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

Investigating the spatial association between supervised consumption services and homicide rates in Toronto, Canada, 2010-2023: an ecological analysis

Background

Supervised consumption services (SCS) are effective at preventing overdose mortality. However, their effect on public safety remains contested. We investigated homicide rates in areas near SCS in Toronto.

Methods

We classified coroner-reported fatal shootings and stabbings (January 1st, 2010 to September 30th 2023) by geographic zone: within 500 m ('near'), between 500 m and 3 km ('far'), and beyond 3 km of an SCS ('out'). We then used Poisson regression to calculate the rate ratio (RR) across zones 18, 36, 48, and 60 months pre vs. post SCS implementation. Finally, we compared spatial homicide incidence prior to and after the date of the implementation of each SCS using interrupted time series (ITS).

Findings

Overall, 956 homicides occurred, and 590 (62%) were fatal shootings and stabbings. There was no meaningful change in the rate of fatal shootings and stabbings within 3 kms of SCS (near and far zones) after their implementation. However, between 48 and 60 months pos-implementation, we detected an increase in out zones. In an ITS analysis, we observed a reduction in the monthly incidence in near zones and an increase in out zones.

Interpretation

SCS implementation was not associated with increased homicide rates; instead, we observed a reduction in monthly incidence near SCS. These results may inform drug market activity responses that optimize community health and safety.

Funding

Canadian Institutes of Health Research, the New Frontiers in Research Fund, St. Michael's Hospital Foundation.

Harm Reduction as a Form of 'Wrap-Around' Care: The Nursing Role

In addiction treatment, harm reduction is a philosophy that aims to reduce the harms from ongoing alcohol and other drug use. Although abstinence may be the 'gold standard' in reducing harm from ongoing alcohol and other drug use, harm reduction recognises that abstinence may not be achievable for certain individuals. Accordingly, harm reduction is used to enable medical or mental health treatment for individuals who continue to use alcohol and other drugs, providing a form of care which meets individuals where they present to healthcare facilities. Harm reduction accepts ongoing alcohol and other drug use, while providing a traditionally marginalised cohort of individuals access to healthcare services. In this perspective paper, we argue that the role of nurses in promoting and utilising harm reduction as part of their regular practice is essential to both reducing harm from alcohol and other drug use, engaging individuals who use alcohol and other drugs in healthcare services, and providing a means to accept individuals as they are to build trust and rapport for engagement in addiction treatment when they are ready, and at their own pace. Nurses, by virtue of their role and number in the healthcare landscape (approximately 28 million globally), are ideally placed to implement harm reduction in their practice to achieve better outcomes for individuals who use alcohol and other drugs.

Modeling the impact of a supervised consumption site on HIV and HCV transmission among people who inject drugs in three counties in California, USA

BACKGROUND

Supervised consumption sites (SCS) have been shown to reduce receptive syringe sharing among people who inject drugs (PWID) in the United States and elsewhere, which can prevent HIV and hepatitis C virus (HCV) transmission. PWID are at risk of disease transmission and may benefit from SCS, however legislation has yet to support their implementation. This study aims to determine the potential impact of SCS implementation on HIV and HCV incidence among PWID in three California counties.

METHODS

A dynamic HIV and HCV joint transmission model among PWID (sexual and injecting transmission of HIV, injecting transmission of HCV) was calibrated to epidemiological data for three counties: San Francisco, Los Angeles, and San Diego. The model incorporated HIV and HCV disease stages and HIV and HCV treatment. Based on United States data, we assumed access to SCS reduced receptive syringe sharing by a relative risk of 0.17 (95 % CI: 0.04-1.03). This model examined scaling-up SCS coverage from 0 % to 20 % of the PWID population within the respective counties and assessed its impact on HIV and HCV incidence rates after 10 years.

RESULTS

By increasing SCS from 0 % to 20 % coverage among PWID, 21.8 % (95 % CI: -1.2-32.9 %) of new HIV infections and 28.3 % (95 % CI: -2.0-34.5 %) of new HCV infections among PWID in San Francisco County, 17.7 % (95 % CI: -1.0-30.8 %) of new HIV infections and 29.8 % (95 % CI: -2.1-36.1 %) of new HCV infections in Los Angeles County, and 32.1 % (95 % CI: -2.8-41.5 %) of new HIV infections and 24.3 % (95 % CI: -1.6-29.0 %) of new HCV infections in San Diego County could be prevented over ten years.

CONCLUSION

Our models suggest that SCS is an important intervention to enable HCV elimination and could help end the HIV epidemic among PWID in California. It could also have additional benefits such facilitating pathways into drug treatment programs and preventing fatal overdose.

Evaluation of Strategies to Enhance Community-Based Naloxone Distribution Supported by an Opioid Settlement

Importance

Many US states are substantially increasing community-based naloxone distribution, supported in part through settlements from opioid manufacturers and distributors.

