). A 65% increase in hazard (hazard ratio, 1.65; 95% CI, 1.21-2.25; P = .002) for time to respiratory rate of at least 10 and an 81% increase in hazard (hazard ratio, 1.81; 95% CI, 1.28-2.56; P = .001) for time to Glasgow Coma Scale score of at least 13 were observed for the group receiving intranasal naloxone compared with the group receiving intramuscular naloxone. No major adverse events were reported for either group.

CONCLUSIONS AND RELEVANCE

This trial showed that intranasally administered naloxone in a supervised injecting facility can reverse opioid overdose but not as efficiently as intramuscularly administered naloxone can, findings that largely replicate those of previous unblinded clinical trials. These results suggest that determining the optimal dose and concentration of intranasal naloxone to respond to opioid overdose in real-world conditions is an international priority.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12611000852954.

Supervised Injection Facility Utilization Patterns: A Prospective Cohort Study in Vancouver, Canada

INTRODUCTION

Although the health and community benefits of supervised injection facilities are well documented, little is known about long-term patterns of utilization of this form of health service. The present study seeks to longitudinally characterize discontinuation of use of a supervised injection facility in Vancouver, Canada.

METHODS

Data were drawn from 2 community-recruited prospective cohorts of people who inject drugs between December 2005 and December 2016. In 2018, extended Cox regression for recurrent events was used to examine factors associated with time to cessation of supervised injection facility use during periods of active injection.

RESULTS

Of 1,336 people who inject drugs that were followed for a median of 50 months, 847 (63.4%) participants reported 1,663 6-month periods of supervised injection facility use cessation while actively injecting drugs (incidence density of 26.6 events per 100 person-years). An additional 2,282 (57.8%) of the total 3,945 6-month periods of supervised injection facility use cessation occurred during periods of injection cessation. In multivariable analyses, enrollment in methadone maintenance therapy (adjusted hazard ratio=1.41) and HIV seropositivity (adjusted hazard ratio=1.23) were positively associated with supervised injection facility use cessation during periods of active injection, whereas homelessness (adjusted hazard ratio=0.59), at least daily heroin injection (adjusted hazard ratio=0.70), binge injection (adjusted hazard ratio=0.68), public injection (adjusted hazard ratio=0.67), nonfatal overdose (adjusted hazard ratio=0.73), difficulty accessing addiction treatment (adjusted hazard ratio=0.69), and incarceration (adjusted hazard ratio=0.70) were inversely associated with this outcome (all p<0.05). The most commonly reported reasons for supervised injection facility use cessation were injection drug use cessation (42.3%) and a preference for injecting at home (30.7%).

CONCLUSIONS

These findings suggest that this supervised injection facility successfully retains people who inject drugs at elevated risk of drug-related harms and indicate that many supervised injection facility clients neither use this service nor inject drugs perpetually.

Acceptability of safe drug consumption spaces among people who inject drugs in rural West Virginia

Aim

Safe consumption spaces (SCS) are indoor environments in which people can use drugs with trained personnel on site to provide overdose reversal and risk reduction services. SCS have been shown to reduce fatal overdoses, decrease public syringe disposal, and reduce public drug consumption. Existing SCS research in the USA has explored acceptability for the hypothetical use of SCS, but primarily among urban populations of people who inject drugs (PWID). Given the disproportionate impact of the opioid crisis in rural communities, this research examines hypothetical SCS acceptability among a rural sample of PWID in West Virginia.

Methods

Data were drawn from a 2018 cross-sectional survey of PWID (n = 373) who reported injection drug use in the previous 6 months and residence in Cabell County, West Virginia. Participants were asked about their hypothetical use of a SCS with responses dichotomized into two groups, likely and unlikely SCS users. Chi-square and t tests were conducted to identify differences between likely and unlikely SCS users across demographic, substance use, and health measures.

