Stakeholder preferences for supervised consumption site design, staff, and ancillary services: A scoping review of feasibility studies.

BACKGROUND: Supervised consumption services (SCS) prevent drug related harms for people who use drugs (PWUD) and often require a feasibility study before implementation. While there is a growing feasibility study literature, it has not been synthesized for use by researchers and SCS planners. We conducted a scoping review of feasibility studies reporting on preferred SCS design characteristics, staffing models and ancillary services. MATERIALS AND METHODS: We searched academic databases and grey literature sources with key terms related to SCS and feasibility studies. Team members reviewed search results and included feasibility studies with findings relevant to SCS design, staff, or ancillary services. The research methods and findings from included studies regarding design elements were charted, collated, and reported. RESULTS: The search yielded 1347 results; 26 met eligibility criteria for review. Most reported preferences for SCS location, hours and wait times. Few reported preferences for security, space allocation by type of drug use, and onsite opioid prescribing. PWUD generally preferred aligning design elements with the goal of harm reduction for clients while other stakeholders valued treatment as a goal. Specific considerations varied by implementation context. CONCLUSIONS: These results can be used by SCS planners and researchers to help resolve implementation concerns and improve uptake among PWUD, which is critical during an overdose crisis. Future feasibility studies should ask about design preferences that may be significant to uptake but are not commonly covered in studies. These should also explore how context influences preferences to develop an evidence-based framework for context-specific design decisions.

Supervised methadone consumption: client issues and stigma.

Supervised methadone consumption is an important part of methadone maintenance treatment (MMT) but may contribute to stigma for clients. Data from qualitative interviews with MMT clients (n = 64) conducted in 2002-2003 in Canada were analyzed using thematic analytic methods. Three themes dominated clients' accounts of supervised consumption (convenient access to services, relationships with pharmacists and dispensing staff, and attributes of the dispensing space) and were interwoven with experiences of stigmatization. While some dispensing contexts may help clients manage a stigmatized identity, others confer or make visible this identity. Reducing stigmatizing experiences within dispensing environments may improve MMT outcomes and decrease barriers to treatment. The study's limitations are noted.

Reduction in injection-related HIV risk after 6 months in a low-threshold methadone treatment program.

This study assessed injection-related HIV risk behavioral changes among opioid users 6 months after enrollment in low-threshold (harm reduction based) metha-done maintenance treatment (MMT) programs within needle exchange services in Kingston and Toronto, Ontario, Canada. Changes were assessed for all participants (whole cohort), participants who continued to use illicit drugs by any route (drug-using subcohort); and those who continued to inject drugs (injecting subcohort). In this prospective observational cohort study, an interviewer-administered questionnaire examining injection-related HIV risk behaviors was administered to 183 study participants at entry to treatment and 6 months later. Changes in risk behaviors were analyzed using conditional logistic regression which took into account the paired nature of the data. We found that the proportion of participants injecting drugs, sharing needles, sharing drug equipment, indirectly sharing and using shooting galleries declined with follow-up for the whole cohort. Within the drug-using subcohort, there was a decrease in the proportion of individuals who injected drugs, while within the injecting subcohort the sharing of injection equipment and the use of shooting galleries declined. Our findings suggest that low-threshold MMT programs can reduce the risk of HIV without the enforcement of abstinence-based policies.

Potential cost-effectiveness of supervised injection facilities in Toronto and Ottawa, Canada.

BACKGROUND AND AIMS: Supervised injection facilities (legally sanctioned spaces for supervised consumption of illicitly obtained drugs) are controversial public health interventions. We determined the optimal number of facilities in two Canadian cities using health economic methods. DESIGN: Dynamic compartmental model of HIV and hepatitis C transmission through sexual contact and sharing of drug use equipment. SETTING: Toronto and Ottawa, Canada. PARTICIPANTS: Simulated population of each city. INTERVENTIONS: Zero to five supervised injection facilities. MEASUREMENTS: Direct health-care costs and quality-adjusted life-years (QALYs) over 20 years, discounted at 5% per year; incremental cost-effectiveness ratios. FINDINGS: In Toronto, one facility cost $4.1 million and resulted in a gain of 385 QALYs over 20 years, for an incremental cost-effectiveness ratio (ICER) of $10,763 per QALY [95% credible interval (95CrI): cost-saving to $278,311]. Establishing one facility in Ottawa had an ICER of $6127 per QALY (95CrI: cost-saving to $179,272). At a $50,000 per QALY threshold, three facilities would be cost-effective in Toronto and two in Ottawa. The probability that establishing three, four, or five facilities in Toronto was cost-effective was 17, 21, and 41%, respectively. Establishing one, two, or three facilities in Ottawa was cost-effective with 13, 35, and 41% probability, respectively. Establishing no facility was unlikely to be the most cost-effective option (14% in Toronto and 10% in Ottawa). In both cities, results were robust if the reduction in needle-sharing among clients of the facilities was at least 50% and fixed operating costs were less than $2.0 million. CONCLUSIONS: Using a $50,000 per quality-adjusted life-years threshold for cost-effectiveness, it is likely to be cost-effective to establish at least three legally sanctioned spaces for supervised injection of illicitly obtained drugs in Toronto, Canada and two in Ottawa, Canada.

