Supervised injecting can reach the most vulnerable in remote settings in North America
Many mid-sized, remote cities in North America are dealing with epidemics of opioid use – new research reveals supervised injecting facilities are acceptable in these settings.
Supervised injecting facilities or services (SIS) have the potential to reach the most vulnerable populations of people who inject drugs in remote, mid-sized cities in Canada. Research findings offer important evidence to the feasibility of these types of interventions, as opioid epidemics, and associated harms such as drug overdose, HIV and hepatitis C (HCV) are on the rise in these settings across North America.
Supervised injecting facilities are places where people who use drugs can take their previously obtained, illicit substances under the supervision of a health professional. They are intended to take drug use off the street and out of public places, facilitate the proper disposal of used needles and cartridges, and limit drug-related hospitalisation. People who use the facilities have access to clean needles and hygienic conditions for their drug-taking, while also being exposed to health information and referrals to other health and social services.
Their efficacy has been evaluated rigorously in large urban settings where they exist – such as Vancouver, Canada and Sydney, Australia. Here supervised injecting facilities are attributed to reducing the risk of transmission of blood-borne infections and fatal overdose, while also increasing uptake of medical care and addiction treatment.
But more evidence is urgently needed to evaluate which harm reduction services are feasible and effective in more rural settings where drug use and overdose is an increasing, major concern. Most of the current evidence focuses on large, urban settings, but the experiences of people using drugs in remote, rural, small- to mid-sized city settings may vary greatly. For example, conservatism, stigma, discrimination, social isolation and concerns around confidentiality in smaller communities may impede access to these services.
Researchers conducted surveys of 200 people who inject drugs in Thunder Bay, a mid-sized city situated in the outlying and expansive region of North-western Ontario, Canada with a metropolitan population of 121,600. It is remote from other neighbouring cities and towns and serves as a hub for the region. Here, opioid use, overdose and other drug-related harms were significantly higher than the rest of the region. There are high rates of needle and syringe borrowing and lending, hepatitis C is the second highest in the Ontario, over half (51%) having lifetime exposure.
Thunder Bay already has an active needle and syringe exchange programme but is looking at evidence of feasibility of other harm reduction interventions, including supervised injecting, as part of their harm reduction strategy.
The research revealed moderately high levels of willingness to use supervised injecting facilities at 69%. The study population comprised 43% females with a mean age of 35. Those who indicated that they would use supervise injecting facilities were more likely to be unstably housed, and more likely to report public injecting, daily cocaine injecting, and to be involved in sex work. Of those who said they would use a supervised injecting facility – 64% said they would use one all the time, and 36% said they would use one sometimes. Frequency of use was more positively associated with being female, injecting alone, and daily opioid injecting.
The researchers also sought to understand design and operation preferences for supervised injecting in this setting. The results revealed that 76% preferred a private cubicle set-up for injecting, 63% preferred daytime operating hours, and 52% believed people who inject drugs in that space should be involved in the daily operations of the facility. Additional services that the respondents believed should be included were clean needle distribution, preventing and responding to overdose, access to HIV and HCV testing, and other health services.
In their discussion, the authors note that willingness to use supervised injecting facilities was slightly lower than in other, larger urban settings. There, rates were as high as 86% compared to the 69% found in Thunder Bay, which they postulate could be the result of stigma experienced by this group in smaller communities.
But the research also indicated that these services could reach highly vulnerable groups – mainly women and people who inject alone. People who inject alone are known to be at an increased risk of fatal overdose and have also been shown to be less knowledgeable about blood-borne illnesses, and less likely to engage in any health or harm reduction services.
Women who use drugs are also more vulnerable than men, as they experience higher rates of violence and are more stigmatised.
Safe injecting facilities can create a safe space for women to take drugs, also giving them access to other health and social wellbeing services. The authors note that there is potential here in Thunder Bay, given women’s increased frequency of use of these facilities, to provide tailored interventions and strategies. These could include women’s only SIS, women’s specific drop-in hours, women-centred health and social services, and case management.
The authors concluded, “If implemented in Thunder Bay, to optimize the uptake of services, program planners and policy-makers should take into consideration the preferences and characteristics of local [people who inject drugs], while also recognizing the unique challenges faced by [people who inject drugs] and harm reduction services in locations that serve the diverse needs of suburban, rural, and remote communities.”