Supervised Injection Services Research Articles

Integrated supervised consumption services and hepatitis C testing and treatment among people who inject drugs in Toronto, Canada: A cross-sectional analysis.

Despite the availability of publicly funded hepatitis C (HCV) treatment in Canada, treatment gaps persist, particularly among people who inject drugs. We estimate correlates of HCV care cascade engagement (testing, diagnosis, and treatment) among people who inject drugs in Toronto, Canada and examine the effect of accessing differing supervised consumption service (SCS) models on self-reported HCV testing and treatment. This is a cross-sectional baseline analysis of 701 people who inject drugs surveyed in the Toronto, Ontario integrated Supervised Injection Services (OiSIS-Toronto) study between November 2018 and March 2020. We examine correlates of self-reported HCV care cascade outcomes including SCS model, demographic, socio-structural, drug use, and harm reduction characteristics. Overall, 647 participants (92%) reported ever receiving HCV testing, of whom 336 (52%) had been diagnosed with HCV. Among participants who reported ever being diagnosed with HCV, 281 (84%) reported chronic HCV, of whom 130 (46%) reported HCV treatment uptake and 151 (54%) remained untreated. Compared to those with no SCS use, participants who had ever injected at an integrated SCS model with co-located HCV care had greater prevalence of both ever receiving HCV testing (adjusted prevalence ratio [aPR]: 1.12, 95% confidence interval [CI]: 1.02-1.24) and ever receiving HCV treatment (aPR: 1.67, 95% CI: 1.04-2.69). Over half of participants diagnosed with chronic HCV reported remaining untreated. Our findings suggest that integrated SCS models with co-located HCV care represent key strategies for linkage to HCV care, but that more is needed to support scale-up.

From drug prohibition to regulation: a public health imperative

From drug prohibition to regulation: a public health imperative

Dynamics of drug overdose in the 20th and 21st centuries: The exponential curve was not inevitable, and continued increases are preventable.

While much has been written about the positive individual and collective effects of Supervised injection services (SIS), notably on health and drug-related harm, little research focuses on their operational context and constraints. Building on Lascoumes and Le Gales's “public policy instrument and instrumentation” framework (2007), this article analyzes the implementation of Montreal SIS and discusses how the organizational aspects of SIS produce the contexts for drug injection.Using an ethnographic approach, this article draws on three types of data: 10 months of participant observation in a SIS (700 h); 19 semi-structured interviews with staff members (social workers, peers, heads of staff, management); and analysis of organizational documents (protocols, staff notebooks).First, this article examines how political context and advocacy coalitions produced Montreal SIS as a public policy instrument, affecting both the philosophy and the implementation of the service. It shows that Montreal SIS were developed under a health care network blueprint rather than a community organization harm reduction framework. Then, it analyzes how SIS as a policy instrument defines what constitutes appropriate injection practices, trying to supervise injection as an individual and technical act, rather than a broader social practice composed of pleasure, rituals, routines, and group dynamics.Montreal SIS were conceptualized under a “health banner” and through alliances between regional public health administration and local well-known community organizations. They were then developed mostly under a health care administration blueprint, although operated at a ground-level by local community organizations. It created tensions between the logics of “zero risk” and “harm reduction”, and ambiguity about how injection should be supervised and what parts of drug use could be managed.

Reply commentary by Jalal and Burke.

While much has been written about the positive individual and collective effects of Supervised injection services (SIS), notably on health and drug-related harm, little research focuses on their operational context and constraints. Building on Lascoumes and Le Gales's “public policy instrument and instrumentation” framework (2007), this article analyzes the implementation of Montreal SIS and discusses how the organizational aspects of SIS produce the contexts for drug injection.Using an ethnographic approach, this article draws on three types of data: 10 months of participant observation in a SIS (700 h); 19 semi-structured interviews with staff members (social workers, peers, heads of staff, management); and analysis of organizational documents (protocols, staff notebooks).First, this article examines how political context and advocacy coalitions produced Montreal SIS as a public policy instrument, affecting both the philosophy and the implementation of the service. It shows that Montreal SIS were developed under a health care network blueprint rather than a community organization harm reduction framework. Then, it analyzes how SIS as a policy instrument defines what constitutes appropriate injection practices, trying to supervise injection as an individual and technical act, rather than a broader social practice composed of pleasure, rituals, routines, and group dynamics.Montreal SIS were conceptualized under a “health banner” and through alliances between regional public health administration and local well-known community organizations. They were then developed mostly under a health care administration blueprint, although operated at a ground-level by local community organizations. It created tensions between the logics of “zero risk” and “harm reduction”, and ambiguity about how injection should be supervised and what parts of drug use could be managed.

