Article

The impact of a supervised injecting facility on ambulance call-outs in Sydney, Australia

Authors:
  • University of NSW
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Abstract

Supervised injecting facilities (SIFs) are effective in reducing the harms associated with injecting drug use among their clientele, but do SIFs ease the burden on ambulance services of attending to overdoses in the community? This study addresses this question, which is yet to be answered, in the growing body of international evidence supporting SIFs efficacy. Ecological study of patterns in ambulance attendances at opioid-related overdoses, before and after the opening of a SIF in Sydney, Australia. A SIF opened as a pilot in Sydney's 'red light' district with the aim of accommodating a high throughput of injecting drug users (IDUs) for supervised injecting episodes, recovery and the management of overdoses. A total of 20,409 ambulance attendances at opioid-related overdoses before and after the opening of the Sydney SIF. Average monthly ambulance attendances at suspected opioid-related overdoses, before (36 months) and after (60 months) the opening of the Sydney Medically Supervised Injecting Centre (MSIC), in the vicinity of the centre and in the rest of New South Wales (NSW). The burden on ambulance services of attending to opioid-related overdoses declined significantly in the vicinity of the Sydney SIF after it opened, compared to the rest of NSW. This effect was greatest during operating hours and in the immediate MSIC area, suggesting that SIFs may be most effective in reducing the impact of opioid-related overdose in their immediate vicinity. By providing environments in which IDUs receive supervised injection and overdose management and education SIF can reduce the demand for ambulance services, thereby freeing them to attend other medical emergencies within the community.

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... This may partly be due to the difficulty of creating studies that have sufficient statistical power to detect real, important but small changes in outcomes that are extremely harmful, but relatively rare. It is easier to study effects on more common outcomes, such as ambulance callouts (107,108). Multiple studies have been done on OPCs, using various methods, looking at difference mechanisms and outcomes. This enables us to build up a suggestive picture of how these services work, and what they do. ...
... It is unlikely an OPC can facilitate every consumption event in an area for this reason (104). We also know that the risks of overdose increase outside of hours of opening (107,184,199,422). Support can mitigate some of these such as Buddy Up which can support individuals using drugs alone, the provision of take-home naloxone, and risk-prevention measures. ...
... Efficient handling of overdose events at an OPC can avoid the need for an ambulance call-out and/or an emergency department visit. from the Sydney OPC noted ambulance call outs for overdose were reduced by 68% during the time in which the OPC was open(107). Evidence from an OPC in Calgary found that the need for ambulance responses to overdoses had ...
... In total, there were 24 articles reviewed, 13 articles of which were from Canada, with 11 from Vancouver ( Andresen and Boyd, 2010 ;DeBeck et al., 2011 ;Irvine et al., 2019 ;Kennedy, et al., 2019Kennedy, et al., a, 2019Kennedy et al., 2020 ;Marshall et al., 2011 ;Pinkerton, 2010 ;Small et al., 2012 ), 1 from Ottawa ( Kerman et al., 2020 ), and 1 from Toronto ( Scheim et al., 2020 ). Three articles were from the United States ( Davidson et al., 2018 ;León et al., 2018 ;Olding et al., 2020 ), 2 from Australia ( Rance and Fraser, 2011 ;Salmon et al., 2010 ), and 6 from Europe ( Bergamo et al., 2019 ;Espelt et al., 2017 ;Folch, et al., 2018 ;Kinnard et al., 2014 ;Madah-Amiri et al., 2019 ;Scherbaum et al., 2010 ). The articles in this review included data collected from as early as 1998 ( Salmon et al., 2010 )) up until March 2020 ( Scheim et al., 2020 ). ...
... Three articles were from the United States ( Davidson et al., 2018 ;León et al., 2018 ;Olding et al., 2020 ), 2 from Australia ( Rance and Fraser, 2011 ;Salmon et al., 2010 ), and 6 from Europe ( Bergamo et al., 2019 ;Espelt et al., 2017 ;Folch, et al., 2018 ;Kinnard et al., 2014 ;Madah-Amiri et al., 2019 ;Scherbaum et al., 2010 ). The articles in this review included data collected from as early as 1998 ( Salmon et al., 2010 )) up until March 2020 ( Scheim et al., 2020 ). Among the 24 articles, there were a variety of research methods and analytic approaches, including cross-sectional methods, ethnographic fieldwork, and longitudinal observational analysis. ...
... logistic regression, Bayesian hierarchical models) ( Irvine et al., 2019 ;Kennedy, et al., 2019 a;Kennedy et al., 2020 ;Madah-Amiri et al., 2019 ), and 6 using longitudinal analyses (e.g. pretest/post-test) ( DeBeck et al., 2011 ;Espelt et al., 2017 ;Kennedy, et al., 2019 b;León et al., 2018 ;Marshall et al., 2011 ;Salmon et al., 2010 ). Finally, there were 7 articles using qualitative methods, including 5 using qualitative interviews ( Davidson et al., 2018 ;Kerman et al., 2020 ;Olding et al., 2020 ;Small et al., 2012 ) and 3 using recorded data or ethnographic fieldwork ( Bergamo et al., 2019 ;Rance and Fraser, 2011 ;Small et al., 2012 ). ...
Article
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Globally, the rate of injection drug use has increased, leading to a rise in injection-related injuries, infections, disease transmission, and death. Safe consumption facilities (SCFs) were developed with the aim of reducing injection-related disease transmission and death. There is a rapidly growing body of literature related the individual and community level outcomes associated with SCFs that warrants a comprehensive review. Thus, this scoping review examined the impact and effectiveness of SCFs related to: 1) individual outcomes for people who inject drugs; 2) community outcomes associated with SCFs; and 3) the cost-effectiveness of SCFs. The search strategy, developed by the lead author and a social work librarian, followed the PRISMA scoping review extension guidelines. We searched eight databases for peer-reviewed qualitative and quantitative articles published in English over the past decade, returning a total of 1,255 articles. After screening, we extracted data from 24 articles. Findings indicate that SCFs were associated with reducing drug use related infection and disease transmission, enhancing access to addiction and other health services, reducing the risk of non-fatal overdoses, and were not associated with a significant increase in drug use, an increased rate of drug-related crime. Both qualitative and quantitative research support SCFs as a cost-effective approach to harm reduction for people who inject drugs with positive community outcomes as well. This review discusses the current state of the evidence and provides recommendations for future research directions.
... 9,[17][18][19][20][21][22][23][24] The evidence supports positive impacts on both public health and order 15,25,26 and improvements in individual health outcomes. 27,28 Despite the growing evidence demonstrating the benefits of SIFs, the movement to establish and operate these facilities has often faced significant challenges. Notably, in 2016, the UK Advisory Committee on the Misuse of Drugs gave a recommendation to implement SIFs but was rejected by the UK government in 2017. ...
... Over 60 months following the opening of the Sydney MSIC, there was an 80% decrease in ambulance attendances in the immediate vicinity compared to a 45% decrease in neighbouring areas (45%). 27 Although ambulance attendance patterns in the rest of NSW also decreased by 61%, the area where the MSIC was located still showed a net benefit, with a greater reduction of 68%. The differences in decline seen in both comparisons were statistically significant. ...
... The differences in decline seen in both comparisons were statistically significant. 27 Also investigating the Sydney MSIC, Belackova et al 37 collected health and social information from clients using interviewer-administered questions similar to those collected from clients at registration. This data was then compared to data collected at the client's initial registration. ...
Article
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Background: Drug consumption rooms (DCRs) and supervised injecting facilities (SIFs) provide a safe environment in which people who inject drugs (PWIDs) can inject under hygienic and supervised conditions. Numerous reviews have documented the benefits of these facilities; however, there is a lack of clarity surrounding their long-term effects. Purpose: To conduct, with a systematic approach, a literature review, of published peer-reviewed literature assessing the long-term impacts of DCRs/SIFs. Methods: A systematic search of the PubMed and Embase database was performed using the keywords: ("SUPERVISED" OR "SAFE*") AND ("CONSUMPTION" OR "INJECT*" OR "SHOOTING") AND ("FACILITY*" OR "ROOM*" OR "GALLERY*" OR "CENTRE*" OR "CENTER*" OR "SITE*"). Included studies were original articles reporting outcomes for five or more years and addressed at least one of the following client or community outcomes; (i) drug-related harms; (ii) access to substance use treatment and other health services; (iii) impact on local PWID population; (iv) impact on public drug use, drug-related crime and violence; and (v) local community attitudes to DCRs. Results: Four publications met our inclusion criteria, addressing four of the five outcomes. Long-term data suggested that while the health of PWID naturally declined over time, DCRs/SIFs helped reduce injecting-related harms. The studies showed that DCRs/SIFs facilitate drug treatment, access to health services and cessation of drug injecting. Local residents and business owners reported less public drug use and public syringe disposal following the opening of a DCR/SIF. Conclusion: Long-term evidence on DCRs/SIFs is consistent with established short-term research demonstrating the benefits of these facilities. A relative paucity of studies was identified, with most evidence originating from Sydney and Vancouver. The overall body of evidence would be improved by future studies following outcomes over longer periods and being undertaken in a variety of jurisdictions and models of DCRs/SIFs.
... 17 Table 2 shows the summary results for the studies assigned greatest suitability of study design. There were significantly favorable results reported by this subset of studies across all outcome domains except for injection behaviors and harm reduction, which had 1 study 39 Marshall (2011) 41 Canada Greatest-good ++ Salmon (2010) 48 Australia Greatest-good ++ Linked study: Lloyd-Smith (2010). 39 Lloyd-Smith (2009) 37 Lloyd-Smith (2008) 43 Canada Least-fair ⌀ Madah-Amiri (2019) 40 Norway Least-good ++ Kerr (2005) 35 Canada Least-fair ++ Kerr (2006) 34 Canada Least-fair ⌀ Bravo (2009) 28 Spain Least-fair ++ Wood (2005) 53 Canada Least-fair ++ Stoltz (2007) 49 Canada Least-good ++ Gaddis (2017) 33 Canada Least-fair ++ Milloy (2010) 44 Canada Least-fair ⌀ McKnight (2007) 42 Canada Least-fair ++ Milloy (2009) 45 Canada Least-fair ⌀ Wood (2006) 52 Canada Least-fair ⌀ Wood (2004) 17 Canada Least-good ++ a ++ indicates favorable and significant (p<0.05); ...
... A total of 5 studies 31,40,41,43,48 reported outcomes relevant to overdose-induced mortality and morbidity. Two studies with the greatest suitability of design and good quality of execution (Marshall et al. 41 and Salmon and colleagues 48 ) found that illicit drug overdose deaths and opioid-involved overdoses, respectively, declined at a greater magnitude in the vicinity of a SIF than in the rest of the city/region. ...
... A total of 5 studies 31,40,41,43,48 reported outcomes relevant to overdose-induced mortality and morbidity. Two studies with the greatest suitability of design and good quality of execution (Marshall et al. 41 and Salmon and colleagues 48 ) found that illicit drug overdose deaths and opioid-involved overdoses, respectively, declined at a greater magnitude in the vicinity of a SIF than in the rest of the city/region. Marshall et al. 41 found a 26% net reduction in overdose deaths in the area immediately surrounding a SIF in Vancouver, Canada after its establishment compared with that in the rest of the city. ...
