Introducing safer injecting facilities (SIFs) in the Republic of Ireland: ‘Chipping away’ at policy change

Stakeholders’ Problematisation of Drug Consumption Rooms: A Case Study of the Policy Initiative in Helsinki

Drug consumption rooms are one of the harm reduction interventions to handle complex social problems. The Helsinki city initiative puts drug consumption room (DCR) on a government agenda in Finland, which has also triggered a broader discussion. This study presents how stakeholders problematise and what solutions they propose for DCRs. The research is based on in-depth interviews of 23 stakeholders and the theoretical perspective of Bacchi’s approach – ‘What’s the problem represented to be?’ (WPR).

The results show that while stakeholders’ solutions resemble each other on the core DCR functions, the variations are found mainly in the introduction of extended services, policy development strategy, types of drug allowance in DCRs, and drug testing options. Stigmatisation of PWUDs still leads the harm reduction services to be considered from a moral framework. Stakeholders tend to take their positions according to strategic considerations related to electoral politics, expedience and the symbolic role of policies.

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.

A systematic review of stakeholder perceptions of supervised injection facilities

INTRODUCTION

Supervised injection facilities (SIFs) have been developed to address the public health burden associated with substance use. While these facilities have been associated with a number of positive outcomes, stakeholder opinion (the opinions of those potentially affected by these facilities) is likely to influence their future development. This systematic review aims to answer the question, "how do stakeholders perceive SIFs?"

MATERIALS AND METHODS

Articles were located through nine academic databases, by searching for grey literature, by contacting health departments in countries where SIFs have been implemented, by searching articles that cited included articles, and by searching the reference lists of included articles. Two reviewers screened all articles. Data was double-extracted and quality appraised. All extracted perceptions were analyzed by two coders.

RESULTS

Forty-seven articles were synthesized. Key themes included (1) benefits of SIFs, such as the increased safety of people who use drugs (PWUD) and the education that was provided at these facilities; (2) concerns regarding SIFs, such as the location of these facilities and existing rules and regulations; and (3) suggestions for SIFs, such as changing restrictions and regulations. Perceptions often fluctuated between stakeholders with first-hand experience of SIFs (e.g. staff and PWUD) and stakeholders not involved in the operation of SIFs (e.g. the general public).

CONCLUSION

The findings of this review illustrate how perceptions vary and align across different types of SIFs. Going forward, it will be important to draw on these insights to facilitate a more informed discussion on the implementation and continuation of these facilities.

The implementation of overdose prevention sites as a novel and nimble response during an illegal drug overdose public health emergency

BACKGROUND

Drug-related overdoses were declared a public health emergency in British Columbia, Canada in April, 2016 facilitating the scale-up of responses including rapid sanctioning and implementation of overdose prevention sites (OPSs). OPSs are a health service providing supervised injection and immediate overdose response. In BC, OPSs were operational within weeks of sanctioning. In the first year of operation over 20 OPSs were established with approximately 550,000 visits and no overdose deaths at any site. In this paper, we examine the implementation of OPSs as a novel and nimble response to prevent overdose deaths as a result of injection drug use.

METHODS

A multiple case study design was used with the Consolidated Framework for Implementation (CFIR) informing the analysis. Three sites in a single city were included with each site constituting a case. In this paper, we focus on qualitative interviews with 15 staff and their perceptions of the implementation of the OPSs as well as provincial and local documents.

RESULTS

The legislative process to implement OPSs was unprecedented as it sanctioned supervised injection services as an extraordinary measure under a declared public health emergency. Innovative and inclusionary practices were possible within state-sanctioned OPSs, as the sites were government-directed yet community-developed, with PWUD centred in service design, implementation and delivery. OPSs lack permanency and may be limited to the duration of the public health emergency.

CONCLUSION

The rapid implementation of OPSs provides an international example of an alternative to lengthy and often onerous sanctioning processes for supervised consumption services (SCSs). Overdose prevention sites provide an example of a novel service design and nimble implementation process that combines the benefits of state-sanctioned injection services with community-driven implementation. Such evidence questions the continued acceptability of governments' restrictive sanctioning processes, which have limited expansion of SCSs internationally and the implementation of services that are not necessarily aligned with the needs of PWUD.

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.

The validity of reporting willingness to use a supervised injecting facility on subsequent program use among people who use injection drugs

BACKGROUND

Innovative health programs for injection drug users (IDUs), such as supervised injecting facilities (SIFs), are often preceded by evaluations of IDUs' willingness to use the service. The validity of these surveys has not been fully evaluated. We sought to determine whether measures of willingness collected prior to the opening of a Canadian SIF accurately predicted subsequent use of the program.

METHODS

Data were derived from a prospective cohort of IDUs. The sample size for this study was 640 IDUs. Using multivariate logistic regression, it was assessed if a history of reporting willingness to use the program, were it available, was associated with subsequent use. In sub-analysis restricted to individuals who had a history of reported willingness, we used multivariate longitudinal analysis to identify factors associated with not attending the SIF.

RESULTS

Among 442 IDUs, 72% of those who reported initial willingness to use a SIF later attended the program, and a prior willingness to use a SIF significantly predicted later attendance (adjusted odds ratio = 1.67). In sub-analyses restricted to those who had a history of reporting willingness to use the SIF, not using the program was predicted by not frequenting the neighborhood where the SIF was located.

CONCLUSION

Our findings indicate that reported willingness measures collected from IDUs regarding potential SIF program participation prior to its opening independently predicted later attendance even when variables that were likely determinants of willingness were adjusted for. These data suggest that willingness measures are reasonably valid tools for planning the delivery of health services among IDU populations.