Between zero risk and harm reduction: An ethnography of Montreal supervised injection services as a public policy instrument.

While much has been written about the positive individual and collective effects of Supervised injection services (SIS), notably on health and drug-related harm, little research focuses on their operational context and constraints. Building on Lascoumes and Le Gales's "public policy instrument and instrumentation" framework (2007), this article analyzes the implementation of Montreal SIS and discusses how the organizational aspects of SIS produce the contexts for drug injection. Using an ethnographic approach, this article draws on three types of data: 10 months of participant observation in a SIS (700h); 19 semi-structured interviews with staff members (social workers, peers, heads of staff, management); and analysis of organizational documents (protocols, staff notebooks). First, this article examines how political context and advocacy coalitions produced Montreal SIS as a public policy instrument, affecting both the philosophy and the implementation of the service. It shows that Montreal SIS were developed under a health care network blueprint rather than a community organization harm reduction framework. Then, it analyzes how SIS as a policy instrument defines what constitutes appropriate injection practices, trying to supervise injection as an individual and technical act, rather than a broader social practice composed of pleasure, rituals, routines, and group dynamics. Montreal SIS were conceptualized under a "health banner" and through alliances between regional public health administration and local well-known community organizations. They were then developed mostly under a health care administration blueprint, although operated at a ground-level by local community organizations. It created tensions between the logics of "zero risk" and "harm reduction", and ambiguity about how injection should be supervised and what parts of drug use could be managed.

Overdose prevention centres in the UK

Overdose prevention centres in the UK

Health impacts of a scale-up of supervised injection services in a Canadian setting: an interrupted time series analysis.

In response to a dramatic rise in overdose deaths due to injection drug use, there was a rapid scale-up of low-threshold supervised injection services (SIS), termed 'overdose prevention sites' (OPS), in Vancouver, Canada in December 2016. We measured the potential impact of this intervention on SIS use and related health outcomes among people who inject drugs (PWID). Segmented regression analyses of interrupted time series data from two community-recruited prospective cohorts of PWID from January 2015 to November 2018 were used to measure the impact of the OPS scale-up on changes in SIS use, public injection, syringe sharing and addiction treatment participation, controlling for pre-existing secular trends. Vancouver, Canada. Of 745 PWID, 292 (39.7%) were women, 441 (59.6%) self-reported white ancestry and the median age was 47 years (interquartile range = 38, 53) at baseline. Immediate (i.e. step level) and gradual (i.e. slope) changes in the monthly proportion of participants who self-reported past 6-month SIS use, public injection, syringe sharing and participation in any form of addiction treatment. Post OPS expansion, the monthly prevalence of SIS use immediately increased by an estimated 6.4% [95% confidence interval (CI) = 1.7, 11.2] and subsequently further increased by an estimated 0.7% (95% CI = 0.3, 1.1) per month. The monthly prevalence of addiction treatment participation immediately increased by an estimated 4.5% (95% CI = 0.5, 8.5) following the OPS expansion, while public injection and syringe sharing were estimated to immediately decrease by 5.5% (95% CI = 0.9, 10.0) and 2.5% (95% CI = 0.5, 4.6), respectively. Findings were inconclusive as to whether or not an association was present between the intervention and subsequent gradual changes in public injection, syringe sharing and addiction treatment participation. Scaling-up overdose prevention sites in Vancouver, Canada in December 2016 was associated with immediate and continued gradual increases in supervised injection service engagement and immediate increases in related health benefits.

