Injection Facilities Research Articles

Evaluation of a fentanyl drug checking service for clients of a supervised injection facility, Vancouver, Canada

BackgroundBritish Columbia, Canada, is experiencing a public health emergency related to opioid overdoses driven by consumption of street drugs contaminated with illicitly manufactured fentanyl. This cross-sectional study evaluates a drug checking intervention for the clients of a supervised injection facility (SIF) in Vancouver.MethodsInsite is a facility offering supervised injection services in Vancouver’s Downtown East Side, a community with high levels of injection drug use and associated harms, including overdose deaths. During July 7, 2016, to June 21, 2017, Insite clients were offered an opportunity to check their drugs for fentanyl using a test strip designed to test urine for fentanyl. Results of the drug check were recorded along with information including the substance checked, whether the client intended to dispose of the drug or reduce the dose and whether they experienced an overdose. Logistic regression models were constructed to assess the associations between drug checking results and dose reduction or drug disposal. Crude odds ratios (OR) and 95% confidence intervals (CI) were reported.ResultsAbout 1% of the visits to Insite during the study resulted in a drug check. Out of 1411 drug checks conducted by clients, 1121 (79.8%) were positive for fentanyl. Although most tests were conducted post-consumption, following a positive pre-consumption drug check, 36.3% (n = 142) of participants reported planning to reduce their drug dose while only 11.4% (n = 50) planned to dispose of their drug. While the odds of intended dose reduction among those with a positive drug check was significantly higher than those with a negative result (OR = 9.36; 95% CI 4.25–20.65), no association was observed between drug check results and intended drug disposal (OR = 1.60; 95% CI 0.79–3.26). Among all participants, intended dose reduction was associated with significantly lower odds of overdose (OR = 0.41; 95% CI 0.18–0.89).ConclusionsAlthough only a small proportion of visits resulted in a drug check, a high proportion (~ 80%) of the drugs checked were contaminated with fentanyl. Drug checking at harm reduction facilities such as SIFs might be a feasible intervention that could contribute to preventing overdoses in the context of the current overdose emergency.

Performance studies on homogeneous charge compression ignition (HCCI) engine powered with alternative fuels

Abstract Experiments were carried out on homogeneous charge compression ignition (HCCI) engine to study its performance at different hydrogen fuel energy ratio (HFER) and loads. The engine was powered with two fuels: Hydrogen (H2) as inducted fuel along with air and diesel/Biodiesel fuel (BDF) as injected fuel. Diesel and BDF were injected into the cylinder using common rail direct injection (CRDI) facility developed. Electronic control unit (ECU) was developed to inject the fuel at any required crank angle (CA) for any magnitude of duration. At 80% load, engine operation was associated with severe knocking without exhaust gas recirculation (EGR), however engine operated well only for EGR percentage about 50% and 54% with diesel and BDFs respectively. Beyond this EGR level, HCCI engine showed misfiring and unstable combustion. At this condition, maximum HFER possible was less than 8% in both diesel and biodiesel HCCI operations and misfiring occurred beyond HFER of 8%. The maximum brake thermal efficiency (BTE) of 31.5%, 30.6% and 30.2% were reported with diesel, honge biodiesel (BHO) and cotton seed biodiesel (BCO) respectively in diesel hydrogen HCCI (DHHCCI) and biodiesel hydrogen HCCI (BHHCCI) modes. At 80% load, HCCI engine powered with BDFs showed 65–67% lower smoke, and 98–99% lower NOx emissions with HFER of 7% and EGR of 54% as compared to conventional compression ignition (CI) mode. However this engine operation resulted in nearly 11 times higher HC emissions with HFER of 7% and EGR of 54%. Hence HCCI mode of engine operation could be a feasible technological option to minimize the pollution levels besides improving the fuel economy.

