From risky places to safe spaces: Re-assembling spaces and places in Vancouver's Downtown Eastside

Four decades of overdose prevention centres: lessons for the future from a realist review

BACKGROUND

Overdose prevention centres (OPCs) are spaces where people can consume previously obtained illicit drugs under the supervision of staff who can intervene to prevent and manage overdose. They have been provided in Europe and elsewhere for nearly 40 years, initially in response to the epidemic of HIV/AIDS. We can learn from their operation history to inform future developments in harm reduction services.

METHODS

We carried out a realist review of 391 documents, reported according to the RAMESES I guidelines, and carried out realist synthesis of these documents.

RESULTS

We present a full realist programme theory of OPCs, with a diagrammatic logic model, of how the contexts and mechanisms of OPCs combine to produce various outcomes for service users and their communities in different settings. Three specific causal pathways were evidenced through which OPCs produce their outcomes for particular groups in specific contexts of housing status, gender identity and ethnicity, and local drug markets, with frequency of use, legal and political contexts, and stigma as overlapping contextual factors. Key OPC interventions include the provision of a safe and hygienic consumption space, safe consumption education, timely overdose response, and protection from drug scene and gender-based violence. These can trigger the underlying mechanisms of safety, trust, social inclusion, engagement, autonomy, and empowerment when supported with health care and other services, including detoxification and opioid agonist treatment. The combinations of these contexts and mechanisms create important outcomes for individual service users, for the communities they live in, and for wider society. We also describe causal pathways that can lead to unintended, adverse outcomes.

CONCLUSION

This review provides useful information for policy makers, practitioners, and researchers on how to implement and evaluate OPCs in future to maximise their benefits; an important task in the context of the ongoing public health crises of drug poisoning deaths in North America and the UK, and the possibility of increasing deaths from synthetic opioids in Europe and elsewhere.

Home as a Place of Refuge, Despair, and Self-Care for Men Living With Mental Health Challenges

Men's poor mental health outcomes and heightened risk for suicide have been linked to their maladaptive responses to life stressors. In this photovoice study of 21 New Zealand-based men who experienced depression, anxiety, and suicidality, participants' home emerged as an important place and resource for dealing with their mental health challenges. Utilizing the therapeutic landscapes "enabling places" framework combined with masculinities theory, we explored the affective, material, and social resources of home for determining how men's mental health challenges play out behind closed doors. Reflexive thematic analysis was used to analyze individual photovoice interviews, revealing how home served along a continuum of enabling and disabling spaces. In this context, home could be a place of refuge, despair, and self-care for participants, and the specificities of those inhabiting forces are described thematically. In terms of refuge, the materiality of home created an affective sense of safety that afforded men spaces to privately conceal and deal with their mental health challenges. Home could also invoke despair in being a risky or disabling place where men felt trapped and isolated, heightening self-harm risks. These same spaces could also promote men's self-care practices in the context of managing their anxiety, depression, and/or suicidality. The current study findings confirm the need for more research that is place and space based to inform mental health supports for men. Implications for men's mental health promotion are discussed.

Qualitative findings from North America's first drug compassion club

In Canada, the ongoing fatal overdose crisis remains driven by the unpredictable potency and content of the illicit drug supply. From August 2022 until October 2023, the Drug User Liberation Front [DULF] operated a drug compassion club [CC], which sells drugs of known composition and purity without medical oversight. The present study is a qualitative evaluation of this project. From December 2022 to February 2023, we interviewed 16 CC members about their experiences with DULF's CC. Using a semi-structured interview guide, participants were interviewed in a private space to ensure confidentiality. Thematic analysis was used to code for a priori and unexpected themes. Participants spoke positively of their experiences with the CC, which ranged from lower overdose risk, health improvements, preference for the drug purchasing process, and mutual respect and trust among CC members, founders, and staff. No participants reported overdosing on CC-sourced drugs, and drugs were described as safe and reliable. For opioid users, the tolerance developed for opioid-potent fentanyl hampered the transition to CC heroin. Suggestions for CC improvements were also identified. Despite political backlash to the project, the CC appears to be a novel and promising approach to reducing overdose morbidity in high needs communities. By promoting participant autonomy, regulating an unstable drug supply, and creating community, this intervention has reduced self-reported overdose risk and improved the health and social wellbeing of members. No overdoses reported from CC-sourced drugs suggests that authorizing, expanding and continually evaluating the CC model is warranted.