Validation of Self-reported Opioid Agonist Treatment Among People Who Inject Drugs Using Prescription Dispensation Records.

Studies of people who inject drugs (PWID) commonly use questionnaires to determine whether participants are currently, or have recently been, on opioid agonist treatment for opioid use disorder. However, these previously unvalidated self-reported treatment measures may be susceptible to inaccurate reporting. We linked baseline questionnaire data from 521 PWID in the Ontario integrated Supervised Injection Services cohort in Toronto (November 2018-March 2020) with record-level health administrative data. We assessed the validity (sensitivity, specificity, positive and negative predictive value [PPV and NPV]) of self-reported recent (in the past 6 months) and current (as of interview) opioid agonist treatment with methadone or buprenorphine-naloxone relative to prescription dispensation records from a provincial narcotics monitoring system, considered the reference standard. For self-reported recent opioid agonist treatment, sensitivity was 78% (95% CI = 72, 83), specificity was 90% (95% CI = 86, 94), PPV was 90% (95% CI = 85, 93), and NPV was 79% (95% CI = 74, 84). For self-reported current opioid agonist treatment, sensitivity was 84% (95% CI = 78, 90), specificity was 87% (95% CI = 83, 91), PPV was 74% (95% CI = 67, 81), and NPV was 93% (95% CI = 89, 95). Self-reported opioid agonist treatment measures were fairly accurate among PWID, with some exceptions. Inaccurate recall due to a lengthy lookback window may explain underreporting of recent treatment, whereas social desirability bias may have led to overreporting of current treatment. These validation data could be used in future studies of PWID to adjust for misclassification in similar self-reported treatment measures.

Feasibility, acceptability, concerns, and challenges of implementing supervised injection services at a specialty HIV hospital in Toronto, Canada: perspectives of people living with HIV

BackgroundSubstance use significantly impacts health and healthcare of people living with HIV/AIDS (PLHIV), especially their ability to remain in hospital following admission. Supervised injection services (SIS) reduce overdoses and drug-related harms, but are not often provided within hospitals/outpatient programs. Leading us to question, what are PLHIV’s perceptions of hospital-based SIS?MethodsThis mixed-methods study explored feasibility and acceptability of implementing SIS at Casey House, a Toronto-based specialty HIV hospital, from the perspective of its in/outpatient clients. We conducted a survey, examining clients’ (n = 92) demand for, and acceptability of, hospital-based SIS. Following this, we hosted two focus groups (n = 14) and one-on-one interviews (n = 8) with clients which explored benefits/drawbacks of in-hospital SIS, wherein participants experienced guided tours of a demonstration SIS space and/or presentations of evidence about impacts of SIS. Data were analysed using descriptive statistics and thematic analysis.ResultsAmong survey participants, 76.1% (n = 70) identified as cis-male and over half (n = 49;54.4%) had been a hospital client for 2 years or less. Nearly half (48.8%) knew about clients injecting in/near Casey House, while 23.6% witnessed it. Survey participants were more supportive of SIS for inpatients (76.1%) than for outpatients (68.5%); most (74.7%) reported SIS implementation would not impact their level of service use at Casey House, while some predicted coming more often (16.1%) and others less often (9.2%). Most focus group/interview participants, believed SIS would enhance safety by reducing health harms (e.g. overdose), increasing transparency between clients and clinicians about substance use, and helping retain clients in care. Debate arose about who (e.g., in/outpatients vs. non-clients) should have access to hospital-based SIS and how implementation may shift organizational priorities/resources away from services not specific to drug use.ConclusionsOur data showed widespread support of, and need for, hospital-based SIS among client stakeholders; however, attempts to reduce negative impacts on non-drug using clients need to be considered in the balance of implementation plans. Given the increased risks of morbidity and mortality for PLHIV who inject drugs as well as the problems in retaining them in care in a hospital setting, SIS is a key component of improving care for this marginalized group.

