Impact of a medically supervised safer injection facility on community drug use patterns: a before and after study

Economic Evaluations of Establishing Opioid Overdose Prevention Centers in 12 North American Cities: A Systematic Review

OBJECTIVES

Overdose prevention centers (OPCs) provide a safe place where people can consume preobtained drugs under supervision so that a life-saving medical response can be provided quickly in the event of an overdose. OPCs are programs that are established in Canada and have recently become legally sanctioned in only a few United States jurisdictions.

METHODS

We conducted a systematic review that summarizes and identifies gaps of economic evidence on establishing OPCs in North America to guide future expansion of OPCs.

RESULTS

We included 16 final studies that were evaluated with the Consolidated Health Economic Evaluation Reporting Standards and Drummond checklists. Eight studies reported cost-effectiveness results (eg, cost per overdose avoided or cost per quality-adjusted life-year), with 6 also including cost-benefit; 5 reported only cost-benefit results, and 3 cost offsets. Health outcomes primarily included overdose mortality outcomes or HIV/hepatitis C virus infections averted. Most studies used mathematical modeling and projected OPC outcomes using the experience of a single facility in Vancouver, BC.

CONCLUSIONS

OPCs were found to be cost-saving or to have favorable cost-effectiveness or cost-benefit ratios across all studies. Future studies should incorporate the experience of OPCs established in various settings and use a greater diversity of modeling designs.

Overdose mortality incidence and supervised consumption services in Toronto, Canada: an ecological study and spatial analysis

BACKGROUND

Supervised consumption services (SCS) prevent overdose deaths onsite; however, less is known about their effect on population-level overdose mortality. We aimed to characterise overdose mortality in Toronto, ON, Canada, and to establish the spatial association between SCS locations and overdose mortality events.

METHODS

For this ecological study and spatial analysis, we compared crude overdose mortality rates before and after the implementation of nine SCS in Toronto in 2017. Data were obtained from the Office of the Chief Coroner of Ontario on cases of accidental death within the City of Toronto for which the cause of death involved the use of an opiate, synthetic or semi-synthetic opioid, or other psychoactive substance. We assessed overdose incident data for global spatial autocorrelation and local clustering, then used geographically weighted regression to model the association between SCS proximity and overdose mortality incidence in 2018 and 2019.

FINDINGS

We included 787 overdose mortality events in Toronto between May 1, 2017, and Dec 31, 2019. The overdose mortality rate decreased significantly in neighbourhoods that implemented SCS (8·10 deaths per 100 000 people for May 1-July 31, 2017, vs 2·70 deaths per 100 000 people for May 1-July 31, 2019; p=0·037), but not in other neighbourhoods. In a geographically weighted regression analysis that adjusted for the availability of substance-use-related services and overdose-related sociodemographic factors by neighbourhood, the strongest local regression coefficients of the association between SCS and overdose mortality location ranged from -0·60 to -0·64 per mile in 2018 and from -1·68 to -1·96 per mile in 2019, suggesting an inverse association.

INTERPRETATION

We found that the period during which SCS were implemented in Toronto was associated with a reduced overdose mortality in surrounding neighbourhoods. The magnitude of this inverse association increased from 2018 to 2019, equalling approximately two overdose fatalities per 100 000 people averted in the square mile surrounding SCS in 2019. Policy makers should consider implementing and sustaining SCS across neighbourhoods where overdose mortality is high.

FUNDING

The Canadian Institutes of Health Research.

"The Slums Have To Be Shown": Documenting Drug Injection in Public Spaces Ahead of the Opening of a Drug Consumption Room in Marseille

EPOSIM is a community-based participatory research study which used the Photovoice method with people who inject drugs (PWID) ahead of a possible opening of a drug consumption room (DCR) in Marseille, France. It aimed to identify the strategies used by PWID when injecting, and the risks they take when they have no safe private space to inject in the area they live in. A total of 7 PWID participated in the full study process. The 189 photographs they took provided us with a good understanding of their injection practices in public places. The main results highlighted the spatiality and materiality of injecting experience in a context where no DCR was available. They also showed the relevance of Photovoice to valorize the voices of PWID when implementing a DCR. Through the showcasing of their photographs at various public exhibitions, the participants seized the opportunity to use Photovoice to make their voices heard beyond the group formed for the study, in order to show the different forms of stigma and insalubrious contexts which they faced on a daily basis. Furthermore, the photographs taken demonstrated that having only health and safety records is not enough to fully understand PWID injection practices. Future studies must take into account PWID perceptions of their relationship with injecting in public spaces and with the management of stigma. The questions of pleasure and comfort must also be explored in evaluation studies of harm reduction measures, for example, DCR.

'Why would we not want to keep everybody safe?' The views of family members of people who use drugs on the implementation of drug consumption rooms in Scotland

BACKGROUND

People who use drugs in Scotland are currently experiencing disproportionately high rates of drug-related deaths. Drug consumption rooms (DCRs) are harm reduction services that offer a safe, hygienic environment where pre-obtained drugs can be consumed under supervision. The aim of this research was to explore family member perspectives on DCR implementation in Scotland in order to inform national policy.

METHODS

Scotland-based family members of people who were currently or formerly using drugs were invited to take part in semi-structured interviews to share views on DCRs. An inclusive approach to 'family' was taken, and family members were recruited via local and national networks. A convenience sample of 13 family members were recruited and interviews conducted, audio-recorded, transcribed, and analysed thematically using the Structured Framework Technique.

RESULTS

Family members demonstrated varying levels of understanding regarding the existence, role, and function of DCRs. While some expressed concern that DCRs would not prevent continued drug use, all participants were in favour of DCR implementation due to a belief that DCRs could reduce harm, including saving lives, and facilitate future recovery from drug use. Participants highlighted challenges faced by people who use drugs in accessing treatment/services that could meet their needs. They identified that accessible and welcoming DCRs led by trusting and non-judgemental staff could help to meet unmet needs, including signposting to other services. Family members viewed DCRs as safe environments and highlighted how the existence of DCRs could reduce the constant worry that they had of risk of harm to their loved ones. Finally, family members emphasised the challenge of stigma associated with drug use. They believed that introduction of DCRs would help to reduce stigma and provide a signal that people who use drugs deserve safety and care.

CONCLUSIONS

Reporting the experience and views of family members makes a novel and valuable contribution to ongoing public debates surrounding DCRs. Their views can be used to inform the implementation of DCRs in Scotland but also relate well to the development of wider responses to drug-related harm and reduction of stigma experienced by people who use drugs in Scotland and beyond.

'Why would we not want to keep everybody safe?' The views of family members of people who use drugs on the implementation of drug consumption rooms in Scotland

BACKGROUND

People who use drugs in Scotland are currently experiencing disproportionately high rates of drug-related deaths. Drug consumption rooms (DCRs) are harm reduction services that offer a safe, hygienic environment where pre-obtained drugs can be consumed under supervision. The aim of this research was to explore family member perspectives on DCR implementation in Scotland in order to inform national policy.

