Patterns of Socioeconomic Marginalization among People Who Use Drugs: A Gender-Stratified Repeated Measures Latent Class Analysis.

Socioeconomic factors are important correlates of drug use behaviors and health-related outcomes in people who use drugs (PWUD) residing in urban areas. However, less is known about the complex overlapping nature of socioeconomic conditions and their association with a range of individual, drug use, and health-related factors in men and women who use drugs. Data were obtained from two community-recruited prospective cohorts of PWUD. Using a gender-stratified approach, we conducted repeated measures latent class analyses (RMLCA) to identify discrete latent socioeconomic subgroups. Multivariable generalized estimating equations were then used to identify correlates of class membership. Between June 2014 and December 2018, RMLCA of 9844 observations from 1654 participants revealed five distinct patterns of socioeconomic status for both men and women. These patterns were primarily distinguished by variations in income, material and housing security, income generation activity, exposure to violence, criminal justice involvement, and police contact. Across gender, progressive increases in exposure to multiple dimensions of socioeconomic disadvantage were found to be associated with frequent use of opioids and stimulants, accessing social services, and being hepatitis C virus antibody-positive. Similar but less congruent trends across gender were observed for age, binge drug use, engagement with opioid agonist therapy, and living with HIV. Gendered patterns of multiple and overlapping dimensions of socioeconomic adversity aligned with patterns of frequent drug use and health-related concerns, highlighting priority areas for gender-inclusive, multilevel responses to mitigate health disparities and meet the diverse socioeconomic needs of urban-dwelling men and women who use drugs.

Socioeconomic marginalization and risk of overdose in a community-recruited cohort of people who use drugs: A longitudinal analysis.

BACKGROUND: Poverty and socioeconomic disadvantage are important contributors to drug-related harm, but their precise role in overdose risk remains poorly understood. We sought to examine linkages between socioeconomic marginalization and non-fatal overdose risk in a community deeply affected by the ongoing drug poisoning crisis. METHODS: This observational study used data derived from two community-recruited prospective cohorts of people who use drugs (PWUD) in Vancouver, British Columbia, Canada. Generalized linear mixed-effects models were used to assess longitudinal associations between multiple dimensions of socioeconomic disadvantage and self-reported non-fatal overdose. RESULTS: Between 2014 and 2020, 1,493 participants (38.2% women; 59.6% white; 35.7% Indigenous) provided 9,968 interviews. Non-fatal overdose was reported by 32.5% of participants over the study period. In multivariable analyses, non-fatal overdose was independently associated with incarceration (adjusted odds ratios [AOR]: 1.42, 95% confidence interval [CI]: 1.08-1.88, p=0.012), homelessness (AOR: 1.57, 95%CI: 1.27-1.93, p<0.001), increased monthly income (AOR: 1.01, 95%CI: 1.00-1.01, p=0.029), and lower material security (AOR: 0.76, 95%CI: 0.67-0.88, p<0.001). We also observed differing strengths of association between illegal income generation and overdose in men (AOR: 1.84, 95%CI: 1.46-2.32, p<0.001) compared to women (AOR: 1.37, 95%CI: 1.06-1.78, p=0.016). CONCLUSION: Non-fatal overdose was positively associated with incarceration, homelessness, higher monthly income, material insecurity, and engagement illegal income generating activities, underscoring the importance of addressing the socioeconomic production of overdose risk. These initiatives may include supportive housing interventions, alternative economic supports, and broader drug policy reform.

Pathways connecting socioeconomic marginalization and overdose: A qualitative narrative synthesis.

