Summary of findings from the evaluation of a pilot medically supervised safer injecting facility

"Make yourself un-NIMBY-able": stakeholder perspectives on strategies to mobilize public and political support for overdose prevention centers in the United States of America

BACKGROUND

Overdose prevention centers (OPCs), also known as supervised injection facilities and safe consumption sites, are evidenced-based interventions for preventing overdose deaths and drug-related morbidities. The pathways to legalizing OPCs in the USA have confronted multiple social, political, and legal obstacles. We conducted a multi-site, qualitative study to explore heterogeneities in these pathways in four jurisdictions, as well as to understand stakeholder perspectives on valuable strategies for galvanizing political and public support for OPCs.

METHODS

From July 2022 to February 2023, we conducted 17 semi-structured, in-depth interviews with OPC policymakers, service providers, advocates, and researchers from California, New York City, Philadelphia, and Rhode Island, where efforts have been undertaken to authorize OPCs. Using inductive thematic analysis, we identified and compared contextually relevant, salient approaches for increasing support for OPCs.

RESULTS

Participants described several strategies clustering around five distinct domains: (1) embedding OPC advocacy into broader overdose prevention coalitions to shape policy dialogs; (2) building rapport with a plurality of powerbrokers (e.g., lawmakers, health departments, law enforcement) who could amplify the impact of OPC advocacy; (3) emphasizing specific benefits of OPCs to different audiences in different contexts; (4) leveraging relationships with frontline workers (e.g., emergency medicine and substance use treatment providers) to challenge OPC opposition, including 'NIMBY-ism,' and misinformation; and (5) prioritizing transparency in OPC decision-making to foster public trust.

CONCLUSION

While tailored to the specific socio-political context of each locality, multiple OPC advocacy strategies have been deployed to cultivate support for OPCs in the USA. Advocacy strategies that are multi-pronged, leverage partnerships with stakeholders at multiple levels, and tailor communications to different audiences and settings could yield the greatest impact in increasing support for, and diffusing opposition to, future OPC implementation.

High willingness to use overdose prevention sites among suburban people who use drugs who do not inject

INTRODUCTION

Overdose prevention sites (OPS) are evidence-based interventions to improve public health, yet implementation has been limited in the USA due to a variety of legal impediments. Studies in various US settings have shown a high willingness to use OPS among urban and rural people who inject drugs, but data among people who use drugs (PWUD) via non-injection routes of administration in suburban areas are lacking.

METHODS

We utilized cross-sectional data from a sample of suburban PWUD who have not injected drugs in the past 3 months (N = 126) in Anne Arundel County, Maryland. We assessed PWUDs' likelihood of using a hypothetical OPS and perceived potential barriers to accessing OPS. We tested for associations between sociodemographic characteristics, drug use, service access, and overdose experiences with willingness to utilize OPS.

FINDINGS

Participants' median age was 42, and the majority were men (67%) and non-Hispanic Black (79%). Sixty-six percent reported willingness to use an OPS. Concerns about confidentiality (29%), arrest (20%), and transportation costs (22%) were the most anticipated barriers to using OPS. Men (75% vs 55%, p = 0.015), participants who used heroin (53% vs 32%, p = 0.017), and participants who used multiple overdose prevention behaviors (e.g., using fentanyl test strips) (36% vs 19%, p = 0.006) were more likely to report willingness to use OPS.

CONCLUSION

Most suburban non-injecting PWUD in the sample were willing to use an OPS. OPS implementation strategies in suburban settings should be tailored to reach PWUD via non-injection routes of administration while meeting the unique needs of suburban contexts.

People with lived and living experience of methamphetamine use and admission to hospital: what harm reduction do they suggest needs to be addressed?

INTRODUCTION

People who use substances may access hospital services for treatment of infections and injuries, substance use disorder, mental health issues and other reasons. Our aim was to identify the experiences, issues and recommendations of people who use methamphetamine and have accessed hospital services.

METHODS

Of the 114 people with lived and living experience of methamphetamine use recruited for a mixed-methods study conducted in southwestern Ontario, Canada, 104 completed the qualitative component. Interviews were conducted from October 2020 to April 2021. Participants were asked open-ended questions and the responses were analyzed using an ethnographic thematic approach.

RESULTS

Negative patient-staff interactions included stigma and a lack of understanding of addiction and methamphetamine use, leading to distrust, avoidance of hospital care and reduced help-seeking and health care engagement. The consequences can be infections, unsafe needle use, discharge against medical advice and withdrawal. Almost all participants were in favour of in-hospital harm reduction strategies including safe consumption services, provision of sterile equipment and sharps containers, and withdrawal support. Clinical implications include education to reduce knowledge gaps about methamphetamine use and addiction and address stigma, which could facilitate the introduction of harm reduction strategies.

CONCLUSION

Although the strategies identified by participants could promote a safer care environment, improving therapeutic relationships through education of health care providers and hospital staff is an essential first step. The addition of in-hospital harm reduction strategies requires attention as the approach remains uncommon in hospitals in Canada.

Increased solitary drug use during COVID-19: An unintended consequence of social distancing

BACKGROUND

During the COVID-19 pandemic, overdose rates substantially increased in the United States. One possible contributor to this phenomenon may be solitary drug use resulting from social distancing efforts to prevent COVID-19 transmission.

METHODS

We surveyed 458 people who use drugs (PWUD) who were recruited from harm reduction and drug treatment providers located in nine states and the District of Columbia. We assessed if solitary drug use had increased since the start of COVID-19. Associations between increased solitary drug use and sociodemographic characteristics, drug use characteristics, and COVID-19 prevention behaviors were examined using multiple logistic regression.