METHODS

Scotland-based family members of people who were currently or formerly using drugs were invited to take part in semi-structured interviews to share views on DCRs. An inclusive approach to 'family' was taken, and family members were recruited via local and national networks. A convenience sample of 13 family members were recruited and interviews conducted, audio-recorded, transcribed, and analysed thematically using the Structured Framework Technique.

RESULTS

Family members demonstrated varying levels of understanding regarding the existence, role, and function of DCRs. While some expressed concern that DCRs would not prevent continued drug use, all participants were in favour of DCR implementation due to a belief that DCRs could reduce harm, including saving lives, and facilitate future recovery from drug use. Participants highlighted challenges faced by people who use drugs in accessing treatment/services that could meet their needs. They identified that accessible and welcoming DCRs led by trusting and non-judgemental staff could help to meet unmet needs, including signposting to other services. Family members viewed DCRs as safe environments and highlighted how the existence of DCRs could reduce the constant worry that they had of risk of harm to their loved ones. Finally, family members emphasised the challenge of stigma associated with drug use. They believed that introduction of DCRs would help to reduce stigma and provide a signal that people who use drugs deserve safety and care.

CONCLUSIONS

Reporting the experience and views of family members makes a novel and valuable contribution to ongoing public debates surrounding DCRs. Their views can be used to inform the implementation of DCRs in Scotland but also relate well to the development of wider responses to drug-related harm and reduction of stigma experienced by people who use drugs in Scotland and beyond.

Assessing Drug Consumption Rooms and Longer Term (5 Year) Impacts on Community and Clients

BACKGROUND

Drug consumption rooms (DCRs) and supervised injecting facilities (SIFs) provide a safe environment in which people who inject drugs (PWIDs) can inject under hygienic and supervised conditions. Numerous reviews have documented the benefits of these facilities; however, there is a lack of clarity surrounding their long-term effects.

PURPOSE

To conduct, with a systematic approach, a literature review, of published peer-reviewed literature assessing the long-term impacts of DCRs/SIFs.

METHODS

A systematic search of the PubMed and Embase database was performed using the keywords: ("SUPERVISED" OR "SAFE*") AND ("CONSUMPTION" OR "INJECT*" OR "SHOOTING") AND ("FACILITY*" OR "ROOM*" OR "GALLERY*" OR "CENTRE*" OR "CENTER*" OR "SITE*"). Included studies were original articles reporting outcomes for five or more years and addressed at least one of the following client or community outcomes; (i) drug-related harms; (ii) access to substance use treatment and other health services; (iii) impact on local PWID population; (iv) impact on public drug use, drug-related crime and violence; and (v) local community attitudes to DCRs.

RESULTS

Four publications met our inclusion criteria, addressing four of the five outcomes. Long-term data suggested that while the health of PWID naturally declined over time, DCRs/SIFs helped reduce injecting-related harms. The studies showed that DCRs/SIFs facilitate drug treatment, access to health services and cessation of drug injecting. Local residents and business owners reported less public drug use and public syringe disposal following the opening of a DCR/SIF.

CONCLUSION

Long-term evidence on DCRs/SIFs is consistent with established short-term research demonstrating the benefits of these facilities. A relative paucity of studies was identified, with most evidence originating from Sydney and Vancouver. The overall body of evidence would be improved by future studies following outcomes over longer periods and being undertaken in a variety of jurisdictions and models of DCRs/SIFs.

Supervised Injection Facilities as Harm Reduction: A Systematic Review

CONTEXT

Supervised injection facilities are harm reduction interventions that allow people who inject drugs to use previously obtained substances under the supervision of health professionals. Although currently considered illegal under U.S. federal law, several U.S. cities are considering implementing supervised injection facilities anyway as a response to the escalating overdose crisis. The objective of this review is to determine the effectiveness of supervised injection facilities, compared with that of control conditions, for harm reduction and community outcomes.

EVIDENCE ACQUISITION

Studies were identified from 2 sources: a high-quality, broader review examining supervised injection facility-induced benefits and harms (from database inception to January 2014) and an updated search using the same search strategy (January 2014‒September 2019). Systematic review methods developed by the Guide to Community Preventive Services were used (screening and analysis, September 2019‒December 2020).

EVIDENCE SYNTHESIS

A total of 22 studies were included in this review: 16 focused on 1 supervised injection facility in Vancouver, Canada. Quantitative synthesis was not conducted given inconsistent outcome measurement across the studies. Supervised injection facilities in the included studies (n=number of studies per outcome category) were mostly associated with significant reductions in opioid overdose morbidity and mortality (n=5), significant improvements in injection behaviors and harm reduction (n=7), significant improvements in access to addiction treatment programs (n=7), and no increase or reductions in crime and public nuisance (n=7).

CONCLUSIONS

For people who inject drugs, supervised injection facilities may reduce the risk of overdose morbidity and mortality and improve access to care while not increasing crime or public nuisance to the surrounding community.

Harm Reduction Services to Prevent and Treat Infectious Diseases in People Who Use Drugs

This article reviews the principles of harm reduction, evidence-based harm reduction strategies such as syringe service programs and supervised injection facilities, and provides approaches to integrating a harm reduction approach into clinical practice. As providers strive to increase capacity to treat underlying substance use disorder, we must also recognize that some people may continue to use drugs. In this setting, providers can still deliver nonjudgmental, individualized care, and advocate for the health and safety of people who inject drugs.

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.

Federal and State Action Needed to End the Infectious Complications of Illicit Drug Use in the United States: IDSA and HIVMA's Advocacy Agenda

In response to the opioid crisis, IDSA and HIVMA established a working group to drive an evidence- and human rights-based response to illicit drug use and associated infectious diseases. Infectious diseases and HIV physicians have an opportunity to intervene, addressing both conditions. IDSA and HIVMA have developed a policy agenda highlighting evidence-based practices that need further dissemination. This paper reviews (1) programs most relevant to infectious diseases in the 2018 SUPPORT Act; (2) opportunities offered by the "End the HIV Epidemic" initiative; and (3) policy changes necessary to affect the trajectory of the opioid epidemic and associated infections. Issues addressed include leveraging harm reduction tools and improving integrated prevention and treatment services for the infectious diseases and substance use disorder care continuum. By strengthening collaborations between infectious diseases and addiction specialists, including increasing training in substance use disorder treatment among infectious diseases and addiction specialists, we can decrease morbidity and mortality associated with these overlapping epidemics.

Impact of overdose prevention sites during a public health emergency in Victoria, Canada

The primary objective of this study was to examine the impacts associated with implementation of overdose preventions sites (OPSs) in Victoria, Canada during a declared provincial public health overdose emergency. A rapid case study design was employed with three OPSs constituting the cases. Data were collected through semi-structured interviews with 15 staff, including experiential staff, and 12 service users. Theoretically, we were informed by the Consolidated Framework for Implementation Research. This framework, combined with a case study design, is well suited for generating insight into the impacts of an intervention. Zero deaths were identified as a key impact and indicator of success. The implementation of OPSs increased opportunities for early intervention in the event of an overdose, reducing trauma for staff and service users, and facilitated organizational transitions from provision of safer supplies to safer spaces. Providing a safer space meant drug use no longer needed to be concealed, with the effect of mitigating drug related stigma and facilitating a shift from shame and blame to increasing trust and development of relationships with increased opportunities to provide connections to other services. These impacts were achieved with few new resources highlighting the commitment of agencies and harm reduction workers, particularly those with lived experience, in achieving beneficial impacts. Although mitigating harms of overdose, OPSs do not address the root problem of an unsafe drug supply. OPSs are important life-saving interventions, but more is needed to address the current contamination of the illicit drug supply including provision of a safer supply.