PURPOSE: This qualitative narrative synthesis sought to identify pathways connecting socioeconomic marginalization (SEM) and overdose for people who use drugs. METHODS: We included studies with qualitative examination of SEM and fatal and non-fatal overdose published in English between 2000 and 2021. Studies were systematically identified and screened by searching MEDLINE (Ovid), Embase (Ovid), PsycINFO (EBSCOhost), CINAHL (EBSCOhost), Google Scholar, Cochrane Central Registry of Controlled Trials (CENTRAL), and Cochrane Drug and Alcohol Group (CDAG) Specialized Registry, citations, and contacting experts. Risk of bias and quality assessments were performed using the Critical Appraisal Skills Programme checklist and the Confidence in the Evidence from Reviews of Qualitative Research approach. Data were synthesized using a thematic synthesis approach. RESULTS: The primary search strategy found 5909 articles that met the initial screening criteria. The review and screening process led to a final dataset of 27 qualitative articles. The four key findings of this narrative synthesis revealed aspects of SEM which shaped drug poisoning risk for people who use drugs: (1) resource insufficiency, labor market exclusion and deindustrialization, (2) homelessness and housing, (3) policing, criminalization, and interactions with emergency services, and (4) gendered and racialized dimensions of inequality. Findings led to creating a typology that includes material, behavioral, psychological, social, and environmental pathways that contain multiple mechanisms connecting SEM to overdose. This review revealed reciprocal connections between overdose and SEM via institutional pathways with reinforcing mechanisms, and interrelationships present within and between pathways. Quality assessments indicated moderate confidence in three of four findings (Findings 2,3, and 4 above) and high confidence in one finding (Finding 1). CONCLUSION: SEM is strongly linked to drug poisoning, and the mechanisms establishing these connections can be classified within four pathways. The interconnectedness of these mechanisms can lead to intensification of overdose risk and reinforcement of SEM itself.

Perceived Mistreatment in Health Care Settings and its Relationship with HIV Clinical Outcomes in HIV-positive People who Use Drugs in Vancouver, Canada.

People living with HIV (PLWH) often experience stigma and discrimination by health care professionals. We investigated the prevalence of perceived mistreatment in health care settings and its associations with HIV clinical outcomes and health care-seeking behaviour using data from a long-running prospective cohort of PLWH who use drugs. Of the 857 participants included, 19% reported at least one instance of perceived mistreatment during the study period. In adjusted longitudinal analyses, perceived mistreatment was positively associated with not being on ART in the same follow-up period, and participants who reported perceived mistreatment were less likely to report seeing a physician in the subsequent follow-up period. Daily use of injection drugs was positively associated with reporting perceived mistreatment. These findings demonstrate the implications of negative health care interactions in a population that must consistently engage with the health care system, and the need for stigma-reducing educational interventions for health care professionals.

Requiring help injecting among people who inject drugs in Toronto, Canada: Characterising the need to address sociodemographic disparities and substance-use specific patterns.

INTRODUCTION: Those requiring help injecting are at an elevated risk of injection-related injury and blood-borne infections and are thus a priority group for harm reduction programs. As supervised consumption services (SCS) are scaled-up across Canada, information on those who require help injecting is necessary to inform equitable service uptake. We characterised the sociodemographic, structural and drug use correlates of needing help injecting among a cohort of people who inject drugs in Toronto, Canada. METHODS: A cross-sectional baseline survey was administered between November 2018 and March 2020. Unadjusted and multivariable logistic regression models examined associations with requiring help injecting in the past 6 months. A gender-stratified sub-analysis described characteristics of receiving help among those requiring it. RESULTS: Of 701 participants (31.0% cisgender women), 294 (41.9%) needed recent help injecting. In unadjusted analyses, being a racialised, non-Indigenous person (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.13-2.86) or a cisgender woman (OR 1.72, 95% CI 1.24-2.39) were associated with needing help. In multivariable analyses, requiring assistance was associated with needing frequent help preparing drugs (adjusted OR [AOR] 9.52, 95% CI 4.78-21.28), fewer years since first injection (AOR for 1 year increase: 0.97, 95% CI 0.95-0.99) and injecting stimulants. Among those who required help, cisgender women reported needing assistance more often than cisgender men (P = 0.009). DISCUSSION AND CONCLUSIONS: Over two-fifths of the sample required help injecting; requiring assistance was associated with sociodemographic indicators and substance use-specific patterns. Findings highlight the need to scale-up educational resources for those who receive or provide help injecting, as well as SCS that accommodate onsite injection assistance.

Assessing the Temporality Between Transitions onto Opioid Agonist Therapy and Engagement with Antiretroviral Therapy in a Cohort of HIV-Positive People Who Use Opioids Daily.