Factors predicting 2-year retention in methadone maintenance treatment for opioid dependence.

Factors predicting 2-year retention in methadone maintenance and the impact of repeat treatment episodes on retention are examined. Data (n=9555 episodes) were drawn from a population-based treatment registry and analyses were performed using episode-weighted data. We estimated a binary logistic regression model with a duration of 730 days or greater as the dependent variable. The odds of remaining in treatment for 730 days or more increase with age and vary by region and provider type, but decrease with increasing number of treatment episodes. In comparison with other studies, these analyses show much higher rates of retention in methadone treatment but suggest that repeat episodes may not be as beneficial as existing research suggests.

Policy changes and the methadone maintenance treatment system for opioid dependence in Ontario, 1996 to 2001.

BACKGROUND: Until recently, the availability of methadone treatment in Ontario, Canada was limited. In 1996, policy changes were introduced to increase the availability of treatment. The 5-year impact of these policy changes is assessed. METHODS: For these census data, descriptive statistics were used to examine changes in the patient and provider populations over time using data from the College of Physicians and Surgeons of Ontario Methadone Maintenance Registry of Patients and the Registry of Methadone Prescribing Physicians. RESULTS: Between 1996 and 2001, the total number of clients in treatment increased substantially from: 1595 to 7787. Over this time period, the number of physicians prescribing methadone increased from 60 to 161. INTERPRETATION: Policy changes resulted in substantial increases in the patient and provider populations across Ontario. However, the estimated low proportion of opiate users in treatment indicates that more efforts are needed to address the potential demand for treatment.

Pushing the boundaries of outreach work: the case of needle exchange outreach programs in Canada.

In this paper, we examine the challenges of defining the boundaries of outreach work using the example of needle exchange programs. In particular, we examine the multiple and inter-related factors that extend needle exchange outreach work beyond its official mandate. Using semi-structured interviews, 59 workers at 15 programs in Ontario, Canada were asked questions about operational policies and routines. An iterative and inductive analytic process was used. Over time, most outreach workers develop a well-defined sense of the activities they consider to be consistent with a harm reduction approach and the types of conduct that are considered to be acceptable and professional. Workers conceptualize their roles to encompass education and support but are reluctant to impose a rigid definition of their roles. A pragmatic and humble stance combined with strong beliefs in social justice encourages workers to find informal solutions to meet client needs that extend beyond the program mandate. As a result, doing 'extra' is the norm. These extra efforts are informal, but often regular, expansions of the service complement. Construction of flexible boundaries provides opportunities to meet many client needs and unexpected situations; however, going the extra-mile strains resources. A minority of workers blur the boundaries between private and professional lives. Further, a variety of personal, social and socio-political forces encourage outreach workers to continually redefine the boundaries of their roles and service complements.

Needle exchange: how the meanings ascribed to needles impact exchange practices and policies.

The consistency among needle exchange practices, HIV prevention, harm reduction goals, and potential program effectiveness are analyzed. Using a modified ethnographic approach, qualitative interviews were conducted with staff (n = 59) of needle exchange programs (NEPs; n = 15). Interviews addressed operational policies; funding and challenges. An iterative, inductive analytic process was used. Differences in exchange practices are traced to differences in how workers define needles as objects of "risk" and/or "prevention." The weight accorded to each definition has implications for service delivery. Among NEPs that ascribe a "risk" meaning, workers enforce a strict one-for-one exchange, encourage clients to take fewer needles, and penalize clients. Programs that focus on the "prevention" meaning of needles work towards improving access, problem solving about proper disposal and do not penalize clients. Operational policies that restrict access to sterile equipment or discourage attendance need to be reconsidered if HIV prevention goals are to be realized.

Who seeks treatment for cannabis-related problems?