Results

Survey participants were 59.5% male, 83.4% non-Hispanic White, and 79.1% reported likely hypothetical SCS use. Hypothetical SCS users were significantly (p < .05) more likely to have recently (past 6 months) injected cocaine (38.3% vs. 25.7%), speedball (41.0% vs. 24.3%), and to report preferring drugs containing fentanyl (32.5% vs. 20.3%). Additionally, likely SCS users were significantly more likely to have recently experienced an overdose (46.8% vs. 32.4%), witnessed an overdose (78.3% vs. 60.8%), and received naloxone (51.2% vs. 37.8%). Likely SCS users were less likely to have borrowed a syringe from a friend (34.6% vs. 48.7%).

Conclusions

Rural PWID engaging in high-risk behaviors perceive SCS as an acceptable harm reduction strategy. SCS may be a viable option to reduce overdose fatalities in rural communities.

"Beyond Safer Injecting"-Health and Social Needs and Acceptance of Support among Clients of a Supervised Injecting Facility

Health and social issues in aging populations of people who inject drugs (PWID) tend to aggregate, despite risky injecting practices decreasing with age. Identifying needs and avenues of support is becoming increasingly important. We described the health and social situation among clients of a long-running supervised injecting facility (SIF) in Sydney, Australia. An interviewer-administered survey (n = 182) assessed current housing status, employment, physical and mental health, incarceration history, drug use, engagement in drug treatment, health service utilization, and willingness to accept support. Results were compared to the information provided at initial visit. Up to half of the participants transitioned between lower- and higher-risk health and social indicators over time. Willingness to accept support was greatest amongst those with higher self-perceived need. Support for mental health was a low priority, despite the high self-reporting of mental health issues. SIF clients are open to support for health and social issues, despite ongoing active drug use. Lower-threshold services such as SIFs are well-positioned to recognize and respond to deteriorating health and social issues for PWID. Facilitating care and treatment remains a challenge when the services to which people are being referred are higher-threshold with a more rigid approach.

Implementation contexts and the impact of policing on access to supervised consumption services in Toronto, Canada: a qualitative comparative analysis

BACKGROUND

Supervised consumption services (SCS) are being implemented across Canada in response to a variety of drug-related harms. We explored the implementation context of newly established SCS in Toronto and the role of policing in shaping program access by people who inject drugs (PWID).

METHODS

We conducted one-to-one qualitative semi-structured interviews with 24 PWID. Participants were purposively recruited. Ethnographic observations were conducted at each of the study sites as well as in their respective neighbourhoods. Relevant policy documents were also reviewed.

RESULTS

Policing was overwhelmingly discussed by participants from both SCS sites. However, participant responses varied depending on the site in question. Subthemes from participant responses on policing at site #1 described neighbourhood police presence and fears of police harassment and drug arrests before, during, or after accessing SCS. Conversely, subthemes from participant responses on policing at site #2 described immunity and protection from police while using the SCS, as well as a lack of police presence or fears of police harassment and arrests. These differences in implementation contexts were largely shaped by differences in local neighbourhoods and drug scenes. Police policies highlighted federal laws protecting PWID within SCS, but also the exercise of discretion when applying the rule of law outside of these settings.

CONCLUSIONS

Participants' perspectives on, and experiences with, policing as they relate to accessing SCS were shaped by the implementation contexts of each SCS site and how neighbourhoods, drug scenes, and differences in policing practices affected service use. Our findings also demonstrate the disconnect between the goals of policing and those of SCS. Until larger structural barriers are addressed (e.g. criminalization), future SCS programming should consider the impact of policing on the SCS implementation context to improve client experience with, and access to, SCS.

Drug consumption rooms: A systematic review of evaluation methodologies

ISSUES

Drug consumptions rooms (DCR) and supervised injecting facilities (SIF) are expanding internationally. Previous reviews have not systematically addressed evaluation methodologies.

APPROACH

Results from systematic searches of scientific databases in English until June 2017 were coded for paper type, country and year of publication. For evaluation papers, study outcome, methodology/study design and main indicators of DCR/SIF 'exposure' were recorded.