A robust evidence-base describes the beneficial association between opioid agonist therapy (OAT) and HIV-related outcomes among people living with HIV and opioid use disorder. While some evidence suggests the stabilizing effect of OAT on antiretroviral therapy (ART) treatment engagement, less is understood about the potential for an inverse relationship. We sought to examine the relationship between transitions in ART engagement and transitions onto OAT. We used data from a prospective cohort of people living with HIV who use drugs in Vancouver, Canada-a setting with no-cost access to ART and low or no-cost access to OAT among low-income residents. Restricting the sample to those who reported daily or greater opioid use, we used generalized linear mixed-effects models to estimate the relationships between our primary outcome of transitions onto OAT (methadone or buprenorphine/naloxone) and transitions (1) onto ART and (2) into ART adherence. Subsequent analyses assessed the temporal sequencing of transitions. Between 2005 and 2017, among 433 participants, 48.3% reported transitioning onto OAT at least once. In concurrent analyses, transitions onto ART were positively and significantly associated with transitions onto OAT. Temporal sequencing revealed that transitions into OAT were also positively and significantly associated with subsequent transitions onto ART. OAT's potential to facilitate the uptake of ART points to the continued need to scale-up low-threshold, client-centered substance use services integrated alongside HIV care.

Mental disorder and opioid overdose: a systematic review.

PURPOSE: This systematic review summarizes and presents the current state of research quantifying the relationship between mental disorder and overdose for people who use opioids. METHODS: The protocol was published in Open Science Framework. We used the PECOS framework to frame the review question. Studies published between January 1, 2000, and January 4, 2021, from North America, Europe, the United Kingdom, Australia, and New Zealand were systematically identified and screened through searching electronic databases, citations, and by contacting experts. Risk of bias assessments were performed. Data were synthesized using the lumping technique. RESULTS: Overall, 6512 records were screened and 38 were selected for inclusion. 37 of the 38 studies included in this review show a connection between at least one aspect of mental disorder and opioid overdose. The largest body of evidence exists for internalizing disorders generally and mood disorders specifically, followed by anxiety disorders, although there is also moderate evidence to support the relationship between thought disorders (e.g., schizophrenia, bipolar disorder) and opioid overdose. Moderate evidence also was found for the association between any disorder and overdose. CONCLUSION: Nearly all reviewed studies found a connection between mental disorder and overdose, and the evidence suggests that having mental disorder is associated with experiencing fatal and non-fatal opioid overdose, but causal direction remains unclear.

The Ontario Integrated Supervised Injection Services Cohort Study of People Who Inject Drugs in Toronto, Canada (OiSIS-Toronto): Cohort Profile.

The Ontario Integrated Supervised Injection Services cohort in Toronto, Canada (OiSIS-Toronto) is an open prospective cohort of people who inject drugs (PWID). OiSIS-Toronto was established to evaluate the impacts of supervised consumption services (SCS) integrated within three community health agencies on health status and service use. The cohort includes PWID who do and do not use SCS, recruited via self-referral, snowball sampling, and community/street outreach. From 5 November 2018 to 19 March 2020, we enrolled 701 eligible PWID aged 18+ who lived in Toronto. Participants complete interviewer-administered questionnaires at baseline and semi-annually thereafter and are asked to consent to linkages with provincial healthcare administrative databases (90.2% consented; of whom 82.4% were successfully linked) and SCS client databases. At baseline, 86.5% of participants (64.0% cisgender men, median ([IQR] age= 39 [33-49]) had used SCS in the previous 6 months, of whom most (69.7%) used SCS for <75% of their injections. A majority (56.8%) injected daily, and approximately half (48.0%) reported fentanyl as their most frequently injected drug. As of 23 April 2021, 291 (41.5%) participants had returned for follow-up. Administrative and self-report data are being used to (1) evaluate the impact of integrated SCS on healthcare use, uptake of community health agency services, and health outcomes; (2) identify barriers and facilitators to SCS use; and (3) identify potential enhancements to SCS delivery. Nested sub-studies include evaluation of "safer opioid supply" programs and impacts of COVID-19.

A gender comparative analysis of post-traumatic stress disorder among a community-based cohort of people who use drugs in Vancouver, Canada.