Overdose prevention centres as spaces of safety, trust and inclusion: A causal pathway based on a realist review

ISSUES

Overdose prevention centres (OPC) are non-residential spaces where people can use illicit drugs (that they have obtained elsewhere) in the presence of staff who can intervene to prevent and manage any overdoses that occur. Many reviews of OPCs exist but they do not explain how OPCs work.

APPROACH

We carried out a realist review, using the RAMESES reporting standards. We systematically searched for and then thematically analysed 391 documents that provide information on the contexts, mechanisms and outcomes of OPCs.

KEY FINDINGS

Our retroductive analysis identified a causal pathway that highlights the feeling of safety - and the immediate outcome of not dying - as conditions of possibility for the people who use OPCs to build trust and experience social inclusion. The combination of safety, trust and social inclusion that is triggered by OPCs can - depending on the contexts in which they operate - generate other positive outcomes, which may include less risky drug use practices, reductions in blood borne viruses and injection-related infections and wounds, and access to housing. These outcomes are contingent on relevant contexts, including political and legal environments, which differ for women and people from racialised minorities.

CONCLUSIONS

OPCs can enable people who live with structural violence and vulnerability to develop feelings of safety and trust that help them stay alive and to build longer term trajectories of social inclusion, with potential to improve other aspects of their health and living conditions.

The ethics of enhancement among image and performance enhancing drug coaches

This research examines image and performance-enhancing drug (IPED) use, specifically focusing on the emerging role of IPED coaches. Situating drug use within broader assemblage theory, we investigated how these coaches, often operating in an online context, function as enabling environments, influencing practices, and contributing to harm reduction in a broader social context within and for IPED communities. Ten IPED coaches were interviewed, with this work focusing on their legal, ethical, and moral considerations, risk assessment, and harm reduction strategies of their practices. We employed a critical realist approach, following flexible coding to identify and develop themes which were further framed an enabling environments framework. Coaches operated along an ethical tightrope, emphasising the conscious regulation of conduct within established norms and the nuanced assessment of risks aligned with individual goals and motivations. Power dynamics and responsibility concerns unfolded through the lens of collaborative decision-making, where trust emerged as an essential element of these relations within contextual risk assessments. IPED coaches play a role in harm reduction by fostering trust and informed decision-making, balancing clients' goals with health considerations. These findings emphasise the potential for collaboration between IPED coaches and the health workforce to enhance health promotion and support within IPED communities.

Using drugs alone in single room occupancy housing: Understanding environmental drivers of overdose risk

BACKGROUND

Across North America most overdose deaths occur in housing, largely due to individuals using drugs alone. In cities, fatalities are disproportionately concentrated in low-income housing, including single room occupancy (SRO) housing. While research has highlighted how SROs operate as risk environments for various poor outcomes, there has been little attention to specific drug use practices (i.e., using alone) associated with overdose vulnerability in these spaces. This study explores how environmental contexts of SROs shape overdose risks, with specific attention to practices of using drugs alone.

METHODS

In-depth semi-structured interviews were conducted with 30 people who use drugs (PWUD) living in Vancouver SROs. Interviews covered topics such as social-structural environments of housing, drug use practices, and housing-based harm reduction. Thematic analysis drew on the intersectional risk environment framework.

RESULTS

Narratives positioned SROs as extensions of public space, with similar expectations of risks and behaviours as in public spaces. For some participants, using alone in their room was characterized as a practice in claiming privacy within the context of a public existence. Participants highlighted how certain features of SRO's social-structural environments were routinely leveraged against them (e.g., security cameras, staff surveillance), suggesting using alone as a tactic to minimize risks of hyper-surveillance and punitive policies. Further, participants discussed using alone as "safer," describing how this practice mitigated place-based risks of social-structural harms (e.g., violence, criminalization) in ways that eclipsed overdose risk.