KEY FINDINGS

Two hundred and nineteen eligible peer-reviewed papers were published since 1999: the majority from Canada (n = 117 papers), Europe (n = 36) and Australia (n = 32). Fifty-six papers reported evaluation outcomes. Ecological study designs (n = 10) were used to assess the impact on overdose, public nuisance and crime; modelling techniques (n = 6) estimated impact on blood-borne diseases, overdose deaths and costs. Papers using individual-level data included four prospective cohorts (n = 28), cross-sectional surveys (n = 7) and service records (n = 5). Individual-level data were used to assess safer injecting practice, uptake into health and social services and all the other above outcomes except for impact on crime and costs. Four different indicators of DCR/SIF attendance were used to measure service 'exposure'.

IMPLICATIONS

Research around DCRs/SIFs has used ecological, modelling, cross-sectional and cohort study designs. Further research could involve systematic inclusion of a control group of people who are eligible but do not access SIFs, validation of self-reported proportion of injections at SIFs or a stepped-wedge or a cluster trial comparing localities.

CONCLUSIONS

Methodologies appropriate for DCR/SIF evaluation have been established and can be readily replicated from the existing literature. Research on operational aspects, implementation and transferability is also warranted.

Drug consumption rooms (DCRs) as a setting to address hepatitis C - findings from an international online survey

BACKGROUND

Prevalence of Hepatitis C Virus (HCV) among people who inject drugs (PWID) is high. Risky injecting behaviours have been found to decrease in drug consumption rooms (DCRs) and supervised injecting facilities (SIFs), yet HCV prevention and treatment in these settings have not been extensively explored.

METHODS

To determine the range and scope of HCV prevention and treatment options in these services, we assessed DCR/SIF operational features, their clients' characteristics and the HCV-related services they provide. A comprehensive online survey was sent to the managers of the 91 DCRs/SIFs that were operating globally as of September 2016. A descriptive cross-country analysis of the main DCR/SIF characteristics was conducted and bivariate logistic models were used to assess factors associated with enhanced HCV service provision.

RESULTS

Forty-nine valid responses were retrieved from DCRs/SIFs in all countries where they were established at the time of the survey (Australia, Canada, Denmark, France, Germany, Luxembourg, Netherlands, Norway, Spain and Switzerland). Internationally, the operational capacities of DCRs/SIFs varied in terms of funding, location, size and staffing, but their clients all shared common features of vulnerability and marginalisation. Estimated HCV prevalence rates were around 60%. Among a range of health and social services and referrals to other programs, most DCRs/SIFs provided HCV testing onsite (65%) and/or offered liver monitoring or disease management (54%). HCV treatment onsite was offered or was planned to be offered by 21% of DCRs/SIFs. HCV testing onsite was associated with provision of other services addressing blood-borne diseases and HCV treatment was linked to the provision of OST. HCV disease management was associated with employing a nurse at a DCR/SIF and HCV treatment was associated with employing a medical doctor.

CONCLUSIONS

DCRs/SIFs offer easy-to-access HCV-related services for PWID. The availability of onsite medical professionals and provision of support and education to non-medical staff are key to enhanced provision of HCV-related services in DCRs/SIFs. Funding and support for HCV treatment at the community level, via low-threshold services such as DCRs/SIFs, are worthy of action.

Changes in public order after the opening of an overdose monitoring facility for people who inject drugs

BACKGROUND

In the face of an increasingly fatal opioid crisis, Boston Health Care for the Homeless Program (BHCHP) opened the Supportive Place for Observation and Treatment (SPOT), a unique low-threshold harm reduction program for monitoring people who have injected drugs and are at imminent risk of overdose. This study examines the impact of the opening of the SPOT program on measures of injection drug-related public order in the neighborhood surrounding the facility.

METHODS

Data was collected at 10 weeks prior and 12 weeks post SPOT implementation on: number of over-sedated individuals in public, publicly discarded syringes, publicly discarded injection-related litter, and instances of active injection drug use or exchange of drugs. Changes were evaluated using Poisson log-linear regression models. Potential confounders such as weather and police presence were measured and controlled for.