Establishing need and population priorities to improve the health of homeless and vulnerably housed women, youth, and men: A Delphi consensus study

Background

Homelessness is one of the most disabling and precarious living conditions. The objective of this Delphi consensus study was to identify priority needs and at-risk population subgroups among homeless and vulnerably housed people to guide the development of a more responsive and person-centred clinical practice guideline.

Methods

We used a literature review and expert working group to produce an initial list of needs and at-risk subgroups of homeless and vulnerably housed populations. We then followed a modified Delphi consensus method, asking expert health professionals, using electronic surveys, and persons with lived experience of homelessness, using oral surveys, to prioritize needs and at-risk sub-populations across Canada. Criteria for ranking included potential for impact, extent of inequities and burden of illness. We set ratings of ≥ 60% to determine consensus over three rounds of surveys.

Findings

Eighty four health professionals and 76 persons with lived experience of homelessness participated from across Canada, achieving an overall 73% response rate. The participants identified priority needs including mental health and addiction care, facilitating access to permanent housing, facilitating access to income support and case management/care coordination. Participants also ranked specific homeless sub-populations in need of additional research including: Indigenous Peoples (First Nations, Métis, and Inuit); youth, women and families; people with acquired brain injury, intellectual or physical disabilities; and refugees and other migrants.

Interpretation

The inclusion of the perspectives of both expert health professionals and people with lived experience of homelessness provided validity in identifying real-world needs to guide systematic reviews in four key areas according to priority needs, as well as launch a number of working groups to explore how to adapt interventions for specific at-risk populations, to create evidence-based guidelines.

Opioid overdose detection using smartphones

Early detection and rapid intervention can prevent death from opioid overdose. At high doses, opioids (particularly fentanyl) can cause rapid cessation of breathing (apnea), hypoxemic/hypercarbic respiratory failure, and death, the physiologic sequence by which people commonly succumb from unintentional opioid overdose. We present algorithms that run on smartphones and unobtrusively detect opioid overdose events and their precursors. Our proof-of- concept contactless system converts the phone into a short-range active sonar using frequency shifts to identify respiratory depression, apnea, and gross motor movements associated with acute opioid toxicity. We develop algorithms and perform testing in two environments: (i) an approved supervised injection facility (SIF), where people self-inject illicit opioids, and (ii) the operating room (OR), where we simulate rapid, opioid-induced overdose events using routine induction of general anesthesia. In the SIF (n = 209), our system identified postinjection, opioid-induced central apnea with 96% sensitivity and 98% specificity and identified respiratory depression with 87% sensitivity and 89% specificity. These two key events commonly precede fatal opioid overdose. In the OR, our algorithm identified 19 of 20 simulated overdose events. Given the reliable reversibility of acute opioid toxicity, smartphone-enabled overdose detection coupled with the ability to alert naloxone-equipped friends and family or emergency medical services (EMS) could hold potential as a low-barrier, harm reduction intervention.

How to overcome political and legal barriers to the implementation of a drug consumption room: an application of the policy agenda framework to the Belgian situation

BACKGROUND

For more than 30 years, drug consumption rooms (DCRs) have been implemented in Western countries. DCRs are supported by a large body of evidence about public safety and public health effectiveness. However, a political consensus has never been achieved in Belgium on amending the existing law that explicitly penalises the supply of a room for facilitating drug use. Despite this adverse legal and policy framework, a DCR opened in the city of Liège in 2018. In this case report, we applied the theoretical framework proposed by Shiffman and Smith for policy agenda setting, in order to describe and assess how political and legal barriers were overcome in the process of opening the DCR.

CASE PRESENTATION

For some years, fieldworkers and some city policymakers argued for DCR implementation in Belgium, but without gaining the support of the national authorities, mainly for ideological reasons. In order to address this debate, a feasibility study of DCR implementation in Belgian cities was commissioned. At the national level, an institutional debate took place about the political responsibility for DCRs as a public health intervention, as health care is mainly a matter of regional policy. The lack of consensus led to a situation of political deadlock. Meanwhile, the publication of the study report and the context of local elections offered an opportunity for Liège authorities to reignite the local debate on DCRs. At the local level, law enforcement, care professionals, residents, users, and the press were all involved in the implementation process. Therefore, a local consensus was formed and despite the absence of any national legal change, the DCR opened 1 month before the local elections. It has been working without major medical or legal incident since then. Incidentally, the mayor of Liège was re-elected.

CONCLUSIONS

Although the lack of a legal framework may engender instability and affect longer-term effectiveness, the DCR implementation in Liège was successful and was based on a local consensus and effective communication rather than on an appropriate legal framework. The experience provides lessons for other cities that are considering opening a DCR despite an adverse legal and political context.

Opioid Use Among Those Who Have Criminal Justice Experience: Harm Reduction Strategies to Lessen HIV Risk

PURPOSE OF REVIEW

We reviewed the HIV and opioid literature relevant to harm reduction strategies for those with criminal justice experience.

RECENT FINDINGS

Opioid use in the United States has risen at an alarming rate recently. This has led to increased numbers of people who inject drugs, placing new populations at risk for HIV, including those who have criminal justice experience. In recent years, there has been a gradual decrease in the number of individuals under the supervision of the criminal justice system. However, concurrently, there has been a rise in the number of individuals incarcerated in jails in rural counties that are at the center of the current opioid epidemic. We provide a number of harm reduction strategies that could be implemented in correctional settings such as access and linkage to medication-assisted treatment, connection to syringe exchange programs and safe injection facilities (where available), and the repackaging of pre-exposure prophylaxis as a harm reduction tool.

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.

Impact of drug consumption rooms on risk practices and access to care in people who inject drugs in France: the COSINUS prospective cohort study protocol

INTRODUCTION

The high prevalence of hepatitis C and the persistence of HIV and hepatitis C virus (HCV) risk practices in people who inject drugs (PWID) in France underlines the need for innovative prevention interventions. The main objective of this article is to describe the design of the COSINUS cohort study and outline the issues it will explore to evaluate the impact of drug consumption rooms (DCR) on PWID outcomes. Secondary objectives are to assess how DCR (a) influence other drug-related practices, such as the transition from intravenous to less risky modes of use, (b) reduce drug use frequency/quantity, (c) increase access to treatment for addiction and comorbidities (infectious, psychiatric and other), (d) improve social conditions and (e) reduce levels of violence experienced and drug-related offences. COSINUS will also give us the opportunity to investigate the impact of other harm reduction tools in France and their combined effect with DCR on reducing HIV-HCV risk practices. Furthermore, we will be better able to identify PWID needs.

