Supervised Consumption Sites Research Articles

The estimated costs and benefits of a hypothetical supervised consumption site in Providence, Rhode Island.

Overdose deaths have increased dramatically in the United States, including in Rhode Island. In July 2021, the Rhode Island government passed legislation supporting a two-year pilot program authorizing supervised consumption sites (SCSs) in response to this crisis. We estimated the costs and benefits of a hypothetical SCS in Providence, Rhode Island. We utilized a decision analytic mathematical model to compare costs and outcomes for people who inject drugs under two scenarios: (1) a SCS that includes syringe services provision, and (2) a syringe service program only (i.e., status quo). We assumed 0.95% of injections result in overdose, the SCS would serve 400 clients monthly and have a net cost of $783,899 annually, 46% of overdoses occurring outside of the SCS result in an ambulance run and 43% result in an emergency department (ED) visit, 0.79% of overdoses occurring within the SCS result in an ambulance run and ED visit, and the SCS would lead to a 25.7% reduction in fatal overdoses near the site. The model was developed from a modified societal perspective with a one-year time horizon. A hypothetical SCS in Providence would prevent approximately 2 overdose deaths, 261 ambulance runs, 244 ED visits, and 117 inpatient hospitalizations for emergency overdose care annually compared to a scenario that includes a syringe service program only. The SCS would save $1,104,454 annually compared to the syringe service program only, accounting only for facility costs and short-term costs of emergency overdose care and ignoring savings associated with averted deaths. Influential parameters included the percentage of injections resulting in overdose, the total annual injections at the SCS, and the percentage of overdoses outside of the SCS that result in an ED visit. A SCS in would result in substantial cost savings due to prevention of costly emergency overdose care.

Perception of Resource Allocations to Address the Opioid Epidemic.

Despite billions of dollars spent on opioid policy initiatives, public knowledge of evidence-based policies to reduce opioid-related morbidity remain low. Consequences of this knowledge gap for support of initiatives remains understudied. Our objective was to evaluate how participants with and without lived experience allocate funding for initiatives to address the opioid epidemic. A secondary objective was to collect proof-of-concept data of an informational intervention designed to improve support for evidence-based policies. Participants (N = 284; 57.2% female) without lifetime nonmedical opioid use (n = 98) and those with lifetime use (past year [n = 81] or nonpast year [n = 105]) of nonmedical opioids were recruited. All participants reported how they would allocate funds to demand reduction, supply reduction, harm reduction, and treatment policies. Half of all participants were then randomized to a brief informational intervention designed to emphasize evidence-based harm reduction and treatment programs. Funding allocations were highest for policies related to community services and treatment and lowest for those related to harm reduction. Participants with lived experience allocated less to supply reduction policies. Participants (12%) who reallocated funds after information exposure increased funding to supervised consumption sites, dz = 0.77, naloxone distribution, dz = 0.85, syringe exchange programs, dz = 0.63, and medications for opioid use disorder access, dz = 0.70. This study illustrates how people with and without lived experience prioritize various policies to address the opioid epidemic and emphasize comparably low support for harm reduction policies. Proof-of-concept data suggest that brief informational interventions may increase funding support for harm reduction strategies, at least in a subset of people.

Impact of Calgary’s supervised consumption site on opioid-related emergency health care usage

Background: Opioid overdoses have been an increasing public health problem in North America for several years. Supervised consumption sites (SCSs) – hygienic and medically supervised spaces to use illicit substances – are one harm reduction strategy intended to decrease morbidity and mortality, with literature suggesting they reduce emergency department (ED) visits, overdoses, and deaths. Calgary’s sole SCS opened in 2017 and received over 6000 monthly visits prior to the COVID-19 pandemic, but recent provincial policy has jeopardized its longevity. To our knowledge, there has not been an evaluation of its effectiveness, so we sought to investigate its impact on opioid-related ED visits.
 Methods: Calgary’s SCS was not implemented in our institution specifically. It was implemented for the Calgary region by Safeworks, an outreach program under the Alberta Health Services (AHS) umbrella, after obtaining a Health Canada exemption and funding from the provincial government. Implementation also required close collaboration with public services (e.g., Calgary Police Services) and the municipal government.
 The Safeworks SCS opened on October 30, 2017 and remains the only supervised consumption facility in the Calgary region. It is currently located in the Sheldon Chumir Health Centre in downtown Calgary. In addition to supervised consumption, the SCS also offers all clients harm reduction supplies (e.g., naloxone kits), health services (e.g., testing and counselling for sexually transmitted infections, referral to Calgary Opioid Dependency Program), education (e.g., vein care), and access to social services (e.g., housing supports).
 