Article
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Context: Supervised injection facilities are harm reduction interventions that allow people who inject drugs to use previously obtained substances under the supervision of health professionals. Although currently considered illegal under U.S. federal law, several U.S. cities are considering implementing supervised injection facilities anyway as a response to the escalating overdose crisis. The objective of this review is to determine the effectiveness of supervised injection facilities, com- pared with that of control conditions, for harm reduction and community outcomes. Evidence Acquisition: Studies were identified from 2 sources: a high-quality, broader review examining supervised injection facility−induced benefits and harms (from database inception to January 2014) and an updated search using the same search strategy (January 2014‒September 2019). Systematic review methods developed by the Guide to Community Preventive Services were used (screening and analysis, September 2019‒December 2020). Evidence Synthesis: A total of 22 studies were included in this review: 16 focused on 1 supervised injection facility in Vancouver, Canada. Quantitative synthesis was not conducted given inconsis- tent outcome measurement across the studies. Supervised injection facilities in the included studies (n=number of studies per outcome category) were mostly associated with significant reductions in opioid overdose morbidity and mortality (n=5), significant improvements in injection behaviors and harm reduction (n=7), significant improvements in access to addiction treatment programs (n=7), and no increase or reductions in crime and public nuisance (n=7). Conclusions: For people who inject drugs, supervised injection facilities may reduce the risk of overdose morbidity and mortality and improve access to care while not increasing crime or public nuisance to the surrounding community.
... In this study, in every participating state, less than 10% of respondents reported that their libraries have restroom monitoring. While this type of policy could be perceived as unwanted surveillance, it also could provide a degree of supervision and protection for PWUD [32][33][34]. While increasing naloxone uptake in public libraries and establishing thoughtful policies may enhance public library employees' ability to respond to on-site drug use/overdose, these strategies do not address the drivers of public drug use/ overdose [5]. ...
... Research from facilities outside the U.S. found benefits among those who utilized SCF services, including reductions in risk of overdose mortality [37] and risk of HIV and HCV infection, [38,39] as well as improved access to drug treatment and social services [40,41]. SCFs were also associated with benefits to the surrounding community including reductions in public drug use, improperly discarded syringes, and ambulance calls [34,42,43]. While harm reduction strategies are needed to address the current state of substance use in public libraries, SCFs may offer a promising avenue to divert public drug use, and to ultimately decrease morbidity and mortality among PWUD. ...
Article
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In the U.S., overdoses have become a health crisis in both public and private places. We describe the impact of the overdose crisis in public libraries across five U.S. states, and the front-line response of public library workers. We conducted a cross-sectional survey, inviting one worker to respond at each public library in five randomly selected states (CO, CT, FL, MI, and VA), querying participants regarding substance use and overdose in their communities and institutions, and their preparedness to respond. We describe substance use and overdose patterns, as well as correlates of naloxone uptake, in public libraries. Participating library staff (N = 356) reported witnessing alcohol use (45%) and injection drug use (14%) in their libraries in the previous month. Across states surveyed, 12% of respondents reported at least one on-site overdose in the prior year, ranging from a low of 10% in MI to a high of 17% in FL. There was wide variation across states in naloxone uptake at libraries, ranging from 0% of represented libraries in FL to 33% in CO. Prior on-site overdose was associated with higher odds of naloxone uptake by the library (OR 2.5, 95% CI 1.1–5.7). Although 24% of respondents had attended a training regarding substance use in the prior year, over 90% of respondents wanted to receive additional training on the topic. Public health professionals should partner with public libraries to expand and strengthen substance use outreach and overdose prevention efforts.
... Additionally, studies have identified associations between SIF use and various positive changes in health-related outcomes among PWID, including reduced likelihood of engaging in injection practices associated with infectious disease transmission (e.g., syringe sharing), as well as increased uptake of addiction treatment and other health and social services [21,[32][33][34][35][36][37][38][39][40][41][42][43]. Past research has also found that SIFs contribute to reductions in overdose-related morbidity and mortality [13,[44][45][46][47][48][49]. For example, a geospatial analysis of death records demonstrated that the establishment of Insite in Vancouver was associated with a 35% population-level decrease in the fatal overdose rate in the area surrounding the SIF, compared to a 9% decrease in the rest of the city [44]. ...
... The 811 PWID included in present study were followed for a median duration of 72 months (interquartile range [IQR] 24-123) and collectively contributed a total of 4,928.1 person-years of observation. At baseline, 278 (34.3%) study participants were women, and the median age was 39 years (IQR [33][34][35][36][37][38][39][40][41][42][43][44][45][46]. A total of 432 (53.3%) participants reported frequent (i.e., at least weekly) SIF use at baseline. ...
Article
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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.
... 39 The implementation of OPCs has also been associated with a significant decrease in ambulance attendances at opioid-related overdoses in the community. 46 OPCs contribute to numerous positive public health outcomes beyond overdose prevention, as PWUD can readily access harm reduction services, medical care referrals, and social connection in these spaces. Some of these positive public health outcomes are described below. ...
Article
Given increasing rates of fatal overdoses in the United States and the rapidly changing drug supply, overdose prevention centers (OPCs; also known as safe consumption sites) have been identified as a vital, evidence-based strategy that provide people who use drugs (PWUD) the opportunity to use drugs safely and receive immediate, life-saving overdose support from trained personnel. In addition to providing a safe, supervised space to use drugs, OPCs can house further essential harm reduction drop-in services such as sterile supplies, social services, and medical care. There are established national and international data demonstrating the lifesaving services provided by OPCs, inspiring a groundswell of advocacy efforts to expand these programs in the United States. Thus, the Association for Multidisciplinary Education and Research in Substance Use and Addiction (AMERSA) endorses OPCs, in addition to other harm reduction strategies that protect PWUD. Ultimately, it is imperative to increase access to OPCs across the United States and support key policy changes at the local, state, and federal levels that would facilitate urgent expansion.
... However, only two evaluations of SCS using population-level data on overdose outcomes have been conducted, and both assessed the effect of a single, standalone SCS at one timepoint, finding that SCS were associated with reduced overdose mortality and ambulance call-outs in surrounding areas. 15,16 Furthermore, these studies were conducted before the so-called fentanyl era, which began around 2016, 8 and it is plausible that the higher risk of overdose associated with fentanyl use could attenuate the effect of SCS on community-level overdose prevention. ...
... Drug-checking services (DCS) and harm reduction strategies mandated by law give drug users the chance to have their substances tested before consumption, and to consume previously acquired narcotics under the supervision of medical specialists [119,120]. Based on data from multiple studies, it has been determined that supervised injection facilities are primarily linked to significant decreases in opioid overdose morbidity and mortality, improvements in injection practices and harm reduction, significant increases in access to addiction treatment programs, positive behavior change, and the reduction of harm without having any impact on crime or public nuisance [119,[121][122][123][124][125][126]. ...
Article
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This review article offers an outlook on the use of opioids as therapeutics for treating several diseases, including cancer and non-cancer pain, and focuses the analysis on the opportunity to target opioid receptors for treating opioid use disorder (OUD), drug withdrawal, and addiction. Unfortunately, as has been well established, the use of opioids presents a plethora of side effects, such as tolerance and physical and physiological dependence. Accordingly, considering the great pharmacological potential in targeting opioid receptors, the identification of opioid receptor ligands devoid of most of the adverse effects exhibited by current therapeutic agents is highly necessary. To this end, herein, we analyze some interesting molecules that could potentially be useful for treating OUD, with an in-depth analysis regarding in vivo studies and clinical trials.
... Research on supervised consumption and overdose prevention sites elsewhere has identified benefits, including a decrease in overdose fatalities and an increase in access to addiction services in Vancouver, Canada, and a reduction in ambulance visits in Sydney, Australia. [3][4][5] Community-based nalox one programs have found success in the United States, with a region in Massachusetts identifying a decrease in fatalities and a region of North Carolina reporting reduced health care costs. 6,7 However, since 2019, 3 out of 7 supervised consumption sites in the province of Alberta have been closed, and implementation of 2 additional sites has been halted by provincial authorities. ...
Article
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Background: To date, there has been little research on the effect of safe consumption site and community-based naloxone programs on regional opioid-related emergency department visits and deaths. We sought to determine the impact of these interventions on regional opioid-related emergency department visit and death rates in the province of Alberta. Methods: We used a retrospective observational design, via interrupted time series analysis, to assess municipal opioid-related emergency department visit volume and opioid-related deaths (defined by poisoning and opioid use disorder). We compared rates before and after program implementation in individual Alberta municipalities and province-wide after safe consumption site (March 2018 to October 2018) and community-based naloxone (January 2016) program implementation. Results: A total of 24 107 emergency department visits and 2413 deaths were included in the study. After safe consumption site opening, we saw decreased opioid-related emergency department visits in Calgary (level change -22.7 [-20%] visits per month, 95% confidence interval [CI] -29.7 to -15.8) and Lethbridge (level change -8.8 [-50%] visits per month, 95% CI -11.7 to -5.9), and decreased deaths in Edmonton (level change -5.9 [-55%] deaths per month, 95% CI -8.9 to -2.9). We observed increased emergency department visits after community-based naloxone program implementation in urban Alberta (level change 38.9 [46%] visits, 95% CI 33.3 to 44.4). We also observed an increase in urban opioid-related deaths (level change 9.1 [40%] deaths, 95% CI 6.7 to 11.5). Interpretation: The results of this study suggest differences exist between municipalities employing similar interventions. Our results also suggest contextual variation; for example, illicit drug supply toxicity may modify the ability of a community-based naloxone program to prevent opioid overdose without a thorough public health response.
... Studies in Europe, Canada, and Australia support that OPCs reduce the adverse harms associated with substance use. OPCs are associated with safer substance use, increased service connections, and decreased overdoses (Potier et al., 2014), and overdose deaths are greatly reduced in the area surrounding an OPC compared to the rest of a city (Marshall et al., 2011;Salmon et al., 2010). Additionally, OPCs are associated with decreased syringe/needle sharing, syringe/needle reuse, and public injections (Levengood et al., 2021;Myer & Belisle, 2018;Stoltz et al., 2007). ...
... Since the first drug consumption site opened in Switzerland in 1986, additional facilities have become operational in countries including Australia, Canada, the Netherlands, Germany, Spain, and Norway [5]. Since establishment of these programs, numerous independent studies have demonstrated SIFs to be associated with decreases in overdose morbidity and mortality, decreases in HIV and injectionassociated infections, enrollment in detoxification and rehabilitation services, decreases in outdoor injecting, reduction in equipment sharing, and delays in average onset of injection drug use [6][7][8][9][10][11]. In addition, multiple studies have observed community benefits related to the presence of SIFs, including decreases in criminal incidents related to drug use, decreases in publicly discarded injection equipment, decreases in average usage of ambulatory services, as well as overall cost-effectiveness [6,12]. ...
Article
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Background Supervised injection facilities (SIFs) provide spaces where persons who inject drugs (PWID) can inject under medical supervision and access harm reduction services. Though SIFs are not currently sanctioned in most of the US, such facilities are being considered for approval in several Upstate New York communities. No data exist from PWID in Upstate New York, and little from outside major US urban centers, on willingness to use SIFs and associated factors. Methods This analysis included 285 PWID (mean age = 38.7; 57.7% male; 72.3% non-Hispanic white) recruited for a study on hepatitis C prevalence among PWID in Upstate New York, where participants were recruited from syringe exchange programs ( n = 80) and able to refer other PWID from their injection networks ( n = 223). Participants completed an electronic questionnaire that included a brief description of SIFs and assessed willingness to use SIFs. We compared sociodemographic characteristics, drug use/harm reduction history, healthcare experience, and stigma between participants who were willing vs. unwilling to use such programs. Results Overall, 67.4% were willing to use SIFs, 18.3% unwilling, and 14.4% unsure. Among those reporting being willing or unwilling, we found higher willingness among those who were currently homeless (91.8% vs. 74.6%; p = 0.004), who had interacted with police in the past 12 months (85.7% vs. 74.5%; p = 0.04), and who were refused service within a healthcare setting (100% vs. 77.1%; p = 0.03). Conclusion Our results support SIF acceptability in several Upstate New York PWID communities, particularly among those reporting feelings of marginalization. A large proportion reported being unsure about usage of SIFs, suggesting room for educating PWID on the potential benefits of this service. Our results support SIF acceptability in Upstate New York and may inform programming for underserved PWID, should SIFs become available.
... Future studies are needed to explore the positioning and role of law enforcement in providing overdose response and ongoing care for PWUO in Ohio. Given the overwhelming burden placed on law enforcement and emergency responders, the presence of safe injection sites with staff trained to administer naloxone could alleviate ambulance calls and reduce fatal overdose rates [31][32][33]. ...
