Mobilizing drug consumption rooms: inter-place networks and harm reduction drug policy

A place of encounter: Health and social care workers' perspectives on public gathering spaces for people using drugs

Background: The use of drugs is an escalating concern, with significant implications for the health and daily functionality for individuals. It has proven challenging to provide accessible health and social services. In the context of addressing substance use issues in urban areas, public gathering places for individuals who use drugs play a multifaceted role, serving as sites of belonging, support and potential illicit activity. This qualitative study explores the experiences of healthcare and social workers regarding a public gathering place, referred to as "the Bench", in a medium-sized Norwegian city. Methods: A qualitative research design consisting of semi-structured focus group interviews and individual interviews with 13 participants representing various support agencies. Results: The analysis resulted in four thematic areas: (1) belonging and a gateway to support and services; (2) balancing user autonomy at the Bench and systems support; (3) the role of a centralised location; and (4) the preventive role of support workers at the Bench. Conclusion: While the Bench fosters a sense of community and provides access to vital services, concerns about illicit activities persist due to its visibility. Nevertheless, its central location facilitates outreach efforts and ensures easy access to support services. The study underscores the preventive role of healthcare and social workers in stabilising the environment and mitigating conflicts. Furthermore, it highlights the importance of central locations for public gathering places, emphasising the proximity to low-threshold services. The Bench represents a crucial venue for establishing relationships and providing assistance to individuals who use drugs, contributing to harm reduction efforts in the community.

Assessing stigma: Health and social worker regard towards working with people using illicit drugs in Athens, Greece

BACKGROUND

After the 2008 Global Financial Crisis and resulting economic austerity, the rise in illicit drug use engendered an increased need for people who use drugs (PWUD) to access medical care, compounded by the COVID-19 pandemic. Research shows that perceptions of medical staff towards PWUD facilitate or act as a barrier to accessing health care. This study provides a better understanding of health and social work professionals' perceptions by assessing stigma levels towards PWUD in Athens, Greece.

METHODS

This is a mixed-method study. It calculates the stigma score for professionals (n = 60) and the stigma score associated with specific drugs based on the Medical Condition Regard Scale through a quantitative analysis of responses to a semi-structured online survey about attitudes of health and social work professionals towards PWUD. It draws on the qualitative analysis of 12 semi-structured interviews with 16 service managers, providers, and health services advocates working in the charity sector to determine whether perceptions of PWUD affect writing and implementing policy and protocols for services.

RESULTS

Stigma towards PWUD exists amongst health and social work professionals in Athens. Professionals who have worked with PWUD for longer periods of time, professionals who have had specific training on working with PWUD, and professionals who feel that they have the necessary training to work with PWUD all demonstrated a higher stigma score than those reporting the opposite. Cannabis and opioids were associated with lower stigma scores while shisha had the highest level of stigma associated with it. Finally, professional environments are not conducive to alleviating stigma as the lack of training specific to stigma, the lack of professional supervision, and worker burn-out are key barriers faced by professionals in their everyday practice.

CONCLUSIONS

Reducing and eliminating stigma towards PWUD among health and social workers requires immediate action. Measures to be taken include: introducing training programs focused on stigma towards PWUD to healthcare providers, social workers, lawyers, police, the media; increasing professional supervision on field work for health and social workers; introducing low barrier health care and specialist units. Peers and field-focused organisations should meaningfully participate in drug and alcohol policymaking, program development, and implementation.

Policy windows for drug consumption rooms in Finland

Background: Use of drug consumption rooms is a novel harm reduction approach to reach marginalised and isolated people who used drugs, under the high risk of overdose deaths and infectious diseases. The aim of this article was to evaluate the policy opportunities and barriers of the Helsinki City initiative for establishing the first drug consumption room (DCR) in Finland from the multiple streams framework. Method: A qualitative interview research method is used to evaluate the perspectives of stakeholders. By including 23 participants, we analysed the political, social and policy level advantages and disadvantages of the current initiative. Findings: Our results show that the cost of DCRs, the COVID-19 burdens on public resources, the requirement of legislative change, public unawareness, potential policy failure of DCRs, and its impacts on electoral votes constitute the main policy barriers. On the other hand, an increase in drug-related deaths, economic benefits of DCR for society, its effects on street safety and public order, being a local initiative, prospectus change in national drug strategy plans and motivation to catch up with EU standards were underlined as policy opportunities. Four issues, leadership, moral perspective, social change and generational differences, act as mediating factors, which are fluctuated according to public opinions and political environment. Conclusion: By applying the multiple streams framework, our results show that experts' DCR problematisation is still beyond the public and political interest, which needs additional effort around problem identification and prioritisation. Besides public unawareness, the COVID-19 situation seems to be postponing policy progress since the primary attention and available funds have already been dedicated to public health. Already having a local initiative and an upcoming drug strategy plan might be good formal leverage, but unexpected events might also trigger discussions.