 Evaluation Methods: This was a retrospective observational study examining the impact of the SCS on two markers of opioid related morbidity (EMS responses and ED visits). Calgary EMS responses, wherein the opioid overdose protocol was activated or naloxone was administered, were queried from the Alberta Health Services (AHS) information management database. ED visits due to opioid toxicity were queried from AHS using ICD-10 codes T40.0-T40.4 and T40.6. Data was collected from January 2014 to February 2020. The impact of Calgary’s SCS was analyzed with an interrupted time series using ordinary least squares regression with Newey-West standard errors.
 Results: Our data query yielded 9208 EMS responses and 8442 ED visits related to opioid use over the 74-month period. There were no months with missing data. Prior to the opening of Calgary’s SCS, monthly EMS responses and ED visits increased significantly by 3.69 [3.08, 4.30] and 7.09 [5.92, 8.26] visits/month, respectively (p<0.001). After the SCS’ opening, the trends in EMS responses and ED visits declined significantly, relative to the pre-intervention trends, by 7.14 [5.72, 8.56] (p<0.001) and 15.34 [12.21, 18.48] (p<0.001) visits/month, respectively. After the intervention, EMS responses declined at a rate of 3.45 visits per month (p <0.001) and ED visits declined at a rate of 8.25 visits per month (p< 0.001).
 Our interrupted time series suggest that Calgary’s SCS led to a significant change (and in fact, a reversal) in the trends of opioid-related EMS responses and ED visits. This evidence suggests that ongoing access to Calgary’s SCS has a favourable impact.
 Advice and Lessons Learned: 
 1) Similar studies in the future should consider partnering with their local SCSs (e.g., Safeworks) to conduct a multi-faceted program evaluation, including organization-driven outcomes. This could also facilitate respectful and ethical patient engagement.
 2) Evaluating mortality data or other more direct markers of morbidity in addition to ED visits may be high yield in future research as it provides greater insight into the breadth of medical outcomes and further informs advocacy efforts.
 3) Our study did not consider the impacts of other opioid-related interventions in Calgary/Alberta. This was a deliberate choice, however it is ultimately difficult to estimate the impact of an isolated intervention. One option would be to evaluate all relevant interventions as a group of interventions, given that substance misuse and associated harms is a multifaceted problem that requires a multidisciplinary approach

Why has the Opioid Crisis Remained Unchanged in Canada? The Limits of Bio-Scientific Based Policy Approaches

ABSTRACT Canada’s latest drug policy, the Canadian Drugs and Substances Strategy (CDSS) with its emphasis on an evidence-based public health approach to substance misuse, has remained unidimensional in response to the current opioid crisis. Its coexistence with a prohibitionist drug policy—the Controlled Drugs and Substances Act contravenes the evidence frame of drug addiction as a health issue rather than a crime. We argue that CDSS’s focus on individualizing, bio-scientifically driven tools involving naloxone, opioid agonist therapy, supervised consumption sites, and surveillance of legal opioid prescribing do not fully explain why the opioid crisis has remained intact, disproportionately affecting vulnerable populations by not including social factors as a key component of the strategy. By examining contradictions inherent in these bio-scientific evidenced interventions, we call for a more holistic drug policy framework that considers broader structural conditions including a greater emphasis on engaging with those misusing substances to address underlying issues that affect them.