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Background Naloxone is a life-saving and easy-to-administer opioid antagonist medicine. Despite naloxone's legality in Ohio, unintentional drug overdoses remain the leading cause of injury deaths. Understanding the barriers and facilitators to naloxone's community uptake will help inform interventions to increase the awareness, accessibility, and use of naloxone. Our study aimed to identify barriers and facilitators to opioid overdose reversal uptake to inform community-driven interventions. Methods We conducted in-depth interviews and focus group discussions with people who use opioids, community members, and key stakeholders in Central Ohio from February 2019 to October 2019. We used qualitative thematic analysis to identify barriers and facilitators to the uptake of naloxone in a community setting. We classified barriers and facilitators to community naloxone uptake using the socio-ecological model's exterior levels – organizational, community, and societal. Results A total of 47 Central Ohio residents participated in five focus group discussions and fifteen in-depth interviews. Community members (n = 23), harm reduction service providers (n = 4), and religious organizational staff (n = 5) participated in focus group discussions ranging in size from 4 to 10 participants. We conducted in-depth interviews with law enforcement officers (n = 3), pharmacists (n = 2), and people who use opioids (n = 10). At the organizational level, access to naloxone, lack of resources, organizational stigma, and misinformation emerged as barriers. In contrast, naloxone awareness and availability, safe spaces for people who use opioids, and organizational collaboration emerged as facilitators. We identified the following community-level barriers: naloxone misinformation, knowledge, awareness, and substance use stigma. Perspectives on collective responsibility to administer naloxone was identified as both a barrier and facilitator. At the societal level, despite Ohio's Good Samaritan law and the legality of naloxone, poor communication of naloxone laws was a prevalent barrier to naloxone uptake, as was the burden of law enforcement to respond to and manage overdoses. Conclusions Community-based interventions that develop collaborations among local organizations to provide naloxone information, training, and distribution may address prominent barriers to naloxone uptake and reduce the current burden of law enforcement to respond to overdoses. Future interventions should also dispel naloxone misinformation, substance-use stigma, and confusion about the legal consequences of administering naloxone.
... One ecological before-after study showed a 35% decrease in fatal overdoses after the opening of the first DCR in Canada, 23 whereas another in Australia found a link between calls to emergency services for opioid-related overdoses and the opening hours of a DCR in Sydney. 24 However, no study to date has compared overdoses between DCR-exposed and non-exposed PWID. Moreover, studies evaluating the impact of DCR have not taken into account the potential bias related to specific characteristics of the population of PWID attending DCRs by comparing exposed participants to those unexposed. ...
Article
Background The effectiveness of drug consumption rooms (DCRs) for people who inject drugs (PWID) has been demonstrated for HIV and hepatitis C virus risk practices, and access to care for substance use disorders. However, data on other health-related complications are scarce. Using data from the French COSINUS cohort, we investigated the impact of DCR exposure on non-fatal overdoses, abscesses and emergency department (ED) visits, all in the previous 6 months. Methods COSINUS is a 12-month prospective cohort study of 665 PWID in France studying DCR effectiveness on health. We collected data from face-to-face interviews at enrolment, and at 6 and 12 months of follow-up. After adjusting for other correlates (P-value < 0.05), the impact of DCR exposure on each outcome was assessed using a two-step Heckman mixed-effects probit model, allowing us to adjust for potential non-randomization bias due to differences between DCR-exposed and DCR-unexposed participants, while taking into account the correlation between repeated measures. Results At enrolment, 21%, 6% and 38% of the 665 participants reported overdoses, abscesses and ED visits, respectively. Multivariable models found that DCR-exposed participants were less likely to report overdoses [adjusted coefficient (95% CI): −0.47 (−0.88; −0.07), P = 0.023], abscesses [−0.74 (−1.11; −0.37), P < 0.001] and ED visits [−0.74 (−1.27; −0.20), P = 0.007]. Conclusion This is the first study to show the positive impact of DCR exposure on abscesses and ED visits, and confirms DCR effectiveness in reducing overdoses, when adjusting for potential non-randomization bias. Our findings strengthen the argument to expand DCR implementation to improve PWID injection environment and health.
... D rug consumption rooms (DCRs) are a proven efficacious public health approach to reducing HIV 1 and hepatitis infection via decreased syringe sharing and discarded syringes in public space 2,3 as well as to prevent overdose. [4][5][6] Thus, DCRs may be a suitable tool for fighting the dramatic opioid overdose crisis in North America. ...
Article
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Drug consumption rooms (DCRs) have the potential to have a positive impact on the opioid overdose crisis. DCRs could also potentially change the political environment for public health because they can affect the distribution of responsibility for harm reduction between the individual and society by collectivizing responsibility for harm reduction through welfare regimes. The methodology is based on 2 case studies-1 in Copenhagen, Denmark, and 1 in Paris, France-about residents, people who inject drugs (PWID), and politicians' experiences of DCRs involving semidirective interviews. Denmark has a long history of harm-reduction policy, and the implementation of DCRs in Copenhagen has happened through close collaboration between local authorities and the local community. France is far more centralized and paternalistic in terms of the distribution of authority and decision-making in welfare and drug policy. Difficulties in cohabitation between local residents and PWID happened in both countries and can sometimes make public authorities hesitate to implement DCRs because of the NIMBY ("not in my backyard") phenomenon. However, the Danish and French case studies show that DCRs have the potential to become an instrument for civic cohabitation as well as to contribute to the destigmatization and health of PWID. (Am J Public Health. 2022;112(S2):S159-S165. https://doi.
... 4 DCRs are one form of structural intervention among many that have proven effective in reducing overdose, thereby protecting the welfare of vulnerable people who use drugs. [5][6][7] DCRs seek to adapt the drug use and social environment to make these safer in the face of multiple risks and constraints. 8 Yet, the introduction of DCRs has become a matter of controversy, including in policy environments that historically enable harm reduction approaches, such as the United Kingdom. ...
... D rug consumption rooms (DCRs) are a proven efficacious public health approach to reducing HIV 1 and hepatitis infection via decreased syringe sharing and discarded syringes in public space 2,3 as well as to prevent overdose. [4][5][6] Thus, DCRs may be a suitable tool for fighting the dramatic opioid overdose crisis in North America. ...
Article
Full-text available
Drug consumption rooms (DCRs) have the potential to have a positive impact on the opioid overdose crisis. DCRs could also potentially change the political environment for public health because they can affect the distribution of responsibility for harm reduction between the individual and society by collectivizing responsibility for harm reduction through welfare regimes. The methodology is based on 2 case studies—1 in Copenhagen, Denmark, and 1 in Paris, France—about residents, people who inject drugs (PWID), and politicians’ experiences of DCRs involving semidirective interviews. Denmark has a long history of harm-reduction policy, and the implementation of DCRs in Copenhagen has happened through close collaboration between local authorities and the local community. France is far more centralized and paternalistic in terms of the distribution of authority and decision-making in welfare and drug policy. Difficulties in cohabitation between local residents and PWID happened in both countries and can sometimes make public authorities hesitate to implement DCRs because of the NIMBY (“not in my backyard”) phenomenon. However, the Danish and French case studies show that DCRs have the potential to become an instrument for civic cohabitation as well as to contribute to the destigmatization and health of PWID. (Am J Public Health. 2022;112(S2):S159–S165. https://doi.org/10.2105/AJPH.2022.306808 )
... De même, les études internationales suggèrent que les SCMR permettent une baisse des surdoses mortelles liées à l'injection (Potier et al., 2014 ;Marshall et al., 2011 ;Salmon et al., 2010 ;Milloy et al., 2008 ;Kennedy et al., 2019). La fréquentation d'une SCMR semble également diminuer les risques liés aux pratiques d'injection et améliorer l'accès aux soins : moins d'injections précipitées, une meilleure gestion des seringues usagées, un meilleur accès à des médicaments de l'addiction aux opiacés et une meilleure prise en charge addictologique (Petrar et al., 2007 ;Kinnard et al., 2014 ;Stoltz et al., 2007 ;DeBeck et al., 2011;Evan Wood, Tyndall, Zhang, et al., 2006;Evan Wood et al., 2007 ;Kimber et al., 2008 ;Folch et al., 2018a ;Krüsi et al., 2009 ;Kerman et al., 2020). ...
... Three common interventions are supervised injection facilities (SIF), needle and syringe programmes (NSP) and opioid agonist treatment (OAT). 1 While there is considerable evidence that SIFs, NSPs and OAT help mitigate morbidity and mortality from overdoses, HIV and hepatitis C (HCV), these interventions remain politically controversial. [2][3][4][5][6][7][8] Critical gaps in the literature contribute to the underrating of these harm reduction interventions as crucial health services. For starters, much of the available research is specific to the concentrated epidemics of Vancouver's Downtown Eastside and Sydney's 'red light' district. ...
Article
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Introduction The main harm reduction interventions for people who inject drugs (PWID) are supervised injection facilities, needle and syringe programmes and opioid agonist treatment. Current evidence supporting their implementation and operation underestimates their usefulness by excluding skin, soft tissue and vascular infections (SSTVIs) and anoxic/toxicity-related brain injury from cost-effectiveness analyses (CEA). Our goal is to conduct a comprehensive CEA of harm reduction interventions in a setting with a large, dispersed, heterogeneous population of PWID, and include prevention of SSTVIs and anoxic/toxicity-related brain injury as measures of benefit in addition to HIV, hepatitis C and overdose morbidity and mortalities averted. Methods and analysis This protocol describes how we will develop an open, retrospective cohort of adult PWID living in Québec between 1 January 2009 and 31 December 2020 using administrative health record data. By complementing this data with non-linkable paramedic dispatch records, regional monthly needle and syringe dispensation counts and repeated cross-sectional biobehavioural surveys, we will estimate the hazards of occurrence and the impact of Montréal’s harm reduction interventions on the incidence of drug-use-related injuries, infections and deaths. We will synthesise results from our empirical analyses with published evidence to simulate infections and injuries in a hypothetical population of PWID in Montréal under different intervention scenarios including current levels of use and scale-up, and assess the cost-effectiveness of each intervention from the public healthcare payer’s perspective. Ethics and dissemination This study was approved by McGill University’s Institutional Review Board (Study Number: A08-E53-19B). We will work with community partners to disseminate results to the public and scientific community via scientific conferences, a publicly accessible report, op-ed articles and open access peer-reviewed journals.
... While positive changes in state health policy have been introduced in recent years, including a 7-day limit to first opioid analgesic prescription, implementation of a prescription drug monitoring program, initiation of new syringe services programs, and development of statewide overdose education and naloxone distribution program, high rates of opioid-related overdoses have persisted in MA and present a substantial public health challenge, meriting further research. In the recent years, the success of these safe injection sites in other nations [18,19] has prompted increased interest in establishment of safe injection sites in the USA. A recent letter to the editor published in NEJM describes the effectiveness of an unsanctioned injection site in the USA [20,21], and in July 2021, Rhode Island passed legislation to plan and pilot safe consumption spaces. ...
Article
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Background People who experience non-fatal overdose (NFOD) are at high risk of subsequent overdose. With unprecedented increases in fentanyl in the US drug supply, many Massachusetts (MA) communities have seen a surge in opioid-related overdoses. The objective of this study was to determine factors associated with lifetime and past year NFOD in at-risk MA communities. Methods We conducted multiple rapid assessments among people who use drugs (PWUD) in eight MA communities using non-probability sampling (purposive, chain referral, respondent-driven) methods. We collected sociodemographic, substance use, overdose history, substance use treatment, and harm reduction services utilization data. We examined the prevalence of NFOD (lifetime and past year) and identified factors associated with NFOD through multivariable logistic regression analyses in a subset of 469 study participants between 2017 and 2019. Results The prevalence of lifetime and last year non-fatal opioid overdose was 62.5% and 36.9%, respectively. Many of the study participants reported heroin (64%) and fentanyl (45%) use during the 30 days preceding the survey. Nonprescription buprenorphine and fentanyl use were independently associated with higher odds of lifetime NFOD, while marijuana use was associated with lower odds of lifetime NFOD ( p < 0.05). Injection as the route of administration, benzodiazepine, nonprescription buprenorphine, heroin, and fentanyl use were independently associated with higher odds, while methadone use was associated with lower odds of past year NFOD ( p < 0.05). Conclusion We documented a high prevalence of past year and lifetime NFOD among PWUD in MA. Our findings provide indicators that can help inform interventions to prevent overdoses among PWUD, including overdose prevention, medication treatment, and naloxone distribution.
