Supervised Injection Sites Research Articles

How free are classroom teachers? Understanding teacher academic freedom in the United States and Canada

ABSTRACT This paper presents the results of an international survey of teachers’ perspectives on academic freedom. We surveyed 173 social studies and science teachers from the United States and Canada about the importance of academic freedom, their comfort level broaching controversial topics in four broad areas (politics, economics, health and safety, and science), and the factors that influence their decision-making around discussing controversial topics. The study found that teachers value academic freedom despite being aware of how limited their freedom is in practice. Particularly controversial topics included safe injection sites, abortion, prisons, medically assisted dying, and same-sex marriage. Analysis via Mann-Whitney U tests was conducted to analyse whether teachers’ individual differences (e.g., experience, gender, or job status) influenced their pedagogical approach. Gender and years of experience had little influence, but teachers’ cautiousness was significantly influenced by whether they have tenure and the political climate of the area where they work.

The public health impacts of supervised injection sites in Canada: Moving beyond social acceptability and impacts on crime.

Canada has been a pioneer in adopting a harm reduction approach to address risks associated with drug use for people who inject drugs. Today, Canada is home to 39 supervised injection sites spread throughout the country. The scientific literature demonstrates, unequivocally, that these sites have numerous health benefits for people who inject drugs, namely by decreasing risks of blood-borne diseases, overdose, and mortality. Yet, a lack of clear guidelines on optimal locations for the implementation of such sites and NIMBYISM ("Not In My Back Yard") have been stumbling blocks for planned and operating sites. Various Canadian governments have introduced their own policies to overcome the lack of national public health guidelines on community planning. Namely, policies aim to limit the exposure to sites and drug use for vulnerable populations, such as children. However, there is a veritable lack of research on the public health impacts of supervised injection sites for local communities, who tend to be disadvantaged. The existing literature fails to address the broader and differential impacts of such sites for local vulnerable and disadvantaged populations, including use of active transportation, psychological distress, perceived safety, and social cohesion. Moreover, existing research, largely focusing on assessing pre-implementation social acceptability and post-implementation impacts on crime, faces important methodological limitations. The following commentary reviews the existing literature and makes recommendations for future public health research on the impacts of supervised injection sites.

Advocating for Policy Change: Examples Emerging From a Medical-Legal Partnership in Primary Care.

Medical-legal partnerships bring legal services directly into clinical settings. Policy advocacy is often opportunistic and varies across partnerships. Our objective was to study policy advocacy that emerged from a medical-legal partnership in Toronto over a four-year period. This study consisted of a document review and thematic analysis, triangulated with data from interviews with legal team members and health providers. We defined policy advocacy as actions associated with attempts to change policy or legislation. The medical-legal partnership engaged in seven distinct cases of policy advocacy: disability support form requirements, changing workplace review, challenging barriers to citizenship, housing, publicly funded medication program (pharma care), safe injection sites, and the need for increased social assistance. Actions taken included presentations at conferences and submissions of briefs to government. We found that a medical-legal partnership resulted in policy advocacy with issues arising from both the health and the legal team with impacts likely greater than if each group had acted alone.

Managing Addiction and Overdose Deaths: The Debate Over America's Safe Injection Spaces.

In the decade between 2010 and 2020, the number of people killed by opioid overdoses more than tripled, reaching 68,630. Among drug users in their second and third decades of life, hepatitis B and C are also on the rise. New York City's two new supervised drug injection sites (SDISs) reversed 114 overdoses within two months, and 585 people injecting drugs visited the facility 4,974 times. By providing medical professionals and a sterile and safe environment, supervised injection sites reduce overdose risk and save lives. This suggests that SDISs could be an important adjunct to currently failing strategies to combat the nation's raging opioid crisis, particularly in the aftermath of the COVID-19 pandemic. Here, we examine the perception and impact of SDISs as well as efforts by the United States Congress (H.R. 7029 and H.R. 6159) toward their prevention. We look into the perspectives of major stakeholders, such as residents, business owners, drug users, legislators, taxpayers, and the general public, and investigate the short- and long-term consequences of SDISs based on crime statistics and published data on opioid use, overdose deaths, and blood-borne disease transmission rates.

Siting issues still prominent hurdle in planned development of OPCs

Whether they're called “overdose prevention centers (OPCs),” “safe injection sites” or something else, operations that seek to combine spaces for supervised drug use with health and support services continue to elicit strong reaction in the local communities where they're proposed. A persistent lack of direction from the federal government on the legality of these operations has done nothing to quell the controversy, only fueling it further if anything.

