Injection drug users' access to a supervised injection facility in Vancouver, Canada: the influence of operating policies and local drug culture

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.

Accessibility gaps of physical supervised consumption sites in Canada motivating the use of overdose response technology/phone based virtual overdose response services: a retrospective cohort study

Background

Overdose response technology or virtual overdose response services are an evolving complementary harm reduction intervention which may overcome certain accessibility barriers of physical supervised consumption sites (SCS) and overdose prevention sites (OPS). We sought to characterize SCS/OPS accessibility barriers among clients accessing a nationwide overdose response phone-based hotline in Canada.

Methods

We performed a retrospective cohort analysis using anonymized call logs of the National Overdose Response Service (NORS) between December 2020 to July 2023. De-identified caller locations were cross-referenced with the locations, policies and operational hours of existing physical SCS/OPS. The primary outcome was accessibility of physical SCS/OPS defined hierarchically according to alignment with caller postal code, substance use routes reported, and calling times.

Findings

Our cohort comprised 4501 calls from 331 unique clients. Despite always having nearby SCS/OPS open and supporting substance use routes of choice, 100 clients (30.2%) preferentially utilized NORS. Among 191 clients (57.7%) who never had access to physical SCS/OPS at time of calling, 92 (27.8%) lacked a nearby site, 58 (17.5%) called outside of operational hours, and 41 (12.4%) would not be permitted to smoke on premises. Secondary analyses identified correlations between accessibility and the urbanicity and geographical region of callers within Canada.

Interpretation

Overdose response technology or virtual overdose response services are a novel complementary harm reduction strategy both for clients with access barriers to physical SCS/OPS and those who prefer virtual services. System-level correlates of client location urbanicity and inter-provincial variation indicate actionable targets for expanding harm reduction services both physical and virtual to better engage with people who use drugs.

Funding

Health Canada Substance Use and Addictions Program, Canadian Institutes of Health Research, and Grenfell Ministries.

Effect of modified income assistance payment schedules on substance use service access: Evidence from an experimental study

BACKGROUND

Despite being critical to reducing the impacts of poverty internationally, synchronized monthly government income assistance payments are linked to intensified drug use and associated harms, including disrupted access to substance use-related services. This study evaluates whether alternative income assistance distribution schedules improve harm reduction (HR), pharmacotherapy and substance use service utilization.

METHODS

This exploratory, parallel group, unblinded, randomized controlled trial analyzed data from adults (n = 192) in Vancouver, Canada receiving income assistance, and reporting active, regular illicit drug use. Participants were randomly assigned on a 1:2:2 basis for six income assistance payment cycles to: (1) existing government schedules (control); (2) a "staggered" single monthly payment; or (3) "split & staggered" twice-monthly payments. Generalized linear mixed models analyzed secondary outcomes of HR, pharmacotherapy and substance use service utilization as well as barriers accessing these services.

RESULTS

Forty-five control, 71 staggered, and 76 split & staggered volunteers participated between 2015 and 2019. Multivariable modified per-protocol analyses demonstrate increased access to substance use services (Adjusted Odds Ratio [AOR] 1.64, 95% Confidence Interval [CI] 1.02-2.64) for split & staggered arm participants, and, conversely, increased barriers to HR for participants in the staggered (AOR 2.34, 95% CI 1.24-4.41) and split & staggered (AOR 2.16, 95% CI 1.08-4.35) arms. Results also showed decreased barriers to pharmacotherapy around government payments (AOR 0.23, 95% CI 0.06-0.90), pharmacotherapy around individual payments (AOR 0.12, 95% CI 0.02-0.58), and HR around individual payments (AOR 0.11, 95% CI 0.02-0.63) for staggered arm participants.

CONCLUSION

Modifying payments schedules demonstrate improved access to overall substance use services, and reduced barriers to HR and pharmacotherapy around income assistance payments. However, increased overall barriers to HR access were also shown. These complex, predominantly beneficial findings support the exploration of offering alternative payment schedules to support service access.

"We just don't have the space for it": Geographies of survival and spatial triage in overdose prevention sites

This study explores the role of Overdose Prevention Sites (OPS) within the geographies of survival of vulnerably housed people who use drugs (PWUD) in Vancouver, British Columbia (BC), Canada. In BC, OPS are low-barrier spaces where people may use drugs under monitoring of trained staff. OPS have been established by people who use drugs, activists, and allied organizations as an emergency measure to prevent overdose deaths. However, OPS have other important uses for PWUD who are vulnerably housed and rely on public spaces for survival. Drawing on two years (2018-2020) of ethnographic fieldwork and interviews with fifty-five people who work at and/or use OPS, we explore how OPS operators negotiated multiple and at times competing uses of service space for everyday survival. Data analysis was guided by critical urban theory to explore the place of OPS within PWUD's geographies of survival, with attention to how different uses of space were negotiated within the context of an illicit drug poisoning crisis and urban control practices that displace and exclude unhoused and vulnerably housed PWUD from the city. We find that OPS accommodated other important potential uses of space for unhoused and vulnerably housed PWUD who relied on public space for survival and were routinely displaced by revanchist urban control strategies. Low-barrier approaches and facility enhancements to OPS improved program accessibility and enabled PWUD to use the sites more broadly to meet survival needs including for mutual-aid, sheltering, and income-generation. However, these secondary uses of OPS presented multiple operational challenges as service volumes increased. We observed processes of 'spatial triage' emerge within sites to manage these challenges, which we characterise as a pragmatic set of rules, procedures, and spatial practices that constrained broader uses of OPS within PWUD's geographies of survival. While spatial triage offered a pragmatic way of prioritizing service delivery to address the most acute survival threats of overdose fatality, these practices had unintended and inequitable impacts on service access. Our findings indicate the need for complementary structural changes as part of overdose responses to reduce the need for spatial triage (i.e., safe, affordable housing and drug decriminalisation) and service innovations to mitigate potential harms (e.g., Expanded drop-in and chill spaces, temporary storage spaces for service user).

Decriminalization thresholds for drug possession: A multi-criteria policy analysis framework

BACKGROUND

Decriminalization of personal possession of drugs has been proposed as an approach to mitigate the harms of drug prohibition. Despite growing interest, particularly in Canadian settings, analyses of approaches to defining the parameters of what constitutes personal possession within decriminalization models are lacking. Using the Province of British Columbia, Canada, as a case study, we undertook an evidence-based multi-criteria policy analysis of three models for defining personal possession: 1) a model that defines personal possession as the absence of evidence of drug trafficking; 2) a cumulative threshold of 15 grams; and 3) a cumulative threshold of 2.5 grams.

METHODS

We utilized data from four sources: qualitative interviews with 16 experts, including representatives from government and law enforcement; Vancouver Police drug seizure data; self-reported drug consumption data from longitudinal cohorts of people who use drugs in Vancouver; and publicly available government documents (e.g., the Government of BC's submission for decriminalization). Data was used to identify and define evaluation criteria which reflect the stated policy objectives of decriminalization alongside other policy considerations. This framework was used to conduct a multi-criteria policy analysis of the three different models.

RESULTS

The seven evaluation criteria included: 1) reduction in interactions with police; 2) reduction of police drug seizures; 3) coverage for those with high consumption; 4) impact on equity-deserving groups; and acceptance on the part key stakeholders, including: 5) people who use drugs; 6) law enforcement; and 7) the public. The model that performed the best was the cumulative threshold model of 15 grams.

CONCLUSION

Findings highlight that different threshold models advance and constrain the stated policy objectives of drug decriminalization to varying degrees. This analysis provides a framework that other jurisdictions considering decriminalization could use to help inform determinations of threshold levels based on stated policy objectives.