... [41][42][43][44][45][46][47][48][49][50][51] Samples are also frequently identified through medical claims (eg, from health-care providers or prescription records), clinical (eg, emergency departments, hospital admissions, and community doctors), and criminal justice sources. [52][53][54][55][56][57][58] Emergency medical service data are often used in geographical analyses of overdoses [59][60][61] and have provided some of the earliest empirical evidence that overdoses are increasing during the COVID-19 pandemic. 37,38 Substantial variation exists across studies in the rates of opioid overdose (appendix p 5), with overdoses more common among men than among women. ...
Article
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A need exists to accurately estimate overdose risk and improve understanding of how to deliver treatments and interventions in people with opioid use disorder in a way that reduces such risk. We consider opportunities for predictive analytics and routinely collected administrative data to evaluate how overdose could be reduced among people with opioid use disorder. Specifically, we summarise global trends in opioid use and overdoses; describe the use of big data in research into opioid overdose; consider the potential for predictive modelling, including machine learning, for prevention and monitoring of opioid overdoses; and outline the challenges and risks relating to the use of big data and machine learning in reducing harms that are related to opioid use. Future research for improving the coverage and provision of existing interventions, treatments, and resources for opioid use disorder requires collaboration of multiple agencies. Predictive modelling could transport the concept of stratified medicine to public health through novel methods, such as predictive modelling and emulated trials for evaluating diagnoses and prognoses of opioid use disorder, predicting treatment response, and providing targeted treatment recommendations.
... Most reviews of SCS are strongly positive (e.g., Kennedy et al., 2017;Kerr et al., 2007;McNeil & Small, 2014;Potier et al., 2014), but as is true for many community-level interventions, few of the underlying studies provide insights about what would have happened had an SCS not opened in that community (Caulkins et al., 2019). Staff at the more than 150 SCSs around the world have reversed thousands of overdoses, but the modeling of population-level effects is largely based on outcomes in just three cities: Barcelona, Sydney, and Vancouver (Caulkins et al., 2019). 2 The higher quality quasi-experimental studies find no evidence that opening an SCS increases crime (Donnelly & Mahoney, 2013;Fitzgerald et al., 2010;Freeman et al., 2005) with one study demonstrating a decrease (Myer & Belisle, 2018), some evidence that SCS decrease fatal overdoses -one study (Marshall et al., 2011) found a reduction and another (Salmon et al., 2010) found no effect; however, the latter did find a reduction in ambulance call-outs for overdoses, and mixed evidence about the effect on discarded syringes (Espelt et al., 2017;Vecino et al., 2013). ...
Article
Background To address the overdose crisis in the United States, expert groups have been nearly unanimous in calls for increasing access to evidence-based treatment and overdose reversal drugs. In some places there have also been calls for implementing supervised consumption sites (SCSs). Some cities—primarily in coastal urban areas—have explored the feasibility and acceptability of introducing them. However, the perspectives of community stakeholders from more inland and rural areas that have also been hard hit by opioids are largely missing from the literature. Methods To examine community attitudes about implementing SCSs for people who use opioids (PWUO) in areas with acute opioid problems, the research team conducted in-depth interviews and focus groups in four counties: Ashtabula and Cuyahoga Counties in Ohio, and Carroll and Hillsborough Counties in New Hampshire, two states with high rates of opioid overdose. Participants were policy, treatment, and criminal justice professionals, frontline harm reduction and service providers, and PWUO. Results Key informants noted benefits to SCSs, but also perceived potential drawbacks such as that they may enable opioid use, and potential practical barriers, including lack of desire among PWUO to travel to an SCS after purchasing opioids and fear of arrest. Key informants generally believed their communities likely would not currently accept SCSs due to cultural, resource, and practical barriers. They viewed publication of evidence on SCSs and community education as essential for fostering acceptance. Conclusions Despite cultural and other barriers, implementation of SCSs may be more feasible in urban communities with existing (and perhaps more long-standing) harm reduction programs, greater treatment resources, and adequate transportation, particularly if there is strong evidence to support them.
... Fatal heroin overdose cases in which the final injection occurred in a public location were also observed to have shorter survival times, with corresponding less time to intervene ( Darke & Duflou, 2016 ). SIF and overdose prevention sites (OPSs) are designed to save lives and reduce public injection ( Boyd et al., 2018 ;Marshall, Milloy, Wood, Montaner, & Kerr, 2011 ;Salmon, Van Beek, Amin, Kaldor, & Maher, 2010 ) by providing people who use and inject drugs with a safe, supervised environment for the consumption of illicit drugs ( Pauly et al., 2020 ;Wood et al., 2003 ). In the event of an overdose, medical care can be provided immediately and onsite, and it has been estimated that between 2004 and 2008, 453 deaths were averted at Insite, the SIF located in Vancouver's Downtown East Side ( Milloy, Kerr, Tyndall, Montaner, & Wood, 2008 ). ...
Article
Background Non-fatal overdose (NFOD) is a major cause of morbidity among people who inject drugs (PWID) and multiple NFOD is associated with increased risk of fatal overdose. Despite this, few studies have examined the prevalence and correlates of drug-specific multiple NFOD. The current study aimed to determine the prevalence and correlates of recent multiple non-fatal opioid overdose (NFOOD) among PWID who access needle syringe programs (NSPs) in Australia. Methods The Australian Needle and Syringe Program Survey is conducted annually and was conducted at 46 sites across Australia in 2019. Participation involves completion of a self-administered questionnaire and a capillary dried blood spot for HIV and hepatitis C virus testing. In 2019, respondents who reported a minimum of one NFOOD in the previous 12 months (recent NFOOD) were asked to complete supplementary questions regarding their last NFOOD. Bivariate and multivariate logistic regression were used to determine factors independently associated with multiple recent NFOOD. Results A total of 222 respondents reported recent NFOOD. Respondents were predominantly male (59%), one third (39%) were aged less than 39 years and 73% reported last injecting heroin at their last NFOOD. One in two respondents (48%, n = 107) reported multiple opioid overdoses (median 3, interquartile range 2–5). The odds of reporting multiple NFOOD were higher among respondents who reported injecting in a public location at their last NFOOD (adjusted odds ratio [AOR] 2.10, 95% CI 1.14–3.90, p = 0.018) and benzodiazepine use in the 12 h prior to NFOOD (AOR 2.74, 95% CI 1.50–4.99, p = 0.001). Conclusions Multiple NFOOD was prevalent among PWID who utilised NSPs who reported recent NFOOD. Public injecting and benzodiazepine use were associated with increased risk of multiple NFOOD, and there is a need for interventions specifically targeting PWID who report these high risk injecting practices.
... SCS have an expanded mandate and allow clients to consume drugs under supervision using various routes of administration (e.g., smoke, snort, swallow and/or inject). Outcome studies show that SCS contribute to a reduction in: overdose deaths (Andresen & Boyd, 2010;Hedrich, 2004;Marshall et al., 2011;Milloy et al., 2008); emergency department visits and ambulatory services for drug related issues (National Centre in HIV Epidemiology and Clinical Research (NCHECR), 2007;Salmon et al., 2010); and certain drug use behaviors such as sharing injection equipment (Evan et al., 2005;Kinnard et al., 2014;Stoltz et al., 2007) among numerous other benefits Lange & Bach--Mortensen, 2019;Potier et al., 2014). SCS also contribute to a decrease in new HIV and Hepatitis C cases (Andresen & Boyd, 2010;Bayoumi & Zaric, 2008;Pinkerton, 2011). ...
Article
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.
... Evidence on the impacts of OPS demonstrates their significant association with reducing overdose fatalities, HIV and HCV transmission, syringe sharing, public injection, ambulance usage, and crime. [161][162][163][164] Furthermore, OPS increase entry into drug treatment, have never housed a fatal overdose, and have been found to be cost-effective. [165][166][167] There is one unsanctioned OPS documented in the United States, 168 although many more likely exist, and a number of US jurisdictions, including Maryland, are considering legislation to legalize these potentially lifesaving spaces. ...
Article
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Policy Points • This article reconceptualizes our understanding of the opioid epidemic and proposes six strategies that address the epidemic's social roots. • In order to successfully reduce drug‐related mortality over the long term, policymakers and public health leaders should develop partnerships with people who use drugs, incorporate harm reduction interventions, and reverse decades of drug criminalization policies. Context Drug overdose is the leading cause of injury‐related death in the United States. Synthetic opioids, predominantly illicit fentanyl and its analogs, surpassed prescription opioids and heroin in associated mortality rates in 2016. Unfortunately, interventions fail to fully address the current wave of the opioid epidemic and often omit the voices of people with lived experiences regarding drug use. Every overdose death is a culmination of a long series of policy failures and lost opportunities for harm reduction. Methods In this article, we conducted a scoping review of the opioid literature to propose a novel framework designed to foreground social determinants more directly into our understanding of this national emergency. The “continuum of overdose risk” framework is our synthesis of the global evidence base and is grounded in contemporary theories, models, and policies that have been successfully applied both domestically and internationally. Findings De‐escalating overdose risk in the long term will require scaling up innovative and comprehensive solutions that have been designed through partnerships with people who use drugs and are rooted in harm reduction. Conclusions Without recognizing the full drug‐use continuum and the role of social determinants, the current responses to drug overdose will continue to aggravate the problem they are trying to solve.
... The establishment and implementation of the Sydney MSIC in Australia was associated with a large decline in non-fatal opioid overdoses attended by ambulance (defi ned as ambulance attendances where naloxone was administered) in the areas surrounding the MSIC. This decline was statistically signifi cantly larger than any similar eff ects seen across Sydney and New South Wales more broadly (Salmon, van Beek, Amin, Kaldor, & Maher, 2010). Similarly, overdose death rates within 500 metres of the Vancouver facility declined following the implementation of the SIF, which was statistically signifi cantly greater than any decline seen in other areas of Vancouver (Marshall, Milloy, Wood, Montaner, & Kerr, 2011). ...
Article
Background: Harm reduction is an integral component of Australia’s overall national drug policy. Harm reduction policy and interventions can be applied to any legal or illegal drug to mitigate harm without necessarily reducing use, but harm reduction is traditionally conceptualised in relation to injecting drug use. Early and comprehensive adoption of many innovative harm reduction interventions has meant that Australia has had significant success in reducing a number of drug related harms, avoided disease epidemics experienced in other countries, and established programs and practices that are of international renown. However, these gains were not easily established, nor necessarily permanent. Aim: In this paper we explore the past and present harm reduction policy and practice contexts that normalised and facilitated harm reduction as a public health response, as well as those converse contexts currently creating opposition to additional or expanded interventions. Importantly, this paper discusses the intersection between various interventions, such as needle and syringe distribution and drug treatment programs. Finally, we detail some of the practical lessons that have been learned via the Australian experience, with the hope that these lessons will assist to inform and improve international harm reduction implementation.
... Community testing evaluations might usefully draw on drug consumption room evaluations not only in terms of monitoring referrals to drugs services, ambulance callouts and DRDs, but also utilising broader indicators of positive impact on local communities. [42][43][44] Leaving aside the potentially greater challenges and resource implications of evaluation, a key benefit of community-based drug safety testing is that if testing reaches beyond festival-goers, it provides an opportunity to engage with broader (including more disadvantaged or marginalised) drug using communities, thus becoming more inclusive and impactful. 41 This is particularly salient given levels of opioid-related deaths around the world including in the UK, where over half of DRDs involve opiates. ...