BACKGROUND: While exposure to traumatic events and subsequent post-traumatic stress disorder (PTSD) are common among people who use drugs (PWUD), little is known about gender-based differences associated with PTSD in this population. We explore gender-based differences in factors associated with a probable PTSD diagnosis in a cohort of PWUD from Vancouver, Canada. METHODS: Data were collected through the Vancouver Injection Drug Users Study (VIDUS) and the AIDS Care Cohort to Evaluate Exposure to Survival Services (ACCESS), two community-recruited cohorts of PWUD. Participants were administered the PTSD Checklist for DSM-5. Multivariable logistic regression was used to investigate social-structural factors and substance use patterns and behaviours associated with a probable PTSD diagnosis, stratified by self-identified gender. PTSD symptom clusters and brief descriptions of the worst traumatic event experienced were also reported. RESULTS: Between December 2016 and December 2018, of 797 eligible participants, 295 (37.0%) identified as women. PTSD was more commonly reported in women compared to men (53.2% vs. 31.5%, p < 0.001). In multivariable analysis involving men, no correlates were associated with PTSD. In multivariable analysis involving women, PTSD was positively associated with exposure to violence (AOR: 3.66; 95%CI: 1.14-11.72), daily stimulant use (AOR: 2.32; 95%CI: 1.32-4.08) and heavy alcohol use (AOR: 3.84; 95%CI: 1.84-8.00), and negatively associated with being in a stable relationship (AOR: 0.46; 95%CI: 0.25-0.84). CONCLUSIONS: Gender-based differences in PTSD diagnosis among a cohort of PWUD point to the need to develop gender-focused and trauma-informed health and social services to meet the immediate needs of PWUD living with PTSD.

Socioeconomic marginalization and opioid-related overdose: A systematic review.

BACKGROUND: Socioeconomic marginalization (SEM) is an important but under-explored determinant of opioid overdose with important implications for health equity and associated public policy initiatives. This systematic review synthesizes evidence on the role of SEM in both fatal and non-fatal overdose among people who use opioids. METHODS: Studies published between January 1, 2000 and March 31, 2018 were identified through searching electronic databases, citations, and by contacting experts. The titles, abstracts, citation information, and descriptor terms of citations were screened by two team members. Data were synthesized using the lumping technique. RESULTS: A total of 37 studies met inclusion criteria and were included in the review, with 34 of 37 finding a significant association between at least one socioeconomic factor and overdose. The included studies contained variables related to eight socioeconomic factors: criminal justice system involvement, income, employment, social support, health insurance, housing/homelessness, education, and composite measures of socio-economic status. Most studies found associations in the hypothesized direction, whereby increased SEM was associated with a higher rate or increased likelihood of the overdose outcome measured. The review revealed an underdeveloped evidence base. CONCLUSIONS: Nearly all reviewed studies found a connection between a socioeconomic variable and overdose, but more research is needed with an explicit focus on SEM, using robust and nuanced measures that capture multiple dimensions of disadvantage, and collect data over time to better inform decision making around opioid overdose.

Elevated prevalence of self-reported unintentional exposure to fentanyl among women who use drugs in a Canadian setting: A cross-sectional analysis.

BACKGROUND: The United States and Canada are in the midst of an overdose epidemic, fueled by illicitly manufactured fentanyl. While marked differences in vulnerability to drug-related harm between men and women who use drugs is well characterized, the extent to which gender differences manifest in the present overdose crisis remains understudied. We examined differences in self-reported unintentional exposure to fentanyl between men and women who use drugs. METHODOLOGY: Data were derived from three prospective cohorts of people who use drugs in Vancouver, Canada. Survey data were extracted on individuals who self-reported having used drugs known or believed to contain fentanyl in the past 30 days between December 2016 and November 2017. We used multivariable logistic regression (MLR) to examine the relationship between self-identified gender (woman vs. man) and self-reported unintentional exposure to fentanyl. As a sub-analysis, correlates of self-reported unintentional exposure to fentanyl were identified using MLR, stratified by gender. RESULTS: Of 578 eligible participants, including 219 (37.9%) women, 200 (33.2%) perceived their exposure to fentanyl as unintentional (40.2% among women and 29.0% among men). In the MLR, being a woman was positively associated with self-reported unintentional fentanyl exposure (adjusted odds ratio = 2.11; 95% confidence interval: 1.45-3.09). Among women at least daily heroin use was negatively associated with self-reported unintentional fentanyl exposure, while perceiving a high or moderate risk of overdosing on fentanyl was positively associated with outcome. Among men older age was positively associated with self-reported unintentional fentanyl exposure, while injection drug use and at least daily heroin use was negatively associated with the outcome (all p<0.05). CONCLUSIONS: Women were more than two times as likely to self-report they were unintentionally exposed to fentanyl compared to men. These findings highlight the urgent need to further understand experiences of gender-based risk differences and develop gender-focused interventions and policies aimed at preventing drug-related harm.