Overdose prevention centers: Innovative strategy or federal law violation?

Among the list of identified strategies to address substance use disorder, none is as controversial as overdose prevention centers. Also known as supervised injection sites, these centers provide clean needles, food, basic hygiene, medical care, referrals to treatment, and overdose reversal medication to people who use drugs, all in a supervised setting. Proponents of these centers argue they save lives and money, while opponents claim they perpetuate and normalize illegal drug use. Furthermore, the very existence of overdose prevention centers in cities across the United States is a blatant violation of an existing federal law, known as the "Crack House Statute." The future of overdose prevention centers in this country is murky at best, though a decision from the Biden Administration is expected in the coming months that may offer some guidance as to whether this particular harm reduction tool will maintain the unique distinction of being both an innovative approach to tackling the opioid epidemic while at the same time violating federal law.

Associations between partisan media consumption, opioid use disorder stigma, and opioid policy support: An exploration of the media’s role in the ongoing opioid epidemic

We report on a preliminary investigation into the relationship between partisan media consumption (PMC) among U.S. adults and their (1) opioid use disorder (OUD) stigma, (2) national OUD policy support (e.g., Medicaid coverage for OUD treatment), (3) local OUD policy support (e.g., safe injection sites), (4) discriminatory OUD policies (e.g., denying housing), and (5) carceral OUD policies (e.g., jailing people who use opioids). We performed a cross-sectional survey of a nationally-representative sample of U.S. adults (n = 6,515) from October 1-November 19, 2021. We surveyed a sample of U.S. adults ages 18 and older drawn from NORC's AmeriSpeak® Panel. AmeriSpeak is a probability-based ongoing panel of over 40,000 households designed to represent the U.S. household population. Cross-sectional analyses revealed significant relationships between PMC and OUD stigma (b = 0.29, p <.001, CI95 = 0.14,0.43), support for national (b = -0.31, p <.01, CI95 = -0.54,-0.09) and local policy responses (b = -0.38, p <.001, CI95 = -0.59,-0.17), and support for discriminatory opioid use disorder policies (b = 0.27, p <.01, CI95 = 0.07,0.45). After controlling for self-reported political affiliation and other potential covariates, Republican-leaning media consumption was significantly associated with increased OUD stigma, less support for national and local harm reduction or rehabilitative policies, and more support for discriminatory policies against individuals experiencing OUD. The opposite associations were observed for Democratic-leaning media consumption. Markers for racism mediated the relationship between PMC and support for carceral policies (indirect path b = -0.41,p <.001, CI95 = -0.50,-0.31). Our results indicate that public health advocates must collaborate with conservative leaders to find bipartisan common ground for targeted communication campaigns.

Opioid Use Disorder Stigma and Support for Harm Reduction in Rural Counties

Background: The opioid crisis is a public health emergency in the United States, particularly in rural Pennsylvania. Stigma in rural communities is a treatment barrier and impacts harm reduction programming availability. Objectives: The current study utilized an observational, cross-sectional design to examine latent subgroups of stigma and differences in support for harm reduction strategies (i.e., safe injection facilities, syringe services programs, fentanyl test strips, Naloxone distribution). Participants included rural Pennsylvanians (n = 252), taken from a statewide survey of opioid use disorder (OUD) stigma. Participants reported OUD public stigma (i.e., attitudes/perceptions about OUD, willingness to engage with individuals with OUD) and support for harm reduction strategies. Results: Latent class analysis identified 4 stigma classes: 1) high stigma (HS), 2) high judgment/low stigmatizing behavior (HJ/LB), 3) high stigmatizing behavior/low stigmatizing attitude (HB/LA), and 4) low stigma (LS). ANCOVAs identified subgroup differences in harm reduction support. The HS group indicated less support for safe injection sites, syringe services programs, and fentanyl test strips, compared to the HB/LA and LS groups. The HS group indicated less support for Naloxone distribution compared to the HJ/LB, HB/LA, and LS groups. Lastly, the HJ/LB group indicated less support for each program compared to the LS group. Conclusions/Importance: Findings highlight that OUD stigma profiles differ across rural Pennsylvania and are associated with varying support for harm reduction strategies. Individuals with less stigma report more support for harm reduction strategies. Interventions to implement harm reduction strategies should consider varying levels of stigma and use a targeted approach to inform implementation and messaging strategies.