RESULTS

The average number of over-sedated individuals observed in public significantly decreased by 28% (4.3 [95% Confidence Interval (CI) 2.7-6.9] v 3.1 [CI 1.4-6.8]) after SPOT opened. The opening of SPOT did not have a significant effect on the other measures of public order. The daily average number of publicly discarded syringes (28.5 [CI 24.5-33.1] v 28.4 [CI 22.0-36.5]), pieces of publicly discarded injection-related litter (376.3 [CI 358.6-394.8] v 375.0 [CI 345.8-406.6]), and observed instances of active use or exchange of drugs (0.2 [CI 0.1-0.9] v 0.1 [CI 0.0-0.1]) were not statistically significantly different after the opening of SPOT.

CONCLUSIONS

The opening of SPOT was associated with a significant decrease in observed over-sedated individuals. Other measures of injection-drug related public order did not improve or worsen with the opening of SPOT, however, they have been shown to improve with the implementation of a supervised injection facility.

Homelessness among clients of Sydney’s supervised injecting facility

Purpose

The Uniting Medically Supervised Injecting Centre (MSIC) opened in Sydney, Australia, in May 2001. Homelessness among people who inject drugs (PWID) in Australia has been increasing, and establishing how supervised injecting facilities (SIFs) might best support clients into housing is an important goal. The purpose of this paper is to update knowledge regarding the accommodation status of MSIC clients, thereby supporting a better understanding of the complex needs of these clients.

Design/methodology/approach

Client accommodation status at MSIC registration (first visit) and in a brief survey (conducted in May 2016) were compared; unstable accommodation was defined as rough sleeping, couch surfing, hostel, boarding house or crisis accommodation. The bivariate logistic regression analysis was used to explore the association between socio-demographics and accommodation status at both time points; a paired t-test was used to compare the visit records for those who reported stable and unstable accommodation in May 2016.

Findings

Of 232 clients who were present at MSIC during the week the Brief Survey was conducted, 107 participated. Most were male (79 per cent) with a mean age of 41.4 years. A total of 64 (60 per cent) identified as living in unstable accommodation; having increased from 40 per cent at the time of registration (first visit). There were significant positive associations between unstable accommodation status and unemployment, imprisonment and history of overdose, all measured at registration. In May 2016, unstable accommodation status was significantly associated with age of first injection and with unemployment status (as measured at registration); those living in unstable accommodation in May 2016 had a lower number of visits, a lower number of referrals to health and social services and a lower number of overdoses at MSIC than those living in a stable accommodation.

Originality/value

The rates of unstable accommodation among MSIC clients have been increasing. These findings highlight the importance of SIFs and drug consumption rooms as venue to address the essential needs of PWID, such as housing. The window of opportunity to support PWID who experience housing instability seems to be narrower than for those who live in stable accommodation.

Highs and Lows: An Interrupted Time-Series Evaluation of the Impact of North America’s Only Supervised Injection Facility on Crime

North America is currently experiencing an opioid crisis. One proposed solution to combat problems associated with injection drug use is the use of supervised injection facilities. These facilities provide drug users a space to inject pre-obtained drugs without any legal repercussions. Research on these facilities has focused on public health outcomes, and generally found positive results. Far fewer studies have investigated the impact supervised injection facilities have on crime. The current study provides an interrupted time-series analysis on the impact of North America’s only supervised injection facility on crime. Analyses of city wide crime data evidence no impact of the supervised injection facility on crime. Disaggregated analyses indicate a significant decrease in crimes in the district where the supervised injection facility is located. Implications of the findings are discussed.

Supervised injection services: what has been demonstrated? A systematic literature review

BACKGROUND

Supervised injection services (SISs) have been developed to promote safer drug injection practices, enhance health-related behaviors among people who inject drugs (PWID), and connect PWID with external health and social services. Nevertheless, SISs have also been accused of fostering drug use and drug trafficking.

AIMS

To systematically collect and synthesize the currently available evidence regarding SIS-induced benefits and harm.

METHODS

A systematic review was performed via the PubMed, Web of Science, and ScienceDirect databases using the keyword algorithm [("supervised" or "safer") and ("injection" or "injecting" or "shooting" or "consumption") and ("facility" or "facilities" or "room" or "gallery" or "centre" or "site")].