Supervised consumption sites' variability outlined

An article on supervised consumption sites found that there are no strict rules for how they operate, and that they are “as varied as the communities in which they operate.” The article, published in the April 6 issue of the Journal of the American Medical Association (JAMA), quoted Kimberly Sue, M.D., Ph.D., medical director of the National Harm Reduction Coalition, on the fact that “These are things that people who use drugs and people who care about them have been doing for years.” The sites can be as simple as a social service agency restroom stall, or as expansive as Vancouver's Insite, which has hundreds of injection room visits a day and offers detox rooms with private bathrooms, transitional housing and other wraparound services. Because the main cause of opioid overdose deaths is respiratory depression, naloxone is essential. So is sternal pressure to stimulate breathing, the article noted. Most supervised consumption sites aim to prevent HIV transmission, wound infection and help for people who inject drugs in general. “People wrongly assume that people using drugs don't care about their health,” Alex Kral, Ph.D., an epidemiologist with the nonprofit research institute RTI International in Berkeley, California, told JAMA. Jim McDonald, M.D., M.P.H., interim director of the Rhode Island Department of Health, said supervised consumption sites shouldn't operate underground, the way Kral's does. “Let's recognize they need a safe place to use,” McDonald, who oversees the state's overdose prevention efforts, said in an interview. Substance use disorder “is a complex biopsychosocial problem,” he noted, “but it doesn't get better by keeping secrets.” The federal Department of Justice knows what Rhode Island is doing, said McDonald. Rhode Island's first harm‐reduction centers, part of a two‐year pilot program, were hoped to open soon. One problem is NIMBY — the “not in my backyard” issue presented by communities that support supervised consumption sites — somewhere else. Kral's work is supported in part by Arnold Ventures, the article, “Supervised Consumption Sites — A Tool for Reducing Risk of Overdose Deaths and Infectious Diseases in People Who Use Illicit Drugs” by Rita Rubin and colleagues, disclosed.

Mothers Who Use Drugs: Closing the Gaps in Harm Reduction Response Amidst the Dual Epidemics of Overdose and Violence in a Canadian Urban Setting.

Objectives. To identify key gaps in overdose prevention interventions for mothers who use drugs and the paradoxical impact of institutional practices that can increase overdose risk in the context of punitive drug policies and a toxic drug supply. Methods. Semistructured interviews were conducted with 40 women accessing 2 women-only, low-barrier supervised consumption sites in Greater Vancouver, British Columbia, Canada, between 2017 and 2019. Our analysis drew on intersectional understandings of structural, everyday, and symbolic violence. Results. Participants' substance use and overdose risk (e.g., injecting alone) was shaped by fear of institutional and partner scrutiny and loss (or feared loss) of child custody or reunification. Findings indicate that punitive policies and institutional practices that frame women who use drugs as unfit parents continue to negatively shape the lives of women, most significantly among Indigenous participants. Conclusions. Nonpunitive policies, including access to safe, nontoxic drug supplies, are critical first steps to decreasing women's overdose risk alongside gender-specific and culturally informed harm-reduction responses, including community-based, peer-led initiatives to maintain parent-child relationships. (Am J Public Health. 2022;112(S2):S191-S198. https://doi.org/10.2105/AJPH.2022.306776).

Service utilization patterns and characteristics among clients of integrated supervised consumption sites in Toronto, Canada

IntroductionSupervised consumption services (SCS), intended to reduce morbidity and mortality among people who inject drugs, have been implemented in a variety of delivery models. We describe and compare access to and uptake of co-located and external services among clients accessing harm reduction-embedded (HR-embedded) and community health center-embedded (CHC-embedded) SCS models.MethodsCross-sectional baseline data were collected between November 2018 and March 2020 as part of a cohort of people who inject drugs in Toronto, Canada designed to evaluate one HR-embedded and two CHC-embedded SCS. This analysis was restricted to clients who reported accessing these SCS more than once in the previous 6 months. Participants were classified as HR-embedded or CHC-embedded SCS clients based on self-reported usage patterns. Client characteristics, as well as access to onsite services and referral and uptake of external services, were compared by SCS model.ResultsAmong 469 SCS clients, 305 (65.0%) primarily used HR-embedded SCS and 164 (35.0%) primarily used CHC-embedded SCS. Compared to clients accessing CHC-embedded SCS, clients accessing HR-embedded SCS were somewhat younger (37.6 vs. 41.4, p < 0.001), more likely to report fentanyl as their primary injected drug (62.6% vs. 42.7%, p < 0.001), and visited SCS more often (49.5% vs. 25.6% ≥ daily, p < 0.001). HR-embedded SCS clients were more likely to access harm reduction services onsite compared to CHC-embedded SCS clients (94.8% vs. 89.6%, p = 0.04), while CHC-embedded SCS clients were more likely to access non-harm reduction services onsite (57.3% vs. 26.6%, p < 0.001). For external services, HR-embedded SCS clients were more likely to receive a referral (p = 0.03) but less likely to report referral uptake (p = 0.009).ConclusionsClients accessing HR-embedded and CHC-embedded SCS were largely demographically similar but had different drug and SCS use patterns, with CHC-embedded SCS clients using the site less frequently. While clients of CHC-embedded SCS reported greater access to ancillary health services onsite, external service use remained moderate overall, underscoring the importance of co-location and support for clients with system navigation. Importantly, lack of capacity in services across the system may impact ability of staff to make referrals and/or the ability of clients to take up a referral.