Substance use and other factors associated with COVID-19 vaccine uptake among people at risk for or living with HIV: Findings from the C3PNO consortium

ObjectiveWe describe the prevalence of COVID-19 vaccine uptake, substance use, and other factors associated with vaccine hesitancy among participants from nine North American cohort studies following a diverse group of individuals at risk for or living with HIV. MethodsBetween May 2021 and January 2022, participants completed a survey related to COVID-19 vaccination. Participants included those with and without substance use. Those responding as ‘no’ or ‘undecided’ to the question “Do you plan on getting the COVID-19 vaccine?” were categorized as vaccine hesitant. Differences between groups were evaluated using chi-square methods and multivariable log-binomial models were used to calculate prevalence ratios (PR) of COVID-19 vaccine hesitancy with separate models for each substance. ResultsAmong 1,696 participants, COVID-19 vaccination was deferred or declined by 16%. Vaccine hesitant participants were younger, with a greater proportion unstably housed (14.8% vs. 10.0%; p = 0.02), and not living with HIV (48.% vs. 36.6%; p <.01). Vaccine hesitant participants were also more likely to report cannabis (50.0% vs. 42.4%; p = 0.03), methamphetamine (14.0% vs. 8.2%; p <.01), or fentanyl use (5.5% vs. 2.8%; p = 0.03). Based on multivariable analyses methamphetamine or fentanyl use remained associated with COVID-19 vaccine hesitancy (Adjusted PR = 1.4; 95% CI 1.1–1.9 and Adjusted PR = 1.6; 95% CI 1.0–2.6, respectively). ConclusionAs new COVID-19 vaccines and booster schedules become necessary, people who use drugs (PWUD) may remain vaccine hesitant. Strategies to engage hesitant populations such as PWUD will need to be tailored to include special types of outreach such as integration with substance use programs such as safe injection sites or recovery programs.

Housing, addiction and the streets: Kertesz responds to questions

After reading our story on the Tenderloin district in San Francisco last week (https://onlinelibrary.wiley.com/doi/full/10.1002/adaw.33786), many clinicians responded to ADAW to let us know that they were “depressed” by the piece, and didn't see an exit ramp from the non‐stop fentanyl use and overdoses. Things have gone too far for many of the proposed solutions: treatment that people don't want, needed housing that nobody has money for, and quality of life that multiple comorbidities have made impossible. Advocates for drug‐user “autonomy” sent stories about how the small country of Denmark has dealt with the problem, criticized the San Francisco mayor's decision to shut down the safe injection site (Mayor London Breed did so in December because fewer than 1% of participants had been connected with treatment), and attacked Tom Wolf, who guided us through the Tenderloin in person, for his supposed abstinence‐based treatment philosophy (in fact he strongly believes in treatment with methadone and buprenorphine).

Establishment of prediction equations for subcutaneous tissue thickness in two representative intramuscular deltoid injections

This study clarifies the predicted subcutaneous shoulder depth and investigates the safety of the conventional (three-finger breadth method) and new (axillary method) intramuscular injection methods. The anatomical features of 245 volunteers who received the COVID-19 vaccination via the conventional method were investigated at the injection site (T point) and the hypothetical injection site using the new method (A point) via ultrasonography. The body mass index (BMI) and subcutaneous thickness at the T point (men: r = 0.75; women: r = 0.45) and the A point (men: r = 0.81; women: r = 0.55) were positively correlated. The upper arm circumference and subcutaneous thickness at the T point (r = 0.51) and the A point (r = 0.58) were correlated in women. Formulas to predict subcutaneous thickness using BMI and upper arm circumference were established: predicted subcutaneous thickness at the A point = 0.62 × BMI − 7.7 mm (R2 = 0.66) in men and 0.658 × BMI − 5.5 mm (R2 = 0.31) in women. This study demonstrates safe intramuscular injection sites and their depth.

Legal issues pertaining to the collection of sociodemographic data in emergency departments.

Legal issues pertaining to the collection of sociodemographic data in emergency departments.

Environmental Uncertainty and Substance Use Disorders: A Behavior Analytic Perspective.