Equity-oriented frameworks to inform responses to opioid overdoses: a scoping review

OBJECTIVE

The purpose of this scoping review was to systematically identify and describe literature that uses a health equity-oriented approach for preventing and reducing the harms of stigma or overdose for people who use illicit drugs or misuse prescription opioids.

INCLUSION CRITERIA

To be included, papers had to both: i) use a health equity-oriented approach, defined as a response that addresses health inequities and aims to reduce drug-related harms of stigma or overdose; and ii) include at least one of the following concepts: cultural safety, trauma- and violence-informed care, or harm reduction. We also looked for papers that included an Indigenous-informed perspective in addition to any of the three concepts.

METHODS

An a priori protocol was published and the JBI methodology for conducting scoping reviews was employed. Published and unpublished literature from January 1, 2000, to July 31, 2019, was included. The databases searched included CINAHL (EBSCOhost), MEDLINE (Ovid), Academic Search Premier (EBSCOhost), PsycINFO (EBSCOhost), Sociological Abstracts and Social Services Abstracts (ProQuest), JBI Database of Systematic Reviews and Implementation Reports, Cochrane Database of Systematic Reviews, PROSPERO, Aboriginal Health Abstract Database, First Nations Periodical Index, and the National Indigenous Studies Portal. The search for unpublished studies included ProQuest Dissertations and Theses, Google Scholar, and targeted web searches. Screening and data extraction were performed by two reviewers using templates developed by the authors. Data extraction included specific details about the population, concepts, context, and key findings or recommendations relevant to the review objectives.

RESULTS

A total of a total of 1065 articles were identified and screened, with a total of 148 articles included. The majority were published in the previous five years (73%) and were from North America (78%). Most articles only focused on one of the three health equity-oriented approaches, most often harm reduction (n = 79), with only 16 articles including all three. There were 14 articles identified that also included an Indigenous-informed perspective. Almost one-half of the papers were qualitative (n = 65; 44%) and 26 papers included a framework. Of these, seven papers described a framework that included all three approaches, but none included an Indigenous-informed perspective. Recommendations for health equity-oriented approaches are: i) inclusion of people with lived and living experience; ii) multifaceted approaches to reduce stigma and discrimination; iii) recognize and address inequities; iv) drug policy reform and decriminalization; v) ensure harm-reduction principles are applied within comprehensive responses; and vi) proportionate universalism. Gaps in knowledge and areas for future research are discussed.

CONCLUSIONS

We have identified few conceptual frameworks that are both health equity-oriented and incorporate multiple concepts that could enrich responses to the opioid poisoning emergency. More research is required to evaluate the impact of these integrated frameworks for action.

Assembling the Healthopolis: Competitive city-regionalism and policy boosterism pushing Greater Manchester further, faster

Health and care policy is increasingly promoted within visions of the competitive city-region. This paper examines the importance of policy boosterism within the political construction of city-regions in the context of English devolution. Based on a two-year case study of health and social care devolution in Greater Manchester, England, we trace the relational and territorial geographies of policy across and through new "devolved" city-regional arrangements. Contributing to geographical debates on policy assemblages and city-regionalism, we advance a conceptual framework linking crisis and opportunity, emulation and exceptionalism, and evidence and experimentation. The paper makes two key contributions. First, we argue health and care policy is increasingly drawn towards the logic of global competitiveness without being wholly defined by neoliberal political agendas. Fostering transnational policy networks helped embed global "best practice" policies while simultaneously hailing Greater Manchester as a place beyond compare. Second, we caution against positioning the city-region solely at the receiving end of devolutionary austerity. Rather, we illustrate how the urgency of devolution was conditioned by crisis, yet concomitantly framed as a unique opportunity by the local state harnessing policy to negotiate a more fluid politics of scale. In doing so, the paper demonstrates how attempts to resolve the "local problem" of governing health and care under austerity were rearticulated as a "global opportunity" to forge new connections between place, health, and economy. Consequently, we foreground the multiple tensions and contradictions accumulating through turning to health and care to push Greater Manchester further, faster. The paper concludes by asking what the present crisis might mean for city-regions in good health and turbulent times.

"You need to just provide health services:" navigating the politics of harm reduction in the twin housing and overdose crises in Vancouver, BC

BACKGROUND

Since harm reduction's origins as a grassroots, activist movement, cooperation and compromise among people who use drugs, bureaucrats, politicians, and other actors have been critical to its advancement in Canada. Critics have argued, however, that the institutionalization of harm reduction practice within the context of a politically sensitive environment has eroded its radical potential. The overdose crisis in Vancouver's Downtown Eastside (DTES) community has led to innovative harm reduction organizing that has been replicated globally. In this paper, we explore how one such intervention, the Tenant Overdose Response Organizers (TORO) program, has supported a resurgence in tenant-led harm reduction organizing in Single Room Occupancy (SRO) buildings in the DTES.