Article
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Aims To explore the feasibility of delivering community‐based drug safety testing (drug checking), to trial service design characteristics and to compare with festival‐based testing. Methods In total, 171 substances of concern were submitted on 5 dates at 3 venues in 2 UK cities and tested using up to 6 analytical techniques. Test results and harm reduction advice were distributed directly to over 200 service users through 144 tailored healthcare consultations, to stakeholders, and through early warning systems, media and social media alerts. Results The 171 samples were submitted and identified as MDMA (43.3%), cocaine (12.9%), ketamine (12.9%), various psychedelics submitted by students, and heroin and a synthetic cannabinoid submitted by rough sleeping communities, with 76% of samples' test results as expected. The 144 primary service users identified as 91.7% white, 68.1% male, with an average age of 26.7 years. Reported harm reduction intentions included alerting friends and acquaintances (37.5%), being more careful mixing that substance (35.4%), lowered dosage (27.8%), disposal of further substances (6.9%) and additionally 2.8% handed over further substances for verified destruction. Conclusion Community‐based drug safety testing (drug checking) was piloted for the first time in the UK—within a drugs service, a community centre and a church—with consideration given to meso‐level operational feasibility and micro‐level behavioural outcomes. Service design characteristics such as venue, day of week, prior publicity, service provider, and direct and indirect dissemination of results all may impact on outcomes. Future studies should consider cost–benefit analyses of community and event‐based testing and context‐appropriate macro, meso and micro‐level evaluations.
... In a study of heroin overdoses at the MSIC, it was found that between May 2001 and October 2002 the facility managed 409 drug overdoses, the majority of which were related to heroin (80%) and none of which resulted in a fatality (van Beek, Kimber, Dakin, & Gilmour, 2010). Another study found that in the area surrounding Sydney's injecting centre, ambulance callouts related to overdoses were 68% lower while the facility was open (Salmon, van Beek, Amin, Kaldor, & Maher, 2010). ...
Article
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Sydney’s Medically Supervised Injecting Centre in Kings Cross has been a major national and global example of successful harm reduction in relation to illicit drug use ever since it opened its doors 18 years ago. However, since then Sydney has undergone significant transformations as a city, including gentrification of the inner Sydney suburbs where the injecting centre operates and expansions to its Western and South Western suburbs where many of its injecting drug-using population reside. Furthermore, Australia is seeing growing public health concerns about steady increases in opioid overdose deaths worth comparing to the opioid crisis in the United States. Using data from the National Coronial Information System, we explore the distribution of overdose deaths across Sydney and in doing so make the case for the establishment of a second medically supervised injecting centre in Sydney’s outer suburbs.
... Research has also shown that SCS implementation does not increase crime and can lead to reductions in calls for emergency services [28,29]. A research study in Sydney, Australia examined calls to emergency responders for overdose and found an 80% reduction in calls in the area immediately surrounding the SCS during operating hours and a 45% reduction in calls across the broader surrounding area [30]. ...
Article
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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.
... These facilities aim to assist in reversing overdose events in real time (Wood, Montaner et al., 2004). They have also been successful in acting as low-threshold targets for drug treatment services , and decreasing public injecting, public overdosing, and ambulance callouts for overdose (Kerr, Tyndall, Li, Montaner, & Wood, 2005;Madah-Amiri et al., 2018;Salmon, Van Beek, Amin, Kaldor, & Maher, 2010;Wood, Small et al., 2004). ...
Article
Background: People who inject drugs (PWID) are at an elevated risk of fatal overdose in the first year after experiencing a non-fatal event. Such non-fatal events may also result in overdose-related sequelae, ranging from physical injury to paralysis. Given variation in drug markets and treatment availability across countries and regions, we may see similar variations in non-fatal overdose prevalence. Monitoring non-fatal overdose prevalence among PWID is essential for informing treatment intervention efforts, and thus our review aims to estimate the global, regional, and national prevalence of non-fatal overdose, and determine characteristics associated with experiencing such an event. Methods: We conducted a systematic review and meta-analyses to estimate country, regional, and global estimates of recent and lifetime non-fatal overdose prevalence among PWID. Using meta-regression analyses we also determined associations between sample characteristics and non-fatal overdose prevalence. Results: An estimated 3.2 (1.8-5.2) million PWID have experienced at least one overdose in the previous year. Among PWID, 20.5% (15.0-26.1%) and 41.5% (34.6-48.4%) had experienced a non-fatal event in the previous 12 months and lifetime respectively. Frequent injecting was strongly associated with PWID reporting recent and lifetime non-fatal overdose. Estimates of recent non-fatal overdose were particularly high in Asia and North America. Conclusion: Around one in five PWID are at an elevated risk of fatally overdosing every year, however there is substantial geographical variation. In countries with higher rates of non-fatal overdose there is need to introduce or mainstream overdose prevention strategies such as opioid agonist treatment and naloxone administration training programs.
... For example, one study found a significantly greater reduction in the number of fatal overdoses within 500 m of Insite than was observed in areas outside that radius [15]. A study from Sydney found no significant changes in fatal overdoses, but a significant reduction in ambulance service calls for overdose [16]. Specifically, opioid-related outcomes fell precipitously throughout the state of New South Wales because of Australia's heroin drought [17], but they fell even more precipitously near the MSIC. ...
Article
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Background and aims: Supervised consumption sites (SCS) operate in more than 10 countries. SCS have mostly emerged as a bottom-up response to crises, first to HIV/AIDS and now overdose deaths, in ways that make rigorous evaluation difficult. Opinions vary about how much favorable evidence must accumulate before implementation. Our aim was to assess the nature and quality of evidence on the consequences of implementing SCS. Methods: We reviewed the higher-quality SCS literature, focusing on articles evaluating natural experiments and mathematical modeling studies that estimate costs and benefits. We discuss the evidence through the lens of three types of decision makers and from three intellectual perspectives. Results: Millions of drug use episodes have been supervised at SCS with no reported overdose deaths; however, uncertainties remain about the magnitude of the population-level effects. The published literature on SCS is large and almost unanimous in its support but limited in nature and the number of sites evaluated. It can also overlook four key distinctions: (1) between outcomes that occur within the facility and possible spillover effects on behavior outside the SCS, (2) between effects of supervising consumption and the effects of other services offered, such as syringe or naloxone distribution, (3) between association and causation, and (4) between effectiveness and the cost-effectiveness of SCS compared to other interventions. Conclusions: The causal evidence for favorable outcomes of supervised consumption sites (SCS) is minimal, but there appears to be little basis for concern about adverse effects. This raises the question of how context and priors can affect how high the bar is set when deciding whether to endorse SCS. The literature also understates distinctions and nuances that need to be appreciated to have a rich understanding of how a range of stakeholders should interpret and apply that evidence to a variety of decisions.
... Such interventions are a key step towards preventing emergency health situations and reducing the burden on the emergency health system. Existing literature suggests that A c c e p t e d M a n u s c r i p t supervised injecting rooms may be useful in reducing ambulance attendances to opioid-related overdoses (25). Internationally, other novel models of care also exist which may reduce the burden on ambulance services and EDs, including sobering centres for acute alcohol intoxication (26). ...
Article
Objectives: Although the factors driving emergency department demand have been extensively investigated, comparatively little is known about the drivers of increasing emergency ambulance demand. Methods: We conducted a retrospective observational study of consecutive cases attended by Ambulance Victoria in Melbourne, Australia from 2008 to 2015. Incidence rates were calculated, and adjusted time series regression analyses were performed to assess drivers of ambulance demand. Results: A total of 2,443,952 consecutive cases were included. Demand grew by 29.2% over the eight-year period. The age-specific incidence increased significantly over time for patients aged <60 years, but not for patients aged ≥60 years. After adjustment for seasonality and population growth, demand increased by 1.4% per annum (incident rate ratio [IRR] = 1.014 [1.011-1.017]). The largest annual growth in demand was observed in patients with a history of mental health issues (IRR =1.058 [1.054-1.062]), alcohol/drug abuse (IRR =1.061 [1.056-1.066]) or a Charlson Comorbidity Index [CCI] score ≥4 (IRR =1.045 [1.039-1.051]). Cases involving patients of relative socio-economic/educational disadvantage, younger age, or with no pre-existing health conditions according to the CCI also grew faster than the overall patient population. Cases requiring transport to hospital increased by 1.2% annually (IRR =1.012 [1.009-1.016]), although patients not requiring medical intervention from paramedics increased by 6.7% annually (IRR =1.067 [1.063-1.072]). Conclusions: Increases in ambulance demand exceeded population growth. Emergency ambulances were increasingly utilised for transport of patients who did not require medical intervention from paramedics. Identifying the characteristics of patients driving ambulance demand will enable targeted demand management strategies.
Article
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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.
Article
Background: Overdose prevention sites (OPSs) are spaces where individuals can use pre-obtained drugs and trained staff can immediately intervene in the event of an overdose. While some OPSs use a combination of naloxone and oxygen to reverse overdoses, little is known about oxygen as a complementary tool to naloxone in OPS settings. We conducted a mixed methods study to assess the role of oxygen provision at a locally sanctioned OPS in San Francisco, California. Methods: We used descriptive statistics to quantify number and type of overdose interventions delivered in 46 weeks of OPS operation in 2022. We used qualitative data from OPS staff interviews to evaluate experiences using oxygen during overdose responses. Interviews were coded and thematically analyzed to identify themes related to oxygen impact on overdose response. Results: OPS staff were successful in reversing 100% of overdoses (n = 333) during 46 weeks of operation. Oxygen became available 18 weeks after opening. After oxygen became available (n = 248 overdose incidents), nearly all involved oxygen (91.5%), with more than half involving both oxygen and naloxone (59.3%). Overdoses involving naloxone decreased from 98% to 66%, though average number of overdoses concomitantly increased from 5 to 9 per week. Interviews revealed that oxygen improved overdose response experiences for OPS participants and staff. OPS EMTs were leaders of delivering and refining the overdose response protocol and trained other staff. Challenges included strained relationships with city emergency response systems due to protocol requiring 911 calls after all naloxone administrations, inconsistent supplies, and lack of sufficient staffing causing people to work long shifts. Conclusions: Although the OPS operated temporarily, it offered important insights. Ensuring consistent oxygen supplies, staffing, and removing 911 call requirements after every naloxone administration could improve resource management. These recommendations may enable success for future OPS in San Francisco and elsewhere.
Article
Drug consumption room literature often presents overdose as a stable phenomenon, which can be responded to in the same way from one context to the next. The literature is dominated by a clinical paradigm that implies that consumption rooms are effective because they provide sterile spaces and medical supervision, yet this is not the only way in which such services are delivered, nor is it the only component of the care provided at centers with a clinical focus. A growing body of critically oriented social science literature has highlighted the way different socio-material relations of care produce different capacities for service delivery. In order to expand the field’s understanding of care beyond an avowed a-political approach to clinical supervision, we conducted qualitative interviews with staff at Sydney Medically Supervised Injecting Centre (MSIC) about how they respond to overdose. Drawing on feminist notions of the politics of care we argue that overdoses are ontologically multiple phenomena, which are enacted at MSIC in ways that are explicitly differentiated from how they are understood and responded to in more traditional clinical settings. This illustrates how a desirable clinical intervention (saving lives) is made possible at MSIC through a set of constitutive relations (and politics) of care that are aimed at more than simply ensuring the client’s heart keeps beating.
Article
This innovative volume presents twenty comparative case studies of important global questions, such as 'Where should our food come from?' 'What should we do about climate change?' and 'Where should innovation come from?' A variety of solutions are proposed and compared, including market-based, economic, and neoliberal approaches, as well as those determined by humane values and ethical and socially responsible perspectives. Drawing on original research, its chapters show that more responsible solutions are very often both more effective and better aligned with human values. Providing an important counterpoint to the standard capitalist thinking propounded in business school education, People Before Markets reveals the problematic assumptions of incumbent frameworks for solving global problems and inspires the next generation of business and social science students to pursue more effective and human-centered solutions.