Between Care and Control: Examining Surveillance Practices in Harm Reduction

As harm reduction programs and services proliferate, people who use drugs (PWUD) are increasingly subjected to surveillance through the collection of their personal information, systematic observation, and other means. The data generated from these practices are frequently repurposed across various institutional sites for clinical, evaluative, epidemiological, and administrative uses. Rationales provided for increased surveillance include the more effective provision of care, service optimization, risk stratification, and efficiency in resource allocation. With this in mind, our reflective essay draws on empirical analysis of work within harm reduction services and movements to reflect critically on the impacts and implications of surveillance expansion. While we argue that many surveillance practices are not inherently problematic or harmful, the unchecked expansion of surveillance under a banner of health and harm reduction may contribute to decreased uptake of services, rationing and conditionalities tied to service access, the potential deepening of health disparities amongst some PWUD, and an overlay of health and criminal-legal systems. In this context, surveillance relies on the enlistment of a range of therapeutic actors and reflects the permeable boundary between care and control. We thus call for a broader critical dialogue within harm reduction on the problems and potential impacts posed by surveillance in service settings, the end to data sharing of health information with law enforcement and other criminal legal actors, and deference to the stated need among PWUD for meaningful anonymity when accessing harm reduction and health services.

A scoping review of qualitative research on barriers and facilitators to the use of supervised consumption services

A substantial body of evidence demonstrates that supervised consumption services (SCS) mitigate a variety of drug-related harms, including decreasing overdose deaths, infectious disease transmission, and connecting people who use drugs (PWUD) to various health and social services. Research on SCS has predominantly been quantitative, though qualitative research on these services has increased substantially over the last decade. Qualitative methods provide a framework for developing a richer and more nuanced understanding of meanings and contexts associated with drug use, health service implementation, and experience. We present findings from a scoping review of qualitative studies on experiences of PWUD with SCS published between 1997 and 2022. In total, forty-two papers were included in this analysis. Four primary themes emerged from our analysis: 1) Influence of SCS on health and wellbeing among PWUD, 2) the physical environment of SCS can be both a facilitator and barrier to use, 3) social resources can shape and reshape the context within which PWUD benefit from SCS, and 4) various intersecting forces at play both support and harm PWUD in relation to their experiences with SCS. We discuss the primary facilitators and barriers of SCS use and conclude with suggestions to inform future qualitative research, SCS implementation, and PWUD-centered approaches to drug policy.

The "goldfish bowl": a qualitative study of the effects of heightened surveillance on people who use drugs in a rural and coastal Canadian setting

BACKGROUND

A growing body of research has focused on contextual factors that shape health and well-being of people who use drugs (PWUD). However, most of this research focuses on large cities and less is known about the effects of social and structural contexts on drug use and associated risks in rural Canadian settings. Therefore, we undertook this study to examine rural-specific contextual factors that affect the day-to-day experiences of PWUD.

METHODS

Twenty-seven qualitative semi-structured interviews were conducted with PWUD in a rural and coastal setting in British Columbia, Canada. Participants had to be ≥ 19 years old, used illegal opioids and/or stimulants regularly, and lived in the qathet region. Interview transcripts were coded based on themes identified by the research team.

RESULTS

Participants described progressive shifts in politics and culture in the qathet region while also identifying resource scarcity, homelessness, and changes in the drug supply, where illicit drug contents have become highly toxic and unpredictable. Participants discussed the qualities of a small community where everyone knows each other and there is a lack of privacy and confidentiality around drug use, which resulted in experiences of stigma, discrimination, and surveillance. Participants also reported rural-specific policing issues and experiences of surveillance on ferries when traveling to larger cities to purchase drugs. This led to significantly higher drug prices for PWUD due to the time dedication and criminalized risks associated with drug possession and trafficking.

CONCLUSIONS

Our findings illustrate the unique experiences faced by PWUD in a rural and coastal setting. The "goldfish bowl" effect in this rural community created heightened social and structural surveillance of PWUD, which led to a variety of negative consequences. There is a clear need for interventions to address the larger contextual drivers affecting people who use drugs in rural settings, including decriminalization and peer-led anti-stigma strategies, in order to improve the lives of PWUD.

Safety in solitude? Competing risks and drivers of solitary drug use among women who inject drugs and implications for overdose detection

BACKGROUND AND AIMS

Solitary drug use (SDU) can amplify risks of fatal overdose. We examined competing risks and drivers of SDU, as well as harm reduction strategies implemented during SDU episodes, among women who inject drugs (WWID).

DESIGN

A cross-sectional qualitative study, including telephone and face-to-face in-depth interviews.

SETTING

Baltimore City, MD, USA.

PARTICIPANTS

Twenty-seven WWID (mean age = 39 years, 67% white, 74% injected drugs daily) recruited via outreach and street intercept (April-September 2021).

MEASUREMENTS

Interviews explored the physical (i.e. indoor/private, outdoor/public) and social (i.e. alone, accompanied) risk environments in which drug use occurred. Guided by the principles of emergent design, we used thematic analysis to interrogate textual data, illuminating women's preferences/motivations for SDU and strategies for minimizing overdose risks when using alone.

FINDINGS

Many participants reported experiences with SDU, despite expressed preferences for accompanied drug use. SDU motivations clustered around three primary drivers: (1) avoiding opioid withdrawal, (2) preferences for privacy when using drugs and (3) safety concerns, including threats of violence. Participants nevertheless acknowledged the dangers of SDU and, at times, took steps to mitigate overdose risk, including naloxone possession, communicating to peers when using alone ('spotting') and using drugs in public spaces.

CONCLUSIONS

WWID appear to engage frequently in SDU due to constraints of the physical and social environments in which they use drugs. They express a preference for accompanied drug use in most cases and report implementing strategies to mitigate their overdose risk, especially when using drugs alone.

Difficulty accessing supervised consumption services during the COVID-19 pandemic among people who use drugs in Vancouver, Canada

BACKGROUND

The overdose crisis in Canada has worsened since the emergence of the COVID-19 pandemic. Although this trend is thought to be driven in part by closures or reduced capacity of supervised consumption services (SCS), little is known about the factors that may impede access to such services during the COVID-19 pandemic among people who use drugs. This study sought to characterize the prevalence and correlates of having difficulty accessing SCS during the COVID-19 pandemic among people who use drugs in Vancouver, Canada.

METHODS

Cross-sectional data from two open prospective cohorts of people who use drugs were collected via phone or videoconferencing interviews conducted between July 2020 and November 2020. Multivariable logistic regression analyses were used to examine factors associated with experiencing difficulty accessing SCS.

RESULTS

Among the 428 people who use drugs who participated in the study, 223 (54.7%) self-identified as men and the median age was 51 years (1st to 3rd quartile: 42-58). A total of 58 (13.6%) participants reported experiencing difficulty accessing SCS. In a multivariable analysis, factors positively associated with difficulty accessing SCS included daily crystal methamphetamine use (Adjusted odds ratio [AOR] = 2.60; 95% confidence interval [CI] 1.28-5.30), active injection drug use (AOR = 4.06; 95% CI 1.38-11.90), recent non-fatal overdose (AOR = 2.45; 95% CI 1.24-4.85), and unstable housing (AOR = 2.14; 95% CI 1.08-4.23). Age was inversely associated with the outcome (AOR = 0.96; 95% CI 0.93-0.99) in multivariable analyses. The most commonly reported reasons for experiencing difficulty accessing SCS were: COVID-19-related site closure or shortened hours (42.9%) and having to wait too long to use a site (39.3%).

CONCLUSIONS

We found that people who use drugs with markers of structural vulnerability and drug-related risk were more likely to experience difficulty accessing SCS during the COVID-19 pandemic. These findings point to the need for strategies to support access to such services as part of pandemic response efforts.