CONCLUSION

Using drugs alone may be understood as a spatial negotiation of vulnerability to diverse harms produced by environmental contexts of SROs. Interventions accounting for broader contextual factors (e.g., improvements housing quality/quantity, providing a safer supply of drugs) that render using alone as instrumental to survival, and that reduce the implicit threat of punishment from intensive surveillance and control practices are critical to reduce vulnerability to overdose and other harms.

"As long as that place stays open, I'll stay alive": Accessing injectable opioid agonist treatment during dual public health crises

BACKGROUND

Since the onset of the COVID-19 pandemic, overdose rates in North America have continued to rise, with more than 100,000 drug poisoning deaths in the past year. Amidst an increasingly toxic drug supply, the pandemic disrupted essential substance use treatment and harm reduction services that reduce overdose risk for people who use drugs. In British Columbia, one such treatment is injectable opioid agonist treatment (iOAT), the supervised dispensation of injectable hydromorphone or diacetylmorphine for people with opioid use disorder. While evidence has shown iOAT to be safe and effective, it is intensive and highly regimented, characterized by daily clinic visits and provider-client interaction-treatment components made difficult by the pandemic.

METHODS

Between April 2020 and February 2021, we conducted 51 interviews with 18 iOAT clients and two clinic nurses to understand how the pandemic shaped iOAT access and treatment experiences. To analyze interview data, we employed a multi-step, flexible coding strategy, an iterative and abductive approach to analysis, using NVivo software.

RESULTS

Qualitative analysis revealed the ways in which the pandemic shaped clients' lives and the provision of iOAT care. First, client narratives illuminated how the pandemic reinforced existing inequities. For example, socioeconomically marginalized clients expressed concerns around their financial stability and economic impacts on their communities. Second, clients with health comorbidities recognized how the pandemic amplified health risks, through potential COVID-19 exposure or by limiting social connection and mental health supports. Third, clients described how the pandemic changed their engagement with the iOAT clinic and medication. For instance, clients noted that physical distancing guidelines and occupancy limits reduced opportunities for social connection with staff and other iOAT clients. However, pandemic policies also created opportunities to adapt treatment in ways that increased patient trust and autonomy, for example through more flexible medication regimens and take-home oral doses.

CONCLUSION

Participant narratives underscored the unequal distribution of pandemic impacts for people who use drugs but also highlighted opportunities for more flexible, patient-centered treatment approaches. Across treatment settings, pandemic-era changes that increase client autonomy and ensure equitable access to care are to be continued and expanded, beyond the duration of the pandemic.

Temporal association of pre-pandemic perceived social support with psychological resilience and mental well-being during the COVID-19 pandemic among people with a history of injection drug use

BACKGROUND

There are limited data on whether modifiable social factors foster psychological resilience and mental well-being among people who use drugs following Big Events. We examined the temporal association of pre-pandemic perceived social support with psychological resilience and negative mental health symptoms during the COVID-19 pandemic among people with a history of injection drug use.

METHODS

Between June and September 2020, we conducted a telephone survey among 545 participants in the AIDS Linked to the IntraVenous Experience (ALIVE) study: a community-based cohort of adults with a history of injection drug use. Leveraging data from study visits in 2018-early 2020, associations of pre-pandemic perceived social support with psychological resilience scores (range=1-5) and the probability of negative mental health symptoms during the pandemic were assessed using multivariable linear and modified Poisson regression models, respectively.

RESULTS

Participants' median age was 58 years, 38.2% were female, 83.3% identified as Black, and 30.3% were living with HIV. During the pandemic, 14.5% had low (<3) resilience scores, 36.1% experienced anxiety, and 35.8% reported increased loneliness. Compared to participants in the lowest tertile of pre-pandemic social support, participants in the highest tertile had higher mean resilience scores (β = 0.27 [95% CI = 0.12, 0.43]), a lower probability of anxiety (prevalence ratio [PR] = 0.71 [95% CI = 0.52, 0.96]), and a lower probability of increased loneliness (PR = 0.62 [95% CI = 0.45, 0.84]).