The Ontario Integrated Supervised Injection Services Cohort Study of People Who Inject Drugs in Toronto, Canada (OiSIS-Toronto): Cohort Profile

The Ontario Integrated Supervised Injection Services cohort in Toronto, Canada (OiSIS-Toronto) is an open prospective cohort of people who inject drugs (PWID). OiSIS-Toronto was established to evaluate the impacts of supervised consumption services (SCS) integrated within three community health agencies on health status and service use. The cohort includes PWID who do and do not use SCS, recruited via self-referral, snowball sampling, and community/street outreach. From 5 November 2018 to 19 March 2020, we enrolled 701 eligible PWID aged 18+ who lived in Toronto. Participants complete interviewer-administered questionnaires at baseline and semi-annually thereafter and are asked to consent to linkages with provincial healthcare administrative databases (90.2% consented; of whom 82.4% were successfully linked) and SCS client databases. At baseline, 86.5% of participants (64.0% cisgender men, median ([IQR] age= 39 [33–49]) had used SCS in the previous 6 months, of whom most (69.7%) used SCS for <75% of their injections. A majority (56.8%) injected daily, and approximately half (48.0%) reported fentanyl as their most frequently injected drug. As of 23 April 2021, 291 (41.5%) participants had returned for follow-up. Administrative and self-report data are being used to (1) evaluate the impact of integrated SCS on healthcare use, uptake of community health agency services, and health outcomes; (2) identify barriers and facilitators to SCS use; and (3) identify potential enhancements to SCS delivery. Nested sub-studies include evaluation of “safer opioid supply” programs and impacts of COVID-19.

Public and semi-public injection drug use in Thunder Bay, Ontario: the case for supervised injection services

Although public injecting has been studied in large urban centres, little is known about the factors that drive public injecting in remote communities. This study sought to explore public and semi-public injection in Thunder Bay, a remote and mid-sized city in Northwestern Ontario. Peer researchers completed surveys with people who inject drugs. Multivariable logistic regression was used to examine sociodemographic characteristics and behavioural patterns associated with injecting in public or semi-public settings. Among 200 people who inject drugs, 128 (64%) individuals reported engaging in public injection. In multivariable analyses, public injecting was positively associated with age (Adjusted Odds Ratio [AOR], 0.97, 95% Confidence Interval [CI]: 0.97–1.00; p = 0.05), homelessness (AOR 2.34, 95% CI: 1.10–5.02; p = 0.02), sex work (AOR 4.62, 95% CI: 1.37–21.61; p = 0.02), injecting alone (AOR 2.66, 95% CI: 1.19–6.02; p = 0.01), opioid injecting (AOR 3.64, 95% CI: 1.48–9.41; p = 0.05) and cocaine injecting (AOR 4.35, 95% CI: 2.11–9.44). The most frequent reasons for public injecting were proximity to where people buy drugs (59.4%), being too far from home (27.3%), and being homeless (25.8%). Our findings suggest that the scale-up of additional harm reduction programming in Thunder Bay, including supervised injection services, may address public injecting and reduce associated harms in this setting.

Do Mock-Ups, Presentations of Evidence, and Q&amp;As Help Participants Voice their Opinions During Focus Groups and Interviews About Supervised Injection Services?

Controversial facilities (e.g., supervised injection services (SIS), methadone clinics, and social housing) may require feasibility studies that asses their acceptability among community stakeholders before their implementation. However, controversies about these facilities may make stakeholders ambivalent or hesitant to express opinions about them because various sources of information disagree about their harms and benefits. We responded to this challenge by creating and piloting the use of “grounding aids” or tools, objects, and methods used before qualitative data collection to provide research participants with an experience in which they can learn about how the controversial facility operates in practice. Before interviews and focus groups in a recent SIS feasibility study we conducted, participants were introduced to three of these grounding aids: a physical mock-up of an SIS, a presentation regarding evidence on SIS, and a Q&amp;A with SIS staff. We then asked additional questions in the interviews and focus groups about participants’ experience with these grounding aids. With few exceptions, participants generally perceived the grounding aids to help them express their opinions without feeling that we were directing their opinions about SIS. Participants’ reasons for this included that the grounding aids helped them experience unfamiliar aspects of SIS visually and concretely, served as a cue for questions and as a reference for discussions, and personalized SIS and its operations. We also observed that they voiced less hesitancy overall regarding SIS than participants in our previous feasibility studies where we did not employ these grounding aids before data collection. Researchers planning to study perceptions of controversial facilities or other phenomena about which sources of information tend to disagree on may want to consider creating, evaluating, and using grounding aids to improve participant responsiveness.