A Thematic Synthesis of the Roles of Nurses at Safer Consumption Sites

ABSTRACT

Opioid use, particularly via injection, is associated with an increased risk of infection, injury, and death. Safer consumption sites (SCSs), where people may consume previously obtained drugs under observation, have been shown to reduce these risks among people who use drugs. Most SCSs employ nurses, but there is limited research into their roles. The objective of this article is to describe and synthesize the roles of nurses at SCSs to better understand their importance in a rapidly proliferating public health intervention. We extracted data from 48 qualitative, quantitative, peer-reviewed, and gray literature, as well as primary source narrative articles on SCSs, whether they were explicitly about nursing or not. We coded each mention of nurses or nursing in each article and identified 11 descriptive themes or roles that SCS nurses carry out. From these, we identified the following three analytical themes or hypotheses about the character of these roles: (a) The primary aim of SCS nursing care is to reduce morbidity and mortality; (b) SCS nurses create a therapeutic community; and (c) SCS nurses engage in research, professional activities, and activism to better understand and promote SCSs. More research into the roles of SCS nurses is needed to better serve a vulnerable population.

Harm Reduction Services in Ottawa: The Culture of Drug Use

Between January 2016 and June 2019, there were over 13,900 apparent opioid-related deaths in Canada, solidifying the need for appropriate and effective services for people who use drugs (PWUD). Within government initiatives and policies, PWUD are often inappropriately considered a homogeneous group of individuals, with implementation of services nationally often being guided by these governmental bodies without meaningful consultation and collaboration with PWUD. However, recent harm reduction research and best practice guidelines have emphasized the importance of tailoring services to local drug scenes. Despite this, very little research on the cultural norms of PWUD exists in the literature. In an attempt to explore the local culture of drug use in Ottawa, a literature review ultimately uncovered very few articles on this topic. However, by expanding the search beyond Ottawa and using a social determinants of health framework, the factors of culture, income and social status, physical environment, and access to services were revealed as unique experiences for PWUD. Further, through four in-depth interviews with current harm reduction providers in Ottawa, the themes of (1) uncertainty and concerns surrounding the overdose crisis; (2) lack of flexibility in resources and access issues; and (3) diversity in the culture of drug use in Ottawa were explored. Recommendations surrounding partnering with PWUD, policy changes, and a safer supply were subsequently discussed. These findings helped to validate the reality of the unique drug-use culture in Ottawa, and the requirement for harm reduction services to be adapted to the local needs of PWUD.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Drug-related harm coinciding with income assistance payments: results from a community-based cohort of people who use drugs

BACKGROUND AND AIMS

Income assistance is critical to the health and wellbeing of socio-economically marginalized people who use illicit drugs (PWUD). However, past literature paradoxically identifies unintended increases in drug-related harm coinciding with synchronized payments that may magnify signals for drug use. The scope of such harm has not been fully characterized among non-institutionalized populations. This study examined socio-demographic, health and drug use-related correlates of payment-coincident drug-related harm.

DESIGN

This observational study uses data from prospective community-based longitudinal cohorts of PWUD between December 2013 and May 2018.

SETTING

Vancouver, British Columbia, Canada.

PARTICIPANTS

A total of 1604 PWUD receiving monthly income assistance. Our sample included 586 (36.5%) women, 861 (53.7%) non-white participants and 685 (42.7%) people living with HIV.

MEASUREMENTS

The primary outcome was a self-reported composite measure of drug-related harm in the past 6 months coinciding with income assistance, including higher-frequency substance use, non-fatal overdose and service barriers or interruptions. Subanalyses disaggregated this outcome.

FINDINGS

Payment-coincident drug-related harm was reported among 77.7% of participants during the study period. In multivariable models, key correlates positively and significantly associated with payment-coincident harm included: street-based income generation [adjusted odds ratio (aOR) = 1.48, 95% confidence interval (CI) = 1.26-1.74, P < 0.001], sex work (aOR = 1.66, 95% CI = 1.35-2.04, P < 0.001), illegal income generation (aOR = 1.57, 95% CI = 1.35-1.83 P < 0.001), homelessness (aOR = 1.34, 95% CI = 1.13-1.58, P < 0.001), exposure to violence (aOR = 1.31, 95% CI = 1.03-1.66, P = 0.032), daily crack cocaine use (aOR = 1.99, 95% CI = 1.59-2.50, P <  0.001), heavy alcohol use (aOR = 1.64, 95% CI = 1.37-1.97, P < 0.001) and injection drug use (aOR = 2.55, 95% CI = 2.01-3.23, P < 0.001). In subanalyses, specific harms were more likely among individuals reporting social, structural and health vulnerabilities.

CONCLUSIONS

In Vancouver, Canada, people who use illicit drugs who receive income assistance report high prevalence of payment-coincident drug-related harm, particularly people experiencing socioeconomic and structural marginalization or engaging in high-intensity drug use.

Rules and Eligibility Criteria for Supervised Consumption Services Feasibility Studies - A Scoping Review

INTRODUCTION

Supervised consumption services (SCS) reduce HIV risks and overdose for people who use drugs (PWUD) and are known to have wide-ranging public health benefits. Feasibility studies are often conducted as part of program/implementation development. We conducted a scoping review of SCS feasibility/pre-implementation studies to answer: what is known about stakeholders' opinions of SCS rules and eligibility criteria?

METHODS

Using the PRISMA-ScR guidelines, we searched Medline, PsychINFO, Embase, CINAHL, and SCOPUS databases for: (a) empirical research, (b) reported in English, (c) focused on SCS, (d) pre-implementation feasibility studies (research conducted prior to implementation of SCS in a given context), (e) examining SCS operational rules and eligibility criteria. Abstracts were reviewed to verify appropriateness; full articles/reports were retrieved; data were extracted and charted.

RESULTS

Of the 1,268 data sources identified/reviewed, 19 sources, were included. Manuscripts showed the following criteria that might be considered when determining who can and cannot use SCS: age, pregnancy status, and opioid substitution treatment status. To govern behaviours at SCS, manuscripts focused on: acceptable modes of drug consumption, assisted injections, sharing drugs on-site, pill injecting, and mandatory hand washing, etc. Stakeholders generally agreed that; eligibility restrictions and site rules should be minimal to establish low-barrier services. SCS are often forced to contend with the tension between adhering to a medical or public health model and creating low-barrier services. SCS rules are at the center of this intersection because rules and eligibility criteria implemented to mirror other health services may not align with the needs of PWUD.

CONCLUSION

Given the public health significance of SCS, establishing best practices for service delivery is critical for increasing access and addressing implementation issues. Future research should examine other operational elements of SCS, such as design elements, staffing models, and ancillary services. Additional research should also focus on supervised smoking services.

Operational and contextual barriers to accessing supervised consumption services in two Canadian cities

BACKGROUND AND AIMS

While previous scholarship has documented barriers to Supervised Consumption Services (SCS) access, little is known about how Non-SCS-users perceive available, sanctioned SCS, and how such perceptions may hinder their SCS use. The objectives of this study were to examine: 1) barriers to accessing SCS for SCS-users and Non-SCS-users; and 2) the extent to which these barriers are consistent between groups.

METHODS

We conducted semi-structured interviews with 75 PWUD in two cities in Western Canada, Edmonton and Calgary, who may or may not have accessed available SCS. Participants were recruited on the streets near SCS via traditional fieldwork and snowball sampling. We employed a generalized prompt guide and asked a range of questions about how PWUD perceived and/or experienced SCS in the area. All interviews were digitally recorded, transcribed, thematically coded, and analysed.

RESULTS

Despite PWUD's generally positive perceptions of SCS, we identified several operational barriers to SCS access, including wait times and time limits, restrictions on injection assistance, and client bans from clinics. We also identified contextual barriers, including perceptions of the 'unnecessary' use of naloxone and police surveillance. Importantly, these barriers were consistent between SCS-users and Non-SCS-users, though some SCS-users actively worked to counter contextual barriers among peers.

CONCLUSION

Operational and contextual barriers to SCS use contribute to intermittent access for existing clients and preclude SCS access for others. Addressing such barriers may increase SCS uptake, thereby further extending the well-documented and critical reach of these harm reduction initiatives.

