Overdose prevention centres as spaces of safety, trust and inclusion: A causal pathway based on a realist review

ISSUES

Overdose prevention centres (OPC) are non-residential spaces where people can use illicit drugs (that they have obtained elsewhere) in the presence of staff who can intervene to prevent and manage any overdoses that occur. Many reviews of OPCs exist but they do not explain how OPCs work.

APPROACH

We carried out a realist review, using the RAMESES reporting standards. We systematically searched for and then thematically analysed 391 documents that provide information on the contexts, mechanisms and outcomes of OPCs.

KEY FINDINGS

Our retroductive analysis identified a causal pathway that highlights the feeling of safety - and the immediate outcome of not dying - as conditions of possibility for the people who use OPCs to build trust and experience social inclusion. The combination of safety, trust and social inclusion that is triggered by OPCs can - depending on the contexts in which they operate - generate other positive outcomes, which may include less risky drug use practices, reductions in blood borne viruses and injection-related infections and wounds, and access to housing. These outcomes are contingent on relevant contexts, including political and legal environments, which differ for women and people from racialised minorities.

CONCLUSIONS

OPCs can enable people who live with structural violence and vulnerability to develop feelings of safety and trust that help them stay alive and to build longer term trajectories of social inclusion, with potential to improve other aspects of their health and living conditions.

Evaluating the effects of supervised consumption sites on housing prices in Montreal, Canada using interrupted time series and hedonic price models

Background

In 2017, three brick and mortar supervised consumption sites (SCS) opened in Montreal, Canada. Opponents argued the sites would attract people who use drugs and reduce local real estate prices.

Methods

We used interrupted time series and hedonic price models to evaluate the effects of Montreal's SCS on local real estate prices. We linked the Quebec Professional Association of Real Estate Brokers' housing sales data provided by Centris Inc. with census tract data and gentrification scores. Homes sold within 200 m of the SCS locations between 1 January 2014 and 31 December 2021 were included. We adjusted for internal (e.g., number of bed/bathrooms, unit size) and external attributes (e.g., neighbourhood demographics), and included a spatio-temporal lag to account for correlation between sales. For sensitivity analysis we used site-specific dummy variables to better account for unmeasured neighbourhood differences, and repeated analyses using 500 m and 1000 m radii.

Results

We observed a price shock after the opening of the first two SCS in June 2017 (level effect: -10.5%, 95% CI: -19.1%, -1.1%) but prices rose faster month-to-month (trend effect: 1.1%, 95% CI: 0.7%, 1.6%) after implementation. Following the implementation of the third site in November 2017 there was no immediate impact (level effect: 2.4%, 95% CI: -10.4%, 17.0%) but once more prices roses faster (0.9%, 95% CI: 0.4%, 1.5%) thereafter. When we replaced neighbourhood attributes with a site-specific dummy variable, we observed the same pattern. Sales' prices dropped (level effect: -9.6%, 95% CI: -15.0%, -3.8%) but rose faster month-to-month (trend effect: 0.9%, 95% CI: 0.6%, 1.2%) following June 2017's SCS implementations, with no level effect (4.9%, 95% CI: -7.3%, 18.6%) and a positive trend (0.9%, 95% CI: 0.5%, 1.3%) after November 2017's SCS opening. In most 500 m and 1000 m radii models, there were no immediate shocks following SCS opening, however, positive trend effects persisted in all models.

Conclusion

Our models suggest homes sold near SCS may experience a price shock immediately post-implementation, with evidence of market recovery in the months that follow.

Gender, sexual orientation identity, and initiation of amphetamine injecting among people who inject drugs: Examination of an expanding drug era in Montreal, Canada, 2011-19

BACKGROUND

Amphetamine injection is expanding in North America and has been associated with male homosexuality among people who inject drugs (PWID). Applying subcultural evolution theory, we examined overall and gender-stratified trends in amphetamine injection and assessed sexual orientation as a gender-specific predictor of initiation among PWID in Montreal, Canada.