PURPOSE: To examine the types of presenting problems and symptoms among individuals seeking treatment for cannabis-related problems in a large treatment centre in Ontario. METHODS: Data from assessment interviews conducted with clients who identified cannabis as their primary drug problem (n=426) were analyzed using descriptive statistics. RESULTS: The majority of people seeking treatments were male (80%) and single (77%). Cannabis treatment seekers varied in their socio-demographic characteristics, drug consumption, pressure to seek treatment, and adverse consequences of cannabis use. They experienced a broad range of substance-related problems, however, the majority were classified as below the action stage in terms of readiness to change their drug consumption. Daily users were older, more likely to be employed, to be cannabis dependent, to suffer from an anxiety disorder, and to use multiple substances. DISCUSSION: Cannabis treatment seekers are a heterogeneous group. A better understanding of the relationship between client characteristics and different interventions may improve outcomes.

Needle exchange programs. Delivery and access issues.

OBJECTIVE: Examine the challenges of four service delivery models (i.e., fixed, mobile, satellite and home visits) and how service delivery may impact on NEP HIV prevention efforts. METHODS: Using a modified ethnographic approach, semi-structured interviews concerning policies and procedures were conducted with staff (n = 59) of NEPs (n = 15) in Ontario. An iterative, inductive analytic process was used. RESULTS: According to workers and managers, effectiveness of NEP prevention efforts depend on client development and retention and service design. Fixed and satellite sites, home visits and mobile services provide varied levels of temporal and spatial accessibility. Combining modes of delivery can offset the disadvantages of individual modes. DISCUSSION: NEP evaluations that do not consider service and resource factors run the risk of concluding that NEPs are ineffective when it may be that the program works for a small proportion of IDUs whom the NEP has the resources to serve.

Self-perceived health among Canadian opiate users: a comparison to the general population and to other chronic disease populations.

BACKGROUND: There are an estimated 40,000 to 90,000 injection opiate users in Canada. The social, economic and health consequences of opiate addiction have been well documented. However, there are no data on the self-perceived health status of opiate users in Canada. Therefore, the goal of this research is to gain an understanding of the self-perceived health status of opiate users by comparing the health-related quality of life of opiate users to chronic disease populations and to the general population. METHODS: The SF-36 was administered to a nonrandom sample of 143 opiate users entering low-threshold methadone treatment. Two sample t-tests were performed to assess statistical differences, at a 5% level of significance, between population scores across SF-36 dimensions. RESULTS: Opiate users perceived both their mental and physical health as worse than the general population and individuals with minor and serious medical problems, but comparable to those with diagnosed psychiatric illnesses. CONCLUSIONS: Methadone treatment services should incorporate both primary care and psychiatric care into their programs, or at the very least secure appropriate referral mechanisms to ancillary services to ensure that the health concerns of opiate users are dealt with in the context of their treatment program.

Determinants of health-related quality of life of opiate users at entry to low-threshold methadone programs.

OBJECTIVE: The aim of this study was to conduct an exploratory analysis of factors associated with poor health-related quality of life (HRQOL) among opiate users at entry to low-threshold methadone treatment. METHODS: The SF-36 questionnaire was administered to 145 opiate users at enrollment into low-threshold methadone maintenance programs. ANOVA and correlational analyses were performed to investigate the determinants of poor physical and mental composite summary scales (PCS and MCS) of the SF-36 among opiate users. Stepwise regression methods were also employed to fit PCS and MCS multivariate models. RESULTS: Age, employment status, chronic medical conditions, hospitalization, emotional abuse, sexual abuse and age at first injection episode were significantly associated with PCS. Mental health problems, sexual abuse, physical abuse, the use of sedatives, the use of cocaine, the number of days of cocaine use, sedative use and multiple substance use in the past month were significantly associated with MCS. The variances in the MCS and PCS were not readily explained by any one factor. CONCLUSION: The multiplicity of factors influencing HRQOL of opiate users suggests the need for a range of services within the context of a methadone program, addressing primary medical care needs as well as treatment for both mental health problems and abuse issues.

Individuals seeking treatment for cannabis-related problems in Ontario: demographic and treatment profile.

We report on the extent of cannabis treatment-seeking within an addiction treatment system in Canada. Data represent all new admissions in fiscal year 2000 to substance abuse treatment agencies in the province of Ontario (n = 47,995). Analyses examine the prevalence of cannabis problems by demographic and treatment characteristics and provide contrasts with other client subgroups (alcohol, cocaine, and opiates). Clients reporting cannabis as their primary problem substance (13%) were more likely to be male, single, under age 20 and in high school. Legal system involvement and school- or family-based pressure to enter treatment were commonly reported, but less so by older cannabis clients. The distinctiveness of these clients within the larger treatment system raises questions of the relevance to cannabis clients of interventions designed for other substance-abusing populations.