Assisted injection in outdoor venues: an observational study of risks and implications for service delivery and harm reduction programming

Characterizing Use of Supervised Consumption Services among Street-involved Youth and Young Adults in the Context of an Overdose Crisis

In response to an increase in overdose deaths, there was a rapid scale-up of supervised consumption services (SCS), including federally sanctioned SCS and low-barrier SCS known as overdose prevention sites (OPS), in Vancouver, Canada, beginning in December 2016. However, little is known about the use of such services among adolescents and young adults (AYA) in this context. We therefore sought to characterize factors associated with the use of federally sanctioned SCS and OPS among street-involved AYA who inject drugs in Vancouver during an overdose crisis. From December 2016 to March 2020, data were collected from a prospective cohort of street-involved AYA aged 14 to 26 at baseline. Using multivariable generalized estimating equation analyses, we identified factors associated with recent use of federally sanctioned SCS and OPS, respectively. Among 298 AYA who inject drugs, 172 (57.8%) and 149 (50.0%) reported using federally sanctioned SCS and OPS during the study period, respectively. In multivariable analyses, public injecting, negative police interactions, and residing or spending time ≥ weekly in the Downtown Eastside neighborhood were all positively associated with the use of federally sanctioned SCS and OPS, respectively. Additionally, ≥ daily unregulated opioid use and residential eviction were positively associated with federally sanctioned SCS use, while requiring help injecting was inversely associated. Self-identified female or non-binary gender was also positively associated with OPS use (all p < 0.05). Both federally sanctioned SCS and OPS successfully engaged AYA at heightened risk of adverse health outcomes. However, the lack of accommodation of AYA who require manual assistance with injecting at federally sanctioned SCS may be inhibiting service engagement.

Requiring help injecting among people who inject drugs in Toronto, Canada: Characterising the need to address sociodemographic disparities and substance-use specific patterns

INTRODUCTION

Those requiring help injecting are at an elevated risk of injection-related injury and blood-borne infections and are thus a priority group for harm reduction programs. As supervised consumption services (SCS) are scaled-up across Canada, information on those who require help injecting is necessary to inform equitable service uptake. We characterised the sociodemographic, structural and drug use correlates of needing help injecting among a cohort of people who inject drugs in Toronto, Canada.

METHODS

A cross-sectional baseline survey was administered between November 2018 and March 2020. Unadjusted and multivariable logistic regression models examined associations with requiring help injecting in the past 6 months. A gender-stratified sub-analysis described characteristics of receiving help among those requiring it.

RESULTS

Of 701 participants (31.0% cisgender women), 294 (41.9%) needed recent help injecting. In unadjusted analyses, being a racialised, non-Indigenous person (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.13-2.86) or a cisgender woman (OR 1.72, 95% CI 1.24-2.39) were associated with needing help. In multivariable analyses, requiring assistance was associated with needing frequent help preparing drugs (adjusted OR [AOR] 9.52, 95% CI 4.78-21.28), fewer years since first injection (AOR for 1 year increase: 0.97, 95% CI 0.95-0.99) and injecting stimulants. Among those who required help, cisgender women reported needing assistance more often than cisgender men (P = 0.009).

DISCUSSION AND CONCLUSIONS

Over two-fifths of the sample required help injecting; requiring assistance was associated with sociodemographic indicators and substance use-specific patterns. Findings highlight the need to scale-up educational resources for those who receive or provide help injecting, as well as SCS that accommodate onsite injection assistance.

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.

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.

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.

Employment Cessation, Long Term Labour Market Engagement and HIV Infection Risk Among People Who Inject Drugs in an Urban Canadian Setting

The potential for changes in socio-economic status, such as employment exits, to increase HIV infection risk are not well examined among people who inject illicit drugs (PWID). We used longstanding cohort data from Vancouver, Canada, to longitudinally assess associations between employment cessation and outcomes with documented linkages to HIV infection risk among PWID. From 2005 to 2015, 1222 participants reported 1154 employment exits. Employment exits were significantly associated with transitions into unstable housing; moving to the inner-city; initiating informal, prohibited or illegal income generation; high risk drug use practices; and exiting methadone maintenance therapy. HIV infection rates were higher among participants with lower long-term labour market engagement. These findings suggest that employment cessation coincides with initiating exposure to aspects of socioeconomic marginalization and drug use associated with HIV infection risk. Support for employment retention that prevents poverty entrenchment and harmful drug use could contribute to HIV prevention measures for PWID.

Activism and scientific research: 20 years of community action by the Vancouver area network of drug users

Background

Over the past several decades, there have been numerous peer-reviewed articles written about people who use drugs (PWUDs) from the Downtown Eastside neighborhood of Vancouver, Canada. While individual researchers have engaged and acknowledged this population as participants and community partners in their work, there has been comparatively little attention given to the role of PWUDs and drug user organizations in directing, influencing, and shaping research agendas.

Methods

In this community-driven research, we examine 20 years of peer-reviewed studies, university theses, books, and reports that have been directed, influenced, and shaped by members of the activist organization the Vancouver Area Network of Drug Users (VANDU). In this paper, we have summarized VANDU’s work based on different themes from each article.