RESULTS

Half the sample identified as men (52.7%), White (49.7%), and single (49.3%). The average age was 43.2 (SD:11.8) years. Two-thirds (66.8%) recently injected drugs. 44% reported increased solitary drug use since COVID-19. Significant correlates of increased solitary drug use included being single (adjusted Odds Ratio [aOR]=1.99, 95% Confidence Interval [CI]: 1.33, 2.98), increasing drug use (aOR=2.74, 95% CI: 1.72, 4.37), using more in private locations (aOR=1.91, 95% CI: 1.34, 2.72), and social distancing behaviors (aOR=1.31, 95% CI: 1.11, 1.54). Experiencing homelessness (aOR=0.45, 95% CI: 0.31, 0.65) and identifying as a sexual minority (aOR=0.53, 95% CI: 0.31, 0.93) were associated with being less likely to increase solitary drug use.

CONCLUSIONS

Solitary drug use increased during the COVID-19 pandemic. Increases in solitary drug use, in the context of a drug market increasingly permeated by fentanyl, indicates an urgent need for comprehensive harm reduction interventions to reduce overdose mortality.

Prevalence and factors associated with neck injection among people who inject drugs in San Francisco, California

BACKGROUND

Groin and neck injections are generally a last resort for people who inject drugs (PWID) who do not have easy access to functioning veins. These alternative injection practices can lead to an increased likelihood of adverse health outcomes. There is still much we do not know about groin and neck injections among PWID in the US, as the literature to-date comes from studies primarily focused on groin injections outside the US. We assessed prevalence, predictors, and associated behaviors of neck injection through a survey fielded in San Francisco, California, US.

METHODS

The sample comes from a longitudinal observational study that used targeted sampling to recruit PWID in San Francisco. The current study sample includes 239 PWID who completed their 12-month survey between June 2019 and June 2020.

RESULTS

About a third of the sample reported injecting in their neck in the past 30 days, with the most common reason being lack of available veins. Age, past 6-month abscess / soft tissue infection, and past 30-day use of opioids mixed with cocaine were significantly associated with past 30-day neck injection in the final multivariate model. Past 30-day neck injection was also significantly associated with being injected by another person in the past 30 days.

CONCLUSIONS

PWID at higher risk for vein deterioration were more likely to inject into their neck. Harm reduction strategies such as safer injection counseling, safe smoking supplies, use of "street doctors," and safe consumption sites may reduce instances of neck injection and/or associated health risks.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

"It wasn't here, and now it is. It's everywhere": fentanyl's rising presence in Oregon's drug supply

Background

Illicit fentanyl has contributed to a drastic increase in overdose drug deaths. While fentanyl has subsumed the drug supply in the Northeastern and Midwestern USA, it has more recently reached the Western USA. For this study, we explored perspectives of people who use drugs (PWUD) on the changing drug supply in Oregon, experiences of and response to fentanyl-involved overdose, and recommendations from PWUD to reduce overdose risk within the context of illicit fentanyl’s dramatic increase in the recreational drug supply over the past decade.

Methods

We conducted in-depth interviews by phone with 34 PWUD in Oregon from May to June of 2021. We used thematic analysis to analyze transcripts and construct themes.

Results

PWUD knew about fentanyl, expressed concern about fentanyl pills, and were aware of other illicit drugs containing fentanyl. Participants were aware of the increased risk of an overdose but remained reluctant to engage with professional first responders due to fear of arrest. Participants had recommendations for reducing fentanyl overdose risk, including increasing access to information, harm reduction supplies (e.g., naloxone, fentanyl test strips), and medications for opioid use disorder; establishing drug checking services and overdose prevention sites; legalizing and regulating the drug supply; and reducing stigma enacted by healthcare providers.

Conclusion

PWUD in Oregon are aware of the rise of fentanyl and fentanyl pills and desire access to tools to reduce harm from fentanyl. As states in the Western USA face an inflection point of fentanyl in the drug supply, public health staff, behavioral health providers, and first responders can take action identified by the needs of PWUD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-022-00659-9.

Evaluating the population-level effects of overdose prevention sites and supervised consumption sites in British Columbia, Canada: Controlled interrupted time series

Background

On 14 April 2016, British Columbia’s Provincial Medical Health Officer declared the overdose crisis a public health emergency, sanctioning the implementation of new overdose prevention sites (OPS) and supervised consumption sites (SCS) across the province.

Methods

We used the BC Centre for Disease Control’s Provincial Overdose Cohort of all overdose events between 1 January 2015 and 31 December 2017 to evaluate the population-level effects of OPSs and SCSs on acute health service use and mortality. We matched local health areas (LHA) that implemented any site with propensity score matched controls and conducted controlled interrupted time series analysis.

Results

During the study period, twenty-five OPSs and SCSs opened across fourteen of British Columbia’s 89 LHAs. Results from analysis of LHAs with matched controls (i.e. excluding Vancouver DTES) were mixed. Significant declines in reported overdose events, paramedic attendance, and emergency department visits were observed. However, there were no changes to trends in monthly hospitalization or mortality rates. Extensive sensitivity analyses found these results persisted.

Conclusions

We found OPSs and SCSs reduce opioid-related paramedic attendance and emergency department visit rates but no evidence that they reduce local hospitalization or mortality rates.

Indicators of Drug-Related Community Impacts of Open Drug Scenes: A Scoping Review

INTRODUCTION

Places where people deal and/or use drugs publicly are known as open drug scenes (ODSs). Drug-related community impacts (DRCIs) refer to drug-related issues that negatively influence public and individual health, communities, businesses, and recreational and public space enjoyment. There are no well-established criteria for identification of DRCIs. We therefore performed a scoping review of literature to determine DRCIs indicators associated with ODSs.

METHODS

The review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews (PRISMA-ScP). We searched English articles in PubMed, Scopus, Web of Science, and EMBASE databases from 1990 to 2021. The keywords were drug-related crime, drug-related offense, misconduct, social marginalization, homeless drug users, open drug scene, drug-related street disorder, public nuisance, and community impact.

RESULTS

Sixty-four studies were identified. Twenty-five studies were included. Two studies (8%) were about drug-related public nuisance, 1 (4%) considered drug-related social problems, 2 (8%) focused on drug-related social disorder, and 18 studies (72%) discussed indicators of community impacts such as crime, drug-related litter, safety, noise, and drug use in public. Two studies (8%) included the frequency of drug use in ODSs.