Assisted injection within supervised injection services: Uptake and client characteristics among people who require help injecting in a Canadian setting

BACKGROUND

People who require help injecting illicit drugs experience elevated rates of a range of health-related harms, including overdose and acquisition of blood-borne pathogens. In response, some supervised injection services (SIS) in Canada have begun to permit clients to be physically injected by fellow clients or staff members. However, little is known about uptake and characteristics of clients who engage in this practice. We therefore sought to examine factors associated with receiving injection assistance at SIS among people who require help injecting drugs in Vancouver, Canada.

METHODS

Data were drawn from two community-recruited prospective cohort studies of people who inject drugs (PWID). We used multivariable generalized estimating equation (GEE) analyses with time-updated covariates to identify factors associated with self-reported receipt of injection assistance at SIS.

RESULTS

Between June 2017 and December 2018, 319 individuals who reported having recently required help injecting were included in the study. Of these, 160 (51.0%) were women and the median age was 42 years at baseline. In total, 54 (16.9%) participants reported receiving injection assistance at a SIS at least once over an average of 3.3 months of follow-up. In multivariable GEE analyses, recent homelessness (Adjusted Odds Ratio [AOR] = 2.04; 95% confidence interval [CI]: 1.13 - 3.66), fentanyl injection (AOR = 3.45; 95% CI: 1.42 - 8.41), non-fatal overdose (AOR = 1.86; 95% CI: 1.02 - 3.38) and enrolment in methadone maintenance therapy (AOR = 1.89; 95% CI: 1.03 - 3.47) were associated with increased odds of receiving injection assistance at SIS.

CONCLUSION

Although uptake of assisted injection at SIS was relatively low among this sample of people who require help injecting, this practice was associated with several indicators of structural vulnerability and drug-related risk. These findings suggest that accommodating assisted injection within SIS may be providing opportunities to engage and reduce harms among higher-risk subpopulations of PWID in this setting.

Practices of care among people who buy, use, and sell drugs in community settings

BACKGROUND

Popular perception of people who sell drugs is negative, with drug selling framed as predatory and morally reprehensible. In contrast, people who use drugs (PWUD) often describe positive perceptions of the people who sell them drugs. The "Satellite Sites" program in Toronto, Canada, provides harm reduction services in the community spaces where people gather to buy, use, and sell drugs. This program hires PWUD-who may move into and out of drug selling-as harm reduction workers. In this paper, we examine the integration of people who sell drugs directly into harm reduction service provision, and their practices of care with other PWUD in their community.

METHODS

Data collection included participant observation within the Satellite Sites over a 7-month period in 2016-2017, complemented by 20 semi-structured interviews with Satellite Site workers, clients, and program supervisors. Thematic analysis was used to examine practices of care emerging from the activities of Satellite Site workers, including those circulating around drug selling and sharing behaviors.

RESULTS

Satellite Site workers engage in a variety of practices of care with PWUD accessing their sites. Distribution of harm reduction equipment is more easily visible as a practice of care because it conforms to normative framings of care. Criminalization, coupled with negative framings of drug selling as predatory, contributes to the difficultly in examining acts of mutual aid and care that surround drug selling as practices of care. By taking seriously the importance for PWUD of procuring good quality drugs, a wider variety of practices of care are made visible. These additional practices of care include assistance in buying drugs, information on drug potency, and refusal to sell drugs that are perceived to be too strong.

CONCLUSION

Our results suggest a potential for harm reduction programs to incorporate some people who sell drugs into programming. Taking practices of care seriously may remove some barriers to integration of people who sell drugs into harm reduction programming, and assist in the development of more pertinent interventions that understand the key role of drug buying and selling within the lives of PWUD.

Help me fix: The provision of injection assistance at an unsanctioned overdose prevention site in Toronto, Canada

BACKGROUND

There is an acute public health crisis from opioid-related poisoning and overdose in Canada. The Moss Park Overdose Prevention Site (MP-OPS) - an unsanctioned overdose prevention site - opened in a downtown park in Toronto in August 2017, when no other supervised consumption services existed in the province. As an unsanctioned site, MP-OPS was not constrained by federal rules prohibiting assisted injection, and provided a unique opportunity to examine assisted injection within a supervised setting. Our objective was to examine the association between assisted injection and overdose, and whether any association between assisted injection and overdose differs according to gender.

METHODS

Drawing on data from 5657 visits to MP-OPS from October 2017 to March 2018, we used multivariable logistic regression to investigate the relationship between assisted injection and overdose. To examine the influence of gender on this relationship, we further conducted stratified analyses by gender.

RESULTS

Among 5657 visits to MP-OPS, 471 (8.3%) received assisted injection, of which 242 (51.4%) were received by women and 226 (48.0%) by men. Using multivariable logistic regression, assisted injection was not associated with overdose in the overall sample (adjusted odds ratio [aOR]1.58, 95% confidence interval [CI]: 0.94, 2.67). In gender-stratified models, women receiving assisted injection were more than twice as likely (aOR 2.23, 95% CI: 1.17, 4.27) to experience overdose than women who did not receive assisted injection, and no association between assisted injection and overdose was found among men.

CONCLUSION

Findings that women receiving assisted injecting are at higher odds of overdose within the supervised setting of the MP-OPS are consistent with previous literature on assisted injection in community settings. Rules banning assisted injection in supervised consumption services may be putting a group of people, particularly women and those injecting fentanyl, at higher risk of health harms by denying them access to a supervised space where prompt overdose response is available.

Critical studies of harm reduction: Overdose response in uncertain political times

North America continues to witness escalating rates of opioid overdose deaths. Scale-up of existing and innovative life-saving services - such as overdose prevention sites (OPS) as well as sanctioned and unsanctioned supervised consumption sites - is urgently needed. Is there a place for critical theory-informed studies of harm reduction during times of drug policy failures and overdose crisis? There are different approaches to consider from the critical literature, such as those that, for example, interrogate the basic principles of harm reduction or those that critique the lack of pleasure in the discourses surrounding drug use. Influenced by such work, we examine the development of OPS in Canada, with a focus on recent experiences from the province of Ontario, as an important example of the impacts associated with moving from grassroots harm reduction to institutionalised policy and practice. Services appear to be most innovative, dynamic, and inclusive when people with lived experience, allies, and service providers are directly responding to fast-changing drug use patterns and crises on the ground, before services become formally bureaucratised. We suggest a continuing need to both critically theorise harm reduction and to build strong community relationships in harm reduction work, in efforts to overcome political moves that impede collaboration with and inclusiveness of people who use drugs.

Supervised injection facility use and all-cause mortality among people who inject drugs in Vancouver, Canada: A cohort study

BACKGROUND

People who inject drugs (PWID) experience elevated rates of premature mortality. Although previous studies have demonstrated the role of supervised injection facilities (SIFs) in reducing various harms associated with injection drug use, including accidental overdose death, the possible impact of SIF use on all-cause mortality is unknown. Therefore, we examined the relationship between frequent SIF use and all-cause mortality among PWID in Vancouver, Canada.

METHODS AND FINDINGS

Data were derived from 2 prospective cohort studies of PWID in Vancouver, Canada, between December 2006 and June 2017. Every 6 months, participants completed questionnaires that elicited information regarding sociodemographic characteristics, substance use patterns, social-structural exposures, and use of health services including SIFs. These data were confidentially linked to the provincial vital statistics database to ascertain mortality rates and causes of death. We used multivariable extended Cox regression analyses to estimate the independent association between frequent (i.e., at least weekly) SIF use and all-cause mortality. Of 811 participants, 278 (34.3%) were women, and the median age was 39 years (IQR 33-46) at baseline. In total, 432 (53.3%) participants reported frequent SIF use at baseline, and 379 (46.7%) did not. At baseline, frequent SIF users were on average younger than nonfrequent users, and a higher proportion of frequent SIF users than nonfrequent users were unstably housed, resided in the Downtown Eastside neighbourhood, injected in public, had a recent non-fatal overdose, used prescription opioids at least daily, injected heroin at least daily, injected cocaine at least daily, and injected crystal methamphetamine at least daily. A lower proportion of frequent SIF users than nonfrequent users were HIV positive and enrolled in addiction treatment at baseline. The median duration of follow-up among study participants was 72 months (IQR 24-123). In total, 112 participants (13.8%) died during the study period, yielding a crude mortality rate of 22.7 (95% CI 18.7-27.4) deaths per 1,000 person-years. The median years of potential life lost per death was 34 (IQR 27-42) years. In a time-updated multivariable model, frequent SIF use was inversely associated with risk of all-cause mortality after adjusting for potential confounders, including age, sex, HIV seropositivity, unstable housing, at least daily cocaine injection, public injection, incarceration, enrolment in addiction treatment, and calendar year of interview (adjusted hazard ratio 0.46, 95% CI 0.26-0.80, p = 0.006). The main study limitations are the limited generalizability of findings due to non-random sampling, the potential for reporting biases due to reliance on some self-reported information, and the possibility that residual confounding influenced findings.