METHODS

Data were from HEPCO, an open prospective cohort of PWID. Gender and sexual orientation were self-identified at enrolment. Interviewer-administered questionnaires at three-monthly (HCV RNA-negative participants) or yearly (RNA-positive) intervals captured past three-month amphetamine injection and covariates. Annual prevalence and linear trends in amphetamine injection were estimated using GEE. Incidence was computed among naïve individuals and hazard ratios for initiation estimated using gender-stratified, time-varying Cox regression models.

RESULTS

803 participants contributed 8096 observations between March 2011 and December 2019. Annual prevalence of amphetamine injecting increased from 3.25% [95%CI: 2.06-4.43%] to 12.7% [9.50-16.0] (trend p<0.001). Bivariate Cox regression models suggested similar and divergent predictors of initiation by gender. Incidence was 3.27 per 100 person-years [95%CI: 2.51-4.18] among heterosexual men, 7.18 [3.50-13.2] among gay/bisexual men, 1.93 [0.78-4.02] among heterosexual women and 5.30 [1.69-12.8] among gay/bisexual women. Among men, gay/bisexual identity doubled risk of initiation after adjusting for age, ethnicity, calendar year (aHR 2.16 [1.07-4.36]) and additional covariates (2.56 [1.24-5.30]). Among women, evidence for an association with gay/bisexual identity was inconclusive (aHR 2.63 [0.62-11.2]) and sample size precluded further adjustment CONCLUSIONS: Prevalence of amphetamine injection among PWID increased four-fold from 2011 to 2019, with elevated risk of initiation in gay and bisexual men.

[Drug Consumption Rooms : Opinion and willingness among people who inject drugs in Marseille, France]

BACKGROUND

In France, people who inject drugs (PWID) are still one of the most at risk population for contracting hepatitis C virus (HCV). Drug consumption rooms (DCR) have shown their effectiveness on HCV risk behaviors abroad and in France, where they have been recently evaluated with the COSINUS study. In France, two DCRs opened in 2016, one in Paris and another in Strasbourg. The objective of this sub-analysis was to explore the willingness to use a DCR in PWID living in Marseille, where no DCR is opened.

METHODS

The COSINUS study is a prospective multicenter cohort that included 665 PWID recruited in Bordeaux, Marseille, Paris and Strasbourg between 2016 and 2019. Investigators administered questionnaires face-to-face at regular intervals at baseline, 3 months, 6 months and 12 months. In Marseille, 199 PWID were recruited. A multivariable logistic regression model was performed to assess factors associated with willingness to use DCR among this population.

RESULTS

Among 545 observations corresponding to 195 distinct participants selected for analyses, 57% declared they were willing to attend a DCR. The main reason given was "to consume more cleanly". Receiving allowances (OR = 2.38; 95% confidence interval (CI) (95% CI) = 1.17-4.81), not having health insurance (OR = 3.61; 95% CI = 1.49-8.75), injecting daily (OR = 1.97; 95% CI = 1.05-3.70) and in a public space (OR = 2.66; 95% CI = 1.29-5.47) were all positively associated with willingness to use a DCR.

CONCLUSIONS

DCR are devices that target PWID exposed to high sanitary or social risks, i.e. people living in precarious conditions, who have to inject in public spaces, in deleterious sanitary environments and with rapid gestures in order not to be seen. These analyzes highlight that the people who most want to attend a DCR are aware of the harms associated with their practices and show a desire to seek protection from street-based drug scenes.

Public injecting and its association with mental health and other drug-related outcomes among people who inject drugs in Iran

BACKGROUND

Injecting in public places may increase the risk of drug and health-related harms among people who inject drugs (PWID). We examined the prevalence of public injecting and associations with non-fatal overdose, needle/syringe sharing, sexual health, and mental health among PWID in Iran.