METHODS AND ANALYSIS

Enrollment in this prospective multi-site cohort study started in June 2016. Overall, 680 PWID in four different cities (Bordeaux, Marseilles, Paris and Strasbourg) will be enrolled and followed up for 12 months through face-to-face structured interviews administered by trained staff to all eligible participants at baseline (M0), 3 month (M3), 6 month (M6) and 12 month (M12) follow-up visits. These interviews gather data on socio-demographic characteristics, past and current drug and alcohol consumption, drug-use related practices, access to care and social services, experience of violence (as victims), offences, other psychosocial issues and perception and needs about harm reduction interventions and services. Longitudinal data analysis will use a mixed logistic model to assess the impact of individual and structural factors, including DCR attendance and exposure to other harm reduction services, on the main outcome (HIV-HCV risk practices).

ETHICS AND DISSEMINATION

This study was reviewed and approved by the institutional review board of the French Institute of Medical Research and Health (opinion number: 14-166). The findings of this cohort study will help to assess the impact of DCR on HIV-HCV risk practices and other psycho-social outcomes and trajectories. Moreover, they will enable health authorities to shape health and harm reduction policies according to PWID needs. Finally, they will also help to improve current harm reduction and therapeutic interventions and to create novel ones.

Harm reduction in Italy: the experience of an unsanctioned supervised injection facility run by drug users

Purpose

Efforts to establish harm reduction interventions in Italy have persisted since the mid-1990s. Despite this, no sanctioned SIF has ever been implemented. The purpose of this paper is to provide information about a 10 year unsanctioned drug user-run SIF experience in Italy called Stanzetta.

Design/methodology/approach

The aim of the paper is to assess how Stanzetta met its objectives. Analysis was conducted compiling narrative accounts from the staff working in the NSP, which is adjacent to the Stanzetta, and conducting a simple frequency analysis of the available statistical data.

Findings

The Stanzetta unsanctioned SIF has been running for ten years and continues to be vulnerable due to its legal status. Being open 24 h/days has maximised its accessibility, but at the same time, it has encouraged a misuse of the Stanzetta. Although not trained, drug users became self-empowered to run the Stanzetta and to keep it clean, but the hygiene-health aspect is seen as one of the greatest challenges by the NSP professional staff. Over 10 years, not a single overdose death has been recorded. Drug use in the park has shifted from more visible places to the Stanzetta. As a result, the abandoned syringes have diminished in number and those disposed of correctly have increased. Moreover, no complaints from citizens or law enforcement were ever made. The neighbourhood acceptance seems to be the main goal of the peer-run unsanctioned SIF.

Research limitations/implications

The paper is based on a narrative account from the point of view of the professional staff involved, and results are specific to the context in which the study was conducted. Because of the chosen approach, the research results lack scientific generalisability. A relevant limitation is that no peer was involved in this study. Despite this, the research contributes to the information based on peer-run SIFs and makes a case for the de-medicalisation of SIFs in Europe.

Practical implications

This paper gives visibility to a long-lasting drug user-run SIF experience that was not made public mostly for an unclear legislative background about SIF in Italy.

Social implications

Efforts to establish harm reduction interventions in Italy have persisted since the mid-1990s and were undertaken primarily in response to epidemics of HIV infection and overdose (DPA, 2017). Despite this, no sanctioned SIF has ever been implemented. Primarily, this study wants to underline the urgency for an SIF pilot in Italy, and secondly the need to consider de-medicalising these services through direct support for peer-based models.

Originality/value

The Stanzetta unsanctioned SIF in Italy that has been running for ten years. Despite this, the venue continues to be vulnerable due to its legal status. For this reason, these results were never made public before. The experience showed a good working synergy between NSP professionals and the SIF peers. This model can be considered as a “light” de-medicalisation form to be explored and eventually to be implemented as a pilot SIF in Italy.

Elimination of HIV transmission through novel and established prevention strategies among people who inject drugs

Despite the effectiveness of existing HIV prevention strategies for people who inject drugs (PWID), uncontrolled outbreaks of HIV among this group are common and occur around the world. In this Review, we summarise recent evidence for novel and established HIV prevention approaches to eliminate HIV transmission among PWID. Effective HIV prevention strategies include mobile needle and syringe programmes, pre-exposure prophylaxis, supervised injection facilities, and, to a lesser extent, some behavioural interventions. Studies have also shown the cost-effectiveness of long-standing HIV prevention strategies including needle and syringe programmes, opioid agonist therapy, and antiretroviral therapy for prevention. Although each individual intervention can reduce the risk of HIV acquisition among PWID, there is a consensus that a combination of approaches is required to achieve substantial and durable reductions in HIV transmission. Unfortunately, in many settings, the implementation of these interventions is often limited by public and political opposition that manifests as structural barriers to HIV prevention, such as the criminalisation of drug use. Given that there is ample evidence showing the effectiveness of several HIV prevention methods, social and political advocacy will be needed to overcome these barriers and integrate innovative HIV prevention approaches with addiction science to create effective drug policies.

Perspectives on supervised injection facilities among service industry employees in New York City: A qualitative exploration

BACKGROUND

Approximately 100 supervised injection facilities (SIFs) operate in 66 cities around the world to reduce overdose deaths, the spread of disease and public disorder, though none legally exist in the United States. Public bathrooms are among the most common public places for injection reported by people who inject drugs in New York City (NYC) and service industry employees (SIEs) inadvertently become first-responders when overdoses occur in business bathrooms. The goal of this study was to assess SIE acceptability of SIFs and the perceived effects that SIFs would have on them, their colleagues, their businesses and communities.

METHODS

Semi-structured qualitative interviews were conducted with 15 SIEs recruited through convenience sampling throughout NYC. Participants were provided with peer-reviewed scientific evidence prior to discussing SIFs. Data were analysed using a hybrid deductive and inductive approach.

RESULTS

Most SIEs had encountered drug use (93%, n = 14/15) and syringes (73%, n = 11/15) in their business bathrooms and three had encountered unresponsive individuals. Nearly all workers (93%, n = 14/15) were supportive of SIFs and believed SIFs would reduce injection drug use in their business bathrooms. Participants also believed that 'not in my backyard' arguments from community boards may impede SIF operation.

CONCLUSIONS

Service industry employees are critical stakeholders due to their exposure to occupational health hazards related to public injection. Those interviewed were amenable to SIF operation as a form of occupational harm reduction and their experiences provide an important dimension to the political debate surrounding SIFs.

Changes in supervised drug-injecting practices following a community-based educational intervention: A longitudinal analysis

BACKGROUND

People who inject drugs face several health issues because of unsafe injecting practices. We aimed to evaluate changes in supervised drug-injecting practices following the implementation of a face-to-face educational intervention.

METHODS

The national study ANRS-AERLI was conducted in 17 harm reduction (HR) facilities in France between 2011 and 2013. Eight offered the intervention and nine did not. We conducted a pre-post analysis focusing on injecting practices data, collected in the 8 HR facilities providing the intervention. The intervention consisted of providing face-to-face educational sessions including direct observation of injecting practices, counseling about safer injecting, and shared discussion. Injecting practices were collected following a checklist and classified as safe or unsafe. To assess changes in injecting practices, practices were compared before (at baseline) and after at least one educational session.