DISCUSSION

DRCI indicators are heterogenic, and various factors affect the indicators. The factors include social mores, political discourse, and historical approaches to dealing with and using drugs. Some societies do not tolerate the existence of ODSs. In contrast, many countries have adopted harm reduction programs to manage DRCIs. Identified DRCI indicators were drug using and dealing in public, drug-related litter, crime, drug-related loitering, street-based income generation activities, noise, and unsafety feelings in inhabitants. To solve the problems associated with DRCIs and to make a major change in ODSs, it is necessary to pay attention to the improvement of the economic conditions (e.g., employment opportunities), amendment (e.g., determine the limits of criminalization in drug use), and adoption of social policies (e.g., providing low-threshold and supportive services for homeless drug users).

Harm minimisation for the management of self-harm: a mixed-methods analysis of electronic health records in secondary mental healthcare

BACKGROUND

Prevalence of self-harm in the UK was reported as 6.4% in 2014. Despite sparse evidence for effectiveness, guidelines recommend harm minimisation; a strategy in which people who self-harm are supported to do so safely.

AIMS

To determine the prevalence, sociodemographic and clinical characteristics of those who self-harm and practise harm minimisation within a London mental health trust.

METHOD

We included electronic health records for patients treated by South London and Maudsley NHS Trust. Using an iterative search strategy, we identified patients who practise harm minimisation, then classified the approaches using a content analysis. We compared the sociodemographic characteristics with that of a control group of patients who self-harm and do not use harm minimisation.

RESULTS

In total 22 736 patients reported self-harm, of these 693 (3%) had records reporting the use of harm-minimisation techniques. We coded the approaches into categories: (a) 'substitution' (>50% of those using harm minimisation), such as using rubber bands or using ice; (b) 'simulation' (9%) such as using red pens; (c) 'defer or avoid' (7%) such as an alternative self-injury location; (d) 'damage limitation' (9%) such as using antiseptic techniques; the remainder were unclassifiable (24%). The majority of people using harm minimisation described it as helpful (>90%). Those practising harm minimisation were younger, female, of White ethnicity, had previous admissions and were less likely to have self-harmed with suicidal intent.

CONCLUSIONS

A small minority of patients who self-harm report using harm minimisation, primarily substitution techniques, and the large majority find harm minimisation helpful. More research is required to determine the acceptability and effectiveness of harm-minimisation techniques and update national clinical guidelines.

Community Versus Hospital Opioid-Related Overdose Deaths in Illinois

OBJECTIVE

To better understand approaches to reducing mortality from the opioid epidemic, we analyzed in-hospital versus community opioid-related overdose deaths in Illinois.

METHODS

We used data from the Statewide Unintentional Drug Overdose Reporting System (July 2017 through December 2018) to identify deaths that occurred in hospitals and communities (ie, homes or public spaces). We used census tract-level data for 34 Illinois counties to create bivariate mapping by overdose death rates. We used logistic regression to analyze the association of demographic and overdose characteristics with the likelihood of death in a hospital versus a community.

RESULTS

During the study period, 2833 opioid-related overdose deaths occurred in 24 Illinois counties, 655 (23.1%) of which occurred in the hospital; of 2178 community deaths, 1888 (86.7%) occurred in the same census tract as the decedent's recorded residence and 1285 (59.0%) occurred in the decedent's home. Non-Hispanic Black people were 1.63 (95% CI, 1.27-2.10) times more likely than non-Hispanic White people to die in a hospital. Decedents from suburban Cook County and other Chicago suburban counties were significantly more likely to die in the hospital than decedents from Chicago or other Illinois counties. Documentation of a previous overdose, history of opioid use, and having bystanders present were significantly associated with hospital deaths. Evidence of a rapid overdose, fentanyl present, or prescription opioids were significantly associated with deaths in a community.

CONCLUSIONS

The high number of opioid-related overdose deaths in the community illustrates the need to decriminalize illicit drug use and facilitate treatment seeking. Establishing supervised safe consumption sites may have the biggest effect in reducing the number of opioid-related overdose deaths.

Between Emergency Department Visits: The Role of Harm Reduction Programs in Mitigating the Harms Associated With Injection Drug Use

Injection drug use is a major public health problem in the United States. Cocaine, heroin, and methamphetamine are the most commonly injected illicit drugs, whereas opioids are responsible for the majority of overdose fatalities. Although recent emergency department (ED) efforts have focused on expanding capacity for buprenorphine induction for opioid use disorder treatment, the injection of illicit drugs carries specific health risks that require acknowledgment and management, particularly for patients who decline substance use treatment. Harm reduction is a public health approach that aims to reduce the harms associated with a health risk behavior, short of eliminating the behavior itself. Harm-reduction strategies fundamental to emergency medicine include naloxone distribution for opioid overdose. This clinical Review Article examines the specific health complications of injection drug use and reviews the evidence base for 2 interventions effective in reducing morbidity and mortality related to drug injection, irrespective of the specific drug used, that are less well known and infrequently leveraged by emergency medicine clinicians: syringe service programs and supervised injection facilities. In accordance with the recommendations of health authorities such as the Centers for Disease Control and Prevention, emergency clinicians can promote the use of harm-reduction programs in the community to reduce viral transmission and other risks of injection drug use by providing patients with information about and referrals to these programs after injection drug use-related ED visits.

Charting a path towards a public health approach for gambling harm prevention

Aim

Gambling harm is a serious public health issue affecting the health, financial security, and social well-being of millions of people and their close relations around the world. Despite its population health implications, gambling harm is not typically viewed and treated as a public health policy issue. This paper critically reviews the evolution of the public health perspective on gambling harm. It also considers how gambling harm can be operationalized within a public health model.

Methods

A critical historical review of the emerging public health perspective on gambling harm was conducted. Key documents covering three decades of development were reviewed and appraised through a process of deliberation and debate over source impact in the fields of research, policy, and programming internationally.