Risk Factors for Opioid Overdose

Opioid overdoses have risen starkly over the last two decades in the USA and are now among the leading causes of overall mortality. This review summarizes the current literature on risk factors for overdose as well as public health solutions. Although opioid overdose mortality is highest among men and non-Hispanic whites, the rate of death is rising more rapidly now among women and non-Hispanic blacks. Incarceration remains a significant risk factor for overdose death, especially in the first weeks upon reentry reflecting the absence of treatment in prisons and jails despite strong evidence for the benefits of pharmacotherapy integration into these settings. Pharmacotherapy with either methadone or buprenorphine greatly reduces the risk of overdose; however, treatment discontinuation leads to an increase risk of death. Naloxone distribution both through co-prescribing and community-based opioid overdose prevention programs remains the fundament of the public health response. Both are effective and cost-effective in reducing overdose; however, uptake is hampered due to variance in state naloxone access and Good Samaritan laws. Supervised injection facilities are a promising innovation to address overdose, especially in communities with high overdose rates.

Negative experiences of pain and withdrawal create barriers to abscess care for people who inject heroin. A mixed methods analysis

BackgroundSkin and soft tissue infections (SSTIs) are prevalent among people who inject heroin (PWIH). Delays in seeking health care lead to increased costs and potential mortality, yet the barriers to accessing care among PWIHs are poorly understood. MethodsWe administered a quantitative survey (N = 145) and conducted qualitative interviews (N = 12) with PWIH seeking syringe exchange services in two U.S. cities. Results66% of participants had experienced at least one SSTI. 38% reported waiting two weeks or more to seek care, and 57% reported leaving the hospital against medical advice. 54% reported undergoing a drainage procedure performed by a non-medical professional, and 32% reported taking antibiotics that were not prescribed to them. Two of the most common reasons for these behaviors were fear of withdrawal symptoms and inadequate pain control, and these reasons emerged as prominent themes in the qualitative findings. These issues are often predicated on previous negative experiences and exacerbated by stigma and an asymmetrical power dynamic with providers, resulting in perceived barriers to seeking and completing care for SSTIs. ConclusionsFor PWIH, unaddressed pain and withdrawal symptoms contribute to profoundly negative health care experiences, which then generate motivation for delaying care SSTI seeking and for discharge against medical advice. Health care providers and hospitals should develop policies to improve pain control, manage opioid withdrawal, minimize prejudice and stigma, and optimize communication with PWIH. These barriers should also be addressed by providing medical care in accessible and acceptable venues, such as safe injection facilities, street outreach, and other harm reduction venues.

The role of prevention strategies in achieving HCV elimination in Canada: what are the remaining challenges?

The worldwide economic, health, and social consequences of drug use disorders are devastating. Injection drug use is now a major factor contributing to hepatitis C virus (HCV) transmission globally, and it is an important public health concern. This article presents a narrative review of scientific evidence on public health strategies for HCV prevention among people who inject drugs (PWID) in Canada. A combination of public health strategies including timely HCV detection and harm reduction (mostly needle and syringe programmes and opioid substitution therapy) have helped to reduce HCV transmission among PWID. The rising prevalence of pharmaceutical opioid and methamphetamine use and associated HCV risk in several Canadian settings has prompted further innovation in harm reduction, including supervised injection facilities and low-threshold opioid substitution therapies. Further significant decreases in HCV incidence and prevalence, and in corresponding disease burden, can only be accomplished by reducing transmission among high-risk persons and enhancing access to HCV treatment for those at the greatest risk of disease progression or viral transmission. Highly effective and tolerable direct-acting antiviral therapies have transformed the landscape for HCV-infected patients and are a valuable addition to the prevention toolkit. Curing HCV-infected persons, and thus eliminating new infections, is now a real possibility. Prevention strategies have not yet ended HCV transmission, and sharing of injecting equipment among PWID continues to challenge the World Health Organization goal of eliminating HCV as a global public health threat by 2030. Future needs for research, intervention implementation, and uptake in Canada are discussed.

Caring for Patients with Substance Use Disorders: Addressing a Missed Opportunity in the Hospital.