METHODS

Using respondent-driven sampling, we recruited 2684 PWID from 11 major cities between July 2019 and March 2020. We defined public injecting as injecting primarily in public places, such as streets, parks, or abandoned buildings. Multivariable logistic regression models assessed public injecting and its associated factors, as well as the association of public injecting with certain health outcomes.

RESULTS

Of 2388 respondents, 69.6 % reported public injecting in the previous year. Self-identifying as men (adjusted odds ratio [aOR] = 4.21; 95 % confidence intervals [95 % CI]: 2.31, 7.65), homelessness (aOR = 6.81; 95 % CI: 5.10, 9.10), high injection frequency (aOR = 1.58; 95 % CI: 1.03, 2.44), and free needle/syringe uptake (aOR = 1.47; 95 % CI: 1.04, 2.07) were significantly associated with public injecting. Compared to PWID who primarily inject in non-public places, PWID who mostly used public places had significantly greater odds of reporting non-fatal overdose (aOR = 2.02; 95 % CI: 1.01, 4.02), needle/syringe sharing (aOR = 1.77; 95 % CI: 1.08, 2.90), unsafe sexual practices with casual sexual partners (aOR = 2.16; 95 % CI: 1.03, 4.55), suicidal ideation (aOR = 1.50; 95 % CI: 1.02, 2.21), and self-harm (aOR = 1.78; 95 % CI: 1.24, 2.54) in the last three months.

CONCLUSION

These results suggest the potential utility of a safer injecting environment to mitigate the multiple harms associated with public injecting in Iran. Optimizing health and well-being of PWID necessitates integrating supervised injection facilities into the current harm reduction programs and services in Iran. Future studies should also consider the experiences of additional mental health harms associated with public injecting when exploring adverse health outcomes among PWID.

Evaluating Montréal's harm reduction interventions for people who inject drugs: protocol for observational study and cost-effectiveness analysis

INTRODUCTION

The main harm reduction interventions for people who inject drugs (PWID) are supervised injection facilities, needle and syringe programmes and opioid agonist treatment. Current evidence supporting their implementation and operation underestimates their usefulness by excluding skin, soft tissue and vascular infections (SSTVIs) and anoxic/toxicity-related brain injury from cost-effectiveness analyses (CEA). Our goal is to conduct a comprehensive CEA of harm reduction interventions in a setting with a large, dispersed, heterogeneous population of PWID, and include prevention of SSTVIs and anoxic/toxicity-related brain injury as measures of benefit in addition to HIV, hepatitis C and overdose morbidity and mortalities averted.

METHODS AND ANALYSIS

This protocol describes how we will develop an open, retrospective cohort of adult PWID living in Québec between 1 January 2009 and 31 December 2020 using administrative health record data. By complementing this data with non-linkable paramedic dispatch records, regional monthly needle and syringe dispensation counts and repeated cross-sectional biobehavioural surveys, we will estimate the hazards of occurrence and the impact of Montréal's harm reduction interventions on the incidence of drug-use-related injuries, infections and deaths. We will synthesise results from our empirical analyses with published evidence to simulate infections and injuries in a hypothetical population of PWID in Montréal under different intervention scenarios including current levels of use and scale-up, and assess the cost-effectiveness of each intervention from the public healthcare payer's perspective.

ETHICS AND DISSEMINATION

This study was approved by McGill University's Institutional Review Board (Study Number: A08-E53-19B). We will work with community partners to disseminate results to the public and scientific community via scientific conferences, a publicly accessible report, op-ed articles and open access peer-reviewed journals.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Increased risk of HIV and other drug-related harms associated with injecting in public places: national bio-behavioural survey of people who inject drugs

BACKGROUND

Whilst injecting drugs in public places is considered a proxy for high risk behaviour among people who inject drugs (PWID), studies quantifying its relationship with multiple drug-related harms are lacking and none have examined this in the context of an ongoing HIV outbreak (located in Glasgow, Scotland). We aimed to: 1) estimate the prevalence of public injecting in Scotland and associated risk factors; and 2) estimate the association between public injecting and HIV, current HCV, overdose, and skin and soft tissue infections (SSTI).