Results

After applying the inclusion criteria to over 400 articles, 59 items containing peer-reviewed studies, books, and reports were included and three themes of topics researched or discussed were identified. Theme 1: ‘health needs’ of marginalized groups was found in 39% of articles, Theme 2: ‘evaluation of projects’ related to harm reduction in 19%, and Theme 3: ‘activism’ related work in 42%. Ninety-four percent of co-authors were from British Columbia and 44% of research was qualitative. Works that have been co-authored by VANDU’s members or acknowledged their participations created 628 citations. Moreover, their work has been accessed more than 149,600 times.

Conclusions

Peer-based, democratic harm reduction organizations are important partners in facilitating groundbreaking health and social research, and through research can advocate for the improved health and wellbeing of PWUDs and other marginalized groups in their community. This article also recommends that PWUDs should be more respectfully engaged and given appropriate credit for their contributions.

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.

Declining trends in the rates of assisted injecting: a prospective cohort study

Background

Assisted injecting has been associated with increased risk of blood-borne infections, overdose, and other harms among people who inject drugs (PWID), particularly women. Given the changing availability of relevant harm reduction interventions in Vancouver, Canada, in recent years, we conducted a gender-based analysis to examine changes in rates and correlates of assisted injecting over time among active PWID.

Methods

Using data from a prospective cohort of PWID in Vancouver, we employed gender-stratified multivariable generalized estimating equations to examine trends in assisted injecting and identify the correlates during two periods: June 2006–November 2009 and December 2009–May 2014.

Results

Among 1119 participants, 376 (33.6 %) were females. Rates of assisted injecting declined between 2006 and 2014 among males (21.9 to 13.8 %) and females (37.0 to 25.6 %). In multivariable analyses, calendar year of interview also remained independently and negatively associated with assisted injecting among males (adjusted odds ratio [AOR] 0.95, 95 % confidence interval [CI] 0.92–0.99) and females (AOR 0.93, 95 % CI 0.89–0.97). Syringe borrowing remained independently associated with assisted injecting throughout the study period among females (AOR 1.53, 95 % CI 1.10–2.11 during 2006–2009; AOR 2.15, 95 % CI 1.24–3.74 during 2009–2014) and during 2009–2014 among males (AOR 1.88, 95 % CI 1.02–3.48).

Conclusions

Our findings demonstrate assisted injecting has significantly decreased for both males and females over the past decade. Nevertheless, rates of assisted injecting remain high, especially among women, and are associated with high-risk behavior, indicating a need to provide safer assisted injecting services to these vulnerable sub-populations of PWID.

"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.

Injection drug use and HIV antiretroviral therapy discontinuation in a Canadian setting

We investigated whether drug-related behaviors predicted antiretroviral therapy (ART) discontinuation among a cohort of injection drug users (IDU) in a Canadian setting. Cox regression analyses were used to investigate the impact of drug use patterns on rates of ART discontinuation among a sample of HIV-positive IDU in Vancouver, Canada between May 1996 and April 2008. In total, 408 HIV-positive IDU initiated ART during the study period, among whom 257 (63.0%) discontinued ART at least once. Rates of ART discontinuation were not significantly elevated among those who reported ongoing injection of heroin, cocaine, or other illicit drugs in comparison to those who reported not injecting drugs. However, public drug use was significantly predictive of ART discontinuation. Our findings may contribute to a reconsideration of the role of active drug use in determining retention in ART programs among IDU.

Interest in low-threshold employment among people who inject illicit drugs: implications for street disorder

BACKGROUND

Income generation opportunities available to people who use illicit drugs have been associated with street disorder. Among a cohort of injection drug users (IDU) we sought to examine street-based income generation practices and willingness to forgo these sources of income if other low-threshold work opportunities were made available.

METHODS

Data were derived from a prospective community recruited cohort of IDU. We assessed the prevalence of engaging in disorderly street-based income generation activities, including sex work, drug dealing, panhandling, and recycling/salvaging/vending. Using multivariate logistic regressions based on Akaike information criterion and the best subset selection procedure, we identified factors associated with disorderly income generation activities, and assessed willingness to forgo these sources of income during the period of November 2008 to July 2009.

RESULTS

Among our sample of 874 IDU, 418 (48%) reported engaging in a disorderly income generation activity in the previous six months. In multivariate analyses, engaging in disorderly income generation activities was independently associated with high intensity stimulant use, as well as binge drug use, having encounters with police, being a victim of violence, sharing used syringes, and injecting in public areas. Among those engaged in disorderly income generation, 198 (47%) reported a willingness to forgo these income sources if given opportunities for low-threshold employment, with sex workers being most willing to engage in alternative employment.

CONCLUSION

Engagement in disorderly street-based income generation activities was associated with high intensity stimulant drug use and various markers of risk. We found that a high proportion of illicit drug users were willing to cease engagement in these activities if they had options for causal low-threshold employment. These findings indicate that there is a high demand for low-threshold employment that may offer important opportunities to reduce drug-related street disorder and associated harms.

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

North America's first supervised injection facility (SIF) was established in Vancouver, Canada, in 2003. Although evaluation research has documented reductions in risk behavior among SIF users, there has been limited examination of the influence of operational features on injection drug users' access to these facilities. We conducted an ethnographic study that included observational research within the SIF, 50 in-depth individual interviews with SIF users, and analysis of the regulatory frameworks governing the SIF. The government-granted exemption allowing the facility to operate legally imposes key operating regulations, as well as a cap on capacity, which results in significant wait times to enter the injecting room. Regulations that prohibit practices that are common in the local drug culture also negatively affect SIF utilization. Restructuring policies that shape the operation of the SIF could enhance access to the facility and permit SIF services to better accommodate local drug use practices.