CONCLUSIONS

Pre-pandemic perceived social support was associated with greater psychological resilience and generally better mental well-being during the pandemic. Interventions that improve social support may foster psychological resilience and protect the mental well-being of people who use drugs, especially during periods of social disruption.

The salience of social context, opioid antagonist use, and prior opioid exposure as determinants of fatal and non-fatal opioid overdoses

This study examines the salience of social context for opioid overdoses in Boston from 2014 to 2019. Longitudinal negative binomial models with random effects indicated that higher levels of concentrated disadvantage, residential instability, and illicit drug activity increased annual block group counts of opioid overdoses. Logistic hierarchical and cross-classified random effects models indicated that the use of Narcan and greater exposure to drugs through previous opioid overdose and contextual lillicit drug crime activity reduced the odds of fatal opioid overdose relative to non-fatal opioid overdose. The findings suggest that the accurate tracking of both fatal and non-fatal overdoses, and a consideration of the broader social context, can facilitate effective public health resource allocation to reduce opioid overdoses.

Difficulty accessing supervised consumption services during the COVID-19 pandemic among people who use drugs in Vancouver, Canada

BACKGROUND

The overdose crisis in Canada has worsened since the emergence of the COVID-19 pandemic. Although this trend is thought to be driven in part by closures or reduced capacity of supervised consumption services (SCS), little is known about the factors that may impede access to such services during the COVID-19 pandemic among people who use drugs. This study sought to characterize the prevalence and correlates of having difficulty accessing SCS during the COVID-19 pandemic among people who use drugs in Vancouver, Canada.

METHODS

Cross-sectional data from two open prospective cohorts of people who use drugs were collected via phone or videoconferencing interviews conducted between July 2020 and November 2020. Multivariable logistic regression analyses were used to examine factors associated with experiencing difficulty accessing SCS.

RESULTS

Among the 428 people who use drugs who participated in the study, 223 (54.7%) self-identified as men and the median age was 51 years (1st to 3rd quartile: 42-58). A total of 58 (13.6%) participants reported experiencing difficulty accessing SCS. In a multivariable analysis, factors positively associated with difficulty accessing SCS included daily crystal methamphetamine use (Adjusted odds ratio [AOR] = 2.60; 95% confidence interval [CI] 1.28-5.30), active injection drug use (AOR = 4.06; 95% CI 1.38-11.90), recent non-fatal overdose (AOR = 2.45; 95% CI 1.24-4.85), and unstable housing (AOR = 2.14; 95% CI 1.08-4.23). Age was inversely associated with the outcome (AOR = 0.96; 95% CI 0.93-0.99) in multivariable analyses. The most commonly reported reasons for experiencing difficulty accessing SCS were: COVID-19-related site closure or shortened hours (42.9%) and having to wait too long to use a site (39.3%).

CONCLUSIONS

We found that people who use drugs with markers of structural vulnerability and drug-related risk were more likely to experience difficulty accessing SCS during the COVID-19 pandemic. These findings point to the need for strategies to support access to such services as part of pandemic response efforts.

The practice and embodiment of "goofballs": A qualitative study exploring the co-injection of methamphetamines and opioids

BACKGROUND

Polysubstance use is common among people who use drugs, including the co-use of stimulants and opioids. Research suggests the practice of simultaneous co-injection of methamphetamines and opioids, often referred to as "goofballs", is increasing. As a relatively unique drug use practice, little qualitative research currently exists on goofball injecting. This study explores the practice and embodied experiences of goofball injecting.

METHODS

This article draws on in-depth interviews conducted across two qualitative studies undertaken in Vancouver, Canada's Downtown Eastside neighbourhood examining changing dynamics in relation to stimulant use and experiences with an overdose prevention site-based safer supply intervention, respectively. Interviews containing discussions of goofball use (n=29) were extracted from each study and merged into a single qualitative dataset. Data were analysed thematically and focused on the practices and embodied experiences of goofball injection.

RESULTS

Our analysis uncovered how goofball injection represented a complex drug use practice driven by the desire to achieve particular embodied experiences not attainable by using either drug individually. We identified three distinct practices of goofball use: 1) to alter or enhance the effects of opioids; 2) to alter or enhance the effects of methamphetamines; and 3) to balance out the effects of both drugs.