Results

The first decade mainly focused on identifying gambling harm and framing the public health issue. The second decade featured the expansion of health assessment and emerging areas of policy and program development. The third decade saw an increased focus on public health frameworks that advanced understanding of harm mechanics and impact. As reflected by the essential functions of a general public health model, gambling harm prevention efforts emphasize health promotion over other key functions like health assessment and surveillance.

Conclusion

Gambling harm is a public health issue requiring greater attention to health assessment and surveillance data development.

Ranking evidence in substance use and addiction

Evidence-based medicine has consistently prized the epistemological value of randomized-controlled trials (RCTs) owing to their methodological advantages over alternative designs such as observational studies. However, there are limitations to RCTs that hinder their ability to study chronic and dynamic conditions such as substance use and addiction. For these conditions, observational studies may provide superior evidence based on methodological and practical strengths. Assuming epistemic superiority of RCTs has led to an inappropriate devaluation of other study designs and the findings they support, including support for harm reduction services, especially needle exchange programs and supervised injection facilities. The value offered by observational studies should be reflected in evidence-based medicine by allowing more flexibility in evidence hierarchies that presume methodological superiority of RCTs. Despite the popularity of evidence ranking systems and hierarchies, nothing should replace critical appraisal of study methodology and examining the suitability of applying a given study design to a specific research question.

High willingness to use overdose prevention sites among female sex workers in Baltimore, Maryland

BACKGROUND

Overdose Prevention Sites (OPS) operate worldwide as spaces where people can consume previously purchased drugs under supervision, and are linked to reductions in HIV/HCV transmission and fatal overdoses. As the United States weighs their merits and legality, research is needed to estimate acceptability and use among populations at high risk for overdose. We examine willingness to use OPS among street-based female sex workers (FSW) with prevalent drug use and associated morbidities.

METHODS

We describe self-reported willingness, barriers and conditions around use of a hypothetical OPS among 141 FSW engaged in active drug use in Baltimore City, and describe trends using Pearson's χ2 and Fisher's exact tests.

RESULTS

Most women had history of overdose (55 %) and were likely to use OPS (77 %). Willingness was higher among women who: were sexual minorities (97 %;P=0.002),experienced homelessness (82 %;P=0.019), injected drugs (82 %;P=0.013), shared syringes (82 %;P=0.007), experienced sexual violence (92 %;P=0.045) or reported heroin use (83 %;P=0.039) in the past 3 months. Common anticipated barriers included transportation (45 %) and fear of arrest (41 %).

CONCLUSIONS

This study highlights a population of uniquely high-risk women who would benefit from an OPS integrated with other services. Conditions and barriers discussed are informative for planning and implementation.

"You need to just provide health services:" navigating the politics of harm reduction in the twin housing and overdose crises in Vancouver, BC

BACKGROUND

Since harm reduction's origins as a grassroots, activist movement, cooperation and compromise among people who use drugs, bureaucrats, politicians, and other actors have been critical to its advancement in Canada. Critics have argued, however, that the institutionalization of harm reduction practice within the context of a politically sensitive environment has eroded its radical potential. The overdose crisis in Vancouver's Downtown Eastside (DTES) community has led to innovative harm reduction organizing that has been replicated globally. In this paper, we explore how one such intervention, the Tenant Overdose Response Organizers (TORO) program, has supported a resurgence in tenant-led harm reduction organizing in Single Room Occupancy (SRO) buildings in the DTES.

METHODS

We draw on 15 months of ethnographic fieldwork conducted between May 2017 and August 2018, over 100 hours of participant observation of TORO activities, and 15 semi-structured interviews with key stakeholders in the program.

RESULTS

TORO's leaders attempted to mobilize harm reduction intervention towards collective action on SRO risk environments underlying drug-related harms, but their efforts were constrained by the necessity of meeting practical expectations of funders regarding health education and supply distribution. Navigating these constraints ultimately shaped the development of the TORO program, helping to secure its longevity but also limiting its ability to organize a coordinated harm reduction and tenants' rights response to the dual housing and overdose crises.

CONCLUSION

Our examination of TORO demonstrates how the harm reduction movement continues to be shaped by conflict, cooperation, and compromise between the state and grassroots groups. Even as actors strive to work collaboratively, the unequal distribution of power inherent in this relationship may contribute to the reinscription of a depoliticized harm reduction approach. We discuss the potential role of the risk environment framework in lending political legitimacy to grassroots harm reduction initiatives.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Opioid use disorder

Opioid use disorder (OUD) is a chronic relapsing disorder that, whilst initially driven by activation of brain reward neurocircuits, increasingly engages anti-reward neurocircuits that drive adverse emotional states and relapse. However, successful recovery is possible with appropriate treatment, although with a persisting propensity to relapse. The individual and public health burdens of OUD are immense; 26.8 million people were estimated to be living with OUD globally in 2016, with >100,000 opioid overdose deaths annually, including >47,000 in the USA in 2017. Well-conducted trials have demonstrated that long-term opioid agonist therapy with methadone and buprenorphine have great efficacy for OUD treatment and can save lives. New forms of the opioid receptor antagonist naltrexone are also being studied. Some frequently used approaches have less scientifically robust evidence but are nevertheless considered important, including community preventive strategies, harm reduction interventions to reduce adverse sequelae from ongoing use and mutual aid groups. Other commonly used approaches, such as detoxification alone, lack scientific evidence. Delivery of effective prevention and treatment responses is often complicated by coexisting comorbidities and inadequate support, as well as by conflicting public and political opinions. Science has a crucial role to play in informing public attitudes and developing fuller evidence to understand OUD and its associated harms, as well as in obtaining the evidence today that will improve the prevention and treatment interventions of tomorrow.

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

BACKGROUND

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

CASE PRESENTATION

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

CONCLUSIONS

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

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.

