Mary Clare Kennedy

Supervised injection facilities in Canada: past, present, and future

Canada has long contended with harms arising from injection drug use. In response to epidemics of HIV infection and overdose in Vancouver in the mid-1990s, a range of actors advocated for the creation of supervised injection facilities (SIFs), and after several unsanctioned SIFs operated briefly and closed, Canada’s first sanctioned SIF opened in 2003. However, while a large body of evidence highlights the successes of this SIF in reducing the health and social harms associated with injection drug use, extraordinary efforts were needed to preserve it, and continued activism by local people who inject drugs (PWID) and healthcare providers was needed to promote further innovation and address gaps in SIF service delivery. A growing acceptance of SIFs and increasing concern about overdose have since prompted a rapid escalation in efforts to establish SIFs in cities across Canada. While much progress has been made in that regard, there is a pressing need to create a more enabling environment for SIFs through amendment of federal legislation. Further innovation in SIF programming should also be encouraged through the creation of SIFs that accommodate assisted injecting, the inhalation of drugs. As well, peer-run, mobile, and hospital-based SIFs also constitute next steps needed to optimize the impact of this form of harm reduction intervention.

Public Health and Public Order Outcomes Associated with Supervised Drug Consumption Facilities: a Systematic Review

Purpose of ReviewSupervised drug consumption facilities (SCFs) have increasingly been implemented in response to public health and public order concerns associated with illicit drug use. We systematically reviewed the literature investigating the health and community impacts of SCFs.Recent FindingsConsistent evidence demonstrates that SCFs mitigate overdose-related harms and unsafe drug use behaviours, as well as facilitate uptake of addiction treatment and other health services among people who use drugs (PWUD). Further, SCFs have been associated with improvements in public order without increasing drug-related crime. SCFs have also been shown to be cost-effective.SummaryThis systematic review suggests that SCFs are effectively meeting their primary public health and order objectives and therefore supports their role within a continuum of services for PWUD. Additional studies are needed to better understand the potential long-term health impacts of SCFs and how innovations in SCF programming may help to optimize the effectiveness of this intervention.

Heavy alcohol use and suicidal behavior among people who use illicit drugs: A cohort study

BACKGROUND People who use illicit drugs (PWUD) are known to experience high rates of suicidal behavior. While heavy alcohol use has been associated with suicide risk, its impact on the suicidal behavior of PWUD has not been well characterized. Therefore, we examined the relationship between heavy alcohol use and suicidal behavior among PWUD in Vancouver, Canada. METHODS Data are derived from two prospective cohort studies of PWUD in Vancouver, Canada, from 2005 to 2013. Participants completed questionnaires that elicited information regarding sociodemographics, drug use patterns, and mental health problems, including suicidal behavior. We used recurrent event survival analyses to estimate the independent association between at-risk/heavy drinking (based on National Institute of Alcohol Abuse and Alcoholism [NIAAA] criteria) and risk of incident, self-reported suicide attempts. RESULTS Of 1757 participants, 162 participants (9.2%) reported 227 suicide attempts over the 8-year study period, resulting in an incidence rate of 2.5 cases per 100 person-years. After adjusting for potential confounders, including intensive illicit drug use patterns, heavy alcohol use (adjusted hazard ratio [AHR] = 1.97; 95% confidence interval [CI] = 1.39, 2.78) was positively associated with an increased risk of suicidal behavior. CONCLUSIONS We observed a high burden of suicidal behavior among a community-recruited sample of PWUD. Heavy alcohol use predicted a higher risk of suicide attempt, independent of other drug use patterns. These findings demonstrate the need for evidence-based interventions to address suicide risk among PWUD, particularly those who are heavy consumers of alcohol.