RESULTS

Seventy-five relevant articles were found. All studies converged to find that SISs were efficacious in attracting the most marginalized PWID, promoting safer injection conditions, enhancing access to primary health care, and reducing the overdose frequency. SISs were not found to increase drug injecting, drug trafficking or crime in the surrounding environments. SISs were found to be associated with reduced levels of public drug injections and dropped syringes. Of the articles, 85% originated from Vancouver or Sydney.

CONCLUSION

SISs have largely fulfilled their initial objectives without enhancing drug use or drug trafficking. Almost all of the studies found in this review were performed in Canada or Australia, whereas the majority of SISs are located in Europe. The implementation of new SISs in places with high rates of injection drug use and associated harms appears to be supported by evidence.

Law enforcement practices associated with HIV infection among injection drug users in Odessa, Ukraine

Despite HIV prevention efforts over the past 10 years in Odessa, Ukraine, HIV rates among injection drug users (IDUs) remain high. We explored whether IDUs' experiences with the police and court system in Odessa were associated with HIV serostatus, after controlling for other factors. Qualitative methods, including semi-structured interviews with the police and members of court (N = 19), and focus groups with IDUs (N = 42), were employed to aid in developing a survey instrument for a larger quantitative phase and to assist in interpreting the findings from the quantitative phase, which included 200 participants who were interviewed and tested for HIV. Overall, 55 % tested positive for HIV. Negative experiences with the police were noted by 86 % and included having preloaded syringes taken (66 %), rushed injections due to fear of the police (57 %), police planting drugs (18 %), paying police to avoid arrest (61 %) and threatened by the police to inform on other IDUs (23 %). HIV positive participants were more likely than those who were negative to report these experiences. In a multiple logistic regression, the most significant correlate of HIV infection was rushed injections due to fear of the police. Police actions in Odessa may be contributing to the continued escalation of HIV among IDUs, underscoring the need for structural interventions.

Illicit opioid intoxication: diagnosis and treatment

Opioid intoxications and overdose are associated with high rates of morbidity and mortality. Opioid overdose may occur in the setting of intravenous or intranasal heroin use, illicit use of diverted opioid medications, intentional or accidental misuse of prescription pain medications, or iatrogenic overdose. In this review, we focused on the epidemiology of illict opioid use in the United States and on the mechanism of action of opioid drugs. We also described the signs and symptoms, and diagnoses of intoxication and overdose. Lastly, we updated the reader about the most recent recommendations for treatment and prevention of opioid intoxications and overdose.

Public injecting drug use and the social production of harmful practice in high-rise tower blocks (London, UK): a Lefebvrian analysis

This paper presents, qualitative findings relating to specific environments hitherto unrecognised as settings used for the injecting-use of illicit drugs in an urban setting. This concerns the temporary appropriation of communal space within high-rise social-housing by injecting drug users (IDU); specifically those settings used by tower-block residents for garbage disposal ('bin chute rooms'). These environments were found to be used on daily, habitual bases by all IDU interviewed during the study. Such settings were found to contribute to a wide range of injecting-related harm and hazard. These findings further debate concerning the negative effect of place on health risk in the context of 'public' injecting drug use. These results are situated within Lefebvre's theoretical framework concerning the 'production of space'. It is contended that the 'representational spaces' shaped by IDU creates a dialectic between wider 'spatial practice' and 'representations of space'. Accordingly, it is further suggested that particular 'spaces' of harm reduction (such as 'safer injecting facilities') should be considered in UK settings in order to address injecting-related harm.

Generalizing Applied Qualitative Research on Harm Reduction: The Example of a Public Injecting Typology

The small sample sizes and context-bound findings of qualitative research are commonly viewed as significant factors that limit its use (or “transferability”) in settings other than those in which the research was originally conducted. This perceived limitation is of particular importance in a field such as harm reduction where small sample sizes may be the only realistic option for studying the behavior of hard to reach groups. In this article we use Miles and Huberman's (1994) structured method of appraising qualitative research for its transferability to other settings. We consider the extent to which a typology (based on ethnographic field research into public injecting sites) can be used effectively by practitioners in settings other than those in which the original research was conducted. Through appraising the strengths and weaknesses of this research, we demonstrate that contextualized qualitative findings can enable the transferability of qualitative research findings and be of significant applied value for harm reduction services.