Acceptability of safe drug consumption spaces among people who inject drugs in rural West Virginia

Aim

Safe consumption spaces (SCS) are indoor environments in which people can use drugs with trained personnel on site to provide overdose reversal and risk reduction services. SCS have been shown to reduce fatal overdoses, decrease public syringe disposal, and reduce public drug consumption. Existing SCS research in the USA has explored acceptability for the hypothetical use of SCS, but primarily among urban populations of people who inject drugs (PWID). Given the disproportionate impact of the opioid crisis in rural communities, this research examines hypothetical SCS acceptability among a rural sample of PWID in West Virginia.

Methods

Data were drawn from a 2018 cross-sectional survey of PWID (n = 373) who reported injection drug use in the previous 6 months and residence in Cabell County, West Virginia. Participants were asked about their hypothetical use of a SCS with responses dichotomized into two groups, likely and unlikely SCS users. Chi-square and t tests were conducted to identify differences between likely and unlikely SCS users across demographic, substance use, and health measures.

Results

Survey participants were 59.5% male, 83.4% non-Hispanic White, and 79.1% reported likely hypothetical SCS use. Hypothetical SCS users were significantly (p < .05) more likely to have recently (past 6 months) injected cocaine (38.3% vs. 25.7%), speedball (41.0% vs. 24.3%), and to report preferring drugs containing fentanyl (32.5% vs. 20.3%). Additionally, likely SCS users were significantly more likely to have recently experienced an overdose (46.8% vs. 32.4%), witnessed an overdose (78.3% vs. 60.8%), and received naloxone (51.2% vs. 37.8%). Likely SCS users were less likely to have borrowed a syringe from a friend (34.6% vs. 48.7%).

Conclusions

Rural PWID engaging in high-risk behaviors perceive SCS as an acceptable harm reduction strategy. SCS may be a viable option to reduce overdose fatalities in rural communities.

Prospective client survey and participatory process ahead of opening a mobile drug consumption room in Lisbon

Background

Ahead of opening Portugal’s first mobile drug consumption room (MDCR) in Lisbon, information from People Who Use Drugs (PWUD) and local community members was necessary to determine current needs and shape the intervention. A participatory and peer-led process was ensured at all stages of data gathering and planning of the intervention.

Methods

Prospective clients were surveyed to determine their willingness to use the service and preferences for use and to gain sociodemographic information. Persons over the age of 18 who reported injection drug use (PWID) were recruited using convenience sampling in the main open drug use scenes in Lisbon. In-person interviews were conducted by trained peer workers between November and December of 2017. The results (n = 72) of the questionnaires were analyzed, providing descriptive statistics.

Results

There is a high level of willingness to use the MDCR, primarily for reasons of hygiene, privacy, and security. Most participants expressed a desire to use the MDCR daily. Potential clients are socially marginalized, and many suffer from unstable housing. Most are daily users and engage in unsafe injecting practices, such as public injecting and material sharing. High levels of hepatitis C, HIV, and hepatitis B were observed among the target population with low levels of healthcare access and utilization. Preferences were gauged regarding the scheduling of the MDCR’s hours and amount of time willing to travel to reach the MDCR and will be taken into account for implementation. The combination of high levels of willingness to utilize the service and high levels of need among the target population support the implementation of Lisbon’s first MDCR.

Conclusions

Continual participation of PWUD and other community members will be necessary to maximize the public health and social impacts of this intervention, relative to this baseline. The plan to continue the participatory and peer-led development of the MDCR includes integrating peer workers, clients, and local community members within the operation, management, and evaluation of the service. This research adds to a growing literature about drug consumption rooms (DCRs) in Europe, which is especially limited concerning MDCRs.

Integrating Smoking Cessation Care into a Medically Supervised Injecting Facility Using an Organizational Change Intervention: A Qualitative Study of Staff and Client Views

Background: Clients accessing supervised injecting facilities (SIFs) smoke at high rates. An SIF piloted an organizational change intervention to integrate smoking cessation care as routine treatment. This study aims to explore staff acceptability, perceived facilitators, and perceived barriers to implementing six core components of an organizational change intervention to integrate smoking cessation care in an SIF. Staff and client views on the acceptability, facilitators, and barriers to the provision of smoking cessation care were also examined. Methods: This paper presents findings from the qualitative component conducted post-intervention implementation. Face-to-face semi-structured staff interviews (n = 14) and two client focus groups (n = 5 and n = 4) were conducted between September and October 2016. Recruitment continued until data saturation was reached. Thematic analysis was employed to synthesise and combine respondent views and identify key themes. Results: Staff viewed the organizational change intervention as acceptable. Commitment from leadership, a designated champion, access to resources, and the congruence between the change and the facility’s ethos were important facilitators of organizational change. Less engaged staff was the sole barrier to the intervention. Smoking cessation care was deemed suitable. Key facilitators of smoking cessation care included: Written protocols, ongoing training, and visually engaging information. Key barriers of smoking cessation care included: Lack of access to nicotine replacement therapy (NRT) outside of business hours, practical limitations of the database, and concerns about sustainability of NRT. Conclusion: This study develops our understanding of factors influencing the implementation of an organisational change intervention to promote sustainable provision of smoking cessation care in the SIF setting.

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.

"We don't want him worrying about how he will pay to save his life": Using medical crowdfunding to explore lived experiences with addiction services in Canada

BACKGROUND

The opiate crisis in Canada, among other causes, has led to increased demand and wait times for addiction-related services. One response to this situation has been for Canadians to seek crowdfunding support for services outside of the public system. However, little is known about how large this practice is, what addiction-related services Canadians seek, and what the implications of this practice are.

METHODS

We searched the crowdfunding platforms GoFundMe and YouCaring using keywords related to addiction. This search identified 129 crowdfunding campaigns by Canadian residents seeking addiction-related services. The authors recorded information from the campaigns and conducted a thematic analysis of their narrative content.

