Using drugs in un/safe spaces: Impact of perceived illegality on an underground supervised injecting facility in the United States.

Supervised injection facilities (SIFs) are spaces where people can consume pre-obtained drugs in hygienic circumstances with trained staff in attendance to provide emergency response in the event of an overdose or other medical emergency, and to provide counselling and referral to other social and health services. Over 100 facilities with formal legal sanction exist in ten countries, and extensive research has shown they reduce overdose deaths, increase drug treatment uptake, and reduce social nuisance. No facility with formal legal sanction currently exists in the United States, however one community-based organization has successfully operated an 'underground' facility since September 2014. Twenty three qualitative interviews were conducted with people who used the underground facility, staff, and volunteers to examine the impact of the facility on peoples' lives, including the impact of lack of formal legal sanction on service provision. Participants reported that having a safe space to inject drugs had led to less injections in public spaces, greater ability to practice hygienic injecting practices, and greater protection from fatal overdose. Constructive aspects of being 'underground' included the ability to shape rules and procedures around user need rather than to meet political concerns, and the rapid deployment of the project, based on immediate need. Limitations associated with being underground included restrictions in the size and diversity of the population served by the site, and reduced ability to closely link the service to drug treatment and other health and social services. Unsanctioned supervised injection facilities can provide a rapid and user-driven response to urgent public health needs. This work draws attention to the need to ensure such services remain focused on user-defined need rather than external political concerns in jurisdictions where supervised injection facilities acquire local legal sanction.

Davidson PJ ，Lopez AM ，Kral AH 《-》

'It's our safe sanctuary': Experiences of using an unsanctioned overdose prevention site in Toronto, Ontario.

Overdose prevention sites (OPSs) are spaces where people can consume drugs under the supervision of trained volunteers or staff and receive help in the event of an overdose. Unsanctioned OPSs are a grassroots response to the current opioid crisis in Canada. We used rapid evaluation methods to study the experiences of 30 individuals accessing the smoking and injection services at the first unsanctioned OPS in Toronto, Ontario using semi-structured interviews. Data were analyzed using an applied thematic analysis approach to identify emergent themes related to service user experiences, characteristics of the risk environment, and recommended changes to the service model. The OPS represented a safe sanctuary and brought a sense of belonging to a community that often experiences discrimination. Valued aspects included: shelter; protection from violence; safety from overdoses; free equipment; information about health and social services; food and beverages; and socializing and connecting with others. Integrating peer workers in the design and delivery of services encouraged service users to visit the site. The OPS changed the risk environment by: providing access to the first supervised smoking service in Toronto; having few explicit rules and a communal approach to making new rules; allowing assisted injection, and negotiating with police to allow people to access the site with minimal contact. Service users noted the need to ensure a safe space for women and recommended extended hours of operation and moving to a more permanent space with heat and lighting for both smoking and injecting drugs. The unsanctioned OPS in Toronto served an important role in defining new, community-led, flexible responses to opioid overdose-related deaths at a time of markedly increasing mortality. Providing harm reduction services in diverse settings and expanding services to include smoking and assisted injection may increase access for marginalized people who use drugs.

Foreman-Mackey A ，Bayoumi AM ，Miskovic M ，Kolla G ，Strike C ... -  《-》

Perceptions about supervised injection facilities among people who inject drugs in Philadelphia.