FINDINGS

Mixed logistic models showed that the 78 participants included were more likely to improve in the following drug-use steps: setting up a clean preparation area (Adjusted Odds Ratio (AOR) = 3.4, 95% Confidence Interval (95% CI) = 1.6-7.6), hand washing (AOR = 7.2, 95% CI = 3.1-16.4), skin cleaning (AOR = 5.6, 95% CI = 2.5-12.1), choice of safe injection site (AOR = 6.5, 95% CI = 1.5-28.8) and post-injection bleeding management (AOR = 12.8, 95% CI = 5.5-29.9). Furthermore, participants were less likely to lick their needles before injecting (AOR = 8.1, 95% CI = 1.5-43.4) and to perform booting/flushing (AOR = 2.5, 95% CI = 1.2-5.3).

CONCLUSIONS

The AERLI intervention seems to be effective in increasing safe drug-injecting practices.

Ambulance-attended opioid overdoses: An examination into overdose locations and the role of a safe injection facility

Background: Although the United States and numerous other countries are amidst an opioid overdose crisis, access to safe injection facilities remains limited. Methods: We used prospective data from ambulance journals in Oslo, Norway, to describe the patterns, severity, and outcomes of opioid overdoses and compared these characteristics among various overdose locations. We also examined what role a safe injection facility may have had on these overdoses. Results: Based on 48,825 ambulance calls, 1054 were for opioid overdoses from 465 individuals during 2014 and 2015. The rate of calls for overdoses was 1 out of 48 of the total ambulance calls. Males made up the majority of the sample (n = 368, 79%), and the median age was 35 (range: 18-96). Overdoses occurred in public locations (n = 530, 50.3%), the safe injection facility (n = 353, 33.5%), in private homes (n = 83, 7.9%), and other locations (n = 88, 8.3%). Patients from the safe injection facility and private homes had similarly severe initial clinical symptoms (Glasgow Coma Scale median =3 and respiratory frequency median =4 breaths per minute) when compared with other locations, yet the majority from the safe injection facility did not require further ambulance transport to the hospital (n = 302, 85.6%). Those overdosed in public locations (odds ratio [OR] = 1.66, 95% confidence interval [CI] = 1.17-2.35), and when the safe injection facility was closed (OR =1.4, 95% CI =1.04-1.89), were more likely to receive transport for further treatment. Conclusions: Our findings suggest that the opening hours at the safe injection facility and the overdose location may impact the likelihood of ambulance transport for further treatment.

Opening Canada's first Health Canada-approved supervised consumption sites

SETTING

In response to the opioid overdose crisis, a Public Health Emergency was declared in British Columbia (BC) in April 2016. There were 1448 deaths in BC in 2017 (30.1 deaths per 100,000 individuals).

INTERVENTION

Approximately one third of all overdose deaths in BC in 2016 (333/993) and 2017 (482/1448) occurred within the region served by Fraser Health Authority (FH). We identified a need for a supervised drug use site in Surrey, the city with FH's highest number of overdose deaths in 2016 (n = 122). In order to ensure low-barrier services, FH underwent an internal assessment for a supervised drug use site and determined that a supervised injection site was unlikely to meet the needs of individuals who consumed their drugs using other routes, choosing instead to apply for an exemption to the Controlled Drug and Substances Act in order to open a Supervised Consumption Site (SCS).

OUTCOMES

In assessing population needs, injection was identified as the mode of drug administration in only 32.8% of overdose deaths in FH from 2011 to 2016. Other routes of drug (co-) administration included oral (30.6%); smoking (28.8%); intranasal (24.2%); and unknown/other (17.1%). Interviews with potential service users confirmed drug (co-) administration behaviours and identified other aspects of service delivery, such as hours and co-located services that would help align the services better with client needs. With Health Canada's approval, SafePoint in Surrey opened for supervised injection on June 8, 2017 and received an exemption to allow oral and intranasal consumption on June 26, 2017.

IMPLICATIONS

By assessing drug use practices, the evolving needs of people who use substances, and tailoring services to local context, we can potentially engage with individuals earlier in their substance use trajectory to improve the utility of services and prevent more overdoses and overdose deaths.

[Harm reduction interventions in drug users: current situation and recommendations]

Harm reduction encompasses interventions, programmes and policies that seek to reduce the negative consequences of the consumption of both legal and illegal drugs on the individual and public health. Harm reduction looks to mitigate the harm suffered by drug users through drug use monitoring and prevention, and promotes initiatives that respect and protect the human rights of this population. The harm reduction policies that have proven effective and efficient are: opioid substitution maintenance therapy (methadone); needle and syringe exchange programmes; supervised drug consumption rooms; and overdose prevention through peer-based naloxone distribution. In order to be effective, these policies must have comprehensive coverage and be implemented in areas where the target population is prevalent. Resident-based opposition to the implementation of these policies is known as the NIMBY (Not In My Back Yard) phenomenon, which is characterised by being against the implementation of new measures in a particular place, but does not question their usefulness. Given that any NIMBY phenomenon is a complex social, cultural and political phenomenon, it is important to conduct a thorough analysis of the situation prior to implementing any of these measures. Harm reduction policies must be extended to other substances such as alcohol and tobacco, as well as to other conditions beyond infectious/contagious diseases and overdose.

Using drugs in un/safe spaces: Impact of perceived illegality on an underground supervised injecting facility in the United States

BACKGROUND

Supervised injection facilities (SIFs) are spaces where people can consume pre-obtained drugs in hygienic circumstances with trained staff in attendance to provide emergency response in the event of an overdose or other medical emergency, and to provide counselling and referral to other social and health services. Over 100 facilities with formal legal sanction exist in ten countries, and extensive research has shown they reduce overdose deaths, increase drug treatment uptake, and reduce social nuisance. No facility with formal legal sanction currently exists in the United States, however one community-based organization has successfully operated an 'underground' facility since September 2014.

METHODS

Twenty three qualitative interviews were conducted with people who used the underground facility, staff, and volunteers to examine the impact of the facility on peoples' lives, including the impact of lack of formal legal sanction on service provision.

RESULTS

Participants reported that having a safe space to inject drugs had led to less injections in public spaces, greater ability to practice hygienic injecting practices, and greater protection from fatal overdose. Constructive aspects of being 'underground' included the ability to shape rules and procedures around user need rather than to meet political concerns, and the rapid deployment of the project, based on immediate need. Limitations associated with being underground included restrictions in the size and diversity of the population served by the site, and reduced ability to closely link the service to drug treatment and other health and social services.

CONCLUSION

Unsanctioned supervised injection facilities can provide a rapid and user-driven response to urgent public health needs. This work draws attention to the need to ensure such services remain focused on user-defined need rather than external political concerns in jurisdictions where supervised injection facilities acquire local legal sanction.

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.

The opioid crisis: past, present and future policy climate in Ontario, Canada

BACKGROUND

Addressing opioid use disorder has become a priority in Ontario, Canada, because of its high economic, social and health burden. There continues to be stigma and criticism relating to opioid use disorder and treatment options. The result has been unsystematic, partial, reactive policies and programs developed based on divergent points of view. The aim of this manuscript is to describe how past and present understandings, narratives, ideologies and discourse of opioid use, have impacted policies over the course of the growing opioid crisis.