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

BackgroundOn 14 April 2016, British Columbia’s Provincial Medical Health Officer declared the overdose crisis a public health emergency, sanctioning the implementation of new overdose prevention sites (OPS) and supervised consumption sites (SCS) across the province.MethodsWe used the BC Centre for Disease Control’s Provincial Overdose Cohort of all overdose events between 1 January 2015 and 31 December 2017 to evaluate the population-level effects of OPSs and SCSs on acute health service use and mortality. We matched local health areas (LHA) that implemented any site with propensity score matched controls and conducted controlled interrupted time series analysis.ResultsDuring the study period, twenty-five OPSs and SCSs opened across fourteen of British Columbia’s 89 LHAs. Results from analysis of LHAs with matched controls (i.e. excluding Vancouver DTES) were mixed. Significant declines in reported overdose events, paramedic attendance, and emergency department visits were observed. However, there were no changes to trends in monthly hospitalization or mortality rates. Extensive sensitivity analyses found these results persisted.ConclusionsWe found OPSs and SCSs reduce opioid-related paramedic attendance and emergency department visit rates but no evidence that they reduce local hospitalization or mortality rates.

Overdose prevention centres in the UK

Overdose prevention centres in the UK

A rapid ethnographic study of risk negotiation during the COVID-19 pandemic among unstably housed people who use drugs in Rhode Island.

BackgroundThe COVID-19 pandemic has greatly exacerbated the United States’ overdose crisis. However, the overlapping impacts of COVID-19 and the overdose crisis have not been experienced equally, with unstably housed people who use drugs (PWUD) disproportionately impacted. Amid these changes, there is a need to understand how risk is experienced and managed among unstably housed PWUD to address health and social needs more effectively.MethodsThis project draws on ethnographic research conducted from June 2020 to April 2021 in Rhode Island. Data include 39 in-depth interviews with unstably housed PWUD and approximately 50 h of ethnographic fieldwork conducted alongside street-based outreach workers.ResultsCOVID-19 risks were primarily contextualized in relation to participants’ prior experiences of overdose events and adverse health outcomes. However, participants had varying levels of risk tolerance that were managed in ways that allowed them to reassert control and agency within the uncertainty of overlapping public health crises. Given participants’ level of structural vulnerabilities, COVID-19 risk was managed alongside meeting their basic needs to survive.ConclusionsFindings demonstrate how COVID-related public health measures (e.g., stay-at-home orders, service closures) reinforced participants’ structural vulnerabilities in ways that increased their risk of health and social harms. Implementing and scaling up programs that meet the basic needs of individuals, including permanent housing, social supports, and overdose prevention interventions (e.g., supervised consumption sites) is critically needed to address intersecting risks faced by unstably housed PWUD.

Experiences with compounding surveillance and social control as a barrier to safe consumption service access

Barriers to accessing supervised consumption services are well documented in the literature. Police and security presence in the areas surrounding these sites are two such barriers. Yet, despite what we know about these autonomous social control actors, less is known about whether/how the convergence of actors within neighborhoods housing supervised consumption sites shapes service access. This paper examines how people who use drugs navigate police, security, and residents to access harm reduction services in Calgary, Canada. Based on qualitative interviews with persons who use drugs, our findings suggest that these public health services are undermined when police, security and area residents converge in their efforts to address social ‘disorder’. Participants reported displacement from the area surrounding these health services, resulting in greater public drug use and reduced service access. This research extends knowledge on supervised consumption site access barriers and social control of people who use drugs.