Chapter
This innovative volume presents twenty comparative case studies of important global questions, such as 'Where should our food come from?' 'What should we do about climate change?' and 'Where should innovation come from?' A variety of solutions are proposed and compared, including market-based, economic, and neoliberal approaches, as well as those determined by humane values and ethical and socially responsible perspectives. Drawing on original research, its chapters show that more responsible solutions are very often both more effective and better aligned with human values. Providing an important counterpoint to the standard capitalist thinking propounded in business school education, People Before Markets reveals the problematic assumptions of incumbent frameworks for solving global problems and inspires the next generation of business and social science students to pursue more effective and human-centered solutions.
Article
Background Substance use management in hospitals can be challenging. In response, a Canadian hospital opened an overdose prevention site (OPS) where community members and hospital inpatients can inject pre-obtained illicit drugs under supervision. This study aims to: (1) describe program utilization patterns; (2) characterize OPS visits; and (3) evaluate overdose events and related outcomes. Methods A retrospective chart review was completed at one hospital in Vancouver, Canada. All community members and hospital inpatients who visited the OPS between May 2018 and July 2019 were included. Client measures included: hospital inpatient status, use of intravenous access line for drug injection, and substances used. Program measures included: number of visits (daily/monthly), overdose (fatal/non-fatal) events and overdose-related outcomes. Results Overall, 11,673 OPS visits were recorded. Monthly visits increased from 306 to 1,198 between May 2018 and July 2019 respectively. On average, 26 visits occurred daily. Among all visits, 20% reported being a hospital inpatient, and 5% reported using a hospital intravenous access line for drug injection. Opioids (56%) and stimulants (24%) were the most common substances used. Overall 39 overdose events occurred - 82% required naloxone reversal, 28% required transfer to the hospital’s emergency department and none were fatal. Overdose events were more common among hospital inpatients compared to community clients (6.6 vs 2.2 per 1,000 visits respectively; p value = 0.046). Conclusions This unique OPS is an example of a hospital-based harm reduction initiative. Use of the site increased over time among both groups with no fatal overdose events occurring.
Article
Introduction The inclusion of people who use drugs in the design and evaluation of their health services remains a relatively new phenomenon. The aim of the research was to explore the experiences and perceptions of people accessing the Medical Supervised Injecting Centre (MSIC), and Clinic 180, Sydney Australia, and the factors facilitating and inhibiting their participation. The research was undertaken within a framework of critical ethnography. Methods Twenty‐three participants who inject drugs at the MSIC and five from Clinic 180 who chose not to use the MSIC were interviewed using semi‐structured interviews to hear and raise their experiences and perceptions of these services within their everyday lives. Results People who accessed the MSIC narrated a sense of personhood, survivor‐hood, community and belonging. The overarching emerging theme was “I’m Human.” People who accessed The Clinic services spoke of the MSIC as reinforcing the stigmatisation of the “users” and increasing the temptation to continue to inject drugs. Discussion This research gathered the experiences and perceptions of people accessing MSIC and Clinic 180. This can inform and reinforce public health and harm reduction approaches that embrace trauma informed care and social justice actions. This research also demonstrates the alignment between critical ethnography and the emerging models of co‐design, co‐production and health partnerships, sharing the shifting of power relations. Conclusion The experiences and perceptions of people who inject drugs, and an understanding of their everyday lives, are essential to the design and evaluation of the services they access.
Article
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Objectives To describe the association between population size, population growth and opioid overdose deaths—overall and by type of opioid—in US commuting zones (CZs) in three periods between 2005 and 2017. Settings 741 CZs covering the entirety of the US CZs are aggregations of counties based on commuting patterns that reflect local economies. Participants We used mortality data at the county level from 2005 to 2017 from the National Center for Health Statistics. Outcome Opioid overdose deaths were defined using underlying and contributory causes of death codes from the International Classification of Diseases, 10th revision (ICD-10). We used the underlying cause of death to identify all drug poisoning deaths. Contributory cause of death was used to classify opioid overdose deaths according to the three major types of opioid, that is, prescription opioids, heroin and synthetic opioids other than methadone. Results Opioid overdose deaths were disproportionally higher in largely populated CZs. A CZ with 1.0% larger population had 1.10%, 1.10%, and 1.16% higher opioid death count in 2005–2009, 2010–2014, and 2015–2017, respectively. This pattern was largely driven by a high number of deaths involving heroin and synthetic opioids, particularly in 2015–2017. Population growth over time was associated with lower age-adjusted opioid overdose mortality rate: a 1.0% increase in population over time was associated with 1.4% (95% CI: −2.8% to 0.1%), 4.5% (95% CI: −5.8% to −3.2%), and 1.2% (95% CI: −4.2% to 1.8%) lower opioid overdose mortality in 2005–2009, 2010–2014, and 2015–2017, respectively. The association between positive population growth and lower opioid mortality rates was stronger in larger CZs. Conclusions Opioid overdose mortality in the USA was disproportionately higher in mid-sized and large CZs, particularly those affected by declines in population over time, regardless of the region where they are located.
Article
Background and Aims In response to a dramatic rise in overdose deaths due to injection drug use, there was a rapid scale-up of low-threshold supervised injection services (SIS), termed ‘overdose prevention sites’ (OPS), in Vancouver, Canada in December 2016. We measured the potential impact of this intervention on SIS use and related health outcomes among people who inject drugs (PWID). Design Segmented regression analyses of interrupted time series data from two community-recruited prospective cohorts of PWID from January 2015 to November 2018 were used to measure the impact of the OPS scale-up on changes in SIS use, public injection, syringe sharing and addiction treatment participation, controlling for pre-existing secular trends. Setting Vancouver, Canada. Participants Of 745 PWID, 292 (39.7%) were women, 441 (59.6%) self-reported white ancestry and the median age was 47 years (interquartile range = 38, 53) at baseline. Measurements Immediate (i.e. step level) and gradual (i.e. slope) changes in the monthly proportion of participants who self-reported past 6-month SIS use, public injection, syringe sharing and participation in any form of addiction treatment. Findings Post OPS expansion, the monthly prevalence of SIS use immediately increased by an estimated 6.4% [95% confidence interval (CI) = 1.7, 11.2] and subsequently further increased by an estimated 0.7% (95% CI = 0.3, 1.1) per month. The monthly prevalence of addiction treatment participation immediately increased by an estimated 4.5% (95% CI = 0.5, 8.5) following the OPS expansion, while public injection and syringe sharing were estimated to immediately decrease by 5.5% (95% CI = 0.9, 10.0) and 2.5% (95% CI = 0.5, 4.6), respectively. Findings were inconclusive as to whether or not an association was present between the intervention and subsequent gradual changes in public injection, syringe sharing and addiction treatment participation. Conclusions Scaling-up overdose prevention sites in Vancouver, Canada in December 2016 was associated with immediate and continued gradual increases in supervised injection service engagement and immediate increases in related health benefits.
Article
Opioid use, particularly via injection, is associated with an increased risk of infection, injury, and death. Safer consumption sites (SCSs), where people may consume previously obtained drugs under observation, have been shown to reduce these risks among people who use drugs. Most SCSs employ nurses, but there is limited research into their roles. The objective of this article is to describe and synthesize the roles of nurses at SCSs to better understand their importance in a rapidly proliferating public health intervention. We extracted data from 48 qualitative, quantitative, peer-reviewed, and gray literature, as well as primary source narrative articles on SCSs, whether they were explicitly about nursing or not. We coded each mention of nurses or nursing in each article and identified 11 descriptive themes or roles that SCS nurses carry out. From these, we identified the following three analytical themes or hypotheses about the character of these roles: (a) The primary aim of SCS nursing care is to reduce morbidity and mortality; (b) SCS nurses create a therapeutic community; and (c) SCS nurses engage in research, professional activities, and activism to better understand and promote SCSs. More research into the roles of SCS nurses is needed to better serve a vulnerable population.
Preprint
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Background Supervised injection facilities (SIFs) provide spaces where persons who inject drugs (PWID) can inject under medical supervision and access harm reductions services. Though SIFs are not formally established in the US, such facilities are being considered for approval in several New York State (NYS) communities. No data exists from PWID in NYS, and little from outside major US urban centers, on willingness to use SIFs and associated factors. Methods This analysis included 285 PWID (mean age=38.7; 57.7% male; 72.3% non-Hispanic white) recruited for a study on hepatitis C prevalence among PWID in Upstate New York, where participants were recruited from syringe exchange programs (n=80) and able to refer other PWID from their injection networks (n=223). Participants completed an electronic questionnaire that included a brief description of SIFs and assessed willingness to use SIFs. We compared sociodemographic characteristics, drug use/harm reduction history, healthcare experience, and stigma between participants who were willing vs. unwilling to use such programs. Results Overall, 67.4% were willing to use SIFs, 18.3% unwilling, and 14.4% unsure. Among those reporting being willing or unwilling, we found higher willingness among those who were currently homeless (91.8% vs. 74.6%; p=0.004), who had interacted with police in the past 12 months (85.7% vs. 74.5%; p=0.04), and who were refused service within a healthcare setting (100% vs. 77.1%; p=0.03). Conclusion Our results support SIF acceptability in several Upstate New York PWID communities, particularly among those reporting feelings of marginalization. A large proportion reported being unsure about usage of SIFs, suggesting room for educating PWID on the potential benefits of this service. Our results support SIF acceptability in NYS and may facilitate reaching PWID subgroups that are most marginalized, should SIFs become available.
Technical Report
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The purpose of this needs assessment and feasibility study was to determine the conditions under which a supervised consumption site (SCS) would be used by people who use drugs in Somerville, Massachusetts; the feasibility of implementing an SCS in Somerville; and to identify concerns, challenges, and barriers that may be associated with opening an SCS
Article
Background: Opioid overdose is a leading cause of death in the United States. Emergency medical services (EMS) encounters following overdose may serve as a critical linkage to care for people who use drugs (PWUD). However, many overdose survivors refuse EMS transport to hospitals, where they would presumably receive appropriate follow-up services and referrals. This study aims to (1) identify reasons for refusal of EMS transport after opioid overdose reversal; (2) identify conditions under which overdose survivors might be more likely to accept these services; and (3) describe solutions proposed by both PWUD and EMS providers to improve post-overdose care. Methods: The study comprised 20 semi-structured, qualitative in-depth interviews with PWUD, followed by two semi-structured focus groups with eight EMS providers. Results: PWUD cited intolerable withdrawal symptoms; anticipation of inadequate care upon arrival at the hospital; and stigmatizing treatment by EMS and hospital providers as main reasons for refusal to accept EMS transport. EMS providers corroborated these descriptions and offered solutions such as titration of naloxone to avoid harsh withdrawal symptoms; peer outreach or community paramedicine; and addressing provider burnout. PWUD stated they might accept EMS transport after overdose reversal if they were offered ease for withdrawal symptoms, at either a hospital or non-hospital facility, and treated with respect and empathy. Conclusion: Standard of care by EMS and hospital providers following overdose reversal should include treatment for withdrawal symptoms, including buprenorphine induction; patient-centered communication; and effective linkage to prevention, treatment, and harm reduction services.