CONCLUSIONS

We observed a high burden of premature mortality among a community-recruited cohort of PWID. Frequent SIF use was associated with a lower risk of death, independent of relevant confounders. These findings support efforts to enhance access to SIFs as a strategy to reduce mortality among PWID. Further analyses of individual-level data are needed to determine estimates of, and potential causal pathways underlying, associations between SIF use and specific causes of death.

Supervised Injection Facility Utilization Patterns: A Prospective Cohort Study in Vancouver, Canada

INTRODUCTION

Although the health and community benefits of supervised injection facilities are well documented, little is known about long-term patterns of utilization of this form of health service. The present study seeks to longitudinally characterize discontinuation of use of a supervised injection facility in Vancouver, Canada.

METHODS

Data were drawn from 2 community-recruited prospective cohorts of people who inject drugs between December 2005 and December 2016. In 2018, extended Cox regression for recurrent events was used to examine factors associated with time to cessation of supervised injection facility use during periods of active injection.

RESULTS

Of 1,336 people who inject drugs that were followed for a median of 50 months, 847 (63.4%) participants reported 1,663 6-month periods of supervised injection facility use cessation while actively injecting drugs (incidence density of 26.6 events per 100 person-years). An additional 2,282 (57.8%) of the total 3,945 6-month periods of supervised injection facility use cessation occurred during periods of injection cessation. In multivariable analyses, enrollment in methadone maintenance therapy (adjusted hazard ratio=1.41) and HIV seropositivity (adjusted hazard ratio=1.23) were positively associated with supervised injection facility use cessation during periods of active injection, whereas homelessness (adjusted hazard ratio=0.59), at least daily heroin injection (adjusted hazard ratio=0.70), binge injection (adjusted hazard ratio=0.68), public injection (adjusted hazard ratio=0.67), nonfatal overdose (adjusted hazard ratio=0.73), difficulty accessing addiction treatment (adjusted hazard ratio=0.69), and incarceration (adjusted hazard ratio=0.70) were inversely associated with this outcome (all p<0.05). The most commonly reported reasons for supervised injection facility use cessation were injection drug use cessation (42.3%) and a preference for injecting at home (30.7%).

CONCLUSIONS

These findings suggest that this supervised injection facility successfully retains people who inject drugs at elevated risk of drug-related harms and indicate that many supervised injection facility clients neither use this service nor inject drugs perpetually.

Drug consumption rooms: A systematic review of evaluation methodologies

ISSUES

Drug consumptions rooms (DCR) and supervised injecting facilities (SIF) are expanding internationally. Previous reviews have not systematically addressed evaluation methodologies.

APPROACH

Results from systematic searches of scientific databases in English until June 2017 were coded for paper type, country and year of publication. For evaluation papers, study outcome, methodology/study design and main indicators of DCR/SIF 'exposure' were recorded.

KEY FINDINGS

Two hundred and nineteen eligible peer-reviewed papers were published since 1999: the majority from Canada (n = 117 papers), Europe (n = 36) and Australia (n = 32). Fifty-six papers reported evaluation outcomes. Ecological study designs (n = 10) were used to assess the impact on overdose, public nuisance and crime; modelling techniques (n = 6) estimated impact on blood-borne diseases, overdose deaths and costs. Papers using individual-level data included four prospective cohorts (n = 28), cross-sectional surveys (n = 7) and service records (n = 5). Individual-level data were used to assess safer injecting practice, uptake into health and social services and all the other above outcomes except for impact on crime and costs. Four different indicators of DCR/SIF attendance were used to measure service 'exposure'.

IMPLICATIONS

Research around DCRs/SIFs has used ecological, modelling, cross-sectional and cohort study designs. Further research could involve systematic inclusion of a control group of people who are eligible but do not access SIFs, validation of self-reported proportion of injections at SIFs or a stepped-wedge or a cluster trial comparing localities.

CONCLUSIONS

Methodologies appropriate for DCR/SIF evaluation have been established and can be readily replicated from the existing literature. Research on operational aspects, implementation and transferability is also warranted.

A systematic review of stakeholder perceptions of supervised injection facilities

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

An age-based analysis of nonmedical prescription opioid use among people who use illegal drugs in Vancouver, Canada

BACKGROUND

Nonmedical prescription opioid use (NMPOU) is a serious public health problem in North America. At a population-level, previous research has identified differences in the prevalence and correlates of NMPOU among younger versus older age groups; however, less is known about age-related differences in NMPOU among people who use illegal drugs.

METHODS

Data were collected between 2013 and 2015 from two linked prospective cohort studies in Vancouver, Canada: the At-Risk Youth Study (ARYS) and the Vancouver Injection Drug Users Study (VIDUS). Factors independently associated with NMPOU among younger (ARYS) and older (VIDUS) participants were examined separately using bivariate and multivariate generalized estimating equations.

RESULTS

A total of 1162 participants were included. Among 405 eligible younger participants (Median age = 25; Inter-Quartile Range [IQR]: 22-28), 40% (n = 160) reported engaging in NMPOU at baseline; among 757 older participants (Median age = 48, IQR: 40-55), 35% (n = 262) reported engaging in NMPOU at baseline. In separate multivariate analyses of younger and older participants, NMPOU was positively and independently associated with heroin use (younger: Adjusted Odds Ratio [AOR] = 3.12, 95% Confidence Interval [CI]: 2.08-4.68; older: AOR = 2.79, 95% CI: 2.08-3.74), drug dealing (younger: AOR = 2.22, 95% CI: 1.58-3.13; older: AOR = 1.87, 95% CI: 1.40-2.49), and difficulty accessing services (younger: AOR = 1.47, 95% CI: 1.04-2.09; older: AOR = 1.74, 95% CI: 1.32-2.29). Among the youth cohort only, NMPOU was associated with younger age (AOR = 1.12, 95% CI: 1.05-1.19), crack use (AOR = 1.56, 95% CI: 1.06-2.30), and binge drug use (AOR = 1.41, 95% CI: 1.00-1.97); older participants who engaged in NMPOU were more likely to report crystal methamphetamine use (AOR = 1.97, 95% CI: 1.46-2.66), non-fatal overdose (AOR = 1.76, 95% CI: 1.20-2.60) and sex work (AOR = 1.49, 95% CI: 1.00-2.22).

DISCUSSION

The prevalence of NMPOU is similar among younger and older people who use drugs, and independently associated with markers of vulnerability among both age groups. Adults who engage in NMPOU are at risk for non-fatal overdose, which highlights the need for youth and adult-specific strategies to address NMPOU that include better access to health and social services, as well as a range of addiction treatment options for opioid use. Findings also underscore the importance of improving pain treatment strategies tailored for PWUD.

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.

'Enjoying the kick': Locating pleasure within the drug consumption room

BACKGROUND

Harm reduction policy and praxis has long struggled to accommodate the pleasures of alcohol and other drug use. Whilst scholars have consistently highlighted this struggle, how pleasure might come to practically inform the design and delivery of harm reduction policies and programs remains less clear. The present paper seeks to move beyond conceptual critiques of harm reduction's 'pleasure oversight' to more focused empirical analysis of how flows of pleasure emerge, circulate and, importantly, may be reoriented in the course of harm reduction practice.