COMMENTARY

Assessing the impact of policy is complex. It involves consideration of conceptual issues of what impacts policy change. In this manuscript we argue that the development of polices and initiatives regarding opioids, opioid use disorder and opioid agonist treatment in the last decade, have been more strongly associated with the evolution of ideas, narratives and discourses rather than research relating to opioids. We formulate our argument using a framework by Sumner, Crichton, Theobald, Zulu, and Parkhurs. We use examples from the Canadian context to outline our argument such as: the anti- drug legislation from the Canadian Federal Conservative government in 2007; the removal of OxyContin™ from the drug formulary in 2012; the rapid expansion of opioid agonist treatment beginning in the early 2000s, the unilateral decision made regarding fee cuts for physicians providing opioid agonist treatment in 2015; and the most recent implementation of a narcotics monitoring system, which are all closely linked with the shifts in public opinion and discourse at the time of which these policies and programs are implemented.

CONCLUSION

We conclude with recommendations to consider a multifactorial response using evidence and stakeholder engagement to address the opioid crisis, rather than a reactive policy approach. We suggest that researchers have an important role in shaping future policy by reframing ideas through knowledge translation, formation of values, creation of new knowledge and adding to the quality of public discourse and debate.

Association between public injecting and drug-related harm among HIV-positive people who use injection drugs in a Canadian setting: A longitudinal analysis

BACKGROUND

and Aims Injecting illicit drugs in public settings has been linked to a higher risk of a range of drug-related harms, including overdose and HIV infection. However, the factors associated with public injecting among HIV-positive individuals have not been previously explored. We investigated the links between public drug injecting, drug-related harm, and HIV treatment measures among a cohort of HIV-positive persons who inject drugs (PWID) in a Canadian setting.

METHODS

We used data from a prospective cohort of HIV-positive PWID recruited from community settings in Vancouver, Canada, linked to comprehensive clinical monitoring data in the context of an ongoing Treatment-as-Prevention (TasP) initiative to examine harms associated with public injecting. We used generalized linear mixed-effects analyses to identify longitudinal factors associated with self-reported public drug injection.

RESULTS

Between 2005 and 2014, 626 HIV-seropositive PWID were recruited, of whom 213 (34%) reported public injection in the preceding 180days. In a longitudinal multivariable model, public injection was positively associated with daily heroin injection (Adjusted Odds Ratio [AOR]=2.63), incarceration (AOR=1.78), and detectable plasma HIV-1 RNA viral load (VL, AOR=1.42).

CONCLUSIONS

Public injecting was linked to numerous drug-related harms among HIV-seropositive PWID in this setting. Given its link with detectable VL, an important marker of poor HIV treatment outcomes, our findings support prioritizing individuals engaged in public injecting with harm reduction strategies as well as clinical and social supports as a part of TasP-based efforts to prevent HIV-related morbidity and mortality, and HIV transmission.

Support of supervised injection facilities by emergency physicians in Canada

BACKGROUND

Despite evidence supporting the implementation of supervised injection facilities (SIFs) by multiple stakeholders, no evaluation of emergency physicians' attitudes has ever been documented towards such facilities in Canada or internationally. The primary goal of our study was to determine the opinions and perceptions of emergency physicians regarding the implementation of SIFs in Canada.

METHODS

We conducted a national electronic survey of staff and resident emergency physicians in Canada using an iteratively designed survey tool in consultation with content experts. Invitations to complete the survey were sent via email by the Canadian Association of Emergency Physicians. Inclusion criteria required respondents to have treated an adult patient in a Canadian emergency department within the preceding 6 months. The primary measure was the proportion of respondents who would support, not support or were unsure of supporting SIFs in their community with the secondary measure being the likelihood of respondents to refer patients to a SIF if available.

RESULTS

We received 280 responses out of 1353 eligible physicians (20.7%), with the analysis conducted on 250 responses that met inclusion criteria (18.5%). The majority of respondents stated they would support the implementation of SIFs in their community (N=172; 74.5%) while 10.8% (N=25) would not and 14.7% (N=34) did not know. The majority of respondents said they would refer their patients to SIFs (N=198; 84.6%), with 4.3% (N=10) who would not and 11.1% (N=26) who were unsure.

CONCLUSION

The findings from our study demonstrate that the majority of emergency physician respondents in Canada support the implementation of such sites (74.5%) while 84.6% of respondents would refer patients from the emergency department to such sites if they did exist. Given that many Canadian cities are actively pursuing the creation of SIFs or imminently opening such sites, it appears that our sample population of emergency physicians would both support this approach and would utilize such facilities in an effort to improve patient-centered outcomes for this often marginalized population.

Keeping science’s seat at the decision-making table: Mechanisms to motivate policy-makers to keep using scientific information in the age of disinformation

Policy-makers are confronted with complex problems that require evaluating multiple streams of evidence and weighing competing interests to develop and implement solutions. However, the policy interventions available to resolve these problems have different levels of supporting scientific evidence. Decision-makers, who are not necessarily scientifically trained, may favour policies with limited scientific backing to obtain public support. We illustrate these tensions with two case studies where the scientific consensus went up against the governing parties’ chosen policy. What mechanisms exist to keep the weight of scientific evidence at the forefront of decision-making at the highest levels of government? In this paper, we propose that Canada create “Departmental Chief Science Advisors” (DCSAs), based on a program in the UK, to help complement and extend the reach of the newly created Chief Science Advisor position. DCSAs would provide advice to ministers and senior civil servants, critically evaluate scientific work in their host department, and provide public outreach for the department’s science. We show how the DCSAs could be integrated into their departments and illustrate their potential benefits to the policy making process and the scientific community.

Use of on-site detoxification services co-located with a supervised injection facility

OBJECTIVES

Supervised injection facilities (SIFs) are increasingly being implemented worldwide in response to the harms associated with injection drug use. Although SIFs have been shown to promote engagement of people who use injection drugs (PWID) with external health services, little is known about the potential of co-locating on-site detoxification services with SIFs. The aim of this study was to characterize use of detoxification services co-located at Insite, North America's first SIF, among PWID in Vancouver, Canada.

METHODS

Data were derived from two prospective cohorts of PWID in Vancouver, Canada between November 2010 and December 2012. Using multivariable generalized estimating equation logistic regression, we identified factors independently associated with reporting use of detoxification services at the SIF.

RESULTS

Among 1316 PWID, 147 (11.2%) reported enrolling in detoxification services co-located with the SIF at least once during the two year study period. In multivariable analyses, after adjustment for other potential cofounders, factors independently and positively associated with use of this service included residence<5 blocks from the SIF (Adjusted Odds Ratio [AOR]=1.70), enrollment in methadone maintenance therapy (AOR=1.90), public injection (AOR=1.53), binge injection (AOR=1.93), recent overdose (AOR=1.90) and frequent SIF use (AOR=8.15) (all p<0.05).

DISCUSSION

Use of on-site detoxification services offered at the SIF was common among PWID and associated with frequent SIF use and various markers of vulnerability and drug-related risk. These findings highlight the potential role of SIFs as a point of access to detoxification services for high-risk PWID. Future studies should examine if co-location leads to higher uptake of addiction services in comparison to services that create geographic or other obstacles.