RESULTS

These campaigns requested $12,722,527 and were pledged $204,848 (1.6%). Thematic analysis revealed four core elements discussed in the pursuit of addiction-related crowdfunding: 1) affording treatment, including at private and/or perceived higher quality facilities; 2) surviving treatment by seeking living expenses during and before treatment; 3) life after treatment by addressing needs following receiving treatment for addiction; and 4) publicizing treatment where recipients often struggled with the need to reveal personal details as part of their campaigns.

CONCLUSION

These findings confirm discussion in the academic and policy literature on Canadians seeking addiction-related services that wait times for public services are a significant issue for many. However, these findings also show that the costs of living expenses before and during treatment, as well as restarting lives following treatment, also create struggles for Canadians. These findings confirm and expand concerns in the literature on medical crowdfunding, where this practice is thought to raise issues around the equitable distribution of resources and the loss of personal privacy. While crowdfunding for addictionrelated services has helped some Canadians, the money raised was vastly less than that requested, came at a cost to personal privacy, and raises equity issues.

Gendered violence and overdose prevention sites: a rapid ethnographic study during an overdose epidemic in Vancouver, Canada

BACKGROUND AND AIMS

North America's overdose epidemic is increasingly driven by fentanyl and fentanyl-adulterated drugs. Supervised consumption sites, including low-threshold models (termed overdose prevention sites; OPS), are now being debated in the United States and implemented in Canada. Despite evidence that gendered and racialized violence shape access to harm reduction among women who use drugs (WWUD), this has not been examined in relation to OPS and amid the overdose epidemic. This study explores how overlapping epidemics of overdose and gendered and racialized violence in Vancouver's Downtown Eastside, one of North America's overdose epicenters, impacts how marginalized WWUD experience OPS.

DESIGN

Qualitative analysis using rapid ethnographic fieldwork. Data collection included 185 hours of naturalistic observation and in-depth interviews; data were analyzed thematically using NVivo.

SETTING

Vancouver, Canada.

PARTICIPANTS

Thirty-five WWUD recruited from three OPS.

MEASUREMENTS

Participants' experiences of OPS and the public health emergency.

FINDINGS

The rapid onset and severity of intoxication associated with the use of fentanyl-adulterated drugs in less regulated drug use settings not only amplified WWUD's vulnerability to overdose death but also violence. Participants characterized OPS as safer spaces to consume drugs in contrast to less regulated settings, and accommodation of assisted injections and injecting partnerships was critical to increasing OPS access among WWUD. Peer-administered injections disrupted gendered power relations to allow women increased control over their drug use; however, participants indicated that OPS were also gendered and racialized spaces that jeopardized some women's access.

CONCLUSION

Although women who use drugs in Vancouver, Canada appear to feel that overdose prevention sites address forms of everyday violence made worse by the overdose epidemic, these sites remain 'masculine spaces' that can jeopardize women's access.

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

SETTING

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

INTERVENTION

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

OUTCOMES

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

IMPLICATIONS

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

Willingness to use an in-hospital supervised inhalation room among people who smoke crack cocaine in Vancouver, Canada

INTRODUCTION AND AIMS

People who use illicit drugs (PWUD) often engage in drug use during hospitalisation. Adverse outcomes may arise from efforts to conceal inpatient drug use, especially in hospital settings that rely on abstinence-based policies. Harm reduction interventions, including supervised drug consumption services, have not been well studied in hospital settings. This study examines factors associated with willingness to use an in-hospital supervised inhalation room (SIR) among people who smoke crack cocaine in Vancouver, Canada.

DESIGN AND METHODS

Cross-sectional data from two open prospective cohorts of PWUD involving people who smoke crack cocaine were collected between June 2013 and May 2014. Multivariable logistic regression analyses were used to identify factors associated with willingness to use an in-hospital SIR.

RESULTS

Among 539 participants, 320 (59.4%) reported willingness to use an in-hospital SIR. Independent factors positively associated with willingness included: ever used drugs in hospital [adjusted odds ratio (AOR) = 1.89], and daily non-injection crack use (AOR = 1.63). Difficulty accessing new crack pipes (AOR = 0.51) was negatively associated with willingness (all P < 0.05). The most commonly reported reasons for willingness were to: remain in hospital (50.6%), reduce drug-related risks (25.6%) and reduce the stress of hospital discharge for using drugs (24.7%).

DISCUSSION AND CONCLUSIONS

A high proportion of people who smoke crack cocaine reported willingness to use an in-hospital SIR, and those willing were more likely to report heavy drug use and previous in-hospital use. These findings highlight the potential utility of SIRs to complement existing in-hospital services for PWUD.

Safe and unsafe spaces: Non-fatal overdose, arrest, and receptive syringe sharing among people who inject drugs in public and semi-public spaces in Baltimore City

The spaces in which drug use occurs constitutes a key aspect of the "risk environment" of people who inject drugs (PWID). We aimed to add nuance to the characterization of "safe" and "unsafe" spaces in PWID's environments to further understand how these spaces amplify the risk of morbidities associated with injection drug use. PWID were recruited through the Baltimore City syringe service program and through peer referral. Participants completed a socio-behavioral survey. Multivariable logistic regression was used to identify associations between utilization of public, semi-public and private spaces with arrest, non-fatal overdose, and receptive syringe sharing. The sample of PWID (N = 283) was mostly 45 years and older (54%), male (69%), Black (55%), and heroin users (96%). Compared to PWID who primarily used private settings, the adjusted odds of recent overdose were greater among PWID who mostly used semi-public and public locations to inject drugs. We also found independent associations between arrest and semi-public spaces, and between receptive syringe sharing and public spaces (all p < 0.05). This study highlights the need for safe spaces where PWID can reduce their risk of overdose, likelihood of arrest and blood-borne diseases, and the dual potential of the environment in promoting health and risk.