As physicians, we have seen patients with substance use disorders leave the hospital against medical advice, slipping through the cracks of our health care system. In fact, despite a high burden of life-threatening illnesses, patients with SUDs are at a nearly threefold increased risk of leaving the hospital against medical advice. Leaving against medical advice is associated with an increased thirty-day mortality rate as well as an increased rate of hospital readmission. When a patient leaves in this way, the health care system loses the opportunity to engage with someone who is struggling with an SUD and whose health is at imminent risk. Fortunately, there are ways to address some of these challenges within existing organizational frameworks. Addiction consult teams and supervised injection facilities are two interventions that have proven successful.

Process Design of Cyclic Water Flooding by Real-Time Monitoring

The gradual decline in the oil production rate of water flooded reservoirs leads to decrease in the profit of water flooding system. Although cyclic water injection (CWI) was introduced to reduce the descending trend of oil production in water flooded reservoirs, it must be optimized based upon the process parameters. The objective of this study is to develop all process design criteria based upon the real-time monitoring of CWI process in a naturally fractured reservoir having five producing wells and five injector wells completed in an Arab carbonated formation containing light crude oil (API = 42 deg). For this aim, a small pilot oil field was selected with water injection facilities and naturally producing oil wells and all data were collected from the field tests. During a five years' field test, the primary observations at the onset of shutdown periods of the water injection system revealed a repeatable significant enhancement in oil production rate by a factor of plus 5% leading us to assess the application of CWI. This paper represents the significant parameters of pressure and productivity affected during CWI in naturally fractured carbonate reservoirs based upon a dual porosity generalized compositional model. The results hopefully introduce other oil producer companies to the potential of using CWI to increase oil production in conventional water injection systems. The results also outline situations where such applications would be desirable.

Safe Injection Facilities Save Lives.

Safe Injection Facilities Save Lives.

Opioid Use Among Those Who Have Criminal Justice Experience: Harm Reduction Strategies to Lessen HIV Risk.

We reviewed the HIV and opioid literature relevant to harm reduction strategies for those with criminal justice experience. Opioid use in the United States has risen at an alarming rate recently. This has led to increased numbers of people who inject drugs, placing new populations at risk for HIV, including those who have criminal justice experience. In recent years, there has been a gradual decrease in the number of individuals under the supervision of the criminal justice system. However, concurrently, there has been a rise in the number of individuals incarcerated in jails in rural counties that are at the center of the current opioid epidemic. We provide a number of harm reduction strategies that could be implemented in correctional settings such as access and linkage to medication-assisted treatment, connection to syringe exchange programs and safe injection facilities (where available), and the repackaging of pre-exposure prophylaxis as a harm reduction tool.

Randomization, randomized trials, and analyses using observational data: A commentary on Deaton and Cartwright

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

Harm Reduction Strategies for the Opiod Crisis.

In order to reduce disease transmission and overdose death resulting from the opioid crisis, North Carolina has recently adopted several harm reduction programs, including community based naloxone distribution and syringe exchange. Additionally, discussions are taking place about safe injection facilities as a way to further reduce the harm of opioids.

Expanding supervised injection facilities across Canada: lessons from the Vancouver experience.

The opioid crisis has led to an unprecedented rise in the number of overdose deaths across Canada. In response, there has been an expansion of supervised injection facilities (SIFs), with several new SIFs approved or under review across the country. Much of the evidence for the benefits of SIFs in reducing overdose mortality, infectious-related complications, and public disorder comes from Insite in Vancouver, North America's first SIF. While implementing SIFs in other Canadian cities is a major step forward in combating the opioid epidemic, the diversity within our country's socio-demographic and political landscape leaves the application of SIFs in these new settings a matter of uncertainty. This commentary highlights key lessons learned from Vancouver and the potential modifications required to enhance implementation in other cities to ensure the success of new SIFs across Canada.

Intravenous fentanyl use among people who inject drugs in Australia.