Residential eviction and exposure to violence among people who inject drugs in Vancouver, Canada

BACKGROUND People who inject drugs (PWID) experience markedly elevated rates of physical and sexual violence, as well as housing instability. While previous studies have demonstrated an association between homelessness and increased exposure to violence among PWID, the relationship between residential eviction and violence is unknown. We therefore sought to examine the association between residential eviction and experiencing violence among PWID in Vancouver, Canada. METHODS Data were derived from two open prospective cohort studies of PWID: the Vancouver Injection Drug Users Study (VIDUS) and the AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS). We used generalized estimating equations (GEE) to estimate the relationship between residential eviction and experiencing violence among male and female PWID, respectively. RESULTS Between June 2007 and May 2014, 1689 participants were eligible for the analysis, contributing a median of 5.5 years of follow-up. Of these, 567 (33.6%) were female. In total, 259 (45.7%) of females and 566 (50.4%) of males experienced at least one incident of violence over the study period. In multivariable GEE models, residential eviction was independently associated with greater odds of experiencing violence among both females (Adjusted Odds Ratio [AOR]=2.09; 95% confidence interval [CI]: 1.39-3.13) and males (AOR=1.95; 95% CI=1.49-2.55), after adjustment for potential confounders. CONCLUSION Residential eviction was independently associated with an increased likelihood of experiencing violence among both male and female PWID. These findings point to the need for evidence-based social-structural interventions to mitigate housing instability and violence among PWID in this setting.

Willingness to use drug checking within future supervised injection services among people who inject drugs in a mid-sized Canadian city

BACKGROUND Esclating epidemics of fatal overdose are affecting communities across Canada. In many instances, the unanticipated presence of powerful opioids, such as fentanyl, in street drugs is a contributing factor. Drug checking offered within supervised injection services (SIS) is being considered as a potential measure for reducing overdose and related harms. We therefore sought to characterize the willingness of people who inject drugs (PWID) to use drug checking within SIS. METHODS Data were derived from a cross-sectional survey examining the feasibility of SIS in London, Canada, a mid-sized city. Multivariable logistic regression was used to examine factors associated with willingness to frequently (always or usually) use drug checking at SIS. RESULTS Between March and April 2016, 180 PWID were included in the present study, including 68 (38%) women. In total, 78 (43%) reported that they would frequently check their drugs at SIS if this service were available. In multivariable analyses, female gender (Adjusted Odds Ratio [AOR] = 2.31; 95% confidence interval [CI]: (1.20-4.46), homelessness (AOR = 2.36; 95% CI: 1.14-4.86), and drug dealing (AOR = 2.16; 95% CI: 1.07-4.33) were positively associated with willingness to frequently check drugs at SIS. CONCLUSION These findings highlight the potential of drug checking as a complement to other services offered within SIS, particularly given that subpopulations of PWID at heightened risk of overdose were more likely to report willingness to frequently use this service. However, further research is needed to determine the possible health impacts of offering drug checking at SIS.

Social relationships and social support among street-involved youth

ABSTRACT Recent studies suggest that street-involved youth may have more robust and diverse social networks than previously thought. However, the supports offered by their social relationships have not been studied in detail. We analyzed descriptive quantitative data and open-ended interviews with 130 street-involved youth aged 14–18 in Victoria, Canada, to investigate the perceived roles and supportive functions of their most-valued social relationships. Our results show that most participants were embedded in supportive social relationships. For a substantial minority, these were familial and friendship ties forged prior to street involvement. These off-street relationships were often viewed as reliable and stable long-term sources of social support, including emotional, instrumental and informational support, particularly in times of need. This was the case despite perceived relational difficulties and limited face-to-face contact. Approximately half located themselves primarily within new street-based relationships. In comparison with off-street contacts, street-based social ties provided more consistent, immediate social support, and there was greater diversity in terms of the depth and supportive functions of these relationships. However, street-based relationships were often not perceived as being particularly stable over the long-term. Only a small minority of participants reported having no social contacts to turn to for support. Our results highlight the distinct roles that on- and off-street social relationships play in supporting street-involved youth.

Overdose Prevention in the United States: A Call for Supervised Injection Sites

The authors reflect on overdose prevention efforts in the U.S. and a call for American policymakers to establish supervised injection sites (SISs) where people can inject preobtained drugs under staff supervision. According to the article, deaths involving prescription opioids have quadrupled in the U.S. between 1999 and 2014. Naloxone therapy and syringe sharing prevention are assessed, along with American public health initiatives and the Insite SIS in Vancouver, British Columbia.

Seeking prescription opioids from physicians for nonmedical use among people who inject drugs in a Canadian setting.