Assisted injection within supervised injection services: Uptake and client characteristics among people who require help injecting in a Canadian setting

BackgroundPeople who require help injecting illicit drugs experience elevated rates of a range of health-related harms, including overdose and acquisition of blood-borne pathogens. In response, some supervised injection services (SIS) in Canada have begun to permit clients to be physically injected by fellow clients or staff members. However, little is known about uptake and characteristics of clients who engage in this practice. We therefore sought to examine factors associated with receiving injection assistance at SIS among people who require help injecting drugs in Vancouver, Canada. MethodsData were drawn from two community-recruited prospective cohort studies of people who inject drugs (PWID). We used multivariable generalized estimating equation (GEE) analyses with time-updated covariates to identify factors associated with self-reported receipt of injection assistance at SIS. ResultsBetween June 2017 and December 2018, 319 individuals who reported having recently required help injecting were included in the study. Of these, 160 (51.0%) were women and the median age was 42 years at baseline. In total, 54 (16.9%) participants reported receiving injection assistance at a SIS at least once over an average of 3.3 months of follow-up. In multivariable GEE analyses, recent homelessness (Adjusted Odds Ratio [AOR] = 2.04; 95% confidence interval [CI]: 1.13 – 3.66), fentanyl injection (AOR = 3.45; 95% CI: 1.42 – 8.41), non-fatal overdose (AOR = 1.86; 95% CI: 1.02 – 3.38) and enrolment in methadone maintenance therapy (AOR = 1.89; 95% CI: 1.03 – 3.47) were associated with increased odds of receiving injection assistance at SIS. ConclusionAlthough uptake of assisted injection at SIS was relatively low among this sample of people who require help injecting, this practice was associated with several indicators of structural vulnerability and drug-related risk. These findings suggest that accommodating assisted injection within SIS may be providing opportunities to engage and reduce harms among higher-risk subpopulations of PWID in this setting.

How Do Nursing Organizations Measure Up on Harm Reduction? An Environmental Scan

In the past five years, we have seen a rapid expansion of harm reduction approaches, programs, and policies in Canada. To keep up with the changing policy landscape, a number of Canadian researchers have undertaken projects that seek to analyze policy documents published by provincial and territorial governments. Building on this important body of work, we undertook a similar analysis using documents published by nursing organizations. To present key findings and propose ways that nursing organizations can strengthen their position on harm reduction. We conducted an environmental scan with a two-part analysis. To complete the first part, we used the 17 quality indicators. To complete the second part, we analyzed the documents for specific harm reduction interventions. A total of 39 documents were collected across 76 nursing organizations. The majority of the documents were press or public statements (n = 22), and the most frequently mentioned intervention was supervised injection services (n = 31). On average, documents met 5.6 quality indicators. Documents scored highest on indicator 12 (discuss low-threshold approaches to service provision) and lowest on indicator 3 (acknowledge that not all substance use is problematic). Six areas were identified to strengthen nursing organizations' position on harm reduction.