There is a current epidemic of pharmaceutical opioid (PO) misuse, particularly fentanyl and fentanyl analogues, globally. Fentanyl is a highly potent synthetic opioid with rapid onset and significantly higher risk of overdose compared with other opioids. Contexts and correlates of fentanyl use among people who inject drugs (PWID) in Australia are under-researched. The Australian Needle Syringe Program Survey is conducted annually. Consenting PWID complete a self-administered questionnaire and provide a capillary dried blood spot for human immunodeficiency virus and hepatitis C virus antibody testing. Bivariate and multivariate logistic regressions determined correlates of recent (last 6 months) fentanyl injection in 2014. Recent fentanyl injection was reported by 8% (n = 193) of the total sample. Among the 848 PWID who recently injected POs, 23% injected fentanyl. Compared with PO injectors who had not injected fentanyl, those who had injected fentanyl were significantly more likely to identify as Indigenous Australian [adjusted odds ratio (AOR) 1.61; 95% confidence interval (CI) 1.04, 2.51; P = 0.034], inject daily or more frequently (AOR 1.92; 95% CI 1.30, 2.83; P = 0.005), inject in public (AOR 1.43; 95% CI 1.01, 2.02; P = 0.042) and to have overdosed in the past year (AOR 2.16; 95% CI 1.48, 3.13; P < 0.001), but were significantly less likely to receptively share syringes (AOR 0.56; 95% CI 0.36, 0.87; P = 0.010). Fentanyl injectors in Australia are significantly more likely to identify as Indigenous, report frequent injection, inject in public and experience overdose. Increased access to harm reduction interventions, including naloxone distribution, wheel filters and supervised injection facilities, are likely to benefit this population.

Philadelphia launches first safe injection facilities program in the country

Alcoholism & Drug Abuse WeeklyVolume 30, Issue 5 p. 1-3 Articles Philadelphia launches first safe injection facilities program in the country Alison Knopf, Alison KnopfSearch for more papers by this author Alison Knopf, Alison KnopfSearch for more papers by this author First published: 27 January 2018 https://doi.org/10.1002/adaw.31833Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume30, Issue529 January 2018Pages 1-3 RelatedInformation

Changes in public order after the opening of an overdose monitoring facility for people who inject drugs

BackgroundIn the face of an increasingly fatal opioid crisis, Boston Health Care for the Homeless Program (BHCHP) opened the Supportive Place for Observation and Treatment (SPOT), a unique low-threshold harm reduction program for monitoring people who have injected drugs and are at imminent risk of overdose. This study examines the impact of the opening of the SPOT program on measures of injection drug-related public order in the neighborhood surrounding the facility. MethodsData was collected at 10 weeks prior and 12 weeks post SPOT implementation on: number of over-sedated individuals in public, publicly discarded syringes, publicly discarded injection-related litter, and instances of active injection drug use or exchange of drugs. Changes were evaluated using Poisson log-linear regression models. Potential confounders such as weather and police presence were measured and controlled for. ResultsThe average number of over-sedated individuals observed in public significantly decreased by 28% (4.3 [95% Confidence Interval (CI) 2.7–6.9] v 3.1 [CI 1.4–6.8]) after SPOT opened. The opening of SPOT did not have a significant effect on the other measures of public order. The daily average number of publicly discarded syringes (28.5 [CI 24.5–33.1] v 28.4 [CI 22.0–36.5]), pieces of publicly discarded injection-related litter (376.3 [CI 358.6–394.8] v 375.0 [CI 345.8–406.6]), and observed instances of active use or exchange of drugs (0.2 [CI 0.1–0.9] v 0.1 [CI 0.0–0.1]) were not statistically significantly different after the opening of SPOT. ConclusionsThe opening of SPOT was associated with a significant decrease in observed over-sedated individuals. Other measures of injection-drug related public order did not improve or worsen with the opening of SPOT, however, they have been shown to improve with the implementation of a supervised injection facility.