METHODS

Cross-sectional, bio-behavioural survey (including dried blood spot testing to determine HIV and HCV infection) of 1469 current PWID (injected in last 6 months) recruited by independent interviewers from 139 harm reduction services across Scotland during 2017-18. Primary outcomes were: injecting in a public place (yes/no); HIV infection; current HCV infection; self-reported overdose in the last year (yes/no) and SSTI the last year (yes/no). Multi-variable logistic regression was used to determine factors associated with public injecting and to estimate the association between public injecting and drug-related harms (HIV, current HCV, overdose and SSTI).

RESULTS

Prevalence of public injecting was 16% overall in Scotland and 47% in Glasgow city centre. Factors associated with increased odds of public injecting were: recruitment in Glasgow city centre (aOR=5.45, 95% CI 3.48-8.54, p<0.001), homelessness (aOR=3.68, 95% CI 2.61-5.19, p<0.001), high alcohol consumption (aOR=2.42, 95% CI 1.69-3.44, p<0.001), high injection frequency (≥4 per day) (aOR=3.16, 95% CI 1.93-5.18, p<0.001) and cocaine injecting (aOR=1.46, 95% CI 1.00 to 2.13, p = 0.046). Odds were lower for those receiving opiate substitution therapy (OST) (aOR=0.37, 95% CI 0.24 to 0.56, p<0.001) and older age (per year increase) (aOR=0.97, 95% CI 0.95 to 0.99, p = 0.013). Public injecting was associated with an increased risk of HIV infection (aOR=2.11, 95% CI 1.13-3.92, p = 0.019), current HCV infection (aOR=1.49, 95% CI 1.01-2.19, p = 0.043), overdose (aOR=1.59, 95% CI 1.27-2.01, p<0.001) and SSTI (aOR=1.42, 95% CI 1.17-1.73, p<0.001).

CONCLUSIONS

These findings highlight the need to address the additional harms observed among people who inject in public places and provide evidence to inform proposals in the UK and elsewhere to introduce facilities that offer safer drug consumption environments.

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.

"Taking away the chaos": a health needs assessment for people who inject drugs in public places in Glasgow, Scotland

BACKGROUND

Public injecting of recreational drugs has been documented in a number of cities worldwide and was a key risk factor in a HIV outbreak in Glasgow, Scotland during 2015. We investigated the characteristics and health needs of people involved in this practice and explored stakeholder attitudes to new harm reduction interventions.

METHODS

We used a tripartite health needs assessment framework, comprising epidemiological, comparative, and corporate approaches. We undertook an analysis of local and national secondary data sources on drug use; a series of rapid literature reviews; and an engagement exercise with people currently injecting in public places, people in recovery from injecting drug use, and staff from relevant health and social services.

RESULTS

Between 400 and 500 individuals are estimated to regularly inject in public places in Glasgow city centre: most experience a combination of profound social vulnerabilities. Priority health needs comprise addictions care; prevention and treatment of blood-borne viruses; other injecting-related infections and injuries; and overdose and drug-related death. Among people with lived experience and staff from relevant health and social care services, there was widespread - though not unanimous - support for the introduction of safer injecting facilities and heroin-assisted treatment services.

CONCLUSIONS

The environment and context in which drug consumption occurs is a key determinant of harm, and is inextricably linked to upstream social factors. Public injecting therefore requires a multifaceted response. Though evidence-based interventions exist, their implementation internationally is variable: understanding the attitudes of key stakeholders provides important insights into local facilitators and barriers. Following this study, Glasgow plans to establish the world's first co-located safer injecting facility and heroin-assisted treatment service.

Risky and rushed public crack cocaine smoking: the potential for supervised inhalation facilities

BACKGROUND

Despite the multitude of public health and community harms associated with crack cocaine use, little is known about factors associated with smoking crack in public and related risks such as rushed public crack smoking.