‘It's too much, I'm getting really tired of it’: Overdose response and structural vulnerabilities among harm reduction workers in community settings

BackgroundIn response to the devastating overdose epidemic across Canada, overdose education and naloxone distribution programs (OEND) targeted at people who use drugs have been scaled-up. The ways in which people who use drugs (PWUD) – who experience social and structural vulnerabilities due to their drug use – enact advice from these health education campaigns remains underexplored. This study examines structural vulnerabilities that constrain PWUD as they attempt to implement OEND program advice. MethodsData were drawn from an ethnographic study of “Satellite Sites”, a program where PWUD are employed by a community health center to operate satellite harm reduction programs within their homes. Data collection included participant observation within the Satellite Sites, complemented by semi-structured interviews and a focus group with Satellite Site workers. Thematic analysis was used to explore impacts of responding to overdose. ResultsOEND advice includes not injecting alone, carrying naloxone, and calling 911 if overdose occurs. The ability of Satellite Site workers to respond according to public health guidelines is complicated by contextual and structural factors, including a lack of supervised injection services, vulnerability to eviction, and continued criminalization of drug use. Participants described how responding to increasing numbers of overdoses was stressful, with stress compounded by their close relationships with those who were overdosing. These factors were impacting the willingness of Satellite Site workers to continue to supervise drug use. ConclusionOEND programs are essential and effective; however, they are a response to a crisis within a policy and legal environment framed by the criminalization of drug use. Efforts to expand access to complementary interventions, such as supervised injection services, safer supply interventions, and protection against evictions, are necessary to complement OEND programs and address multiple contextual factors within the risk environment for overdose. Additionally, criminalization will continue to impede and constrain the public health response to drug use.

Potential use of supervised injection services among people who inject drugs in a remote and mid-size Canadian setting

BackgroundWhile supervised injection services (SIS) feasibility research has been conducted in large urban centres across North America, it is unknown whether these services are acceptable among people who inject drugs (PWID) in remote, mid-size cities. We assessed willingness to use SIS and expected frequency of SIS use among PWID in Thunder Bay, a community in Northwestern, Ontario, Canada, serving people from suburban, rural and remote areas of the region.MethodsBetween June and October 2016, peer research associates administered surveys to PWID. Sociodemographic characteristics, drug use and behavioural patterns associated with willingness to use SIS and expected frequency of SIS use were estimated using bivariable and multivariable logistic regression models. Design preferences and amenities identified as important to provide alongside SIS were assessed descriptively.ResultsAmong 200 PWID (median age, IQR: 35, 28–43; 43% female), 137 (69%) reported willingness to use SIS. In multivariable analyses, public injecting was positively associated with willingness to use (Adjusted Odds Ratio (AOR): 4.15; 95% confidence interval (CI): 2.08–8.29). Among those willing to use SIS, 87 (64%) said they would always/usually use SIS, while 48 (36%) said they would sometime/occasionally use SIS. In multivariable analyses, being female (AOR: 2.44; 95% CI: 1.06–5.65) and reporting injecting alone was positively associated with higher expected frequency of use (AOR: 2.59; 95% CI: 1.02–6.58).ConclusionsOur findings suggest that SIS could play a role in addressing the harms of injection drug use in remote and mid-sized settings particularly for those who inject in public, as well as women and those who inject alone, who report higher expected frequency of SIS use. Design preferences of local PWID, in addition to differences according to gender should be taken into consideration to maximize the uptake of SIS, alongside existing health and social service provisions available to PWID.

At-a-glance - Supervised Injection Services: a community-based response to the opioid crisis in the City of Ottawa, Canada.

In response to the current opioid crisis in Canada, establishing safe injection services (SIS) in high risk communities has become more prevalent. In November 2017, The Trailer opened in Ottawa, Canada and tracks client use, overdose treatment and overdoses reversed. We analyzed data collected between November 2017 and August 2018. During peak hours, demand for services consistently exceeded The Trailer's capacity. Overdoses treated and reversed in this facility increased substantially during this period. Results suggest The Trailer provided an important though not optimal (due to space restrictions) harm reduction service to this high-risk community.

Supervised inhalation is an important part of supervised consumption services.

