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Hocknull K, Geiger B, Bartlett M, Colledge-Frisby S, Shand F, Day CA, Jauncey M, Roxburgh A. Improving assessment and management of suicide risk among people who inject drugs: A mixed methods study conducted at the Medically Supervised Injecting Centre, Sydney. Drug Alcohol Rev 2024. [PMID: 38982725 DOI: 10.1111/dar.13900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 06/14/2024] [Accepted: 06/21/2024] [Indexed: 07/11/2024]
Abstract
INTRODUCTION People who inject drugs are 13 times more likely to die by suicide than the general population. Guidelines for responding to risk in this population are limited. Harm reduction services attended by people who inject drugs require targeted strategies to address the complexities of suicide risk among this population. METHODS Co-design, engaging health professionals and people with lived experience informed the study. Mixed methods were used to understand the experience of managing suicide risk among clients attending the Medically Supervised Injecting Centre (MSIC) in Sydney. A survey was administered to assess staff confidence in managing risk. Focus groups were conducted with health professionals and MSIC clients to explore experiences of suicide management, response and opportunities for improvement. RESULTS Half (N = 17) the MSIC staff surveyed reported over 10 years' experience working with this population. Confidence in managing suicide risk was low. Three key themes emerged from focus groups (N = 17): (i) Autonomy and the need to involve clients in the assessment process; (ii) Trust between clients and health professionals, and transparency in decision-making; and (iii) System barriers, described by health professionals as inadequate referral pathways for clients in distress, and by clients as negative experiences of care, including involuntary admission and not receiving medication (e.g. methadone). DISCUSSION AND CONCLUSIONS Revised assessment guidelines and a tailored safety plan were developed. These resources are also suitable for other alcohol and other drug services. The challenge in managing suicide risk in harm reduction services is balancing duty of care with staff-client relationships and client engagement.
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Affiliation(s)
- Kate Hocknull
- Uniting Medically Supervised Injecting Centre, Sydney, Australia
| | | | - Mark Bartlett
- Uniting Medically Supervised Injecting Centre, Sydney, Australia
| | - Samantha Colledge-Frisby
- National Drug Research Institute, Curtin University, Perth, Australia
- Harm and Risk Reduction, Burnet Institute, Melbourne, Australia
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Fiona Shand
- Black Dog Institute, UNSW Sydney, Sydney, Australia
| | - Carolyn A Day
- Uniting Medically Supervised Injecting Centre, Sydney, Australia
- Specialty of Addiction Medicine, Central Clinical School, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Marianne Jauncey
- Uniting Medically Supervised Injecting Centre, Sydney, Australia
| | - Amanda Roxburgh
- Harm and Risk Reduction, Burnet Institute, Melbourne, Australia
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
- Specialty of Addiction Medicine, Central Clinical School, Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Monash Addiction Research Centre, Monash University, Melbourne, Australia
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Atmospheres of engagement within a German drug consumption room. Soc Sci Med 2020; 253:112922. [PMID: 32240889 DOI: 10.1016/j.socscimed.2020.112922] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Revised: 02/11/2020] [Accepted: 03/12/2020] [Indexed: 11/21/2022]
Abstract
Drug consumption rooms directly attempt to intervene in and govern the place and time of drug use. Whilst the risk-reducing potentials of these interventions have been thoroughly evaluated, the consumption room literature offers fewer insights into the embodied, affective and situated dynamics that underscore service delivery. In this paper, we take up the notion of atmosphere to explore these dynamics in greater depth. Drawing on 12 months of ethnographic research in a German drug consumption room, we describe the manner in which atmospheres came to pervade and condition service encounters. More than simply providing texture to activities within the consumption room, we show how atmospheres gave rise to a distinct range of bodily capacities and therapeutic effects. Critically, these atmospheric affordances exceeded the risk-reducing objectives of the consumption room to encompass an emergent capacity to find repose, enact respite and foster modes of sociality and care. Our analysis further highlights the contextual contingencies through which the atmospheres of the consumption room emerged, including the efforts of both staff and clients to cultivate and control particular atmospheric qualities. We conclude by considering how closer attention to the atmospheric and affective dimensions of service delivery may challenge how consumption room interventions are enacted, valued and researched. This is to gesture towards a novel, atmospheric mode of harm reduction that has effects by transforming embodied potentials for both staff and clients.