METHODS

Data were derived from two prospective cohort studies of people who use illicit drugs in Vancouver, Canada between 2010 and 2014. Multivariable generalized estimating equations were used to identify the prevalence and correlates of public crack smoking and rushed public crack smoking.

RESULTS

In total, 1085 participants who had smoked crack in the prior six months were eligible for the analysis, of which 379 (34.9 %) reported always or usually smoking crack in public in the previous six months at some point during the study period. Factors positively and independently associated with public crack smoking included public injection drug use (adjusted odds ratio [AOR]: 5.42, 95 % confidence interval [CI]: 3.76-7.82), homelessness (AOR: 3.48, 95 % CI: 2.77-4.36), at least daily crack use (AOR: 2.69, 95 % CI: 2.19-3.31), crack pipe sharing (AOR: 1.98, 95 % CI: 1.60-2.46), drug dealing (AOR: 1.59, 95 % CI: 1.30-1.94), recent incarceration (AOR: 1.47, 95 % CI: 1.09-1.98), noticing police presence when buying or using drugs (AOR: 1.30, 95 % CI: 1.06-1.60), and younger age (AOR: 1.03, 95 % CI: 1.01-1.04). Rushed public crack smoking, which was reported by 216 (28.8 %) of 751 participants who had smoked crack in public at least once during the study period, was positively and independently associated with homelessness (AOR: 2.61, 95 % CI: 1.96-3.49), at least daily crack use (AOR: 1.48, 95 % CI: 1.11-1.98), crack pipe sharing (AOR: 1.44, 95 % CI: 1.10-1.89), drug dealing (AOR: 1.39, 95 % CI: 1.04-1.86), and younger age (AOR: 1.02, 95 % CI: 1.01-1.04).

CONCLUSIONS

A high prevalence of public crack smoking and rushed public crack smoking was observed in this setting. These findings point to the need for implementing and evaluating evidence-based public health interventions, such as supervised inhalation facilities, to reduce the risks and harms associated with smoking crack in public.

Open drug scenes: responses of five European cities

BACKGROUND

Open drug scenes are gatherings of drug users who publicly consume and deal drugs. The authors conducted a study of five European cities that have met such scenes constructively. The aim was to investigate shared and non-shared interventions and strategies in order to increase the understanding of this type of problem.

METHODS

First a description was made for the cities of Amsterdam, Frankfurt, Vienna, Zürich and Lisbon. These descriptions were sent to contact persons in each city prior to visit by the researchers. The methods and strategies in each city were discussed and core choices and efforts extracted. A report was sent to the contact group for corrections and clarifications. The paper analyses shared and non-shared traits and strategies.

RESULTS

All of the cities had initially a period with conflict between liberal and restrictive policies. A political consensus seems to be a prerequisite for effective action. A core shared characteristic was that drug dependence was met as a health problem and drug use behaviour as a public nuisance problem. Low threshold health services including opioid maintenance treatment were combined with outreach social work and effective policing.

CONCLUSION

Prevention, harm reduction and treatment should be combined with law enforcement based on cooperation between police, health care and social services. The aim should be "coexistence" between society and users of illegal substances and the strategy based on several years planning and conjoint efforts. The solutions are found in appropriate combinations of harm reduction and restrictive measures.

Injecting drug user views (and experiences) of drug-related litter bins in public places: a comparative study of qualitative research findings obtained from UK settings

This paper provides a comparative study of qualitative research concerning drug-related litter in community settings (associated with illicit drug use/rs) and of the modes of intervention (noted by municipal authorities in two different UK settings) aimed at reducing harm associated with this contemporary public health issue. More specifically, the paper focuses upon the views and experiences of 51 injecting drug users regarding DRL-bin provision, service uptake and connected events in the relevant settings. Comparative analysis of these qualitative experiences appears to confirm Fitzpatrick and LaGory's concept of 'place matters' in any consideration of applied, low threshold, health intervention. Accordingly, street-based, drug-related intervention within public settings needs to be culturally, environmentally, spatially and geographically relevant to the intended target population in order to have any meaningful benefit (e.g. reduced opportunities for needlestick injury in community settings), impact (e.g. improved community safety) and related outcome (e.g. service uptake by injecting drug users).