The willingness of people who inject drugs in Boston to use a supervised injection facility

ABSTRACTBackground: In Massachusetts, the number of opioid-related deaths has increased 350% since 2000. In the setting of increasing overdose deaths, one potential intervention is supervised injection facilities (SIFs). This study explores willingness of people who inject drugs in Boston to use a SIF and examines factors associated with willingness. Methods: A cross-sectional survey of a convenience sample of 237 people who inject drugs and utilize Boston's needle exchange program (NEP). The drop-in NEP provides myriad harm reduction services and referrals to addiction treatment. The survey was mostly self-administered (92%). Results: Results showed positive willingness to use a SIF was independently associated with use of heroin as main substance (odds ratio [OR]: 5.47; 95% confidence interval [CI]: 1.9–15.4; P = .0004), public injection (OR: 5.09; 95% CI: 1.8–14.3; P = .002), history of seeking substance use disorder (SUD) treatment (OR: 4.99; 95% CI: 1.2–21.1; P = .05), having heard of SIF (OR: 4.80; 95% CI: 1.6–14.8; P = .004), Hispanic ethnicity (OR: 4.22; 95% CI: 0.9–18.8; P = .04), frequent NEP use (OR: 4.18; 95% CI: 1.2–14.7; P = .02), current desire for SUD treatment (OR: 4.15; 95% CI: 1.2–14.7; P = .03), hepatitis C diagnosis (OR: 3.68; 95% CI: 1.2–10.1; P = .02), posttraumatic stress disorder (PTSD) diagnosis (OR: 3.27; 95% CI: 1.3–8.4; P = .01), report of at least 1 chronic medical diagnosis (hepatitis C, human immunodeficiency virus [HIV], hypertension, or diabetes) (OR: 3.27; 95% CI: 1.2–8.9; P = .02), and comorbid medical and mental health diagnoses (OR: 2.93; 95% CI: 1.2–7.4; P = .02). Conclusions: Most respondents (91.4%) reported willingness to use a SIF. Respondents with substance use behavior reflecting high risk for overdose were significantly more likely to be willing to use a SIF. Respondents with behaviors that contribute to public health burden of injection drug use were also significantly more likely to be willing to use a SIF. Results indicate that this intervention would be well utilized by individuals who could most benefit from the model. As part of a broader public health approach, SIFs should be considered to reduce opioid overdose mortality, decrease public health burden of the opioid crisis, and promote access to addiction treatment and medical care.

Measurement of the hadronic cross sections with the CMD-3 and SND detectors at the VEPP-2000 collider

Since December 2010 the CMD-3 and SND detectors detectors collect data at the VEPP-2000 electron-positron collider. In 2013-2015 the injection facility of the collider has undergone an upgrade of the injection system. The new BINP injection complex has been connected to the VEPP-2000 collider, so the restrictions connected to the lack of positrons and limited beam energy transfer do not apply any more. The collider luminosity in whole energy range is restricted now only by beam-beam effects. VEPP-2000 collider started to collect data with two detectors at 2016 year. The collected data sample since 2010 corresponds more than 100 pb-1 of integrated luminosity per detector in the c.m. energy between 0.32 and 2GeV. We will report here results of analysis of various hadronic cross sections from detectors both published and preliminary. These measurements are important by themselves and also because of the implications for anomaly of the magnetic moment of a muon (g-2) discrepancy.

Using drugs in un/safe spaces: Impact of perceived illegality on an underground supervised injecting facility in the United States