METHODS

We ground our analysis in the context of detailed ethnographic research in a drug consumption room in Frankfurt, Germany. Drawing on recent strands of post-humanist thought, the paper deploys the concept of the 'consumption event' to uncover the manner in which these facilities mediate the practice and embodied experience of drug use and incite or limit bodily potentials for intoxication and pleasure.

RESULTS

Through the analysis, we mapped a diversity of pleasures as they emerged and circulated through events of consumption at the consumption room. Beyond the pleasurable intensities of intoxication's kick, these pleasures were expressed in a range of novel capacities, practices and drug using bodies. In each instance, pleasure could not be reduced to a simple, linear product of drug use. Rather, it arose for our participants through distinctive social and affective transformations enabled through events of consumption at the consumption room and the generative force of actors and associations of which these events were composed.

CONCLUSION

Our research suggests that the drug consumption room serves as a conduit through which its clients can potentially enact more pleasurable, productive and positive relations to both themselves and their drug use. Acknowledging the centrality of pleasure to client engagement with these facilities, the paper concludes by drawing out the implications of these findings for the design and delivery of consumption room services.

Why are some people who have received overdose education and naloxone reticent to call Emergency Medical Services in the event of overdose?

BACKGROUND

Overdose Education and Naloxone Distribution (OEND) training for persons who inject drugs (PWID) underlines the importance of summoning emergency medical services (EMS). To encourage PWID to do so, Colorado enacted a Good Samaritan law providing limited immunity from prosecution for possession of a controlled substance and/or drug paraphernalia to the overdose victim and the witnesses who in good faith provide emergency assistance. This paper examines the law's influence by describing OEND trained PWIDs' experience reversing overdoses and their decision about calling for EMS support.

METHODS

Findings from two complementary studies, a qualitative study based on semi-structured interviews with OEND trained PWID who had reversed one or more overdoses, and an on-going fieldwork-based project examining PWIDs' self-identified health concerns were triangulated to describe and explain participants' decision to call for EMS.

RESULTS

In most overdose reversals described, no EMS call was made. Participants reported several reasons for not doing so. Most frequent was the fear that despite the Good Samaritan law, a police response would result in arrest of the victim and/or witness for outstanding warrants, or sentence violations. Fears were based on individual and collective experience, and reinforced by the city of Denver's aggressive approach to managing homelessness through increased enforcement of misdemeanors and the imposition of more recent ordinances, including a camping ban, to control space. The city's homeless crisis was reflected as well in the concern expressed by housed PWID that an EMS intervention would jeopardize their public housing.

CONCLUSION

Results suggest that the immunity provided by the Good Samaritan law does not address PWIDs' fear that their current legal status as well as the victim's will result in arrest and incarceration. As currently conceived, the Good Samaritan law does not provide immunity for PWIDs' already enmeshed in the criminal justice system, or PWID fearful of losing their housing.

Supervised injection facilities in Canada: past, present, and future

Canada has long contended with harms arising from injection drug use. In response to epidemics of HIV infection and overdose in Vancouver in the mid-1990s, a range of actors advocated for the creation of supervised injection facilities (SIFs), and after several unsanctioned SIFs operated briefly and closed, Canada’s first sanctioned SIF opened in 2003. However, while a large body of evidence highlights the successes of this SIF in reducing the health and social harms associated with injection drug use, extraordinary efforts were needed to preserve it, and continued activism by local people who inject drugs (PWID) and healthcare providers was needed to promote further innovation and address gaps in SIF service delivery. A growing acceptance of SIFs and increasing concern about overdose have since prompted a rapid escalation in efforts to establish SIFs in cities across Canada. While much progress has been made in that regard, there is a pressing need to create a more enabling environment for SIFs through amendment of federal legislation. Further innovation in SIF programming should also be encouraged through the creation of SIFs that accommodate assisted injecting, the inhalation of drugs. As well, peer-run, mobile, and hospital-based SIFs also constitute next steps needed to optimize the impact of this form of harm reduction intervention.

Increased drug use and the timing of social assistance receipt among people who use illicit drugs

BACKGROUND

The monthly disbursement of social assistance (SA) payments to people who use illicit drugs (PWUD) has been temporally associated with increases in drug-related harm. Yet, whether SA receipt changes drug use intensity compared to levels of use at other times in the month has not been established. We therefore examined this relationship among PWUD in Vancouver, Canada (2005-2013).

METHODS

Data were derived from prospective cohorts of HIV-positive and HIV-negative PWUD. Every six months, participants were asked about their illicit drug use during the last 180 days and the past week. We determined whether SA receipt occurred within the assessment's one-week recall period. We employed generalized estimating equations controlling for confounders to examine the relationship between SA receipt and the change in drug use intensity, defined as a 100% increase in the average times per day a given drug was used in the last week compared to the previous 6 months. We tested the robustness of this relationship by stratifying analyses by whether individuals primarily used stimulants, illicit opioids or engaged in polydrug use and examining the timing of SA receipt relative to date of assessment.

RESULTS

Our study included 2661 individuals (median age 36, 32% female) with 1415 (53.2%) reporting SA receipt occurring within the one-week recall period of the assessment at least once. SA receipt was independently associated with intensified drug use (Adjusted Odds Ratio [AOR]: 1.79; 95% Confidence Interval [CI]: 1.53, 2.09), and remained significant when stratified by primary use of stimulants (AOR: 1.87; 95% CI: 1.54, 2.26), opioids (AOR: 1.96; 95% CI: 1.23, 3.13) and polydrug use (AOR: 1.53; 95% CI: 1.11, 2.10).

CONCLUSION

We found a temporal association between SA receipt and drug use intensification. While the health and social benefits of SA are significant, these findings suggest that alternative disbursement strategies, such as staggered or smaller and more frequent SA payments may be able to mitigate drug-related harm. Alternatives should be tested rigorously.

Protocol of the impact of alternative social assistance disbursement on drug-related harm (TASA) study: a randomized controlled trial to evaluate changes to payment timing and frequency among people who use illicit drugs

Background

Government social assistance payments seek to alleviate poverty and address survival needs, but their monthly disbursement may cue increases in illicit drug use. This cue may be magnified when assistance is disbursed simultaneously across the population. Synchronized payments have been linked to escalations in drug use and unintended but severe drug-related harms, including overdose, as well as spikes in demand for health, social, financial and police services.

Methods/design

The TASA study examines whether changing payment timing and frequency can mitigate drug-related harm associated with synchronized social assistance disbursement. The study is a parallel arm multi-group randomized controlled trial in which 273 participants are randomly allocated for six assistance cycles to a control or one of two intervention arms on a 1:1:1 basis. Intervention arm participants receive their payments: (1) monthly; or (2) semi-monthly, in each case on days that are not during the week when cheques are normally issued. The study partners with a community-based credit union that has developed a system to vary social assistance payment timing. The primary outcome is a 40 % increase in drug use during the 3 days beginning with cheque issue day compared to other days of the month. Bi-weekly follow-up interviews collect participant information on this and secondary outcomes of interest, including drug-related harm (e.g. non-fatal overdose), exposure to violence and health service utilization. Self-reported data will be supplemented with participant information from health, financial, police and government administrative databases. A longitudinal, nested, qualitative parallel process evaluation explores participant experiences, and a cost-effectiveness evaluation of different disbursement scenarios will be undertaken. Outcomes will be compared between control and intervention arms to identify the impacts of alternative disbursement schedules on drug-related harm resulting from synchronized income assistance.

Discussion

This structural RCT benefits from strong community partnerships, highly detailed outcome measurement, robust methods of randomization and data triangulation with third party administrative databases. The study will provide evidence regarding the potential importance of social assistance program design as a lever to support population health outcomes and service provision for populations with a high prevalence of substance use.

Trial registration

NCT02457949 Registered 13 May 2015.