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O’Keefe D, Ritter A, Stoove M, Hughes C, Dietze P. Harm reduction programs and policy in Australia: barriers and enablers to effective implementation. SUCHT-ZEITSCHRIFT FUR WISSENSCHAFT UND PRAXIS 2020. [DOI: 10.1024/0939-5911/a000641] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Abstract. Background: Harm reduction is an integral component of Australia’s overall national drug policy. Harm reduction policy and interventions can be applied to any legal or illegal drug to mitigate harm without necessarily reducing use, but harm reduction is traditionally conceptualised in relation to injecting drug use. Early and comprehensive adoption of many innovative harm reduction interventions has meant that Australia has had significant success in reducing a number of drug related harms, avoided disease epidemics experienced in other countries, and established programs and practices that are of international renown. However, these gains were not easily established, nor necessarily permanent. Aim: In this paper we explore the past and present harm reduction policy and practice contexts that normalised and facilitated harm reduction as a public health response, as well as those converse contexts currently creating opposition to additional or expanded interventions. Importantly, this paper discusses the intersection between various interventions, such as needle and syringe distribution and drug treatment programs. Finally, we detail some of the practical lessons that have been learned via the Australian experience, with the hope that these lessons will assist to inform and improve international harm reduction implementation.
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Affiliation(s)
- Daniel O’Keefe
- Burnet Institute
- School of Public Health and Preventive Medicine, Monash University
| | - Alison Ritter
- Drug Policy Modelling Program, Social Policy Research Centre, University of New South Wales
| | - Mark Stoove
- Burnet Institute
- School of Public Health and Preventive Medicine, Monash University
| | - Chad Hughes
- Burnet Institute
- School of Public Health and Preventive Medicine, Monash University
| | - Paul Dietze
- Burnet Institute
- School of Public Health and Preventive Medicine, Monash University
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Belackova V, Salmon AM, Day CA, Ritter A, Shanahan M, Hedrich D, Kerr T, Jauncey M. Drug consumption rooms: A systematic review of evaluation methodologies. Drug Alcohol Rev 2019; 38:406-422. [PMID: 30938025 DOI: 10.1111/dar.12919] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 01/16/2019] [Accepted: 02/12/2019] [Indexed: 01/27/2023]
Abstract
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.
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Affiliation(s)
| | - Allison M Salmon
- Uniting Medically Supervised Injecting Centre, Sydney, Australia
| | - Carolyn A Day
- Central Clinical School, Addiction Medicine, University of Sydney, Royal Prince Albert Hospital, Sydney, Australia
| | - Alison Ritter
- Drug Policy Modelling Program, UNSW Sydney, Sydney, Australia
| | - Marian Shanahan
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Dagmar Hedrich
- European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
| | - Thomas Kerr
- British Columbia Centre on Substance Use, Vancouver, Canada
| | - Marianne Jauncey
- Uniting Medically Supervised Injecting Centre, Sydney, Australia.,National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
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Potential role of safer injection facilities in reducing HIV and hepatitis C infections and overdose mortality in the United States. Drug Alcohol Depend 2011; 118:100-10. [PMID: 21515001 DOI: 10.1016/j.drugalcdep.2011.03.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Revised: 03/08/2011] [Accepted: 03/09/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Safer injection facilities (SIFs) reduce risks associated with injecting drugs, particularly public injection and overdose mortality. They exist in many countries, but do not exist in the United States. We assessed several ethical, operational, and public health considerations for establishing SIFs in the United States. METHOD We used the six-factor Kass framework (goals, effectiveness, concerns, minimization of concerns, fair implementation, and balancing of benefits and concerns), summarized needs of persons who inject drugs in the United States, and reviewed global evidence for SIFs. RESULTS SIFs offer a hygienic environment to inject drugs, provide sterile injection equipment at time of injection, and allow for safe disposal of used equipment. Injection of pre-obtained drugs, purchased by persons who inject drugs, happens in a facility where trained personnel provide on-site counseling and referral to addiction treatment and health care and intervene in overdose emergency situations. SIFs provide positive health benefits (reducing transmission of HIV and viral hepatitis, bacterial infections, and overdose mortality) without evidence for negative health or social consequences. SIFs serve most-at-risk persons, including those who inject in public or inject frequently, and those who do not use other public health programs. It is critical to address legal, ethical, and local concerns, develop and implement relevant policies and procedures, and assess individual- and community-level needs and benefits of SIFs given local epidemiologic data. CONCLUSIONS SIFs have the potential to reduce viral and bacterial infections and overdose mortality among those who engage in high-risk injection behaviors by offering unique public health services that are complementary to other interventions.