METHODS

We draw on 15 months of ethnographic fieldwork conducted between May 2017 and August 2018, over 100 hours of participant observation of TORO activities, and 15 semi-structured interviews with key stakeholders in the program.

RESULTS

TORO's leaders attempted to mobilize harm reduction intervention towards collective action on SRO risk environments underlying drug-related harms, but their efforts were constrained by the necessity of meeting practical expectations of funders regarding health education and supply distribution. Navigating these constraints ultimately shaped the development of the TORO program, helping to secure its longevity but also limiting its ability to organize a coordinated harm reduction and tenants' rights response to the dual housing and overdose crises.

CONCLUSION

Our examination of TORO demonstrates how the harm reduction movement continues to be shaped by conflict, cooperation, and compromise between the state and grassroots groups. Even as actors strive to work collaboratively, the unequal distribution of power inherent in this relationship may contribute to the reinscription of a depoliticized harm reduction approach. We discuss the potential role of the risk environment framework in lending political legitimacy to grassroots harm reduction initiatives.

Drug consumption rooms: A systematic review of evaluation methodologies

ISSUES

Drug consumptions rooms (DCR) and supervised injecting facilities (SIF) are expanding internationally. Previous reviews have not systematically addressed evaluation methodologies.

APPROACH

Results from systematic searches of scientific databases in English until June 2017 were coded for paper type, country and year of publication. For evaluation papers, study outcome, methodology/study design and main indicators of DCR/SIF 'exposure' were recorded.

KEY FINDINGS

Two hundred and nineteen eligible peer-reviewed papers were published since 1999: the majority from Canada (n = 117 papers), Europe (n = 36) and Australia (n = 32). Fifty-six papers reported evaluation outcomes. Ecological study designs (n = 10) were used to assess the impact on overdose, public nuisance and crime; modelling techniques (n = 6) estimated impact on blood-borne diseases, overdose deaths and costs. Papers using individual-level data included four prospective cohorts (n = 28), cross-sectional surveys (n = 7) and service records (n = 5). Individual-level data were used to assess safer injecting practice, uptake into health and social services and all the other above outcomes except for impact on crime and costs. Four different indicators of DCR/SIF attendance were used to measure service 'exposure'.

IMPLICATIONS

Research around DCRs/SIFs has used ecological, modelling, cross-sectional and cohort study designs. Further research could involve systematic inclusion of a control group of people who are eligible but do not access SIFs, validation of self-reported proportion of injections at SIFs or a stepped-wedge or a cluster trial comparing localities.

CONCLUSIONS

Methodologies appropriate for DCR/SIF evaluation have been established and can be readily replicated from the existing literature. Research on operational aspects, implementation and transferability is also warranted.

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

BACKGROUND

Drug-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.

METHODS

A 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.

RESULTS

The 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.

CONCLUSION

The 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.

Ideation, social construction and drug policy: A scoping review

Within drug policy scholarship there is a growing body of literature applying ideational and social constructionist approaches to address the complexity of drug policy making and the apparent failure of the evidence-based policy paradigm to free the process from controversy and contestation. Ideational approaches are concerned with the roles played by ideas and beliefs in policy making, while social construction explores the way policy problems are constructed, and agendas are set and delineated by dominant frames and narratives. Interest in these approaches has developed over the last two decades, but has rapidly gained momentum over the last five years. There has been limited reflection on the state of the field, therefore it is timely to conduct a review of the literature to assess the value of these approaches, capture emerging themes and issues, and identify gaps in the literature to support future research directions. Using the Arksey and O'Malley framework, a scoping review was conducted to survey the breadth of the field. Following database and hand searching, 48 studies from 1996 to 2016 were selected for inclusion in the review. A narrative synthesis was undertaken and the literature was grouped into five broad theoretical approaches: ideational policy theory, problem construction, narratives and frames (including media analysis), construction of target populations, and policy transfer and mobilities. The majority of the studies are focused on single countries and drug policy issues, with few studies undertaking comparative work or reflecting on general theoretical developments in the literature. This study found that the Arksey and O'Malley framework was effective in capturing a potentially diverse field of literature and demonstrates the importance of ideational and social constructionist approaches to drug policy scholarship. Further research is required to achieve expanded geographic coverage, test policy making models and undertake comparative work.

Barriers and facilitators to implementing addiction medicine fellowships: a qualitative study with fellows, medical students, residents and preceptors

Background

Although progress in science has driven advances in addiction medicine, this subject has not been adequately taught to medical trainees and physicians. As a result, there has been poor integration of evidence-based practices in addiction medicine into physician training which has impeded addiction treatment and care. Recently, a number of training initiatives have emerged internationally, including the addiction medicine fellowships in Vancouver, Canada. This study was undertaken to examine barriers and facilitators of implementing addiction medicine fellowships.