Drug use, homelessness and health: responding to the opioid overdose crisis with housing and harm reduction services

BackgroundCanada is in the midst of an opioid overdose crisis and Alberta has one of the highest opioid use rates across the country. Populations made vulnerable through structural inequities who also use opioids, such as those who are unstably housed, are at an increased risk of experiencing harms associated with opioid use. The main purpose of this study was to explore if there was an association between unstable housing and hospital use for people who use opioids.MethodsAnalysis utilized self-reported data from the Alberta Health and Drug Use Survey which surveyed 813 Albertans in three cities. Hospital use was modeled using a logistic regression with our primary variable of interest being housing unstable status. Chi square tests were conducted between hospital use and variables associated with demographics, characteristics of drug use, health characteristics, and experiences of receiving services to establish model inclusion.ResultsResults revealed a significant association between housing instability and hospital use with unstably housed individuals twice as likely torequire hospital care.ConclusionsResults highlight the importance of concurrently addressing housing instability alongside the provision of harm reduction services such as safe supply and supervised consumption sites. These findings have significant implications for policy and policymakers during the opioid overdose epidemic, and provide a foundation for future areas of research.

A qualitative study on overdose response in the era of COVID-19 and beyond: how to spot someone so they never have to use alone

BackgroundSpotting is an informal practice among people who use drugs (PWUD) where they witness other people using drugs and respond if an overdose occurs. During COVID-19 restrictions, remote spotting (e.g., using a telephone, video call, and/or a social media app) emerged to address physical distancing requirements and reduced access to harm reduction and/or sexually transmitted blood borne infection (STBBI’s) prevention services. We explored spotting implementation issues from the perspectives of spotters and spottees.MethodsResearch assistants with lived/living expertise of drug use used personal networks and word of mouth to recruit PWUD from Ontario and Nova Scotia who provided or used informal spotting. All participants completed a semi-structured, audio-recorded telephone interview about spotting service design, benefits, challenges, and recommendations. Recordings were transcribed and thematic analysis was used.ResultsWe interviewed 20 individuals between 08/2020–11/2020 who were involved in informal spotting. Spotting was provided on various platforms (e.g., telephone, video calls, and through texts) and locations (e.g. home, car), offered connection and community support, and addressed barriers to the use of supervised consumption sites (e.g., location, stigma, confidentiality, safety, availability, COVID-19 related closures). Spotting calls often began with setting an overdose response plan (i.e., when and who to call). Many participants noted that, due to the criminalization of drug use and fear of arrest, they preferred that roommates/friends/family members be called instead of emergency services in case of an overdose. Both spotters and spottees raised concerns about the timeliness of overdose response, particularly in remote and rural settings.ConclusionSpotting is a novel addition to, but not replacement for, existing harm reduction services. To optimize overdose/COVID-19/STBBI’s prevention services, additional supports (e.g., changes to Good Samaritan Laws) are needed. The criminalization of drug use may limit uptake of formal spotting services.

Virtual Overdose Response for People Who Use Opioids Alone: Protocol for a Feasibility and Clinical Trial Study.

BackgroundA recent quarterly report released by Alberta Health reports that on average 2.5 Albertans die every day from accidental overdose deaths, and that between April 1, 2020, and June 30, 2020, the province lost a total of 301 people. In Canada, between January 2016 and March 2020, a total of 16,364 people died due to opioid-related overdose. The World Health Organization reports that 70% of the 0.5 million deaths worldwide caused by drugs are related to opioid overdose. Although supervised consumption sites or safe injection sites have been shown to be effective in reducing the harms associated with the use of illicit substances and increasing uptake of addiction treatment and other health services, there is still significant stigma associated with them, and it is unlikely that all of the people who would benefit from supervised consumption service will ever access a site.ObjectiveTo help prevent deaths in populations that cannot or will not access physical safer consumption services in Alberta, we propose to provide virtual (telephone-based) overdose response services, staffed by people with lived experience.The primary outcome for this study is uptake of the service as measured by the number of calls to the service. Secondary outcomes will include patterns of use of the phone line (days of the week and time of calls) and outcomes from the calls (number of emergency medical services dispatches for overdoses from the service and the results of those dispatches).MethodsThis phase 1 clinical study is set to officially launch in early May 2020. The service will be available to up to 15 participants who self-disclose as using opioids unobserved and have given informed consent for both data collection and interviews. This group will have access to a toll-free telephone number and be invited to call when they plan to use opioids alone.ResultsThe analysis will include mixed methods. To improve the design of the service and ensure safety of all involved, quantitative data will be collected on phone calls and participant health care usage, while qualitative data will be collected from both participants and virtual overdose response operatorsConclusionsThis clinical trial aims to test the feasibility of a service that provides virtual overdose response in order to help prevent deaths in populations that cannot or will not access physical supervised consumption services in Alberta.Trial RegistrationClinicalTrials.gov NCT04391192; https://www.clinicaltrials.gov/ct2/show/NCT04391192International Registered Report Identifier (IRRID)DERR1-10.2196/20183

Community perspectives on supervised consumption sites: Insights from four U.S. counties deeply affected by opioids

BackgroundTo 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. MethodsTo 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. ResultsKey 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. ConclusionsDespite 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.