Substance use disorder (SUD) and drug overdose deaths represent major economic, health, and safety issues in the United States. The psychology of uncertainty provides a mechanism for understanding, reducing, and controlling the damage from substance misuse. Illicit drugs (such as heroin or cocaine) are uncertain in their availability, quality, and acquisition (the time and effort required to obtain them) compared with nondrug-related alternatives (such as consumable goods, hobbies, or paychecks). Furthermore, the severity and likelihood of negative outcomes associated with drug use likewise are uncertain. Such uncertainties worsen substance use outcomes. The current review conveys what is known about the impact of uncertainty on substance use: laboratory investigations of uncertain time and effort required to obtain a substance and uncertain drug quality show uncertainty exacerbates harm. Furthermore, uncertain negative outcomes are not likely to deter substance use in individuals with a SUD. Finally, several policy implications include access to agonist medications; creating a safer drug supply; access to clean syringes/needles, naloxone, and safe-injection sites; and ending incarceration for substance use.

NIH tells Congress “Yes” to OPCs

Overdose prevention sites (OPCs), sometimes called supervised injection sites, are hoped to help reduce the overdose deaths due to opioids, as well as provide some other benefits. But do OPCs reduce overdose deaths? Last week ADAW asked around, and few people answered, but the federal government did. The National Institutes of Health (NIH), the country's top expert on research, says yes. Based on a report compiled by the NIH National Institute on Drug Abuse (NIDA) that was sent to Congress in last year, which is an “updated literature review and evaluation of the potential public health impact of Overdose Prevention Sites in the U.S.,” while research is still in its early stages, all signs point to these sites as being helpful, and the federal government — at least the health care side, not necessarily the law enforcement side — endorses them.

Revisiting Harm Reduction Strategy: Is Harm Reduction Harmful?

Harm reduction strategies aim at protecting those with substance use disorders from using in dangerous situations. This is done by providing safe injection sites with clean needles, as well as other controlled situations that prevent the spread of disease and decrease the likelihood of overdose. Some argue that this encourages dangerous behavior when the best approach would be to encourage abstinence. However, advocates say that harm reduction strategies give the best opportunity for counseling and offer hope for recovery. This article explores both arguments.

Anatomical Proposal for Botulinum Neurotoxin Injection Targeting the Platysma Muscle for Treating Platysmal Band and Jawline Lifting: A Review.

The platysma muscle is a thin superficial muscle that covers the entire neck and lower part of the face. The platysma muscle is the primary target muscle for botulinum neurotoxin injection therapy aimed at treating platysmal band and lower facial lifting. In the procedure of botulinum neurotoxin injection therapy, a lack of knowledge of the anatomy of the platysma muscle and the properties of botulinum neurotoxin can lead to side effects such as dysphagia, dysphonia, and weakness of the neck muscles. Anatomically safe injection sites have been proposed for the platysma muscle, and the appropriate injection technique has been reviewed. We proposed optimal injection sites based on the external anatomical features of the mandible. The aim of these proposal was to standardize the procedure for the effective use of botulinum neurotoxin injections by minimizing the dose unit and injection points and thereby preventing adverse events.

93 Mapping Mobile Health Clinics in Canada: Delivering Equitable Primary Care to Children and Vulnerable Populations

Abstract Background Low-income and racially diverse populations often have multiple barriers in accessing healthcare and are at increased risk of poor health outcomes. COVID-19 exacerbated these health inequities: decreased in-person appointments, difficult access to virtual care and deprioritization of elective clinical activity led to delays in well-child visits and vaccination. This public health emergency highlighted a need to develop alternative models to enable access to primary care for vulnerable children. While mobile clinics are well-established in the United States, little is known about them in Canada. Objectives This study aims to characterize Canadian mobile clinics providing primary care health services to vulnerable populations, including children, and seeks to inform the implementation of a pediatric mobile clinic under development. Design/Methods This environmental scan screened scientific databases and the grey literature using a combination of terms designating mobile health clinics and Canadian locations. Relevant Canadian primary care mobile clinic initiatives were subsequently included. We defined primary care mobile clinics as movable health care units providing primary healthcare services delivered by general medical practitioners (pediatricians and family physicians). Examples of excluded initiatives were mobile clinics focused on education/literacy, dental care, vision care, endocrinology, cancer screening, safe injection sites, vaccination, physical rehabilitation and urgent care. Descriptive statistics and qualitative analysis were performed. Results 29 clinics were identified, of which 26 are still active. Most clinics were located in Ontario (n=11), followed by British Columbia (n=8), Alberta (n=5), Quebec (n=2) and the Maritimes (n=2). The first mobile clinic in Canada was launched in 1996, with an increasing number of new clinics in 2021. While all clinics served vulnerable populations, some targeted specific groups, such as children, people experiencing homelessness, immigrants, LGBTQ+ individuals and Indigenous peoples. We identified three pediatric mobile clinics, two of which targeted teenagers. Onboard the clinics, physicians often worked with nurses, outreach workers and social workers. These professionals provided primary care services, as well as healthcare navigation, sexual education, mental health care, harm reduction supplies, vaccination and emergency care. All mobile clinics partnered with their local government, charities or businesses to fund their initiative. Conclusion Mobile health clinics are a growing model of primary care in Canada. They are the result of a multidisciplinary collaboration between healthcare providers, social workers and outreach workers. To this date, Canadian pediatric mobile clinics remain a handful and represent an interesting avenue to address health inequities in children, during the pandemic and beyond.