Overdose Education and Naloxone Distribution Programmes and the Ethics of Task Shifting

North America is in the grips of an epidemic of opioid-related poisonings. Overdose education and naloxone distribution (OEND) programmes emerged as an option for structurally vulnerable populations who could not or would not access mainstream emergency medical services in the event of an overdose. These task shifting programmes utilize lay persons to deliver opioid resuscitation in the context of longstanding stigmatization and marginalization from mainstream healthcare services. OEND programmes exist at the intersection of harm reduction and emergency services. One goal of OEND programmes is to help redress the health-related inequities common among people who use drugs, which include minimizing the gap between people who use drugs and the formal healthcare system. However, if this goal is not achieved these inequities may be entrenched. In this article, we consider the ethical promises and perils associated with OEND as task shifting. We argue that public health practitioners must consider the ethical aspects of task shifting programmes that may inadvertently harm already structurally vulnerable populations. We believe that even if OEND programmes reduce opioid-related deaths, we nevertheless question if, by virtue of its existence, OEND programmes might also unintentionally disenfranchise structurally vulnerable populations from comprehensive healthcare services, including mainstream emergency care.

Developing a scale of domains of negative consequences of chronic heroin use

BACKGROUND

Chronic use of heroin typically leads to numerous negative life consequences and serious clinical impairment. Increased negative consequences can result in poor treatment outcomes as well as adverse health effects and impaired social functioning. Certain risk factors, including early substance use initiation, concurrent use of other illicit substances, and injection drug use are associated with an increase in negative consequences. This study examined whether there are unique domains of heroin consequences and, if so, whether these domains are related to specific substance use characteristics.

METHODS

Data regarding substance use characteristics were collected from 370 non-treatment seeking, heroin-using, 18 to 55year-old participants from the Detroit metropolitan area. Principal component analysis (PCA) was used to analyze the factor structure of 21 negative heroin consequence items.

RESULTS

PCA demonstrated that heroin consequences could be divided into 5 unique domains. These unique domains were related to specific substance use characteristics and heroin consequence domains. Injection heroin use was significantly associated with increased Factor 1 consequences (primarily acute medical problems) but not with consequences in other domains. Certain substance use characteristics, such as injection status and earlier onset of marijuana use, were associated with increased consequences in specific domains.

CONCLUSIONS

These findings support the existence of unique domains of negative consequences, and indicate that some risk factors (e.g. injection use) may be specific to these domains. Potential tailored-treatment strategies aimed at improving treatment engagement and reducing harm for heroin use based on person-specific risks and negative consequences are discussed.

Non-injection Drug Use and Injection Initiation Assistance among People Who Inject Drugs in Tijuana, Mexico

Although most people who inject drugs (PWID) report receiving assistance during injection initiation events, little research has focused on risk factors among PWID for providing injection initiation assistance. We therefore sought to determine the influence of non-injection drug use among PWID on their risk to initiate others. We used generalized estimating equation (GEE) models on longitudinal data among a prospective cohort of PWID in Tijuana, Mexico (Proyecto El Cuete IV), while controlling for potential confounders. At baseline, 534 participants provided data on injection initiation assistance. Overall, 14% reported ever initiating others, with 4% reporting this behavior recently (i.e., in the past 6 months). In a multivariable GEE model, recent non-injection drug use was independently associated with providing injection initiation assistance (adjusted odds ratio [AOR] = 2.42, 95% confidence interval [CI] = 1.39-4.20). Further, in subanalyses examining specific drug types, recent non-injection use of cocaine (AOR = 9.31, 95% CI = 3.98-21.78), heroin (AOR = 4.00, 95% CI = 1.88-8.54), and methamphetamine (AOR = 2.03, 95% CI = 1.16-3.55) were all significantly associated with reporting providing injection initiation assistance. Our findings may have important implications for the development of interventional approaches to reduce injection initiation and related harms. Further research is needed to validate findings and inform future approaches to preventing entry into drug injecting.

Post-war prevention: Emerging frameworks to prevent drug use after the War on Drugs

The prevention of drug use is one of the primary goals of the War on Drugs. However, despite investment in high-profile interventions such as social marketing campaigns and enforcement-based deterrence, these efforts have generally failed. With the emergence of novel policy frameworks to control and regulate drug use, a window of opportunity exists to test approaches to drug prevention that take into account existing evidence and the rights of individuals who use drugs. Specifically, there is a growing consensus that entry into drug use is a socially-defined event that individuals experience within particular socio-structural contexts. This understanding, coupled with a distinction between the value of preventing problematic drug use rather than all drug use, provides a useful framework within which to develop effective and rights-based approaches to drug prevention.

Structural Interventions in HIV Prevention: A Taxonomy and Descriptive Systematic Review

One of the four national HIV prevention goals is to incorporate combinations of effective, evidence-based approaches to prevent HIV infection. In fields of public health, techniques that alter environment and affect choice options are effective. Structural approaches may be effective in preventing HIV infection. Existing frameworks for structural interventions were lacking in breadth and/or depth. We conducted a systematic review and searched CDC's HIV/AIDS Prevention Research Synthesis Project's database for relevant interventions during 1988-2013. We used an iterative process to develop the taxonomy. We identified 213 structural interventions: Access (65%), Policy/Procedure (32%), Mass Media (29%), Physical Structure (27%), Capacity Building (24%), Community Mobilization (9%), and Social Determinants of Health (8%). Forty percent targeted high-risk populations (e.g., people who inject drugs [12%]). This paper describes a comprehensive, well-defined taxonomy of structural interventions with 7 categories and 20 subcategories. The taxonomy accommodated all interventions identified.

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

BACKGROUND

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

COMMENTARY

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A historical review of HIV prevention and care initiatives in British Columbia, Canada: 1996-2015

INTRODUCTION

British Columbia has made significant progress in the treatment and prevention of HIV since 1996, when Highly Active Antiretroviral Therapy (HAART) became available. However, we currently lack a historical summary of HIV prevention and care interventions implemented in the province since the introduction of HAART and how they have shaped the HIV epidemic. Guided by a socio-ecological framework, we present a historical review of biomedical and health services, community and structural interventions implemented in British Columbia from 1996-2015 to prevent HIV transmission or otherwise enhance the cascade of HIV care.