Illicit drug overdose deaths resulting from income assistance payments: Analysis of the 'check effect' using daily mortality data

BACKGROUND

Although income assistance is an important source of support for low income individuals, there is evidence that adverse outcomes may increase when payments are disbursed on the same day for all recipients. The objective of this study was to assess the temporal patterns and causal relation between population-level illicit drug overdose deaths and income assistance payments using daily mortality data for British Columbia over a period of five years.

METHODS

Retrospective data on daily mortality due to illicit drug overdose, 2009-2013, were provided by the BC Coroners Service. These data were analyzed using regression models and time series tests for causality in relation to dates of income assistance payments.

RESULTS

1343 deaths due to illicit drug overdose were reported in BC during 2009-2013; 394 occurred during cheque weeks (n=60) and 949 occurred during non-cheque weeks (n=202). Average weekly mortality due to illicit drug overdose was 40% higher during weeks of income assistance payments compared to weeks without payments (P<0.001). Consistent increases in mortality appeared the day after cheque disbursement and were significantly higher for two days, and marginally higher after 3 days, even when controlling for other temporal trends. Granger causality testing suggests the timing of cheque issue was causally linked to increased drug overdose mortality (P<0.001).

CONCLUSIONS

Our findings clarify the temporal relation and causal impact of income assistance payments on illicit drug deaths. We estimate 77 avoidable deaths were attributable to the synchronized disbursement of income assistance cheques over the five year period. An important consideration is whether varying the timing of payments among recipients could reduce this excess mortality and the related demands on health and social services.

Supportive housing and surveillance

Urban centres in the US, Britain and Canada have responded to identified visible 'social problems' such addiction, mental health and homelessness by providing some supportive housing for the urban poor and marginalized. While some critics have questioned what supportive housing specifically entails in terms of the built environment, what remains under explored, though a growing area of concern, is the relationship between surveillance and supportive housing for urban residents identified as having addiction and mental health problems - a gap addressed in this paper. Drawing upon qualitative ethnographic observational data we examine some of the measures of control and coercion that are encroaching into social housing primarily established for poor and marginalized people with addiction and mental health problems in the urban centre of Vancouver, Canada. We witnessed three modes of regulation and control, that vary widely, among the residencies observed: physical surveillance technologies; site-specific modes of coercion; police presence and staff surveillance, which all together impact the everyday lives of residents living in low-income and supportive housing. We argue that supportive housing has the potential to provide its intended commitment - safe and secure affordable housing. However, owing to an (over)emphasis on 'security', the supportive housing we observed were also sites of social control.

High Prevalence of Assisted Injection Among Street-Involved Youth in a Canadian Setting

Many people who inject illicit drugs receive manual assistance when injecting, and this practice has been linked to increased risk of HIV infection and other harms. Little is known, however, about this practice among youth. This study uses a multivariate generalized estimating equation to identify factors associated with receiving assistance with injecting among a cohort of street-involved youth aged 14-26 in Vancouver, Canada. A total of 253 participants reported injecting drugs during the study period, and 49 % (n = 125) of these youth reported receiving assistance with injecting in the past 6 months. In multivariate analysis, younger age, female gender, binge drug use, heroin injecting, cocaine injecting, crystal methamphetamine injecting, and syringe sharing were positively and independently associated with assisted injection (all p < 0.05). These findings underscore the need for expanding substance abuse treatment alongside HIV prevention and health promotion interventions to empower youth to enact safer injection practices.

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.

Self-care and risk reduction habits in older injection drug users with chronic wounds: a cross-sectional study

Background

We surveyed a population of injection drug users (IDUs) frequenting the mobile Baltimore City Needle Exchange Program (BNEP) to investigate self-care factors associated with chronic wounds, a significant cause of morbidity especially among older IDUs.

Methods

Participants ≥18 years old completed a survey regarding chronic wounds (duration ≥8 weeks), injection and hygiene practices. Study staff visually verified the presence of wounds. Participants were categorized into four groups by age and wound status. Factors associated with the presence of chronic wounds in participants ≥45 years were analyzed using logistic regression.

Results

Of the 152 participants, 19.7% had a chronic wound. Of those with chronic wounds, 18 were ≥45 years old (60.0%). Individuals ≥45 years old with chronic wounds were more likely to be enrolled in a drug treatment program (Odds ratio (OR) 3.4, 95% Confidence interval (CI) 1.0–10.8) and less likely to use cigarette filters when drawing up prepared drug (OR 0.2, 95% CI 0.03–0.7) compared to the same age group without chronic wounds. Compared to individuals <45 years old without chronic wounds, individuals ≥45 with a chronic wound were more likely to report cleaning reused needles with bleach (OR 10.7, 95% CI 1.2–93.9) and to use the clinic, rather than an emergency room, as a primary source of medical care (OR 3.4, 95% CI 1.1–10.4).

Conclusions

Older IDUs with chronic wounds have different, and perhaps less risky, injection and hygiene behaviors than their peers and younger IDUs without wounds in Baltimore City. Because of these differences, older IDUs with wounds may be more receptive to community-based healthcare and substance abuse treatment messages.

'Safer environment interventions': a qualitative synthesis of the experiences and perceptions of people who inject drugs

There is growing acknowledgment that social, structural, and environmental forces produce vulnerability to health harms among people who inject drugs (PWID), and safer environment interventions (SEI) have been identified as critical to mitigating the impacts of these contextual forces on drug-related harm. To date, however, SEIs have been under-theorized in the literature, and how they minimize drug-related risks across intervention types and settings has not been adequately examined. This article presents findings from a systematic review and meta-synthesis of qualitative studies reporting PWID's experiences with three types of SEIs (syringe exchange programmes, supervised injection facilities and peer-based harm reduction interventions) published between 1997 and 2012. This meta-synthesis sought to develop a comprehensive understanding of SEIs informed by the experiences of PWID. Twenty-nine papers representing twenty-one unique studies that included an aggregate of more than 800 PWID were included in this meta-synthesis. This meta-synthesis found that SEIs fostered social and physical environments that mitigated drug-related harms and increased access to social and material resources. Specifically, SEIs: (1) provided refuge from street-based drug scenes; (2) enabled safer injecting by reshaping the social and environmental contexts of injection drug use; (3) mediated access to resources and health care services; and, (4) were constrained by drug prohibition and law enforcement activities. These findings indicate that it is critical to situate SEIs in relation to the lived experiences of PWID, and in particular provide broader environmental support to PWID. Given that existing drug laws limit the effectiveness of interventions, drug policy reforms are needed to enable public health, and specifically SEIs, to occupy a more prominent role in the response to injection drug use.

"People knew they could come here to get help": an ethnographic study of assisted injection practices at a peer-run 'unsanctioned' supervised drug consumption room in a Canadian setting

People who require help injecting are disproportionately vulnerable to drug-related harm, including HIV transmission. North America's only sanctioned SIF operates in Vancouver, Canada under an exemption to federal drug laws, which imposes operating regulations prohibiting assisted injections. In response, the Vancouver Area Network of Drug Users (VANDU) launched a peer-run unsanctioned SIF in which trained peer volunteers provide assisted injections to increase the coverage of supervised injection services and minimize drug-related harm. We undertook qualitative interviews (n = 23) and ethnographic observation (50 h) to explore how this facility shaped assisted injection practices. Findings indicated that VANDU reshaped the social, structural, and spatial contexts of assisted injection practices in a manner that minimized HIV and other health risks, while allowing people who require help injecting to escape drug scene violence. Findings underscore the need for changes to regulatory frameworks governing SIFs to ensure that they accommodate people who require help injecting.

A qualitative study of the perceived effects of blue lights in washrooms on people who use injection drugs

Background

Blue lights are sometimes placed in public washrooms to discourage injection drug use. Their effectiveness has been questioned and concerns raised that they are harmful but formal research on the issue is limited to a single study. We gathered perceptions of people who use injection drugs on the effects of blue lights with the aim of informing harm reduction practice.