BACKGROUND AND OBJECTIVES Despite the high prevalence of prescription opioid (PO) misuse, little is known about the phenomenon of seeking POs for nonmedical use among high-risk populations, such as people who inject drugs (PWID). We therefore sought to examine the prevalence and correlates of seeking POs from a physician for nonmedical use among PWID in Vancouver, Canada. METHODS Cross-sectional data from two open prospective cohort studies of PWID in Vancouver were collected between June 2013 and May 2014 (n = 1252). Multivariable logistic regression was used to identify factors associated with seeking POs from physicians for nonmedical use. RESULTS Of 1252 participants, 458 individuals (36.6%) reported ever trying to get a PO prescription from a physician for nonmedical use and, of these, 343 (74.9%, comprising 27.4% of the total sample) reported ever being successful. Variables independently and positively associated with PO-seeking behavior included older age (adjusted odds ratio [AOR] = 1.02), Caucasian ethnicity (AOR = 1.38), having ever overdosed (AOR = 1.32), having ever participated in methadone maintenance therapy (AOR = 1.90), having ever dealt drugs (AOR = 1.65), and having ever been refused a prescription for pain medication (AOR = 2.02) (all p < .05). DISCUSSION AND CONCLUSIONS We observed that PO-seeking behavior was common among this sample of PWID and associated with several markers of higher intensity drug use. SCIENTIFIC SIGNIFICANCE Our findings highlight the need to identify evidence-based public health and clinical strategies to mitigate PO misuse among PWID without compromising care for PWID with legitimate medical concerns. (Am J Addict 2016;25:275-282).

Longer duration of homelessness is associated with a lower likelihood of non-detectable plasma HIV-1 RNA viral load among people who use illicit drugs in a Canadian setting

ABSTRACT Homelessness is common among people who use drugs (PWUD) and, for those living with HIV/AIDS, an important contributor to sub-optimal HIV treatment outcomes. This study aims to investigate the relationship between the duration of homelessness and the likelihood of plasma HIV-1 RNA viral load (VL) non-detectability among a cohort of HIV-positive PWUD. We used data from the ACCESS study, a long-running prospective cohort study of HIV-positive PWUD linked to comprehensive HIV clinical records including systematic plasma HIV-1 RNA VL monitoring. We estimated the longitudinal relationship between the duration of homelessness and the likelihood of exhibiting a non-detectable VL (i.e., <500 copies/mL plasma) using generalized linear mixed-effects modelling. Between May 1996 and June 2014, 922 highly active antiretroviral therapy-exposed participants were recruited and contributed 8188 observations. Of these, 4800 (59%) were characterized by non-detectable VL. Participants reported they were homeless in 910 (11%) interviews (median: six months, interquartile range: 6–12 months). A longer duration of homelessness was associated with lower odds of VL non-detectability (adjusted odds ratio = 0.71 per six-month period of homelessness, 95% confidence interval: 0.60–0.83) after adjustment for age, ancestry, drug use patterns, engagement in addiction treatment, and other potential confounders. Longer durations of episodes of homelessness in this cohort of HIV-positive illicit drug users were associated with a lower likelihood of plasma VL non-detectability. Our findings suggest that interventions that seek to promptly house homeless individuals, such as Housing First approaches, might assist in maximizing the clinical and public health benefits of antiretroviral therapy among people living with HIV/AIDS.

Factors Associated with Nonfatal Overdose During a Public Health Emergency

Abstract Background: In 2016, in the Canadian province of British Columbia, the Provincial Health Officer declared drug-related overdose deaths a public health emergency. Objectives: In this study, we examine factors associated with recent non-fatal overdose during a time of unprecedented rates of overdose and increasing involvement of fentanyl and fentanyl derivatives in overdose deaths. Methods: Between June and September 2016, a cross-sectional survey was conducted among people who inject drugs (PWID) in Victoria, British Columbia, Canada. Bivariable and multivariable logistic regression analyses were used to examine factors associated with recent non-fatal overdose. Results: A total of 187 PWID were included in the present study, of whom 56 (29.9%) reported having overdosed in the previous 6 months. In multivariable analyses, fentanyl injection (Adjusted Odds Ratio [AOR] = 2.60; 95% confidence interval [CI]: (1.08 – 6.27) and public injection (AOR = 2.20; 95% CI: 1.09 – 4.43) were positively associated with recent non-fatal overdose. Conclusions: Fentanyl injection and public injection were associated with an increased likelihood of non-fatal overdose. These findings underscore the need for drug checking, safer sources of opioids and safer injecting interventions as part of overdose prevention strategies.