Methods

We interviewed trainees and faculty from clinical and research training programmes in addiction medicine at St Paul’s Hospital in Vancouver, Canada (N = 26) about barriers and facilitators to implementation of physician training in addiction medicine. We included medical students, residents, fellows and supervising physicians from a variety of specialities. We analysed interview transcripts thematically by using NVivo software.

Results

We identified six domains relating to training implementation: (1) organisational, (2) structural, (3) teacher, (4) learner, (5) patient and (6) community related variables either hindered or fostered addiction medicine education, depending on context. Human resources, variety of rotations, peer support and mentoring fostered implementation of addiction training. Money, time and space limitations hindered implementation. Participant accounts underscored how faculty and staff facilitated the implementation of both the clinical and the research training.

Conclusions

Implementation of addiction medicine fellowships appears feasible, although a number of barriers exist. Research into factors within the local/practice environment that shape delivery of education to ensure consistent and quality education scale-up is a priority.

Mitigating the heroin crisis in Baltimore, MD, USA: a cost-benefit analysis of a hypothetical supervised injection facility

Background

In Baltimore, MD, as in many cities throughout the USA, overdose rates are on the rise due to both the increase of prescription opioid abuse and that of fentanyl and other synthetic opioids in the drug market. Supervised injection facilities (SIFs) are a widely implemented public health intervention throughout the world, with 97 existing in 11 countries worldwide. Research has documented the public health, social, and economic benefits of SIFs, yet none exist in the USA. The purpose of this study is to model the health and financial costs and benefits of a hypothetical SIF in Baltimore.

Methods

We estimate the benefits by utilizing local health data and data on the impact of existing SIFs in models for six outcomes: prevented human immunodeficiency virus transmission, Hepatitis C virus transmission, skin and soft-tissue infection, overdose mortality, and overdose-related medical care and increased medication-assisted treatment for opioid dependence.

Results

We predict that for an annual cost of $1.8 million, a single SIF would generate $7.8 million in savings, preventing 3.7 HIV infections, 21 Hepatitis C infections, 374 days in the hospital for skin and soft-tissue infection, 5.9 overdose deaths, 108 overdose-related ambulance calls, 78 emergency room visits, and 27 hospitalizations, while bringing 121 additional people into treatment.

Conclusions

We conclude that a SIF would be both extremely cost-effective and a significant public health and economic benefit to Baltimore City.

A review: Fentanyl and non-pharmaceutical fentanyls

BACKGROUND

Fentanyl and non-pharmaceutical fentanyls (NPFs) have been responsible for numerous outbreaks of overdoses all over the United States since the 1970s. However, there has been a growing concern in recent years that NPFs are contributing to an alarming rise in the number of opioid-related overdoses.

METHODS

The authors conducted a narrative review of the published and grey literature on fentanyl and NPFs in PubMed, Google Scholar, and Google using the following search terms: "fentanyl", "non-pharmaceutical fentanyl", "fentanyl analogs", "fentanyl laced heroin" and "fentanyl overdose". References from relevant publications and grey literature were also reviewed to identify additional citations for inclusion.

RESULTS

The article reviews the emergence and misuse of fentanyl and NPFs, their clinical pharmacology, and the clinical management and prevention of fentanyl-related overdoses.

CONCLUSIONS

Fentanyl and NPFs may be contributing to the recent rise in overdose deaths in the United States. There is an urgent need to educate clinicians, researchers, and patients about this public health threat.

Ambivalence about supervised injection facilities among community stakeholders

Background

Community stakeholders express a range of opinions about supervised injection facilities (SIFs). We sought to identify reasons for ambivalence about SIFs amongst community stakeholders in two Canadian cities.

Findings

We used purposive sampling methods to recruit various stakeholder representatives (n = 141) for key informant interviews or focus group discussions. Data were analyzed using a thematic process. We identified seven reasons for ambivalence about SIFs: lack of personal knowledge of evidence about SIFs; concern that SIF goals are too narrow and the need for a comprehensive response to drug use; uncertainty that the community drug problem is large enough to warrant a SIF(s); the need to know more about the “right” places to locate a SIF(s) to avoid damaging communities or businesses; worry that a SIF(s) will renew problems that existed prior to gentrification; concern that resources for drug use prevention and treatment efforts will be diverted to pay for a SIF(s); and concern that SIF implementation must include evaluation, community consultation, and an explicit commitment to discontinue a SIF(s) in the event of adverse outcomes.

Conclusions

Stakeholders desire evidence about potential SIF impacts relevant to local contexts and that addresses perceived potential harms. Stakeholders would also like to see SIFs situated within a comprehensive response to drug use. Future research should determine the relative importance of these concerns and optimal approaches to address them to help guide decision-making about SIFs.