Methods

We interviewed 18 people in two Canadian cities who currently or previously used injection drugs to better understand their perceptions of the rationale for and consequences of blue lights in public washrooms.

Results

Participants described a preference for private places to use injection drugs, but explained that the need for an immediate solution would often override other considerations. While public washrooms were in many cases not preferred, their accessibility and relative privacy appear to make them reasonable compromises in situations involving urgent injecting. Participants understood the aim of blue lights to be to deter drug use. The majority had attempted to inject in a blue-lit washroom. While there was general agreement that blue lights do make injecting more difficult, a small number of participants were entirely undeterred by them, and half would use a blue-lit washroom if they needed somewhere to inject urgently. Participants perceived that, by making veins less visible, blue lights make injecting more dangerous. By dispersing public injection drug use to places where it is more visible, they also make it more stigmatizing. Despite recognizing these harms, more than half of the participants were not opposed to the continued use of blue lights.

Conclusions

Blue lights are unlikely to deter injection drugs use in public washrooms, and may increase drug use-related harms. Despite recognizing these negative effects, people who use injection drugs may be reluctant to advocate against their use. We attempt to reconcile this apparent contradiction by interpreting blue lights as a form of symbolic violence and suggest a parallel with other emancipatory movements for inspiration in advocating against this and other oppressive interventions.

Assisted injection among people who inject drugs in Thailand

Background

Assisted injection is common among people who inject drugs (IDU), and has been associated with elevated risk for HIV infection and overdose. However, this practice has not been explored in the Asian context, including in Thailand, where HIV prevalence among IDU remains high.

Methods

Using multivariate logistic regression, we examined the prevalence and correlates of assisted injecting among IDU participating in the Mitsampan Community Research Project in Bangkok. We also sought to identify reasons for engaging in assisted injecting and those who provide this form of assistance.

Results

In total, 430 IDU participated in this study, including 376 (87.5%) who reported having ever required assistance injecting, and 81 (18.8%) who reported assisted injecting in the previous six months. In multivariate analyses, assisted injecting in the previous six months was independently and positively associated with being female (adjusted odds ratio [AOR] = 2.42; 95% confidence interval [CI]: 1.40 – 4.18), being a weekly heroin injector (AOR = 1.78; 95% CI: 0.99 – 3.20), syringe sharing (AOR = 2.08; 95% CI: 1.18 – 3.68) and soft-tissue infection (AOR = 3.51; 95% CI: 1.43 – 2.53). Having a longer injecting career (AOR = 0.96; 95% CI: 0.94 – 0.99) was negatively associated with assisted injecting. Primary reasons given for engaging in assisted injecting included being new to injecting and lacking knowledge on how to inject. The most common providers of assistance with injecting were close friends.

Conclusion

We found a high prevalence of assisted injecting among IDU in Bangkok, with females, frequent heroin injectors, those with shorter injecting careers being more likely to engage in this practice. Those who require help with the injecting process are more likely to share syringes, and have skin infections. These findings indicate the need for interventions focused on promoting safer and self-administered injections.

Health care among street-involved women: the perpetuation of health inequity

I present the findings from a study that explored the experiences and decision making of street-involved women navigating the health care system. Data were drawn from a larger qualitative study situated in a western Canadian inner-city neighborhood that examined the health-management strategies of street-involved women with a history of crack cocaine use. Data were collected over a 17-month period and included ethnographic methods of participant observation, group interviews (n = 57), and in-depth interviews (n = 10). Inductive thematic analysis derived two major themes: power and punishment, and organization and delivery of care. The themes illustrate how women's experiences and decision making were located within a nexus of power relations that operated across women's shared social location as downtown eastsiders. Implications of the findings are discussed in relation to supporting women's efforts and improving health outcomes.

'It's more about the heroin': injection drug users' response to an overdose warning campaign in a Canadian setting

AIMS

To assess heroin injectors' perceptions of and responses to a warning issued by public health officials regarding high-potency heroin and increases in fatal overdoses.

DESIGN

Semi-structured qualitative interviews.

SETTING

Vancouver, Canada.

PARTICIPANTS

Eighteen active heroin injectors.

MEASUREMENTS

Semi-structured interview guide focussing on heroin injectors' perceptions of and responses to the overdose warning, including reasons for failing to adhere to risk reduction recommendations.

FINDINGS

Although nearly all participants were aware of the warning, their recollections of the message and the timing of its release were obscured by on-going social interactions within the drug scene focussed on heroin quality. Many injection drug users reported seeking the high potency heroin and nearly all reported no change in overdose risk behaviours. Responses to the warning were shaped by various social, economic and structural forces that interacted with individual behaviour and undermined efforts to promote behavioural change, including sales tactics employed by dealers, poverty, the high cost and shifting quality of available heroin, and risks associated with income-generating activities. Individual-level factors, including emotional suffering, withdrawal, entrenched injecting routines, perceived invincibility and the desire for intense intoxication also undermined risk reduction messages.

CONCLUSIONS

Among heroin injectors in British Columbia, a 2011 overdose warning campaign appeared to be of limited effectiveness and also produced unintended negative consequences that exacerbated overdose risk.

Prospects for scaling-up supervised injection facilities in Canada: the role of evidence in legal and political decision-making

BACKGROUND

North America's first supervised injection facility-Insite-opened in Vancouver in 2003 under a special federal legal exemption. Insite has faced significant political and legal opposition, which culminated in a recent Supreme Court of Canada ruling that ordered the federal Minister of Health to extend the facility's exemption and cited evidence that the facility is life-preserving and does not increase public disorder. Officials in several other cities have initiated or accelerated preparations for new facilities due to speculation that the ruling provides sufficient legal basis to expand supervised injection in Canada. However, a comprehensive assessment of the barriers and facilitators to supervised injection facility scale-up is lacking.

METHODS

This policy case study reviews a corpus of jurisprudence, legislation, scientific research and media texts to: describe the role of evidence in legal and political decision-making around Insite; analyze the implications of the Insite decision for new facilities; and discuss alternative avenues for supervised injection facility expansion.

RESULTS

The Insite decision does not simplify the path towards new supervised injection facilities, but nor does it does pose an insurmountable hurdle. Whether new facilities will be established depends largely upon how the Minister of Health interprets the ruling, the proponents' ability to demonstrate need and support from municipal and provincial governments and community members. Formally defining supervised injection as within nurses' scope of practice could further efforts to establish new facilities.

CONCLUSION

Additional court action may be required to establish a stable legal and policy basis for supervised injection facilities in Canada.

Design considerations for supervised consumption facilities (SCFs): preferences for facilities where people can inject and smoke drugs

BACKGROUND

Supervised consumption facilities (SCFs) aim to improve the health and well-being of people who use drugs by offering safer and more hygienic alternatives to the risk environments where people typically use drugs in the community. People who smoke crack cocaine may be willing to use supervised smoking facilities (SSFs), but their facility design preferences and the views of other stakeholders have not been previously investigated in detail.

METHODS

We consulted with people who use drugs and other stakeholders including police, fire and ambulance service personnel, other city employees and city officials, healthcare providers, residents, and business owners (N = 236) in two Canadian cities without SCFs and asked how facilities ought to be designed. All consultations were audio-recorded and transcribed. Thematic analyses were used to describe the knowledge and opinions of stakeholders.

RESULTS

People who use drugs see SSFs as offering public health and safety benefits, while other stakeholders were more sceptical about the need for SSFs. People who use drugs provided insights into how a facility might be designed to accommodate supervised injection and supervised smoking. Their strongest preference would allow both methods of drug use within the same facility with some form of physical separation between the two based on different highs, comfort regarding exposure to different methods of drug administration, and concerns about behaviours often associated with smoking crack cocaine. Other stakeholders raised a number of SSF implementation challenges worthy of consideration.

CONCLUSION

Decision-makers in cities considering SCF or SSF implementation should consider the opinions and preferences of potential clients to ensure that facilities will attract, retain, and engage people who use drugs.