The first regulated supervised inhalation site (safer smoking room) in North America has opened in Lethbridge, Alberta, as part of a supervised consumption site addressing all routes of consumption. When designing the service, we felt it was important to accommodate not just injection drug use but also inhalation because (1) it is not the method of drug use that kills but the drug itself, (2) all people who use drugs deserve service regardless of their mode of use, and (3) people who use drugs should have the opportunity to use the method with the lowest risk. We received approval from Health Canada to offer supervised inhalation services in addition to supervised injection services. Based on a European model, we worked with a local commercial heating, cooling, and ventilation (HVAC) company to create rooms with ventilation systems that complied with Canadian health and safety regulations. People who use drugs by inhalation have repeatedly told us that they want to use indoors and will do so given the option. Since opening the supervised consumption service at the end of February 2018, the response has been overwhelming and both of the inhalation rooms are constantly in use. Supervised inhalation services provide an alternative to public drug use and an opportunity for people who use drugs to engage with harm reduction services. Other supervised consumption services in Canada may alsowish to pursue exemptions for this service.

The implementation of overdose prevention sites as a novel and nimble response during an illegal drug overdose public health emergency

BackgroundDrug-related overdoses were declared a public health emergency in British Columbia, Canada in April, 2016 facilitating the scale-up of responses including rapid sanctioning and implementation of overdose prevention sites (OPSs). OPSs are a health service providing supervised injection and immediate overdose response. In BC, OPSs were operational within weeks of sanctioning. In the first year of operation over 20 OPSs were established with approximately 550,000 visits and no overdose deaths at any site. In this paper, we examine the implementation of OPSs as a novel and nimble response to prevent overdose deaths as a result of injection drug use. MethodsA multiple case study design was used with the Consolidated Framework for Implementation (CFIR) informing the analysis. Three sites in a single city were included with each site constituting a case. In this paper, we focus on qualitative interviews with 15 staff and their perceptions of the implementation of the OPSs as well as provincial and local documents. ResultsThe legislative process to implement OPSs was unprecedented as it sanctioned supervised injection services as an extraordinary measure under a declared public health emergency. Innovative and inclusionary practices were possible within state-sanctioned OPSs, as the sites were government-directed yet community-developed, with PWUD centred in service design, implementation and delivery. OPSs lack permanency and may be limited to the duration of the public health emergency. ConclusionThe rapid implementation of OPSs provides an international example of an alternative to lengthy and often onerous sanctioning processes for supervised consumption services (SCSs). Overdose prevention sites provide an example of a novel service design and nimble implementation process that combines the benefits of state-sanctioned injection services with community-driven implementation. Such evidence questions the continued acceptability of governments’ restrictive sanctioning processes, which have limited expansion of SCSs internationally and the implementation of services that are not necessarily aligned with the needs of PWUD.

Creating and sustaining cooperative relationships between supervised injection services and police: A qualitative interview study of international stakeholders

BackgroundSupervised injection services (SIS) operate with special exemptions from drug law enforcement. Given the expansion of SIS and the opioid overdose crisis in numerous jurisdictions, now is a critical time to examine factors that contribute to cooperative SIS-police relationships. We sought to learn about SIS-police relationships from international jurisdictions with well-established as well as newer SIS. MethodsWe conducted 16 semi-structured telephone interviews with SIS managers (n = 10) and police liaisons (n = 6) from 10 cities in seven different countries (Australia, Canada, Denmark, France, Germany, Netherlands, and Spain). All participants provided informed consent. We focused our coding and analysis on themes that emerged from the data. ResultsFive key contributors to cooperative SIS-police relationships emerged from the data: early engagement and dialogues; supportive police chiefs; dedicated police liaisons; negotiated boundary agreements; and regular face-to-face contact. Most participants perceived the less formalised, on-the-ground approach to relationship-building between police and SIS adopted in their city to be working well in general. SIS managers and police participants reported a lack of formal police training on harm reduction, and some thought that training was unnecessary given the relatively positive local SIS-police relationships they reported. ConclusionOur qualitative study provides new, in-depth empirical examples of how police in varied international jurisdictions can come to accept and work cooperatively with, not against, SIS staff and clients. Investing ongoing effort in SIS-police relationships, in a manner that best suits local needs, may hold greater and more sustainable public health value than delivering specific curricula to police.