The impact of a supervised injecting facility on ambulance call-outs in Sydney, Australia

AIMS

Supervised injecting facilities (SIFs) are effective in reducing the harms associated with injecting drug use among their clientele, but do SIFs ease the burden on ambulance services of attending to overdoses in the community? This study addresses this question, which is yet to be answered, in the growing body of international evidence supporting SIFs efficacy.

DESIGN

Ecological study of patterns in ambulance attendances at opioid-related overdoses, before and after the opening of a SIF in Sydney, Australia.

SETTING

A SIF opened as a pilot in Sydney's 'red light' district with the aim of accommodating a high throughput of injecting drug users (IDUs) for supervised injecting episodes, recovery and the management of overdoses.

MEASUREMENTS

A total of 20,409 ambulance attendances at opioid-related overdoses before and after the opening of the Sydney SIF. Average monthly ambulance attendances at suspected opioid-related overdoses, before (36 months) and after (60 months) the opening of the Sydney Medically Supervised Injecting Centre (MSIC), in the vicinity of the centre and in the rest of New South Wales (NSW).

RESULTS

The burden on ambulance services of attending to opioid-related overdoses declined significantly in the vicinity of the Sydney SIF after it opened, compared to the rest of NSW. This effect was greatest during operating hours and in the immediate MSIC area, suggesting that SIFs may be most effective in reducing the impact of opioid-related overdose in their immediate vicinity.

CONCLUSIONS

By providing environments in which IDUs receive supervised injection and overdose management and education SIF can reduce the demand for ambulance services, thereby freeing them to attend other medical emergencies within the community.

Estimated drug overdose deaths averted by North America's first medically-supervised safer injection facility

BACKGROUND

Illicit drug overdose remains a leading cause of premature mortality in urban settings worldwide. We sought to estimate the number of deaths potentially averted by the implementation of a medically supervised safer injection facility (SIF) in Vancouver, Canada.

METHODOLOGY/PRINCIPAL FINDINGS

The number of potentially averted deaths was calculated using an estimate of the local ratio of non-fatal to fatal overdoses. Inputs were derived from counts of overdose deaths by the British Columbia Vital Statistics Agency and non-fatal overdose rates from published estimates. Potentially-fatal overdoses were defined as events within the SIF that required the provision of naloxone, a 911 call or an ambulance. Point estimates and 95% Confidence Intervals (95% CI) were calculated using a Monte Carlo simulation. Between March 1, 2004 and July 1, 2008 there were 1004 overdose events in the SIF of which 453 events matched our definition of potentially fatal. In 2004, 2005 and 2006 there were 32, 37 and 38 drug-induced deaths in the SIF's neighbourhood. Owing to the wide range of non-fatal overdose rates reported in the literature (between 5% and 30% per year) we performed sensitivity analyses using non-fatal overdose rates of 50, 200 and 300 per 1,000 person years. Using these model inputs, the number of averted deaths were, respectively: 50.9 (95% CI: 23.6-78.1); 12.6 (95% CI: 9.6-15.7); 8.4 (95% CI: 6.5-10.4) during the study period, equal to 1.9 to 11.7 averted deaths per annum.

CONCLUSIONS/SIGNIFICANCE

Based on a conservative estimate of the local ratio of non-fatal to fatal overdoses, the potentially fatal overdoses in the SIF during the study period could have resulted in between 8 and 51 deaths had they occurred outside the facility, or from 6% to 37% of the total overdose mortality burden in the neighborhood during the study period. These data should inform the ongoing debates over the future of the pilot project.

Social and structural aspects of the overdose risk environment in St. Petersburg, Russia

BACKGROUND

While overdose is a common cause of mortality among opioid injectors worldwide, little information exists on opioid overdoses or how context may influence overdose risk in Russia. This study sought to uncover social and structural aspects contributing to fatal overdose risk in St. Petersburg and assess prevention intervention feasibility.