METHODS

We constructed a historical timeline of HIV interventions implemented in BC between 1996 and 2015 by reviewing publicly available reports, guidelines and other documents from provincial health agencies, community organizations and AIDS service organizations, and by conducting searches of peer-reviewed literature through PubMed and Ovid MEDLINE. We collected further programmatic information by administering a data collection form to representatives from BC's regional health authorities and an umbrella agency representing 45 AIDS Service organizations. Using linked population-level health administrative data, we identified key phases of the HIV epidemic in British Columbia, as characterized by distinct changes in HIV incidence, HAART uptake and the provincial HIV response.

RESULTS AND DISCUSSION

In total, we identified 175 HIV prevention and care interventions implemented in BC from 1996 to 2015. We identify and describe four phases in BC's response to HIV/AIDS: the early HAART phase (1996-1999); the harm reduction and health service scale-up phase (2000-2005); the early Treatment as Prevention phase (2006-2009); and the STOP HIV/AIDS phase (2010-present). In doing so, we provide an overview of British Columbia's universal and centralized HIV treatment system and detail the role of community-based and provincial stakeholders in advancing innovative prevention and harm reduction approaches, as well as "seek, test, treat and retain" strategies.

CONCLUSIONS

The review provides valuable insight into British Columbia's HIV response, highlights emerging priorities, and may inform future efforts to evaluate the causal impact of interventions.

Support of supervised injection facilities by emergency physicians in Canada

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Injecting drug use in low and middle-income countries: Opportunities to improve care and prevent harm

Inadequate response to injecting drug use (IDU) is a significant problem the world over. Low levels of funding, political inaction, poor levels of health service coverage, high prevalence and incidence of IDU-related blood-borne viruses (BBVs) and ongoing stigmatization/marginalization affect people who inject drugs (PWID) regardless of the income status of the country they reside in. These barriers and system failings are, however, exacerbated in low and middle-income countries (LMICs), meaning that the potential consequences of inaction are more pressing. In this narrative review, we describe the levels of IDU and IDU-specific BBV prevalence in LMICs; levels of harm reduction implementation; the consequences of late or insufficient response, the shortcomings of data collection and dissemination; and the barriers to effective LMIC harm reduction implementation. We also exemplify cases where IDU-related harms and BBV epidemics have been successfully curtailed in LMICs, showing that effective response, despite the barriers, is possible. In conclusion, we suggest four key priorities on the basis of the review: confirming the presence or absence of IDU in LMICs, improving the collection and dissemination of national IDU-specific data, increasing the level of harm reduction programme implementation in LMICs, and increasing both national and international advocacy for PWID and attendant public health interventions.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

DISCUSSION

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

Harm reduction in name, but not substance: a comparative analysis of current Canadian provincial and territorial policy frameworks

BACKGROUND

In Canada, funding, administration, and delivery of health services-including those targeting people who use drugs-are primarily the responsibility of the provinces and territories. Access to harm reduction services varies across jurisdictions, possibly reflecting differences in provincial and territorial policy commitments. We examined the quality of current provincial and territorial harm reduction policies in Canada, relative to how well official documents reflect internationally recognized principles and attributes of a harm reduction approach.

METHODS

We employed an iterative search and screening process to generate a corpus of 54 provincial and territorial harm reduction policy documents that were current to the end of 2015. Documents were content-analyzed using a deductive coding framework comprised of 17 indicators that assessed the quality of policies relative to how well they described key population and program aspects of a harm reduction approach.

RESULTS

Only two jurisdictions had current provincial-level, stand-alone harm reduction policies; all other documents were focused on either substance use, addiction and/or mental health, or sexually transmitted and/or blood-borne infections. Policies rarely named specific harm reduction interventions and more frequently referred to generic harm reduction programs or services. Only one document met all 17 indicators. Very few documents acknowledged that stigma and discrimination are issues faced by people who use drugs, that not all substance use is problematic, or that people who use drugs are legitimate participants in policymaking. A minority of documents recognized that abstaining from substance use is not required to receive services. Just over a quarter addressed the risk of drug overdose, and even fewer acknowledged the need to apply harm reduction approaches to an array of drugs and modes of use.

CONCLUSIONS

Current provincial and territorial policies offer few robust characterizations of harm reduction or go beyond rhetorical or generic support for the approach. By endorsing harm reduction in name, but not in substance, provincial and territorial policies may communicate to diverse stakeholders a general lack of support for key aspects of the approach, potentially challenging efforts to expand harm reduction services.

Value of Comprehensive HCV Treatment among Vulnerable, High-Risk Populations

OBJECTIVES

The objective of this study was to explore the trade-offs society and payers make when expanding treatment access to patients with chronic hepatitis C virus (HCV) infection in early stages of disease as well as to vulnerable, high-risk populations, such as people who inject drugs (PWID) and HIV-infected men who have sex with men (MSM-HIV).

METHODS

A discrete time Markov model simulated HCV progression and treatment over 20 years. Population cohorts were defined by behaviors that influence the risk of HCV exposure: PWID, MSM-HIV, an overlap cohort of individuals who are both PWID and MSM-HIV, and all other adults. Six different treatment scenarios were modeled, with varying degrees of access to treatment at different fibrosis stages and to different risk cohorts. Benefits were measured as quality-adjusted life-years and a $150,000/quality-adjusted life-year valuation was used to assess social benefits.

RESULTS

Compared with limiting treatment to METAVIR fibrosis stages F3 or F4 and excluding PWID, expanding treatment to patients in all fibrosis stages and including PWID reduces cumulative new infections by 55% over a 20-year horizon and reduces the prevalence of HCV by 93%. We find that treating all HCV-infected individuals is cost saving and net social benefits are over $500 billion greater compared with limiting treatment. Including PWID in treatment access saves 12,900 to 41,200 lives.

CONCLUSIONS

Increased access to treatment brings substantial value to society and over the long-term reduces costs for payers, as the benefits accrued from long-term reduction in prevalent and incident cases, mortality, and medical costs outweigh the cost of treatment.

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.