Article
Background Aiming to reducing overdose mortality, over 40 supervised drug consumption services (SCS) presently operate in Canada. Arguments against SCS include the potential for increased non-fatal overdoses mediated by risk compensation. This study estimates associations between SCS use and recent non-fatal overdose among people who inject drugs (PWID). Methods We analyzed cross-sectional baseline data collected between November 2018 and March 2020 from a cohort of adult PWID in Toronto, Canada. Recent non-fatal overdose was self-reported over the previous six months. The primary exposure was frequency of SCS use, self-reported as the proportion of injections performed at an SCS (all or most [75–100%], some [26–74%], few [≤25%], or none) in the previous six months. The prevalence of recent overdose was compared between all unique pairs of groups based on their frequency of SCS use and expressed as covariate-adjusted prevalence ratios (PR) estimated using modified Poisson regression. Results Among 701 PWID (median [IQR] age, 40 [33 to 49]; 64.3% cisgender men; 56.8% injecting daily), most reported SCS use (all/most, 26.2%; some, 30.9%; few, 29.4%) versus no use (13.5%), with 38.6% reporting a recent overdose. From adjusted regression analyses, more frequent SCS use was not statistically significantly associated with overdose when compared to either no SCS use or less frequent use. Associations between SCS use frequency and overdose were notably smaller among SCS clients compared to associations between SCS clients and non-users (e.g., all/most versus none: PR, 1.43 [95% CI, 0.93 to 2.21]; all/most versus some: PR, 0.94 [95% CI, 0.75 to 1.17]; all/most versus few: PR, 1.15 [95% CI, 0.89 to 1.48]). Conclusion Findings did not indicate statistically significant associations between SCS use frequency and recent non-fatal overdose, particularly among SCS clients who may be more comparable. Nevertheless, overdose was common, underscoring the need to prevent non-fatal overdose and associated morbidity.
Article
This article reviews the principles of harm reduction, evidence-based harm reduction strategies such as syringe service programs and supervised injection facilities, and provides approaches to integrating a harm reduction approach into clinical practice. As providers strive to increase capacity to treat underlying substance use disorder, we must also recognize that some people may continue to use drugs. In this setting, providers can still deliver nonjudgmental, individualized care, and advocate for the health and safety of people who inject drugs.
Article
Background US jurisdictions are considering implementing supervised drug consumption sites (SCSs) to combat the overdose epidemic. No sanctioned SCS exists in the US, but King County, Washington has proposed Community Health Engagement Locations (CHELs), which would include supervised drug consumption. We assessed characteristics of people engaged in syringe services programs (SSPs) who anticipated SCS use. Methods We estimated prevalence of anticipated SCS use in a 2017 cross-sectional sample of King County SSP participants (N = 377). We used Poisson regression with robust standard errors to estimate likelihood of anticipated SCS use by overdose history (experienced, witnessed only, neither), public injection frequency (always, some/most times, never), drug use behaviors, and sociodemographic characteristics. Results The sample was primarily male (66.8%), white (69.5%), and averaged 37 years old. Almost two-thirds of participants witnessed or experienced an overdose in the past year (43.2% witnessed only; 19.6% experienced overdose). Four in five SSP participants (83.0%) anticipated any SCS use. Anticipated SCS use was higher among participants who experienced an overdose (risk ratio [RR] = 1.14, 95% CI = 1.04, 1.24) than those with no overdose experience. In multivariable analyses, anticipated SCS use was higher among people reporting injecting publicly (e.g., always vs. never: aRR = 1.26, 95% CI = 1.11, 1.43), and lower among people primarily using methamphetamine (aRR = 0.80, 95% CI = 0.67, 0.96) compared to people primarily using opioids. Conclusions In King County, SCS services would be used by people at high risk of overdose, including SSP participants reporting injecting in public. SCSs could be an important step to promote health and safety across communities.
Technical Report
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Article
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Objective: To describe public opinion towards supervised injecting centres (SICs) and the Sydney Medically Supervised Injecting Centre (MSIC) before and after the opening of the MSIC. Methods: In 2000 and 2002, telephone interviews were conducted with 515 and 540 residents and 209 and 207 businesses in Kings Cross, Australia, 7 months before and 17 months after the MSIC opened in Kings Cross. Information was obtained on respondents’ characteristics, knowledge of the MSIC, and agreement with SICs. Differences in public opinion before and after the MSIC opened were assessed using the chi-square statistical test. Results: Two-thirds of the businesses and half the residents knew the correct location of the Sydney MSIC in 2002. The level of support for establishment of a MSIC in Kings Cross (68–78%, p<0.001) and other areas of high-drug use (71–80%, p=0.003) increased significantly among residents between 2000 and 2002. Both groups were more likely to disagree than agree that SICs would encourage illicit drug injection. Conclusion: Public opinion towards SICs and the establishment of the MSIC generally was supportive in the short-term. Assessing whether this level of support is sustained over time will involve further research that demonstrates the benefits and effectiveness of such facilities.
Article
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There has been a substantial increase in both the number and the rate of opiate overdose deaths in Australia over the past three decades. In 1964, there were 6 deaths due to opiates among those aged 15-44 years, compared to 600 in 1997. The pattern was similar when rates of death were examined, with an increase from 1.3 per 100 000 persons in 1964 to 71.5 in 1997 (Hall, Degenhardt, & Lynskey, 1999). Approximately half of these deaths occurred in NSW (Lynskey & Hall, 1998). Research suggests that 1-3% of heroin users will die from a heroin-related overdose each year (Darke & Zador, 1996). Non-fatal opiate overdoses are even more common among heroin users. Non-fatal overdoses may be defined as instances where loss of consciousness and depression of respiration occurs but is not fatal, due either to medical intervention or the good health of the person. Approximately two thirds (68%) of a sample of 300 long-term Sydney heroin users reported a non-fatal overdose at some point in their lives. Just under half of these (43%) reported an overdose within the past year, and 80% had witnessed the overdose of another person (Darke, Ross, & Hall, 1996a). Around half (56%) of one sample reported that an ambulance had been called for the most recent overdose they had witnessed (Darke, Ross, & Hall, 1996b). Because overdoses attended by ambulance officers are a more common occurrence than fatal overdoses, they provide an important source of information about heroin use. First, data on the number of ambulance calls to suspected drug overdoses provides an indication of trends in rates of heroin use in the community. Second, the location of ambulance attendances provides information about areas in which the use of heroin may be more common. The current report examined data on ambulance calls in New South Wales over a two-year period, July 1997 to June 1999. There are several elements of interest in the current report. First, we examined the number of these events that occurred over the period. Second, we explored of the quality of the data on these calls. Third, we examined the information that ambulance attendances provided on temporal and geographic trends in heroin use. Finally, we compared geographic data on ambulance attendances with data on fatal heroin overdose deaths in NSW.
Article
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Illicit drug overdose remains a leading cause of premature mortality in urban settings worldwide. We sought to estimate the number of deaths potentially averted by the implementation of a medically supervised safer injection facility (SIF) in Vancouver, Canada. The number of potentially averted deaths was calculated using an estimate of the local ratio of non-fatal to fatal overdoses. Inputs were derived from counts of overdose deaths by the British Columbia Vital Statistics Agency and non-fatal overdose rates from published estimates. Potentially-fatal overdoses were defined as events within the SIF that required the provision of naloxone, a 911 call or an ambulance. Point estimates and 95% Confidence Intervals (95% CI) were calculated using a Monte Carlo simulation. Between March 1, 2004 and July 1, 2008 there were 1004 overdose events in the SIF of which 453 events matched our definition of potentially fatal. In 2004, 2005 and 2006 there were 32, 37 and 38 drug-induced deaths in the SIF's neighbourhood. Owing to the wide range of non-fatal overdose rates reported in the literature (between 5% and 30% per year) we performed sensitivity analyses using non-fatal overdose rates of 50, 200 and 300 per 1,000 person years. Using these model inputs, the number of averted deaths were, respectively: 50.9 (95% CI: 23.6-78.1); 12.6 (95% CI: 9.6-15.7); 8.4 (95% CI: 6.5-10.4) during the study period, equal to 1.9 to 11.7 averted deaths per annum. Based on a conservative estimate of the local ratio of non-fatal to fatal overdoses, the potentially fatal overdoses in the SIF during the study period could have resulted in between 8 and 51 deaths had they occurred outside the facility, or from 6% to 37% of the total overdose mortality burden in the neighborhood during the study period. These data should inform the ongoing debates over the future of the pilot project.
Article
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Heroin users are at risk of overdose, sometimes with fatal consequences. Studies have examined accident and emergency room data1 and recorded deaths,2 though such figures underestimate the full extent to which overdoses occur and are only a rough indicator of the prevalence of overdose among drug takers. A recent Australian study reported that about two thirds of a sample of heroin injectors had taken an overdose.3 The present study describes the frequency of drug overdose and the factors related to overdose among heroin users recruited in non-clinical settings. During 1994, 438 heroin users were contacted and interviewed by privileged access interviewers4 as part of a study of early and episodic heroin users. Information on demographics, patterns of drug use, and overdose was collected by structured interviews. Onset of heroin use was comparatively recent for many of our sample (11% were in the first year of heroin use and 48% in the first three years of use), and …
Article
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In early 2001 there was a dramatic decline in the availability of heroin in New South Wales (NSW), Australia, where previously heroin had been readily available at a low price and high purity.1 The decline was confirmed by Australia's strategic early warning system, which revealed a reduction in heroin supply across Australia and a considerable increase in price,2 particularly from January to April 2001. This “heroin shortage” provided a natural experiment in which to examine the effect of substantial changes in price and availability on injecting drug use and its associated harms in Australia's largest heroin market,2 a setting in which harm reduction strategies were widely used. Publicly funded needle and syringe programmes were introduced to Australia in 1987, and methadone maintenance programmes, which were established in the 1970s, were significantly expanded in 1985 and again in 1999. In NSW needle and syringe programmes are delivered primarily within the public sector through area health services. There is also a private sector programme, subsidised by the government, delivered through pharmacies (known as “fitpacks”). …
Article
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North America's first medically supervised safer injecting facility for illicit injection drug users was opened in Vancouver on Sept. 22, 2003. Although similar facilities exist in a number of European cities and in Sydney, Australia, no standardized evaluations of their impact have been presented in the scientific literature. Using a standardized prospective data collection protocol, we measured injection-related public order problems during the 6 weeks before and the 12 weeks after the opening of the safer injecting facility in Vancouver. We measured changes in the number of drug users injecting in public, publicly discarded syringes and injection-related litter. We used Poisson log-linear regression models to evaluate changes in these public order indicators while considering potential confounding variables such as police presence and rainfall. In stratified linear regression models, the 12-week period after the facility's opening was independently associated with reductions in the number of drug users injecting in public (p < 0.001), publicly discarded syringes (p < 0.001) and injection-related litter (p < 0.001). The predicted mean daily number of drug users injecting in public was 4.3 (95% confidence interval [CI] 3.5-5.4) during the period before the facility's opening and 2.4 (95% CI 1.9-3.0) after the opening; the corresponding predicted mean daily numbers of publicly discarded syringes were 11.5 (95% CI 10.0-13.2) and 5.4 (95% CI 4.7-6.2). Externally compiled statistics from the city of Vancouver on the number of syringes discarded in outdoor safe disposal boxes were consistent with our findings. The opening of the safer injecting facility was independently associated with improvements in several measures of public order, including reduced public injection drug use and public syringe disposal.
Article
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The current study aimed to model the effect of Australia's first Medically Supervised Injecting Centre (MSIC) on acquisitive crime and loitering by drug users and dealers. The effect of the MSIC on drug-related property and violent crime was examined by conducting time series analysis of police-recorded trends in theft and robbery incidents, respectively. The effect of the MSIC on drug use and dealing was examined by (a) time series analysis of a special proxy measure of drug-related loitering; (b) interviewing key informants; and (c) examining trends in the proportion of Sydney drug offences that were recorded in Kings Cross. There was no evidence that the MSIC trial led to either an increase or decrease in theft or robbery incidents. There was also no evidence that the MSIC led to an increase in 'drug-related' loitering at the front of the MSIC after it opened, although there was a small increase in 'total' loitering (by 1.2 persons per occasion of observation). Trends in both 'drug-related' and 'total' loitering at the front of the MSIC steadily declined to baseline levels, or below, after it opened. There was a very small but sustained increase in 'drug-related' (0.09 persons per count) and 'total' loitering (0.37 persons per count) at the back of the MSIC after it opened. Key informant interviews noted an increase in loitering across the road from the MSIC but this was not attributed to an influx of new users and dealers to the area. There was no increase in the proportion of drug use or drug supply offences committed in Kings Cross that could be attributed to the opening of the MSIC. These results suggest that setting up an MSIC does not necessarily lead to an increase in drug-related problems of crime and public loitering.