METHODS

Twenty-one key informant interviews were conducted with drug users, treatment providers, toxicologists, police, and ambulance staff. Thematic coding of interview content was conducted to elucidate elements of the overdose risk environment.

RESULTS

Several factors within St. Petersburg's environment were identified as shaping illicit drug users' risk behaviours and contributing to conditions of suboptimal response to overdose in the community. Most drug users live and experience overdoses at home, where family and home environment may mediate or moderate risk behaviours. The overdose risk environment is also worsened by inefficient emergency response infrastructure, insufficient cardiopulmonary or naloxone training resources, and the preponderance of abstinence-based treatment approaches to the exclusion of other treatment modalities. However, attitudes of drug users and law enforcement officials generally support overdose prevention intervention feasibility. Modifiable aspects of the risk environment suggest community-based and structural interventions, including overdose response training for drug users and professionals that encompasses naloxone distribution to the users and equipping more ambulances with naloxone.

CONCLUSION

Local social and structural elements influence risk environments for overdose. Interventions at the community and structural levels to prevent and respond to opioid overdoses are needed for and integral to reducing overdose mortality in St. Petersburg.

Risk, shame and the public injector: A qualitative study of drug injecting in South Wales

Drug injecting in public places is associated with elevated health harm among injecting drug users (IDUs). Yet there is little research exploring the lived experience of injecting in public places, and specifically, a need to explore the interplay of public injecting environments, risk practices and social marginalisation. We undertook 49 qualitative interviews with IDUs in South Wales, UK, in six locations. Analyses focused on injectors' narratives of injecting in public places and risk identity. Findings show how the lived experience of public injecting feeds a pervasive sense of risk and 'otherness' among street injectors, in which public injecting environments act as contextual amplifiers of social marginalisation. Injecting in public places was characterised by urgency associated with a fear of interruption, a need to maintain privacy to prevent public exposure, and an awareness or sense of shame. We argue that daily interactions involving public exposure of injecting status, combined with the negative social meanings ascribed to public places used for injection, are experienced as potentially degrading to one's sense of self. We conclude that the public injecting environment is experienced in the context of other forms of public shaming in the lives of street injectors, and is thus productive of symbolic violence. This highlights tensions between strategies seeking to create safer communities and environmental interventions seeking to reduce drug-related health harm, including recent innovations such as the 'drug consumption room' (DCR).

Public injecting and the need for 'safer environment interventions' in the reduction of drug-related harm

BACKGROUND

One key structural dimension in the distribution of drug-related harm associated with injecting drug use is the injecting environment. Epidemiological evidence associates elevated blood-borne viral risk with injecting in 'public' and 'semipublic' environments. Yet the quality of evidence on public injecting and related viral risk is variable, and is lacking in many countries such as the United Kingdom.

AIM

This commentary considers the micro-injecting environment as a critical dimension of risk, exploring the need for 'safer injecting environment interventions'.

METHODS

We draw upon published research evidence and qualitative case examples.

RESULTS

We note the limits in epidemiological evidence on public injecting and emphasize the need for ethnographic research to determine the 'social relations' of how drug users and risk practices interact with injecting environments. We identify three main forms of 'safer environment intervention': purpose-built drug consumption rooms; interventions within existing spatial relations; and spatial programming and urban design. While drug consumption rooms find evidence-based support, they are not a panacea. We emphasize the potential of interventions embedded within existing spatial and social relations. These include low-cost pragmatic interventions enhancing facilities and safety at public and semipublic injecting sites and, primarily, peer-based interventions, including peer-supervised injecting sites. We caution against spatial programming and urban design interventions which can cause the displacement of socially marginalized populations and the redistribution of harm.

CONCLUSIONS

Public health interventions in the addictions field have in the past focused upon individual behavioural change at the cost of social interventions and environmental change. We wish to focus greater attention on reducing risks related to public injecting and encourage greater debate on 'safer environment interventions' in harm reduction.