BackgroundSupervised injection facilities (SIFs) are spaces where people can consume pre-obtained drugs in hygienic circumstances with trained staff in attendance to provide emergency response in the event of an overdose or other medical emergency, and to provide counselling and referral to other social and health services. Over 100 facilities with formal legal sanction exist in ten countries, and extensive research has shown they reduce overdose deaths, increase drug treatment uptake, and reduce social nuisance. No facility with formal legal sanction currently exists in the United States, however one community-based organization has successfully operated an ‘underground’ facility since September 2014. MethodsTwenty three qualitative interviews were conducted with people who used the underground facility, staff, and volunteers to examine the impact of the facility on peoples’ lives, including the impact of lack of formal legal sanction on service provision. ResultsParticipants reported that having a safe space to inject drugs had led to less injections in public spaces, greater ability to practice hygienic injecting practices, and greater protection from fatal overdose. Constructive aspects of being ‘underground’ included the ability to shape rules and procedures around user need rather than to meet political concerns, and the rapid deployment of the project, based on immediate need. Limitations associated with being underground included restrictions in the size and diversity of the population served by the site, and reduced ability to closely link the service to drug treatment and other health and social services. ConclusionUnsanctioned supervised injection facilities can provide a rapid and user-driven response to urgent public health needs. This work draws attention to the need to ensure such services remain focused on user-defined need rather than external political concerns in jurisdictions where supervised injection facilities acquire local legal sanction.

Perceptions about supervised injection facilities among people who inject drugs in Philadelphia

BackgroundPeople who inject drugs (PWID) are at high risk for infectious diseases, skin and soft tissue infections, and overdose. However, these harms are all avoidable when sterile injection equipment, hygienic places to inject, and medical care are accessible. Unfortunately, many PWID in the U.S lack these resources. The most vulnerable are forced to inject in public spaces, where individual risks are high and communal harms are sometimes many. Supervised Injection Facilities (SIFs) are an established intervention for reducing these harms. Despite positive experiences in other countries, little research explores how PWID in the U.S. perceive the value of such facilities. MethodsWe conducted a freelisting exercise with PWID (n=42) and healthcare providers (n=20) at a syringe exchange program (SEP) that provides comprehensive clinical and social services in Philadelphia to inform in-depth semi-structured interviews with PWID (n=19) at the same location. ResultsParticipants expressed support for a potential SIF as a valuable public health intervention. They suggested that an SIF would improve PWID health while reducing the public disorder associated with injecting drugs in public. The latter was especially important to participants without stable housing, whose decision to inject furtively in secluded places was often motivated by desire not to upset community members, and particularly children. These participants acknowledged that such seclusion elevated the risk of fatal overdose. Despite similarly positive perceptions about an SIF, participants with stable housing reported that they would prefer to continue injecting at home. ConclusionResults both confirm and extend prior research about PWID and SIFs. Participants expressed support for SIFs as in prior survey research in the U.S. and in other countries. Facility location and housing status were identified as important determinants of facility use. Results extend prior research by illuminating PWID perceptions in the U.S. including motivations grounded in concern for public order.

Back to the core: A network approach to bolster harm reduction among persons who inject drugs

BackgroundInjecting drugs safely almost always includes the presence of one’s social network, especially for the prevention of overdose. Yet, the systematic analysis of users’ social networks has yet to be established as a focal method in harm reduction research, and interventions. MethodsThis study draws from 200 interviews with persons who inject drugs recruited from North America’s first sanctioned supervised injection facility and a drug user’s advocacy group. Respondents were asked about the individuals they personally considered as facilitators of harm reduction, and the relations between them. Collectively, these 200 respondents provided over 900 individuals whom they considered as members of their harm reduction network. The aim was to locate individuals that would potentially make the network denser (harm reduction champions) and users that were situated in the “periphery” of the network, and in practice, further away from the harm reduction core. ResultsOf the 1135 network members, 63 individuals formed the “core” of the harm reduction network, collectively reaching approximately 70% of individuals in the network. We also uncovered 31 individuals that acted as “articulation points”– these individuals were not as connected, but were more effective at reaching peripheral individuals. ConclusionFormer or current injecting drug users that were sampled were surrounded by a relatively rich harm reduction network, but the network approach showed that only a minority of individuals were true harm reduction “champions”. Recruitment of a combination of well-connected harm reduction champions, and strategically connected articulation points, would be most effective in planning network interventions that encourage harm reduction behaviors among this population.