CONCLUSION

Our study fills an important gap in the polysubstance use literature specifically exploring the co-injection of methamphetamines and opioids. Our findings highlight the need to implement and expand interventions and services attentive to polysubstance use and the role of pleasure in drug taking practices, including expanding non-medicalized opioid and stimulant safer supply initiatives across North America.

Cohort Profile: The Assessing Economic Transitions (ASSET) Study-A Community-Based Mixed-Methods Study of Economic Engagement among Inner-City Residents

The Assessing Economic Transitions (ASSET) study was established to identify relationships between economic engagement, health and well-being in inner-city populations given that research in this area is currently underdeveloped. This paper describes the objectives, design, and characteristics of the ASSET study cohort, an open prospective cohort which aims to provide data on opportunities for addressing economic engagement in an inner-city drug-using population in Vancouver, Canada. Participants complete interviewer-administered surveys quarterly. A subset of participants complete nested semi-structured qualitative interviews semi-annually. Between April 2019 and May 2022, the study enrolled 257 participants ages 19 years or older (median age: 51; 40% Indigenous, 11.6% non-Indigenous people of colour; 39% cis-gender women, 3.9% transgender, genderqueer, or two-spirit) and 41 qualitative participants. At baseline, all participants reported past daily drug use, with 27% currently using opioids daily, and 20% currently using stimulants daily. In the three months prior to baseline, more participants undertook informal income generation (75%) than formal employment (50%). Employed participants largely had casual jobs (42%) or jobs with part-time/varied hours (35%). Nested qualitative studies will focus on how inner-city populations experience economic engagement. The resulting evidence will inform policy and programmatic initiatives to address socioeconomic drivers of health and well-being.

Absent and Problematic: The Representation of Fathers in the Program Policies of Organizations that Provide Family-Centred Services in Vancouver's Downtown Eastside

Parenting education interventions and parenting programs are important for health promotion efforts among children and families; however, the majority of parenting programs are directed towards and attended by mothers. This is problematic because research has consistently demonstrated that fathers' active participation in the family can have a positive influence on mothers' well-being, children's self-esteem, success in school, and interpersonal relationships. In this paper, using an intersectional poststructuralist framework, document analysis, and Bacchi and Goodwin's "What's the problem represented to be" approach (WPR), we analyzed the program policies of 12 organizations that provide family-centred services in the Downtown Eastside of Vancouver, British Columbia, Canada. We identified the following three discourses: organizations strive to be client-centred and provide choices; organizations want to empower their participants; and women need safe place to raise their families. Our analysis revealed that fathers are absent or represented as problems in program policies, and that this has consequences for not only fathers but also mothers and children.

Income generation and the patterning of substance use: A gender-based analysis

BACKGROUND

Previous research has demonstrated how income-generating activities among marginalized people who use drugs (PWUD)-including employment, income assistance, street-based activities, sex work, and illegal activities-can provide both benefit (e.g., additional income) and harm (e.g., violence, criminalization). However, little is known about gender differences in factors such as drug use patterns that are associated with income-generating activities among PWUD.

METHODS

Using data from prospective cohorts of HIV-positive and HIV-negative PWUD in Vancouver, Canada, we conducted exploratory gender-stratified analyses of associations between substance use patterns and income-generating activities, using generalized linear mixed-models.

RESULTS

Participants reported income sources as employment (23.4 %), income assistance (88.1 %), street-based activities (24.9 %), sex work (15.2 %), drug dealing (31.5 %), or other illegal activities (13.9 %). GLMM results showed gendered patterns of engagement in specific income-generating activities and some diverging patterns of substance use. For instance, men receiving income assistance were less likely to use opioids (Adjusted odds ratio(AOR) = 0.64; 95 % confidence interval(CI) = 0.50-0.82) and women engaged in sex work were more likely to use crack-cocaine (AOR = 2.74, 95 % CI = 2.22-3.37). However, results reflected primarily converging patterns of substance use between women and men across income-generating activities, particularly for drug dealing and other illegal activities.