Article
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Illicit use of injected drugs is linked with high rates of HIV infection and fatal overdose, as well as community concerns about public drug use. Supervised injecting facilities have been proposed as a potential solution, but fears have been raised that they might encourage drug use. A before and after study. Participants and setting 871 injecting drug users recruited from the community in Vancouver, Canada. Rates of relapse into injected drug use among former users and of stopping drug use among current users. Local health authorities established the Vancouver supervised injecting facility to provide injecting drug users with sterile injecting equipment, intervention in the event of overdose, primary health care, and referral to external health and social services. Analysis of periods before and after the facility's opening showed no substantial increase in the rate of relapse into injected drug use (17% v 20%) and no substantial decrease in the rate of stopping injected drug use (17% v 15%). Recently reported benefits of supervised injecting facilities on drug users' high risk behaviours and on public order do not seem to have been offset by negative community impacts.
Article
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North America's first medically supervised safer injecting facility (SIF) recently opened in Vancouver, Canada. One of the concerns prior to the SIF's opening was that the facility might lead to a migration of drug activity and an increase in drug-related crime. Therefore, we examined crime rates in the neighborhood where the SIF is located in the year before versus the year after the SIF opened. No increases were seen with respect to drug trafficking (124 vs. 116) or assaults/robbery (174 vs. 180), although a decline in vehicle break-ins/vehicle theft was observed (302 vs. 227). The SIF was not associated with increased drug trafficking or crimes commonly linked to drug use.
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Injection drug users (IDUs) are vulnerable to serious health complications resulting from unsafe injection practices. We examined whether the use of a supervised safer injection facility (SIF) promoted change in injecting practices among a representative sample of 760 IDUs who use a SIF in Vancouver, Canada. Consistent SIF use was compared with inconsistent use on a number of self-reported changes in injecting practice variables. More consistent SIF use is associated with positive changes in injecting practices, including less reuse of syringes, use of sterile water, swabbing injection sites, cooking/filtering drugs, less rushed injections, safe syringe disposal and less public injecting.
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To plan an appropriate response to heroin use in Australia, good estimates are needed of the numbers of dependent heroin users, the group who are most in need of treatment, most at risk of fatal opioid overdose and most at risk of contracting and transmitting blood-borne viruses. Back-projection methods were used to estimate the numbers of people starting dependent heroin injecting in Australia between 1960 and 1997. Separate analyses were based on national opioid overdose deaths and numbers of new entrants to methadone treatment in New South Wales (NSW). Estimates of the rates at which dependent heroin users cease heroin use, commence methadone treatment or die from opioid overdoses were estimated from external data sources. Back-projection estimates derived from opioid overdose deaths indicated that there were 104 000 (lower limit of 72 000 and upper limit of 157 000) people who were heroin dependent in Australia between 1960 and 1997. Of these it was estimated that 67 000 (39 000-120 000) were still heroin dependent at the end of 1997. Back-projection estimates based on numbers of new entrants to methadone treatment in NSW indicated that there were 108 000 (82 000-141 000) heroin-dependent people in Australia between 1960 and 1997, of whom 71 000 (47 000-109 000) were estimated to be heroin dependent at the end of 1997. Both analyses indicated that the number of heroin-dependent people in Australia has increased substantially from the early 1970s onwards. Back-projection estimates based on analyses of treatment entries and opioid overdose deaths provide an additional method for estimating the numbers of heroin-dependent people in the population. The addition of these methods to existing methods, using different data sources and statistical methods, should improve consensus estimates of the numbers of heroin-dependent people.
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Using data on New South Wales ambulance calls to suspected overdoses from July 1997 to June 1999 to: a) examine temporal and geographic trends in calls; and b) compare geographic patterns of fatal and non-fatal opioid overdose. The NSW Ambulance Service provided data on the occasions when an ambulance attended a person on whom the drug overdose/poisonings protocol was used, and to whom naloxone was administered. The geographic distribution of ambulance attendances was approximated to the Australian Bureau of Statistics Statistical Local Area (SLA) and Statistical Subdivision (SSD). Estimates of social disadvantage were correlated with the rate of ambulance attendances for each region. 9,116 callouts were made. In cases with data on age and gender, 89% were aged 15-44 years, and 31% were female. South Sydney (n=1,819) and Liverpool (n=1,602) SLAs accounted for 37% of calls; the higher rates outside Sydney were in Newcastle, Orange and Kiama. There was a strong correlation between rates of ambulance callouts and fatal heroin overdoses. The number of calls increased from an average of 361 calls per month in 1997-98 to 399 in 1998-99. The majority of calls (54%) were made between midday and 9 pm. Rates of ambulance attendance at suspected overdoses is a promising indicator that allows monitoring of trends and identification of areas with high rates of opioid use.
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In response to the rising concerns about the rate of heroin-related fatalities, overdose prevention campaigns, run by both users' organizations and government agencies, have been implemented in a number of states across Australia. In Western Australia (WA) in mid-1997, various overdose prevention initiatives were implemented. These included the implementation of a protocol limiting police presence at overdose events; the commencement of naloxone administration by ambulance staff; and the establishment of the Opiate Overdose Prevention Strategy (OOPS) which provided follow-up for individuals treated for overdose in emergency departments. This paper reports the results of a multiple linear regression analysis of 60 months of time-series data, both prior to and following the implementation of these interventions, to determine their impact on the number of fatal heroin overdoses inWA. The model employed in the analysis controlled for changes over time in proxy indicators of use and community concerns about heroin, as well as market indicators. The results suggest that, although the interventions implemented have managed to reduce the expected number of fatalities, they have become less successful in doing so as time passes. This has implications for both existing and potential interventions to reduce fatal heroin-related overdose.
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The monitoring of heroin use and related harms is undertaken in Australia with a view to inform policy responses. Some surveillance data on heroin-related harms is well suited to inform the planning and delivery of heroin-related services, such as needle and syringe provision. This article examines local-area variation in the characteristics of nonfatal heroin overdoses attended by ambulances in Melbourne over the period June 1998 to October 2000 to inform the delivery of services to the heroin-using population in Melbourne. Five so-called hot spot local government areas were considered in relation to the remainder of the Melbourne metropolitan area. Significant local-area variations in the characteristics of nonfatal heroin overdoses were evident over the study period, including the number of heroin overdoses, the age and sex of the people attended, the time of the attendance, the likelihood of hospitalization, and the likelihood of police coattendance. The implications of the findings are discussed in terms of service provision (e.g., opening hours) within the five hot spot local government areas, and it is argued that the analyses undertaken could easily be applied to other jurisdictions for which comparable data are available.
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In the past decade, the utilization of ambulance data to inform the prevalence of nonfatal heroin overdose has increased. These data can assist public health policymakers, law enforcement agencies, and health providers in planning and allocating resources. This study examined the 672 ambulance attendances at nonfatal heroin overdoses in Queensland, Australia, in 2000. Gender distribution showed a typical 70/30 male-to-female ratio. An equal number of persons with nonfatal heroin overdose were between 15 and 24 years of age and 25 and 34 years of age. Police were present in only 1 of 6 cases, and 28.1% of patients reported using drugs alone. Ambulance data are proving to be a valuable population-based resource for describing the incidence and characteristics of nonfatal heroin overdose episodes. Future studies could focus on the differences between nonfatal heroin overdose and fatal heroin overdose samples.
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In early 2001 in Australia there was a sudden and dramatic decrease in heroin availability that occurred throughout the country that was evidenced by marked increases in heroin price and decreases in its purity. This study examines the impact of this change in heroin supply on the following indicators of heroin use: fatal and non-fatal drug overdoses; treatment seeking for heroin dependence; injecting drug use; drug-specific offences; and general property offences. The study was conducted using data from three Australian States [New South Wales (NSW), Victoria (VIC) and South Australia (SA)]. Data were obtained on fatal and non-fatal overdoses from hospital emergency departments (EDs), ambulance services and coronial systems; treatment entries for heroin dependence compiled by State health departments; numbers of needles and syringes distributed to drug users; and data on arrests for heroin-related incidents and property-related crime incidents compiled by State Police Services. Time-series analyses were conducted where possible to examine changes before and after the onset of the heroin shortage. These were supplemented with information drawn from studies involving interviews with injecting drug users. After the reduction in heroin supply, fatal and non-fatal heroin overdoses decreased by between 40% and 85%. Despite some evidence of increased cocaine, methamphetamine and benzodiazepine use and reports of increases in harms related to their use, there were no increases recorded in the number of either non-fatal overdoses or deaths related to these drugs. There was a sustained decline in injecting drug use in NSW and VIC, as indicated by a substantial drop in the number of needles and syringes distributed (to 1999 levels in Victoria). There was a short-lived increase in property crime in NSW followed by a sustained reduction in such offences. SA and VIC did not show any marked change in the categories of property crime examined in the study. Substantial reductions in heroin availability have not occurred often, but in this Australian case a reduction had an aggregate positive impact in that it was associated with: reduced fatal and non-fatal heroin overdoses; reduced the apparent extent of injecting drug use in VIC and NSW; and may have contributed to reduced crime in NSW. All these changes provide substantial benefits to the community and some to heroin users. Documented shifts to other forms of drug use did not appear sufficient to produce increases in deaths, non-fatal overdoses or treatment seeking related to those drugs.
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Safer injection facilities provide medical supervision for illicit drug injections. We aimed to examine factors associated with syringe sharing in a community-recruited cohort of illicit injection drug users in a setting where such a facility had recently opened. Between Dec 1, 2003, and June 1, 2004, of 431 active injection drug users 49 (11.4%, 95% CI 8.5-14.3) reported syringe sharing in the past 6 months. In logistic regression analyses, use of the facility was independently associated with reduced syringe sharing (adjusted odds ratio 0.30, 0.11-0.82, p=0.02) after adjustment for relevant sociodemographic and drug-use characteristics. These findings could help inform discussions about the merits of such facilities.
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To the Editor: In September 2003, the first safer injecting facility in North America opened in Vancouver, Canada. Here, injection-drug users can inject preobtained illicit drugs under medical supervision.1 A concern regarding such facilities is that they may lessen the likelihood that injection-drug users will seek addiction-treatment services.2,3 Randomized trials are lacking to address this concern. We assessed factors associated with time to entry into a detoxification program at one of the city's three detoxification centers. We used data collected by means of a questionnaire as part of a cohort study (supported by Health Canada) of persons who use . . .
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In recent years, controversial interventions such as 'heroin-assisted treatment' (HAT) and 'supervised injection facilities' (SIFs) have been established in attempts to minimise the high morbidity and mortality consequences of illicit drug use. This paper examines public opinion towards HAT and SIF using data from the 2003 Centre for Addiction and Mental Health (CAMH) Monitor, a representative population survey conducted among adults residing in Ontario, Canada. Data relating specifically to SIFs and HAT were isolated from the main database (n=885); agreement scores were collapsed to create a scale and analysed using independent sample t-tests and ANOVAs. Results revealed that 60 percent (n=530) of the sample agreed that SIFs should be made available to injection drug users, while 40 percent (n=355) disagreed. When asked about the provision of HAT, a similar pattern emerged. Variables significantly associated with positive opinions toward SIFs and HAT were: income; higher education; the use of cocaine or cannabis within the last 12 months; being in favour of cannabis decriminalisation; support of needle exchange in prison; view of illicit drug users as ill people; and agreement that drug users are in need of public support. Given the current political climate and the tentative position of SIFs and HAT in Canada, understanding the public's opinion is crucial for the feasibility and long-term sustainability of these interventions.
New South Wales (NSW) Drug Summit 1999: Government Plan of Action