Willingness to use an in-hospital supervised inhalation room among people who smoke crack cocaine in Vancouver, Canada

The utilization and delivery of safer smoking practices and services: a narrative synthesis of the literature

BACKGROUND

Providing sterile drug smoking materials to people who use drugs can prevent the acquisition of infectious diseases and reduce overdose risk. However, there is a lack of understanding of how these practices are being implemented and received by people who use drugs globally.

METHODS

A systematic review of safer smoking practices was conducted by searching PubMed, PsycInfo, Embase for relevant peer-reviewed, English-language publications from inception or the availability of online manuscripts through December 2022.

RESULTS

Overall, 32 peer-reviewed papers from six countries were included. 30 studies exclusively included people who use drugs as participants (n = 11 people who use drugs; generally, n = 17 people who smoke drugs, n = 2 people who inject drugs). One study included program staff serving people who use drugs, and one study included staff and people who use drugs. Sharing smoking equipment (e.g., pipes) was reported in 25 studies. People who use drugs in several studies reported that pipe sharing occurred for multiple reasons, including wanting to accumulate crack resin and protect themselves from social harms, such as police harassment. Across studies, smoking drugs, as opposed to injecting drugs, were described as a crucial method to reduce the risk of overdose, disease acquisition, and societal harms such as police violence. Ten studies found that when people who use drugs were provided with safer smoking materials, they engaged in fewer risky drug use behaviors (e.g., pipe sharing, using broken pipes) and showed improved health outcomes. However, participants across 11 studies reported barriers to accessing safer smoking services. Solutions to overcoming safer smoking access barriers were described in 17 studies and included utilizing peer workers and providing safer smoking materials to those who asked.

CONCLUSION

This global review found that safer smoking practices are essential forms of harm reduction. International policies must be amended to help increase access to these essential tools. Additional research is also needed to evaluate the efficacy of and access to safer smoking services, particularly in the U.S. and other similar countries, where such practices are being implemented but have not been empirically studied in the literature.

Response to substance use during hospitalization: A survey study of current and ideal policies and practices

People may use nonprescribed substances during an acute hospitalization. Hospital policies and responses can be stigmatizing, involve law enforcement, and lead to worse patient outcomes, including patient-directed discharge. In the United States, there is currently little data on hospital policies that address the use of substances during hospitalization. In this cross-sectional study, we surveyed clinicians at US hospitals with Accreditation Council of Graduate Medical Education (ACGME)-accredited addiction medicine fellowships about their current practices and policies and what they would include in an ideal policy. We had 77 responses from 55 out of 86 ACGME-addiction medicine fellowships (63.9%). Respondents identified policies at 21.8% of the institutions surveyed. Current responses to inpatient substance use vary, though most do not match what clinicians identify as an ideal response. Our results suggest that the use of nonprescribed substances during a hospitalization may be common, but a majority of hospitals likely do not have patient-centered policies to address this.

The Missing Link: Exploring the History of Harm Reduction Nursing in Canada 1998-2018 to Provide Recommendations for Inpatient Mental Health Nurses

ABSTRACT

Harm reduction is becoming integrated into the hospital setting, yet there is a dearth of published academic literature on the topic of harm reduction in mental health nursing practice. No results were found in a literature search focused specifically on harm reduction policies in the inpatient psychiatric settings using the databases CINAHL, Google Scholar, and PubMed. The purpose of this article was to provide a historical overview of harm reduction in Canadian nursing from 1998 to 2018. The aim was to help direct care nurses, educators, and administrators understand past and present trends and to identify future possibilities for integration in inpatient mental health care. A historical perspective was used to identify and explore Canadian harm reduction literature published from 1998 to 2018 to establish the significance to inform nursing practice. The exploration began with a brief description of outreach nursing in early Canada. Focus shifted to the human immunodeficiency virus/acquired immunodeficiency syndrome epidemic of the 1980s and 1990s, on to the 2000s when a broader lens of harm reduction was adopted, looking beyond the goal of reducing sexually transmitted illnesses. Literature published in the mid-2000s focused on marginalized populations, highlighting the connection between ethical practice and harm reduction philosophy. At the beginning of the 2010s, the Canadian Nursing Association released position statements that explicitly identified the role of harm reduction in nursing practice. Toward the end of the 2010s, the opioid overdose crisis promoted harm reduction nurses taking a broader focus, entering the hospital settings.

Feasibility, acceptability, concerns, and challenges of implementing supervised injection services at a specialty HIV hospital in Toronto, Canada: perspectives of people living with HIV

BACKGROUND

Substance use significantly impacts health and healthcare of people living with HIV/AIDS (PLHIV), especially their ability to remain in hospital following admission. Supervised injection services (SIS) reduce overdoses and drug-related harms, but are not often provided within hospitals/outpatient programs. Leading us to question, what are PLHIV's perceptions of hospital-based SIS?