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Rance J, Fraser S. Accidental Intimacy: Transformative Emotion and the Sydney Medically Supervised Injecting Centre. ACTA ACUST UNITED AC 2011. [DOI: 10.1177/009145091103800106] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
This article widens the debate surrounding supervised injecting facilities (SIFs) by exploring an aspect of SIFs yet to be examined in the scholarly literature: the relationships created between staff and clients within these settings. By analyzing entries made in the Sydney Medically Supervised Injecting Centre's (MSIC) client comment books we explore the centrality of emotional connection to clients' experiences of the service. We argue that the everyday contact between staff and clients—including the “accidental intimacy” that develops when clients inject in the presence of staff —counters the sensations of shame identified by many in the comment books, creating new relations, and new performative possibilities for the production of self, belonging and citizenship for clients of the service. In exploring the role of emotions in the operation of the MSIC we also aim to highlight the political, policy, and clinical value of qualitative forms of inquiry for the harm-reduction field.
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Beletsky L, Davis CS, Anderson E, Burris S. The law (and politics) of safe injection facilities in the United States. Am J Public Health 2008; 98:231-7. [PMID: 18172151 PMCID: PMC2376869 DOI: 10.2105/ajph.2006.103747] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2007] [Indexed: 11/04/2022]
Abstract
Safe injection facilities (SIFs) have shown promise in reducing harms and social costs associated with injection drug use. Favorable evaluations elsewhere have raised the issue of their implementation in the United States. Recognizing that laws shape health interventions targeting drug users, we analyzed the legal environment for publicly authorized SIFs in the United States. Although states and some municipalities have the power to authorize SIFs under state law, federal authorities could still interfere with these facilities under the Controlled Substances Act. A state- or locally-authorized SIF could proceed free of legal uncertainty only if federal authorities explicitly authorized it or decided not to interfere. Given legal uncertainty, and the similar experience with syringe exchange programs, we recommend a process of sustained health research, strategic advocacy, and political deliberation.
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Affiliation(s)
- Leo Beletsky
- Temple University Beasley School of Law, 1719 N Broad St, Philadelphia, PA 19122, USA.
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Irwin KS, Fry CL. Strengthening drug policy and practice through ethics engagement: An old challenge for a new harm reduction. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2007; 18:75-83. [DOI: 10.1016/j.drugpo.2006.12.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2006] [Revised: 12/01/2006] [Accepted: 12/05/2006] [Indexed: 11/29/2022]
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Rhodes T, Kimber J, Small W, Fitzgerald J, Kerr T, Hickman M, Holloway G. Public injecting and the need for 'safer environment interventions' in the reduction of drug-related harm. Addiction 2006; 101:1384-93. [PMID: 16968336 DOI: 10.1111/j.1360-0443.2006.01556.x] [Citation(s) in RCA: 169] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Tim Rhodes
- Centre for Research on Drugs and Health Behaviour, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, UK.
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