People who inject drugs (PWID) are at high risk for infectious diseases, skin and soft tissue infections, and overdose. However, these harms are all avoidable when sterile injection equipment, hygienic places to inject, and medical care are accessible. Unfortunately, many PWID in the U.S lack these resources. The most vulnerable are forced to inject in public spaces, where individual risks are high and communal harms are sometimes many. Supervised Injection Facilities (SIFs) are an established intervention for reducing these harms. Despite positive experiences in other countries, little research explores how PWID in the U.S. perceive the value of such facilities. We conducted a freelisting exercise with PWID (n=42) and healthcare providers (n=20) at a syringe exchange program (SEP) that provides comprehensive clinical and social services in Philadelphia to inform in-depth semi-structured interviews with PWID (n=19) at the same location. Participants expressed support for a potential SIF as a valuable public health intervention. They suggested that an SIF would improve PWID health while reducing the public disorder associated with injecting drugs in public. The latter was especially important to participants without stable housing, whose decision to inject furtively in secluded places was often motivated by desire not to upset community members, and particularly children. These participants acknowledged that such seclusion elevated the risk of fatal overdose. Despite similarly positive perceptions about an SIF, participants with stable housing reported that they would prefer to continue injecting at home. Results both confirm and extend prior research about PWID and SIFs. Participants expressed support for SIFs as in prior survey research in the U.S. and in other countries. Facility location and housing status were identified as important determinants of facility use. Results extend prior research by illuminating PWID perceptions in the U.S. including motivations grounded in concern for public order.

Harris RE ，Richardson J ，Frasso R ，Anderson ED ... -  《-》

Potential role of safer injection facilities in reducing HIV and hepatitis C infections and overdose mortality in the United States.

Safer injection facilities (SIFs) reduce risks associated with injecting drugs, particularly public injection and overdose mortality. They exist in many countries, but do not exist in the United States. We assessed several ethical, operational, and public health considerations for establishing SIFs in the United States. We used the six-factor Kass framework (goals, effectiveness, concerns, minimization of concerns, fair implementation, and balancing of benefits and concerns), summarized needs of persons who inject drugs in the United States, and reviewed global evidence for SIFs. SIFs offer a hygienic environment to inject drugs, provide sterile injection equipment at time of injection, and allow for safe disposal of used equipment. Injection of pre-obtained drugs, purchased by persons who inject drugs, happens in a facility where trained personnel provide on-site counseling and referral to addiction treatment and health care and intervene in overdose emergency situations. SIFs provide positive health benefits (reducing transmission of HIV and viral hepatitis, bacterial infections, and overdose mortality) without evidence for negative health or social consequences. SIFs serve most-at-risk persons, including those who inject in public or inject frequently, and those who do not use other public health programs. It is critical to address legal, ethical, and local concerns, develop and implement relevant policies and procedures, and assess individual- and community-level needs and benefits of SIFs given local epidemiologic data. SIFs have the potential to reduce viral and bacterial infections and overdose mortality among those who engage in high-risk injection behaviors by offering unique public health services that are complementary to other interventions.

Semaan S ，Fleming P ，Worrell C ，Stolp H ，Baack B ，Miller M ... -  《-》

Perspectives on supervised injection facilities among service industry employees in New York City: A qualitative exploration.

Approximately 100 supervised injection facilities (SIFs) operate in 66 cities around the world to reduce overdose deaths, the spread of disease and public disorder, though none legally exist in the United States. Public bathrooms are among the most common public places for injection reported by people who inject drugs in New York City (NYC) and service industry employees (SIEs) inadvertently become first-responders when overdoses occur in business bathrooms. The goal of this study was to assess SIE acceptability of SIFs and the perceived effects that SIFs would have on them, their colleagues, their businesses and communities. Semi-structured qualitative interviews were conducted with 15 SIEs recruited through convenience sampling throughout NYC. Participants were provided with peer-reviewed scientific evidence prior to discussing SIFs. Data were analysed using a hybrid deductive and inductive approach. Most SIEs had encountered drug use (93%, n = 14/15) and syringes (73%, n = 11/15) in their business bathrooms and three had encountered unresponsive individuals. Nearly all workers (93%, n = 14/15) were supportive of SIFs and believed SIFs would reduce injection drug use in their business bathrooms. Participants also believed that 'not in my backyard' arguments from community boards may impede SIF operation. Service industry employees are critical stakeholders due to their exposure to occupational health hazards related to public injection. Those interviewed were amenable to SIF operation as a form of occupational harm reduction and their experiences provide an important dimension to the political debate surrounding SIFs.

Wolfson-Stofko B ，Elliott L ，Bennett AS ，Curtis R ，Gwadz M ... -  《-》