METHODS

This mixed-methods study explored feasibility and acceptability of implementing SIS at Casey House, a Toronto-based specialty HIV hospital, from the perspective of its in/outpatient clients. We conducted a survey, examining clients' (n = 92) demand for, and acceptability of, hospital-based SIS. Following this, we hosted two focus groups (n = 14) and one-on-one interviews (n = 8) with clients which explored benefits/drawbacks of in-hospital SIS, wherein participants experienced guided tours of a demonstration SIS space and/or presentations of evidence about impacts of SIS. Data were analysed using descriptive statistics and thematic analysis.

RESULTS

Among survey participants, 76.1% (n = 70) identified as cis-male and over half (n = 49;54.4%) had been a hospital client for 2 years or less. Nearly half (48.8%) knew about clients injecting in/near Casey House, while 23.6% witnessed it. Survey participants were more supportive of SIS for inpatients (76.1%) than for outpatients (68.5%); most (74.7%) reported SIS implementation would not impact their level of service use at Casey House, while some predicted coming more often (16.1%) and others less often (9.2%). Most focus group/interview participants, believed SIS would enhance safety by reducing health harms (e.g. overdose), increasing transparency between clients and clinicians about substance use, and helping retain clients in care. Debate arose about who (e.g., in/outpatients vs. non-clients) should have access to hospital-based SIS and how implementation may shift organizational priorities/resources away from services not specific to drug use.

CONCLUSIONS

Our data showed widespread support of, and need for, hospital-based SIS among client stakeholders; however, attempts to reduce negative impacts on non-drug using clients need to be considered in the balance of implementation plans. Given the increased risks of morbidity and mortality for PLHIV who inject drugs as well as the problems in retaining them in care in a hospital setting, SIS is a key component of improving care for this marginalized group.

"You don't have to squirrel away in a staircase": Patient motivations for attending a novel supervised drug consumption service in acute care

BACKGROUND

Acute care hospitals have been described as a high risk environment for people who use drugs (PWUD). Formal and informal bans on drug use can lead patients to conceal their use and consume under unsafe circumstances. Provision of hospital-based supervised consumption services (SCS) could help reduce drug-related harms and improve patient care. However, no peer-reviewed research documents patient experiences with attending SCS in this setting. To address this gap, the present study examines key factors that shape patients' decisions to attend or not attend a novel SCS embedded within a large, urban acute care hospital in Western Canada.

METHODS

We adopted a focused ethnographic design and conducted 28 semi-structured interviews with SCS-eligible patients. We examined participant accounts thematically, and Rhodes' "Risk Environment" framework helped guide our analysis.

RESULTS

Most participants perceived the SCS as a safer environment that made it possible to reduce drug-related risks and avoid using in unsafe areas of the hospital where they could be caught by staff, security, or police. However, some participants did not trust that the SCS would provide adequate protection from criminalization, which motivated them to avoid the site. Several participants also worried about the potential for unwanted changes to their patient care following SCS use. Physical site and policy limitations, such as eligibility requirements and a lack of infrastructure to support supervised inhalation, were additional reasons for not attending the SCS.

CONCLUSION

PWUD in this study attended the hospital-based SCS in an attempt to reduce risks associated with their hospital stay. However, we note a number of access barriers that should be addressed to ensure optimal uptake. Wider provision of SCS in acute care requires both changes to the hospital environment and broader drug policy reform.

Hoots and harm reduction: a qualitative study identifying gaps in overdose prevention among women who smoke drugs

BACKGROUND

Smoking or inhaling illicit drugs can lead to a variety of negative health outcomes, including overdose. However, most overdose prevention interventions, such as supervised consumption services (SCS), prohibit inhalation. In addition, women are underrepresented at SCS and are disproportionately impacted by socio-structural violence. This study examines women's experiences smoking illicit drugs during an overdose epidemic, including their utilization of a women-only supervised inhalation site.

METHODS

Qualitative research methods included on-site ethnographic observation and semi-structured interviews with 32 participants purposively recruited from the women-only site. Data were coded and analyzed using NVivo 12 and thematic analysis was informed by gendered and socio-structural understandings of violence.

RESULTS

Participants had preferences for smoking drugs and these were shaped by their limited income, inability to inject, and perceptions of overdose risk. Participants expressed the need for services that attend to women's specific experiences of gendered, race-based, and structural violence faced within and outside mixed-gender social service settings. Results indicate a need for sanctioned spaces that recognize polysubstance use and drug smoking, accommodated by the women-only SCS. The smoking environment further fostered a sociability where participants could engage in perceived harm reduction through sharing drugs with other women/those in need and were able to respond in the event of an overdose.

CONCLUSIONS

Findings demonstrate the ways in which gendered social and structural environments shape women's daily experiences using drugs and the need for culturally appropriate interventions that recognize diverse modes of consumption while attending to overdose and violence. Women-only smoking spaces can provide temporary reprieve from some socio-structural harms and build collective capacity to practice harm reduction strategies, including overdose prevention. Women-specific SCS with attention to polysubstance use are needed as well as continued efforts to address the socio-structural harms experienced by women who smoke illicit drugs.

'Resurgent', 'twin' or 'silent' epidemic? A select data overview and observations on increasing psycho-stimulant use and harms in North America

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.