Analyzing the Past, Rationalizing the Present, and Formulating the Future of Injection Sites

The Opioid Crisis has historically been a major threat to the Canadian population, and continues to affect the health and wellbeing of Canadians today. This ongoing public health crisis demonstrates the exponential growth of opioid related deaths and drug overdoses, particularly in the midst of a global pandemic. The effects of Covid - 19 have shown a drastic increase in opioid related deaths over the past year. It is important to note that vulnerable individuals are facing a surplus of challenges both physically and mentally during this unprecedented time due to lack of shelter, resources, and support. To adequately care for struggling individuals, it is essential to consider the implication of supervised consumption sites, commonly known as safe injection sites (SIS). They provide a safe and clean environment for injections, a supportive community for drug users, well as resources for preventative and extended healthcare. Though negatively perceived throughout society, these sites offer nutritious food, hygiene supplies and the basic necessities in order to sustain one’s well being and optimal health. Nonetheless, this would not be possible without greater funding from the government that will in turn allow for greater expansion and overall accessibility of these resources. This will hopefully assist in ending the stigma that lingers around SIS while closing the divisions within society. Each individual is entitled to feeling supported and welcomed in a community where they can express their true self without being judged.

"And we just have to keep going": Task shifting and the production of burnout among overdose response workers with lived experience.

Overdose response programs in North America increasingly employ task shifting-shifting overdose response tasks to less specialized workers-to increase effectiveness and promote involvement of people with lived/living experience of drug use (PWLE). In Canada, task shifting has occurred through community-driven implementation of overdose response programs staffed primarily by PWLE. The implications of this task shifting on workers' well-being and service delivery has received little scholarly consideration, despite reports of widespread burnout among frontline responders. This study examines experiences and drivers of burnout among PWLE working at low-barrier supervised consumption sites ("Overdose Prevention Sites" or OPSs) in Vancouver, Canada. Between December 2016 and March 2020, we conducted ethnographic fieldwork at four OPSs, including in-depth interviews with 23 overdose response workers, three site-based focus groups with 20 additional workers, and 150h of naturalistic observation. Data were analyzed to explore how working conditions, labour arrangements, economic insecurity and social disadvantage shaped burnout. We found that overdose response workers commonly reported burnout, which they attributed to the precarious and demanding nature of their work. While casual positions offered low-barrier employment, PWLE often lacked the wages and benefits enjoyed by other frontline workers, with limited supports and opportunities for advancement. Due to their social position within drug-using networks, PWLE's work encompassed hidden care work that participants felt was constant and undervalued. The scarcity of permanent full-time positions, alongside barriers to transitioning into formal employment, prevented many PWLE from earning livable wages or taking time off to 'recharge.' This study highlights how the devaluing and casualization of overdose response labour, compounded by other dimensions of structural vulnerability, are central to burnout among overdose response workers with lived experience. Interventions to address burnout within this setting must extend beyond individual-level interventions (e.g. counselling, self-care) to also strengthen working conditions and economic security of PWLE.

Negotiating sex work and client interactions in the context of a fentanyl-related overdose epidemic

Despite awareness of the role of drug use in shaping sex worker/client interactions, these dynamics remain poorly understood in the context of illicit fentanyl-driven overdose epidemics. This study examined sex workers’ experiences negotiating client interactions amidst a toxic drug supply in Vancouver, Canada. Findings draw from two ethnographic studies. The first, conducted between December 2016 and May 2017, examined the rapid implementation of several low-threshold supervised consumption sites. The second investigated experiences of women accessing a women-only site from May 2017 to June 2018. Data included 200 hours of fieldwork and in-depth semi-structured interviews with 34 street-based sex workers who use illicit drugs. Data were analysed thematically with attention to the risk environment. Participants described providing harm reduction services to clients as a means to reduce overdose-related risks, thus increasing sex workers’ hidden labour. Participants, comments regarding criminalisation and stigma surrounding drug use and sex work indicated a reticence to report overdoses, thereby potentially increasing the risks of overdose-related harms, including death. There is an urgent need for sex worker-led overdose prevention strategies that prioritise health and safety of sex workers and their clients with specific attention to how the criminalisation of particular drugs, practices and people contributes to overdose-related risks.