Objectives

To evaluate the potential impact of increased naloxone availability on opioid overdose deaths (OODs) and explore strategies to enhance this impact by integrating interventions to address solitary drug use.

Design, Setting, and Participants

This decision analytical modeling study used PROFOUND (Prevention and Rescue of Fentanyl and Other Opioid Overdoses Using Optimized Naloxone Distribution Strategies), a previously published simulation model, to forecast annual OODs between January 2023 and December 2025. The simulated study population included individuals from Rhode Island who misused opioids and stimulants and were at risk for opioid overdose.

Exposures

The study modeled expanded naloxone distribution supported by the state's opioid settlement (50 000 naloxone nasal spray kits each year). Two approaches to expanding naloxone distribution were evaluated: one based on historical spatial patterns of naloxone distribution (supply-based approach) and one based on the spatial distribution of individuals at risk (demand-based approach). In addition, hypothetical interventions to enhance the likelihood of witnessed overdoses in private or semiprivate settings were considered.

Main Outcomes and Measures

Annual number of OODs and ratio of fatal to nonfatal opioid overdoses.

Results

Modeling results indicated that distributing more naloxone supported by the state's opioid settlement could reduce OODs by 6.3% (95% simulation interval [SI], 0.3%-13.7%) and 8.8% (95% SI, 1.8%-17.5%) in 2025 with the supply-based and demand-based approaches, respectively. However, increasing witnessed overdoses by 20% to 60% demonstrated greater potential for reducing OODs, ranging from 8.5% (95% SI, 0.0%-20.3%) to 24.1% (95% SI, 8.6%-39.3%). Notably, synergistic associations were observed when combining both interventions: increased naloxone distribution with the 2 approaches and a 60% increase in witnessed overdoses could reduce OODs in 2025 by 33.5% (95% SI, 17.1%-50.4%) and 37.4% (95% SI, 19.6%-56.3%), respectively.

Conclusions and Relevance

These findings suggest that interventions to address solitary drug use are needed to maximize the impact of continued efforts to increase community-based naloxone distribution, which may be particularly important for jurisdictions that have strong community-based naloxone distribution programs.

Economic Evaluations of Establishing Opioid Overdose Prevention Centers in 12 North American Cities: A Systematic Review

OBJECTIVES

Overdose prevention centers (OPCs) provide a safe place where people can consume preobtained drugs under supervision so that a life-saving medical response can be provided quickly in the event of an overdose. OPCs are programs that are established in Canada and have recently become legally sanctioned in only a few United States jurisdictions.

METHODS

We conducted a systematic review that summarizes and identifies gaps of economic evidence on establishing OPCs in North America to guide future expansion of OPCs.

RESULTS

We included 16 final studies that were evaluated with the Consolidated Health Economic Evaluation Reporting Standards and Drummond checklists. Eight studies reported cost-effectiveness results (eg, cost per overdose avoided or cost per quality-adjusted life-year), with 6 also including cost-benefit; 5 reported only cost-benefit results, and 3 cost offsets. Health outcomes primarily included overdose mortality outcomes or HIV/hepatitis C virus infections averted. Most studies used mathematical modeling and projected OPC outcomes using the experience of a single facility in Vancouver, BC.

CONCLUSIONS

OPCs were found to be cost-saving or to have favorable cost-effectiveness or cost-benefit ratios across all studies. Future studies should incorporate the experience of OPCs established in various settings and use a greater diversity of modeling designs.

Understanding the barriers and facilitators to implementing and sustaining Mobile Overdose Response Services from the perspective of Canadian key interest groups: a qualitative study

INTRODUCTION

Unregulated supply of fentanyl and adulterants continues to drive the overdose crisis. Mobile Overdose Response Services (MORS) are novel technologies that offer virtual supervised consumption to minimize the risk of fatal overdose for those who are unable to access other forms of harm reduction. However, as newly implemented services, they are also faced with numerous limitations. The aim of this study was to examine the facilitators and barriers to the adoption of MORS in Canada.

METHODS

A total of 64 semi-structured interviews were conducted between November 2021 and April 2022. Participants consisted of people who use substances (PWUS), family members of PWUS, health care professionals, harm reduction workers, MORS operators, and members of the general public. Inductive thematic analysis was used to identify the major themes and subthemes.

RESULTS

Respondents revealed that MORS facilitated a safe, anonymous, and nonjudgmental environment for PWUS to seek harm reduction and other necessary support. It also created a new sense of purpose for operators to positively contribute to the community. Further advertising and promotional efforts were deemed important to increase its awareness. However, barriers to MORS implementation included concerns regarding privacy/confidentiality, uncertainty of funding, and compassion fatigue among the operators.

CONCLUSION

Although MORS were generally viewed as a useful addition to the currently existing harm reduction services, it's important to monitor and tackle these barriers by engaging the perspectives of key interest groups.