CONCLUSIONS

Our results suggest that substance use patterns may be more closely associated with income generation context than gender. Given potential harms associated with some income generation activities, results highlight the need for further investigation of the social and structural context of income generation, its intersections with gender and substance use, and the expansion of low-threshold work opportunities.

Accessing Medical Care After a Needlestick Injury: First Responders' Perception of HIV Risk and Attitudes Toward Syringe Service Programs

First responders have an increased risk of occupational exposure to HIV as the result of a needlestick injury (NSI) because of the chaotic prehospital environment in which they provide care. Approximately 2.3 of every 1000 first responders (0.23%) who are exposed to HIV via a NSI risk seroconversion if left untreated. Participants completed a 28-question online survey examining level of concern about HIV, thoughts about injection drug use, number of accidental NSIs, and medical services received after a needlestick. First, all data were analyzed descriptively. Second, a multiple linear regression model was used to explore the level of concern about HIV as a function of the predictor variables. Nearly half of the respondents worked as paramedics (n = 141, 23.5%) or emergency medical technicians (n = 154, 25.7%), followed by 15.5% (n = 93) and 11.3% (n = 62) who indicated their primary first responder affiliation as "firefighter" or "police," respectively. The majority of the study population identified as male (75%, n = 450); 24.8% identified as female (n = 149). Slightly more first responders reported receiving no medical services after a needlestick (9.8%, n = 59) than received an HIV screening (9.5%, n = 57), and only 3.2% (n = 19) of those who experienced a needlestick reported receiving post-exposure prophylaxis. The results suggest that perceived risk of HIV infection via needlestick ultimately influences follow-up medical screening. Greater concern about HIV is significantly associated with HIV screening and willingness to obtain post-exposure prophylaxis. Future research should examine the impact of continued HIV education and policies outlining medical evaluation and other post-exposures procedures.

Stigma in place: Black gay men's experiences of the rural South

Black gay men (MSM) in the rural United States South are inequitably burdened by stigmatization and the HIV epidemic. Drawing from twelve oral history interviews with middle-aged and older Black gay narrators from rural North Carolina, this research explores the impact of sexual marginalization and the HIV epidemic on lived experiences of the rural South. Despite describing increasingly empowered views of HIV and sexual health, narrators expressed persistent difficulty managing social determinants of HIV vulnerability-sexual stigma and disconnection from LGBTQ collectivity. Narrators reported better managing sexual marginalization over their lifetimes in urban settings and places outside of the South such as New York (NY). This research suggests stressful structural and interpersonal experiences of stigma may define lived experiences of particular settings.

Factors Associated With the Use of Supervised Consumption Facilities Among Women Who Inject Drugs in a Canadian Setting

BACKGROUND

Supervised consumption facilities (SCFs) are evidence-based harm reduction interventions that have been shown to reduce the risk of social and health-related harms associated with injection drug use. Previous qualitative studies have highlighted important motivations for SCF use among women who use drugs. However, factors associated with SCF use among women have not previously been evaluated.

METHODS

Data were obtained from 2 longitudinal community-recruited cohorts of people who use drugs in Vancouver, Canada between 2003 and 2017. Multivariable generalized estimating equations were used to calculate the odds of SCF use associated with social and structural risk factors for drug-related harm among women who reported injection drug use in the preceding 6-months.

RESULTS

A total of 795 participants were included in the study, contributing to 6302 interviews, with 602 participants (76%) reporting SCF use in at least one interview. Multivariable analysis demonstrated daily heroin and crystal methamphetamine injection (Adjusted Odds Ratio [AOR] = 1.32 and 1.65, respectively), injecting in public (AOR = 1.77), binge injection (AOR = 1.22) and lack of housing (AOR = 1.74) to be associated with SCF use.

CONCLUSIONS

The current study demonstrates higher intensity patterns of drug use, including daily heroin and crystal methamphetamine injection, injecting in public and binge injection, as well as homelessness to be associated with SCF use among women. Future research should identify barriers to SCF use among women to minimize the risk of overdose and other drug-related harms.