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

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

A spatial analysis of the physical and social environmental correlates of discarded needles

The role that the urban environment plays in influencing drug users' injection and needle disposal decisions is poorly understood. We identified potential attractors and deterrents of needle discarding, and then used a geographic information system (GIS) to quantify these factors for a neighborhood in Montréal, Canada. In multivariate logistic regression, discarded needles were found to have more associations with physical factors than with social factors. Visual exposure and proximity to a single-room occupancy hotel, a pay phone, an adult service or a pawnshop were important physical environmental predictors. These findings are discussed in relation to developing public health and urban design-based harm reduction approaches to needle discarding in public space.

Public crack cocaine smoking and willingness to use a supervised inhalation facility: implications for street disorder

Background

The health risks of crack cocaine smoking in public settings have not been well described. We sought to identify factors associated with public crack smoking, and assess the potential for a supervised inhalation facility to reduce engagement in this behavior, in a setting planning to evaluate a medically supervised crack cocaine smoking facility.

Methods

Data for this study were derived from a Canadian prospective cohort of injection drug users. Using multivariate logistic regression we identified factors associated with smoking crack cocaine in public areas. Among public crack smokers we then identified factors associated with willingness to use a supervised inhalation facility.

Results

Among our sample of 623 people who reported crack smoking, 61% reported recently using in public locations. In multivariate analysis, factors independently associated with public crack smoking included: daily crack cocaine smoking; daily heroin injection; having encounters with police; and engaging in drug dealing. In sub analysis, 71% of public crack smokers reported willingness to use a supervised inhalation facility. Factors independently associated with willingness include: female gender, engaging in risky pipe sharing; and having encounters with police.

Conclusion

We found a high prevalence of public crack smoking locally, and this behavior was independently associated with encounters with police. However, a majority of public crack smokers reported being willing to use a supervised inhalation facility, and individuals who had recent encounters with police were more likely to report willingness. These findings suggest that supervised inhalation facilities offer potential to reduce street-disorder and reduce encounters with police.

Public injecting and HIV risk behaviour among street-involved youth

BACKGROUND

Although street-involved youth who inject illicit drugs are known to be at an increased risk of HIV and other adverse health outcomes, little is known about public injecting among this population and how injecting in public environments may impact HIV risk behaviour.

METHODS

We used data derived from a study of 560 street-involved youth in Vancouver, Canada to examine the factors associated with injecting in public environments among youth who reported injecting drugs in the past 6 months.

RESULTS

At baseline, 162 (28.9%) reported injecting drugs in the past 6 months. Among injectors, the 124 (76.5%) participants who reported injecting in public were more likely to be homeless (odds ratio [OR]=6.39, p<0.001), engage in unprotected intercourse (OR=3.09, p=0.004), deal drugs (OR=2.26, p=0.032), smoke crack cocaine (OR=3.00, p=0.005), inject heroin (OR=3.48, p=0.001), drop used syringes outdoors (OR=8.44, p<0.001), share syringes (OR=4.43, p=0.004), and were less likely to clean injection sites >75% of the time (OR=0.36, p=0.008). The majority (62.1%) reported feeling rushed while injecting in public.

CONCLUSIONS

Youth who inject in public are significantly more likely to engage in sexual and injection-related risk behaviour. Given the known elevated rates of HIV infection and other harms among this population, youth-focused interventions that target both sexual and drug-related risks associated with public drug-using environments are in urgent need of evaluation.

Assessing a drop box programme: a spatial analysis of discarded needles

BACKGROUND

Distributing sterile injection equipment to injection drug users is one of few proven ways of lowering the transmission rate of blood borne viruses. Distribution of equipment has also been linked to increased needle discarding, which is a public health risk for both injectors and their host communities. Drop boxes (anonymous and public-access sharps containers) are a promising and increasingly popular means of reducing unsafe disposal, yet there is little empirical research to support or guide their implementation.