HIV and the criminalisation of drug use among people who inject drugs: a systematic review

BACKGROUND

Mounting evidence suggests that laws and policies prohibiting illegal drug use could have a central role in shaping health outcomes among people who inject drugs (PWID). To date, no systematic review has characterised the influence of laws and legal frameworks prohibiting drug use on HIV prevention and treatment.

METHODS

Consistent with PRISMA guidelines, we did a systematic review of peer-reviewed scientific evidence describing the association between criminalisation of drug use and HIV prevention and treatment-related outcomes among PWID. We searched MEDLINE, Embase, SCOPUS, PsycINFO, Sociological Abstracts, CINAHL, Web of Science, and other sources. To be included in our review, a study had to meet the following eligibility criteria: be published in a peer-reviewed journal or presented as a peer-reviewed abstract at a scientific conference; examine, through any study design, the association between an a-priori set of indicators related to the criminalisation of drugs and HIV prevention or treatment among PWID; provide sufficient details on the methods followed to allow critical assessment of quality; be published or presented between Jan 1, 2006, and Dec 31, 2014; and be published in the English language.

FINDINGS

We identified 106 eligible studies comprising 29 longitudinal, 49 cross-sectional, 22 qualitative, two mixed methods, four mathematical modelling studies, and no randomised controlled trials. 120 criminalisation indicators were identified (range 1-3 per study) and 150 HIV indicators were identified (1-5 per study). The most common criminalisation indicators were incarceration (n=38) and street-level policing (n=39), while the most frequent HIV prevention and treatment indicators were syringe sharing (n=35) and prevalence of HIV infection among PWID (n=28). Among the 106 studies included in this review, 85 (80%) suggested that drug criminalisation has a negative effect on HIV prevention and treatment, 10 (9%) suggested no association, five (5%) suggested a beneficial effect, one (1%) suggested both beneficial and negative effects, and five (5%) suggested both null and negative effects.

INTERPRETATION

These data confirm that criminalisation of drug use has a negative effect on HIV prevention and treatment. Our results provide an objective evidence base to support numerous international policy initiatives to reform legal and policy frameworks criminalising drug use.

FUNDING

Canadian Institutes of Health Research and US National Institutes of Health.

Drug use in business bathrooms: An exploratory study of manager encounters in New York City

BACKGROUND

Though public bathroom drug injection has been documented from the perspective of people who inject drugs, no research has explored the experiences of the business managers who oversee their business bathrooms and respond to drug use. These managers, by default, are first-responders in the event of a drug overdose and thus of intrinsic interest during the current epidemic of opioid-related overdoses in the United States. This exploratory study assists in elucidating the experiences that New York City business managers have with people who inject drugs, their paraphernalia, and their overdoses.

METHODS

A survey instrument was designed to collect data on manager encounters with drug use occurring in their business bathrooms. Recruitment was guided by convenience and purposive approaches.

RESULTS

More than half of managers interviewed (58%, n=50/86) encountered drug use in their business bathrooms, more than a third (34%) of these managers also found syringes, and the vast majority (90%) of managers had received no overdose recognition or naloxone training. Seven managers encountered unresponsive individuals who required emergency assistance.

CONCLUSION

The results from this study underscore the need for additional research on the experiences that community stakeholders have with public injection as well as educational outreach efforts among business managers. This research also suggests that there is need for a national dialogue about potential interventions, including expanded overdose recognition and naloxone training and supervised injection facilities (SIF)/drug consumption rooms (DCR), that could reduce public injection and its associated health risks.

Treatment of opioid use disorder in an innovative community-based setting after multiple treatment attempts in a woman with untreated HIV

Opioid use disorder is associated with significant health and social harms. Various evidence-based interventions have proven successful in mitigating these harms, including harm reduction strategies and pharmacological treatment such as methadone. We present a case of a 35-year-old HIV-positive woman who was off antiretroviral therapy due to untreated opioid use disorder, and had a history of frequently self-discharging from hospital against medical advice. During the most recent hospital admission, the patient was transferred to an innovative community-based clinical support residence that supported harm reduction. Initially, she received methadone to only manage the withdrawal symptoms rather than for long-term maintenance therapy. However, with gradual dose increases to treat cravings and withdrawal, she ultimately discontinued all drug use and reinitiated antiretroviral therapy. This case highlights that patients whose goal is not abstinence can be successfully treated for acute medical illnesses and comorbid substance use disorders using harm reduction approaches, including appropriate dosing of pharmacotherapy.

CIHR Canadian HIV Trials Network Coinfection and Concurrent Diseases Core Research Group: 2016 Updated Canadian HIV/Hepatitis C Adult Guidelines for Management and Treatment

Background. Hepatitis C virus (HCV) coinfection occurs in 20-30% of Canadians living with HIV and is responsible for a heavy burden of morbidity and mortality. Purpose. To update national standards for management of HCV-HIV coinfected adults in the Canadian context with evolving evidence for and accessibility of effective and tolerable DAA therapies. The document addresses patient workup and treatment preparation, antiviral recommendations overall and in specific populations, and drug-drug interactions. Methods. A standing working group with HIV-HCV expertise was convened by The Canadian Institute of Health Research HIV Trials Network to review recently published HCV antiviral data and update Canadian HIV-HCV Coinfection Guidelines. Results. The gap in sustained virologic response between HCV monoinfection and HIV-HCV coinfection has been eliminated with newer HCV antiviral regimens. All coinfected individuals should be assessed for interferon-free, Direct Acting Antiviral HCV therapy. Regimens vary in content, duration, and success based largely on genotype. Reimbursement restrictions forcing the use of pegylated interferon is not acceptable if optimal patient care is to be provided. Discussion. Recommendations may not supersede individual clinical judgement. Treatment advances published since December 2015 are not considered in this document.

Public health and international drug policy

In September 2015, the member states of the United Nations endorsed sustainable development goals (SDG) for 2030 that aspire to human rights-centered approaches to ensuring the health and well-being of all people. The SDGs embody both the UN Charter values of rights and justice for all and the responsibility of states to rely on the best scientific evidence as they seek to better humankind. In April 2016, these same states will consider control of illicit drugs, an area of social policy that has been fraught with controversy, seen as inconsistent with human rights norms, and for which scientific evidence and public health approaches have arguably played too limited a role.

The previous UN General Assembly Special Session (UNGASS) on drugs in 1998 – convened under the theme “a drug-free world, we can do it!” – endorsed drug control policies based on the goal of prohibiting all use, possession, production, and trafficking of illicit drugs. This goal is enshrined in national law in many countries. In pronouncing drugs a “grave threat to the health and well-being of all mankind,” the 1998 UNGASS echoed the foundational 1961 convention of the international drug control regime, which justified eliminating the “evil” of drugs in the name of “the health and welfare of mankind.” But neither of these international agreements refers to the ways in which pursuing drug prohibition itself might affect public health. The “war on drugs” and “zero-tolerance” policies that grew out of the prohibitionist consensus are now being challenged on multiple fronts, including their health, human rights, and development impact.