Understanding the Policy Context and Conditions Necessary for the Establishment of Supervised Consumption Sites in Canada: A Comparative Analysis of Alberta and Manitoba

The establishment of supervised consumption sites (SCS) is one policy approach used to address Canada’s growing, national opioid epidemic. Despite the abundance of evidence which demonstrates the numerous public health benefits gained from the existence of SCS, only five of ten Canadian provinces have established SCS. Using Alberta and Manitoba as comparators, the paper seeks to explain the difference in policy outcomes. The paper begins with a brief overview of the history of harm reduction policy in Canada and establishes what the goals of the Alberta and Manitoba governments were in their respective policy approaches to respond to the opioid epidemic. Using John Kingdon’s Multiple Streams Framework, this paper compares the political and policy contexts of Alberta and Manitoba to determine what factors have contributed to the divergence in policy outcomes, whereby Alberta has established SCS while Manitoba has not. The comparative analysis reveals that the framing of the opioid epidemic as a public health matter, the alignment of the establishment of SCS with the provincial government’s values, and political will are all necessary conditions for the establishment of SCS. This paper concludes by discussing the implications of these results for the establishment of SCS in other Canadian provinces. Ouvrir des sites de consommation supervisee (SCS) est une approche utilisee pour affronter l’epidemie nationale croissante d’opioides au Canada. En depit de l’abondance d’evidence demontrant les benefices pour la sante publique de ces SCS, seuls cinq des dix provinces canadiennes en ont etablis. En utilisant l’Alberta et le Manitoba comme comparateurs, cet article cherche a expliquer les differences de politiques. L’article commence par presenter brievement l’histoire de la politique de reduction des dommages au Canada et montre quels buts les gouvernements de l’Alberta et du Manitoba s’etaient assignes dans leurs approches politiques respectives pour repondre a l’epidemie des opioides. Suivant le schema des courants multiples de John Kingdon, cet article compare les contextes politiques et les processus de prise de decision politique en Alberta et au Manitoba afin de determiner quels facteurs ont contribue a la divergence des politiques mises en place, a savoir que l’Alberta a etabli des SCS, mais pas le Manitoba. L’analyse comparative revele que positionner l’epidemie d’opioides comme un probleme de sante publique compte, et que l’alignement de la mise en place de SCS avec les valeurs du gouvernement provincial, ainsi que la volonte politique sont des conditions necessaires pour la mise en place de SCS. Cet article conclue en discutant les consequences de ces observations pour la mise en place de SCS dans les autres provinces canadiennes.

“Accidental Intimacies”: Reconsidering Bodily Encounters Between Police and Young People Who Use Drugs

Youth who use drugs (YWUD) are likely to encounter the police and experience victimization within those encounters. Negative experiences of police among youth can dramatically undermine youths’ trust in police, making them unlikely to ask for help when they need it. In this article, we use Rance and Fraser’s concept of “accidental intimacies” between staff and people who inject drugs arising in encounters within supervised consumption sites. Their exploration of Sarah Ahmed’s work on the social productivity of emotions argues that new subjectivities that counter or transform stigma and shame surrounding drug use can occur from the space between individuals. For Ahmed “emotions do things, and work to align individuals with collectives—[linking] bodily space with social space—through the very intensity of their attachments.” During 2017–2018, 38 youth (aged 16–30 years) who use drugs in three cities in British Columbia, Canada, were interviewed to explore their encounters (both positive and negative) with police and how these influenced their perceptions of police. In this article, we assert that the dynamic of “we” and “them,” of the YWUD and police, is constituted in part through the powerful emotions created and confirmed by negative bodily encounters where the bodies of youth and police collide through physical and/or verbal contact. The repetition of emotions and objectification through stigma within their communities force some youth to repeatedly confront harmful subjectivities. Rance and Fraser’s work provides possibilities for shifting these stigmatizing subjectivities. For change to occur, addressing the historical and present realities that impact YWUD will help facilitate and enhance more respectful communication and interactions between YWUD and police. Bodily encounters may also present opportunities for both YWUD and police to reflect on the subjectivities that reinforce and are shaped by their negative interactions with one another. Incremental change may be possible as we find new meanings in youths’ understanding of and compassion for police and their work.