California governor vetoes overdose prevention center bill

A bill that would have sanctioned overdose prevention programs (OPPs)—the term used in the bill for “safe injection sites” where people could use illegal drugs and health care workers would stand by to rescue them from overdoses—was vetoed by California Gov. Gavin Newsom last week. The governor said it could have resulted in a “world of unintended consequences.” The bill would have allowed for pilot OPPs for five years.

Gaps in hepatitis C virus prevention and care for HIV-hepatitis C virus co-infected people who inject drugs in Canada.

People who inject drugs (PWID) living with HIV are a priority population for eliminating hepatitis C virus (HCV) as a public health threat. Maximizing access to HCV prevention and treatment strategies are key steps towards elimination. We aimed to evaluate engagement in harm reduction programs and HCV treatment, and to describe injection practices among HIV-HCV co-infected PWID in Canada from 2003 to 2019. We included Canadian Coinfection Cohort study participants who reported injecting drugs between 2003 and 2019 in Quebec, Ontario, Saskatchewan, and British Columbia, Canada. We investigated temporal trends in HCV treatment uptake, efficacy, and effectiveness; injection practices; and engagement in harm reduction programs in three time periods based on HCV treatment availability: 1) interferon/ribavirin (2003-2010); 2) first-generation direct acting antivirals (DAAs) (2011-2013); 3) second-generation DAAs (2014-2019). Harm reduction services assessed included needle and syringe programs (NSP), opioid agonist therapy (OAT), and supervised injection sites (SIS). Median age of participants (N=1,077) at cohort entry was 44 years; 69% were males. Province-specific HCV treatment rates increased among HCV RNA-positive PWID, reaching 16 to 31 per 100 person-years in 2014-2019. Treatment efficacy improved from a 50 to 70% range in 2003-2010 to >90% across provinces in 2014-2019. Drug injecting patterns among active PWID varied by province, with an overall decrease in cocaine injection frequency and increasing opioid injections. In the most recent time period (2014-2019), needle/syringe sharing was reported at 8-22% of visits. Gaps remained in engagement in harm reduction programs: NSP use decreased (58-70% of visits), OAT engagement among opioid users was low (8-26% of visits), and participants rarely used SIS (1-15% of visits). HCV treatment uptake and outcomes have improved among HIV-HCV coinfected PWID. Yet, this population remains exposed to drug-related harms, highlighting the need to tie HCV elimination strategies with enhanced harm reduction programs to improve overall health for this population.

Intramuscular Innervation of the Supraspinatus Muscle Assessed Using Sihler's Staining: Potential Application in Myofascial Pain Syndrome.

Despite the positive effects of botulinum neurotoxin (BoNT) injection into the neural arborized area, there is no anatomical evidence in the literature regarding the neural arborization of the supraspinatus muscle. The present study aimed to define the intramuscular neural arborized pattern of the supraspinatus muscle using the modified Sihler’s staining method to facilitate the establishment of safe and effective injection sites in patients with myofascial pain in the supraspinatus muscle. Seventeen supraspinatus muscles from 15 embalmed cadavers were dissected. Precise suprascapular nerve entry locations were also observed. Intramuscular neural arborization was visualized by Sihler’s staining. The supraspinatus muscle was divided into four portions named A, B, C, and D. The nerve entry points were observed in 88.2% (15 of 17 cases) of section B and 76.5% (13 of 17 cases) of section C of the supraspinatus muscle, respectively. The concentration of intramuscular neural arborization was highest in section B of the supraspinatus muscle, which was the center of the supraspinatus muscle. When the clinician performs a trigger point and a BoNT injection into the supraspinatus muscle, injection within the medial 25–75% of the supraspinatus muscle will lead to optimal results when using small amounts of BoNT and prevent undesirable paralysis.