The Johns Hopkins – Lancet Commission on Drug Policy and Health has sought to examine the emerging scientific evidence on public health issues arising from drug control policy and to inform and encourage a central focus on public health evidence and outcomes in drug policy debates, such as the important deliberations of the 2016 UNGASS on drugs.

The Johns Hopkins-Lancet Commission is concerned that drug policies are often colored by ideas about drug use and drug dependence that are not scientifically grounded. The 1998 UNGASS declaration, for example, like the UN drug conventions and many national drug laws, does not distinguish between drug use and drug abuse. A 2015 report by the UN High Commissioner for Human Rights, by contrast, found it important to emphasize that “[d]rug use is neither a medical condition nor does it necessarily lead to drug dependence.” The idea that all drug use is dangerous and evil has led to enforcement-heavy policies and has made it difficult to see potentially dangerous drugs in the same light as potentially dangerous foods, tobacco, alcohol for which the goal of social policy is to reduce potential harms.

Do injection drug users have more adverse events during procedural sedation and analgesia for incision and drainage of cutaneous abscesses?

OBJECTIVE

Injection drug users (IDUs) often undergo procedural sedation and analgesia (PSA) in the emergency department (ED). We compared adverse events (AEs) for IDUs to those for non-IDUs receiving PSA for incision and drainage of cutaneous abscesses.

METHODS

This was a retrospective analysis of a PSA safety audit. IDU status was prospectively documented among consecutive patients undergoing PSA at two urban EDs. Structured data describing comorbidities, vital signs, sedation regimens, and adverse events were collected. Primary outcome was the proportion of patients in each group experiencing an AE, whereas the secondary outcomes included recovery times.

RESULTS

Of 525 consecutive patients receiving PSA for incision and drainage of an abscess, 244 were deemed IDUs and 281 non-IDUs. IDUs received higher doses of sedatives and analgesics, and 14 experienced AEs (5.7%), whereas 10 non-IDUs had AEs (3.6%), for a risk difference of 2.1% (95% CI -1.8, 6.5). Median recovery times were 18 minutes (interquartile range [IQR] 10-36) for IDUs and 12 minutes (IQR 7-19) for non-IDUs, for a difference of 6 minutes (95% CI 2-9 minutes). Median sedation times were also longer in IDUs, for a difference of 6 minutes (95% CI 5-10 minutes). Of 20 IDU patients and 1 non-IDU patient admitted to hospital, none had experienced an AE related to PSA.

CONCLUSIONS

For ED patients requiring PSA for incision and drainage, IDUs had an AE rate similar to that of non-IDUs but longer sedation and recovery times. In experienced hands, PSA may be as safe in IDUs as in patients who do not use injection drugs.

Correlates of public support toward federal funding for harm reduction strategies

Background

Historically, US federal policy has not supported harm reduction interventions, such as safe injection facilities (SIFs) and needle and syringe programs (NSPs), which can reduce the burden associated with injection drug use. Given recent increases in abuse of both legal and illegal opioids, there has been a renewed debate about effective ways to address this problem. The current study (1) assessed participants’ support for SIFs and NSPs, and (2) evaluated several demographic factors (e.g., age, gender, race, education, political ideology, and religiosity) and individual differences in stigmatizing beliefs about people who inject drugs (PWID) that might relate to support for these interventions.

Methods

U.S. adults (N = 899) completed a web-based study that assessed self-reported support for NSPs and SIFs, and stigma about PWID.

Results

The majority of participants were at least somewhat supportive of both NSPs and SIFs. Regression analyses indicated greater support for NSPs and SIFs was predicted by more liberal political ideology, more agreement that PWID deserve help rather than punishment, older age, and male gender. Also, participants who endorsed lower stigma about PWID were more supportive of NSPs and SIFs. Race, religiosity, and education did not predict support for NSPs and SIFs.

Conclusions

Most participants tended to report support for harm reduction strategies. Age, political ideology, and individual differences in stigmatizing beliefs about PWID were significantly associated with support. Given the potential malleability of stigmatizing beliefs, efforts that seek to shift stigma about PWID could have important implications for public policy towards harm reduction strategies for PWID.

Does the sedation regimen affect adverse events during procedural sedation and analgesia in injection drug users?

OBJECTIVES

Injection drug users (IDUs) often undergo procedural sedation and analgesia (PSA) as part of emergency department (ED) treatment. We compared adverse events (AEs) using a variety of sedation regimens.

METHODS

This was a retrospective analysis of a PSA safety audit in two urban EDs. Consecutive self-reported IDUs were identified, and structured data describing comorbidities, vital signs, sedation regimens (propofol [P], propofol-fentanyl [PF], fentanyl-midazolam [FM], ketofol [1:1 ketamine:propofol, KF], and ketamine-propofol [KP]) and AEs were collected. The primary outcome was the proportion of patients in each sedation group having an AE; the secondary outcome was the proportion of patients having a cardiovascular or respiratory AE.

RESULTS

Data were collected on 276 IDUs (78 P, 82 PF, 65 FM, 25 KF, and 26 KP), and 18 patients had AEs (6.5%, 95% CI 4.0-10.3). The AE rates were 0.0%, 8.5%, 9.2%, 12.0%, and 7.6%, respectively, with propofol having a significantly lower rate (Pearson coefficient 14.9, p  =  0.007). The cardiovascular/respiratory AE rates were significantly different as well, with P, KP, and KF having the lowest rates (Pearson coefficient 13.3, p  =  0.01).

CONCLUSIONS

For IDU PSA, the overall AE rate was 6.5%, and propofol appeared to have a significantly lower rate.

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.

Use of a medically supervised injection facility among street youth

PURPOSE

Supervised injecting facilities (SIFs) provide a sanctioned space for injection drug users and are associated with decreased overdose mortality and HIV risk behaviors among adults. Little is known about SIF use among youth. We identified factors associated with use of the Vancouver SIF, the only such facility in North America, among street youth.

METHODS

From September 2005 to May 2012, we collected data from the At-Risk Youth Study, a prospective cohort of street youth in Vancouver, BC, Canada. Eligible youth were aged 14-26 years. Participants reporting injection completed questionnaires at baseline and semiannually. We used generalized estimating equation logistic regression to identify factors associated with SIF use.

RESULTS

During the study period, 42.3% of 414 injecting youth reported use of the SIF at least once. Of all SIF-using youth, 51.4% went to the facility at least weekly, and 44.5% used it for at least one-quarter of all injections. SIF-using youth were more likely to live or spend time in the neighborhood surrounding the SIF (adjusted odds ratio [AOR], 3.29; 95% confidence interval [CI], 2.38-4.54), to inject in public (AOR, 2.08; 95% CI, 1.53-2.84), or to engage in daily injection of heroin (AOR, 2.36; 95% CI, 1.72-3.24), cocaine (AOR, 2.44; 95% CI, 1.34-4.45), or crystal methamphetamine (AOR, 1.62; 95% CI, 1.13-2.31).

CONCLUSIONS

This study, the first to examine SIF use among street youth in North America, demonstrated that the facility attracted high-frequency young drug users most at risk of blood-borne infection and overdose and those who otherwise inject in public spaces.