METHODS

Using a dataset containing the locations of 7274 discarded needles and syringes collected monthly in the non-park open spaces of a 2.5km(2) neighbourhood of Montréal, Canada for a period of five years, we compared levels of discards before and after the installation of 12 drop boxes. We used quasi-Poisson regression to test the effects of drop boxes on monthly counts of collected discards for areas within a walking distance of 25, 50, 100 and 200m of a drop box. We adjusted for known time-dependent covariates linearly and unknown time-dependent covariates using a smoothing function.

RESULTS

We found strong evidence of reduced discarding following the installation of drop boxes; drop boxes were associated with reductions of up to 98% (95% CI: 72-100%) and significant reductions for areas up to 200m from a drop box. Reductions were inversely proportional to walking distance from drop boxes. No measure of weather or use of needle exchange programmes (NEPs) had a consistent relationship with discard counts.

CONCLUSION

Our research suggests that IDUs changed their needle-disposal behaviour in response to increased safe disposal options. In addition to being relatively low-threshold, economical and rapid, drop boxes appear to be a highly effective intervention to reduce discarded needles.

High rates of homelessness among a cohort of street-involved youth

Using multivariate logistic regression, we examined the prevalence and correlates of homelessness among youth enrolled in a community-recruited prospective cohort known as the At-Risk Youth Study (ARYS), between September 2005 and October 2006. Of 478 individuals included in this analysis, 132 (27.6%) were female and 120 (25.1%) self-identified as Aboriginal. The median age was 22 (IQR: 20-24). In total, 284 (56.9%) participants reported baseline homelessness, with most living either at no fixed address, on the street, or in a hostel or shelter. Factors associated with homelessness included public injecting, frequent crack use, experienced violence, having less than a high-school education, and not having been in any addiction treatment. Homeless individuals were at-risk for various adverse health outcomes. These findings indicate the need for additional interventions, including residential addiction treatment, to address homelessness and drug use among youth.

Distinguishing signs of opioid overdose and indication for naloxone: an evaluation of six overdose training and naloxone distribution programs in the United States

AIMS

This study assessed overdose and naloxone administration knowledge among current or former opioid abusers trained and untrained in overdose-response in the United States.

DESIGN AND PARTICIPANTS

Ten individuals, divided equally between those trained or not trained in overdose recognition and response, were recruited from each of six sites (n = 62).

SETTING

US-based overdose training and naloxone distribution programs in Baltimore, San Francisco, Chicago, New York and New Mexico.

MEASUREMENTS

Participants completed a brief questionnaire on overdose knowledge that included the task of rating 16 putative overdose scenarios for: (i) whether an overdose was occurring and (ii) if naloxone was indicated. Bivariate and multivariable analyses compared results for those trained to untrained. Responses were also compared to those of 11 medical experts using weighted and unweighted kappa statistics.

FINDINGS

Respondents were primarily male (72.6%); 45.8% had experienced an overdose and 72% had ever witnessed an overdose. Trained participants recognized more opioid overdose scenarios accurately (t(60) = 3.76, P < 0.001) and instances where naloxone was indicated (t(59) = 2.2, P < 0.05) than did untrained participants. Receipt of training and higher perceived competency in recognizing signs of an opioid overdose were associated independently with higher overdose recognition scores. Trained respondents were as skilled as medical experts in recognizing opioid overdose situations (weighted kappa = 0.85) and when naloxone was indicated (kappa = 1.0).

CONCLUSIONS

Results suggest that naloxone training programs in the United States improve participants' ability to recognize and respond to opioid overdoses in the community. Drug users with overdose training and confidence in their abilities to respond may effectively prevent overdose mortality.

The law (and politics) of safe injection facilities in the United States

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.

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

BACKGROUND

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

AIM

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

METHODS

We draw upon published research evidence and qualitative case examples.

RESULTS

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

CONCLUSIONS

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