Can the financial burden of being a community health volunteer in western Kenya exacerbate poverty?

Community health volunteers (CHVs) act as vital links between communities and health facilities, bridging the health service delivery gap common in low- and middle-income countries. In 2013, changes in funding in western Kenya left most CHVs without their individual monthly stipend. In this article, we explore how the implementation of a pooled incentive model had an impact on the lives of CHVs from two counties in western Kenya. Participation in this form of table banking was meant to allow CHVs to pool their resources together and invest in income-generating activities to offset the costs of unpaid health work. A pre-post qualitative study, consisting of focus group discussions and in-depth interviews explored CHV compensation, motivations and challenges experienced in 2013 and 2015, prior to and after the implementation of this pooled incentive model. Following withdrawal of the monthly stipend, we found that CHVs continued to take on roles and responsibilities of paid health workers, motivated by shared social identities and connections to their communities. However, replacing the stipend with a pooled-group incentive model seemingly exacerbated the financial burden already experienced by this vulnerable population. This study brings into question the sustainability and viability of a volunteer community health worker programme and highlights the need to address the financial burden associated with the CHV role in western Kenya.

"That's a double-edged sword": Exploring the integration of supervised consumption services within community health centres in Toronto, Canada.

Supervised consumption services (SCS) have been integrated into community health centres in Toronto. We draw on qualitative interviews and ethnographic observations to examine the implementation contexts of these SCS. Participants' perspectives on the integration of SCS within CHCs were mixed. Some participants identified the benefits of integrated SCS such as convenience and access to other health and social services. However, others identified negative consequences of integration, including building design, lack of privacy and anonymity, and limited hours of operation. These perspectives highlight the ways in which contextual factors affect the experiences of clients in accessing SCS, and suggest that various factors need to be considered in order to improve service uptake.

Potential use of supervised injection services among people who inject drugs in a remote and mid-size Canadian setting.

BACKGROUND: While supervised injection services (SIS) feasibility research has been conducted in large urban centres across North America, it is unknown whether these services are acceptable among people who inject drugs (PWID) in remote, mid-size cities. We assessed willingness to use SIS and expected frequency of SIS use among PWID in Thunder Bay, a community in Northwestern, Ontario, Canada, serving people from suburban, rural and remote areas of the region. METHODS: Between June and October 2016, peer research associates administered surveys to PWID. Sociodemographic characteristics, drug use and behavioural patterns associated with willingness to use SIS and expected frequency of SIS use were estimated using bivariable and multivariable logistic regression models. Design preferences and amenities identified as important to provide alongside SIS were assessed descriptively. RESULTS: Among 200 PWID (median age, IQR: 35, 28-43; 43% female), 137 (69%) reported willingness to use SIS. In multivariable analyses, public injecting was positively associated with willingness to use (Adjusted Odds Ratio (AOR): 4.15; 95% confidence interval (CI): 2.08-8.29). Among those willing to use SIS, 87 (64%) said they would always/usually use SIS, while 48 (36%) said they would sometime/occasionally use SIS. In multivariable analyses, being female (AOR: 2.44; 95% CI: 1.06-5.65) and reporting injecting alone was positively associated with higher expected frequency of use (AOR: 2.59; 95% CI: 1.02-6.58). CONCLUSIONS: Our findings suggest that SIS could play a role in addressing the harms of injection drug use in remote and mid-sized settings particularly for those who inject in public, as well as women and those who inject alone, who report higher expected frequency of SIS use. Design preferences of local PWID, in addition to differences according to gender should be taken into consideration to maximize the uptake of SIS, alongside existing health and social service provisions available to PWID.

Syringe sharing among people who inject drugs in London, Canada.

OBJECTIVES: London, Ontario, is facing an outbreak of HIV among people who inject drugs (PWID), as well as persistently high levels of hepatitis C virus (HCV). Syringe sharing is the primary driver of HIV and HCV transmission risks among PWID, however, little is known about factors contributing to syringe sharing in this setting. Therefore, we sought to characterize syringe sharing and its correlates among London PWID. METHODS: Between March and April, 2016, PWID participated in a survey administered by peer research associates as part of the Ontario Integrated Supervised Injection Services Feasibility Study. Bivariable and multivariable logistic regression models examined associations with syringe sharing (borrowing or lending previously used syringes) over the previous 6 months. A sub-analysis described patterns of borrowing and lending by self-reported HIV and HCV statuses. RESULTS: Of 198 PWID, 44 (22%) reported syringe sharing in the past 6 months. In the multivariable analysis, selling drugs (adjusted odds ratio; AOR = 1.92, 95% CI = 1.20-3.08), daily crystal methamphetamine injection (AOR = 1.66, 95% CI = 1.07-2.59), and identifying as HIV-positive (AOR = 3.11, 95% CI = 1.61-6.01) were independently associated with increased syringe sharing. While not independently associated with syringe sharing, problems accessing syringes were common (13-50%). Self-reported HIV-positive respondents were more likely to report syringe borrowing (p < 0.001), but not lending (p = 0.26). CONCLUSION: We observed a high rate of syringe sharing among London PWID, with sharing being associated with high-intensity injection of crystal methamphetamine, as well as with involvement in drug sales. Considering the current HIV outbreak in London, multi-level prevention efforts are urgently needed.

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.

Assessing support for supervised injection services among community stakeholders in London, Canada.

OBJECTIVES: Few qualitative studies have examined support for supervised injection services (SIS), and these have been restricted to large cities. This study aimed to assess support for SIS among a diverse representation of community stakeholders in London, a mid-sized city in southwestern Ontario, Canada. METHODS: This qualitative study was undertaken as part of the Ontario Integrated Supervised Injection Services Feasibility Study. We used purposive sampling methods to recruit a diversity of key informants (n=20) from five sectors: healthcare; social services; government and municipal services; police and emergency services; and the business and community sector. Interview data, collected via one-to-one semi structured interviews, were coded and analyzed using thematic analyses through NVivo 10 software. RESULTS: Interview participants unanimously supported the implementation of SIS in London. However, participant support for SIS was met with some implementation-related preferences and/or conditions. These included centralization or decentralization of SIS; accessibility of SIS for people who inject drugs; proximity of SIS to interview participants; and other services and strategies offered alongside SIS. DISCUSSION: The results of this study challenge the assumptions that smaller cities like London may be unlikely to support SIS. Community stakeholders were supportive of the implementation of SIS with some preferences or conditions. Interview participants had differing perspectives, but ultimately supported similar end goals of accessibility and reducing community harms associated with injection drug use. Future research and SIS programming should consider these factors when determining optimal service delivery in ways that increase support from a diversity of community stakeholders.

Acceptability and design preferences of supervised injection services among people who inject drugs in a mid-sized Canadian City.

BACKGROUND: Supervised injection services (SIS) have been shown to reduce the public- and individual-level harms associated with injection drug use. While SIS feasibility research has been conducted in large urban centres, little is known about the acceptability of these services among people who inject drugs (PWID) in mid-sized cities. We assessed the prevalence and correlates of willingness to use SIS as well as design and operational preferences among PWID in London, Canada. METHODS: Between March and April 2016, peer research associates administered a cross-sectional survey to PWID in London. Socio-demographic characteristics, drug-use patterns, and behaviours associated with willingness to use SIS were estimated using bivariable and multivariable logistic regression models. Chi-square tests were used to compare characteristics with expected frequency of SIS use among those willing to use SIS. Design and operational preferences are also described. RESULTS: Of 197 PWID included in this analysis (median age, 39; interquartile range (IQR), 33-50; 38% female), 170 (86%) reported willingness to use SIS. In multivariable analyses, being female (adjusted odds ratio (AOR) 0.29; 95% confidence interval (CI) 0.11-0.75) was negatively associated with willingness to use, while public injecting in the last 6 months (AOR 2.76; 95% CI 1.00-7.62) was positively associated with willingness to use. Participants living in unstable housing, those injecting in public, and those injecting opioids and crystal methamphetamine daily reported higher expected frequency of SIS use (p < 0.05). A majority preferred private cubicles for injecting spaces and daytime operational hours, while just under half preferred PWID involved in service operations. CONCLUSIONS: High levels of willingness to use SIS were found among PWID in this setting, suggesting that these services may play a role in addressing the harms associated with injection drug use. To maximize the uptake of SIS, programme planners and policy makers should consider the effects of gender and views of PWID regarding SIS design and operational preferences.

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.