January 30 th , 2018 12:00 p.m. – 1 p.m. (EDT) Supervised Injection Services: Evidence and Practice Mary Clare Kennedy , MA, PhD (cand) - University of British Columbia, BC Centre on Substance Use Tim Gauthier , MN-NP – Insite Vancouver Welcome! The webinar will begin shortly! To hear audio for this event, please turn up your computer speakers. Please note this event will be recorded.
Coming up… Tim Gauthier Mary Clare Kennedy MN-NP MA, PhD (cand) Insite Vancouver University of British Columbia, BC Centre on Substance Use
Public health and public order outcomes associated with supervised drug consumption facilities: A systematic review Mary Clare Kennedy, Mohammad Karamouzian & Thomas Kerr Current HIV/AIDS Reports. 2017; 14(5):161-183
Background • Supervised drug consumption facilities (SCFs) – Supervised injection facilities (SIFs) – Supervised inhalation rooms (SIRs)
Public health and public order objectives of SCFs 1) Reduce harms associated with illicit drug use A) Overdose-related morbidity & mortality B) Infectious disease transmission 2) Connect people who use drugs (PWUD) with addiction treatment and other health services 3) Reduce public order and safety problems associated with illicit drug use Hedrich et al., 2010
Where do SCFs exist? • 90 in 7 countries in Europe • 1 in Sydney, Australia • 17 in Canada* – BC : Vancouver (3), Surrey (2), Victoria (1), Kamloops (1), Kelowna (1) – Ontario : Toronto (2), Ottawa (2) – Quebec : Montreal (4) – Alberta : Calgary (1) – *11 Additional SCFs approved in Canada EMCDDA, 2017; Health Canada, 2018
Purpose of study 1) To systematically review existing quantitative research on the health and community impacts of SCFs. 2) To identify underexplored opportunities to inform future research specific to SCFs. Kennedy et al., Curr HIV/AIDS Rep. 2017
Methods: Search strategy • Searched 6 databases: MEDLINE, EMBASE, Web of Science, PsychINFO, Google Scholar, CINAHL • Reference lists, conference proceedings, key addiction journals • Grey literature search (e.g., reports, dissertations) Kennedy et al., Curr HIV/AIDS Rep. 2017
Methods: PICOS framework for study inclusion • P opulation: PWUD and broader communities in which SCFs are located • I nterventions: Use, establishment or operation of SCFs • C omparison: No exposure to SCFs • O utcomes: All individual- or population-level health or social outcomes • S tudy design: Original quantitative studies that assessed associations between SCFs and outcome(s) for statistical or clinical significance Kennedy et al., Curr HIV/AIDS Rep. 2017
Methods: Exclusion criteria and quality assessment • Excluded: review articles, case reports, commentaries, qualitative studies, descriptive studies, feasibility studies • Quality assessment: – National Heart, Blood and Lung Institute (NHBLI) Quality Assessment Tool for Observational Cohort and Cross-sectional studies – NHBLI Quality Assessment Tool for Before-After (Pre-Post) Studies – Joanna Briggs Institute’s Critical Appraisal Checklist for Economic Evaluations Kennedy et al., Curr HIV/AIDS Rep. 2017
Results • 47 eligible studies included (2003 – 2017) – 28 from Vancouver – 10 from Sydney, Australia – 9 from European countries (Germany; Denmark; Spain; the Netherlands) • Study designs: – 17 prospective cohort – 10 pre-post ecological – 9 cross-sectional – 8 mathematical simulation – 3 series cross-sectional Kennedy et al., Curr HIV/AIDS Rep. 2017
Results – Objective 1a: Reduce overdose (OD)- related morbidity and mortality 8 studies: • 4/5 – reduction in OD deaths – 1/5 – no association but low statistical power • 1/1 – reduction in OD emergency department presentations • 1/1 – reduction in OD ambulance attendances • 1/1 – no association with non-fatal OD – Reduction in non-fatal overdose not key goal of SCFs • 1/1 – increased likelihood of OD within SCF – likely due to greater exposure time at SCF Kennedy et al., Curr HIV/AIDS Rep. 2017
Results – Objective 1b: Drug-related behaviours associated with infectious disease transmission and other harms 9 studies: • 3/4 – declines in syringe sharing – 1/4 – no association with syringe sharing but underpowered • 2/2 – declines in syringe reuse, outdoor injection, rushed injection • 2/2 – no association with injection-related infections • 2/2 – no changes in community drug use patterns (e.g., injection relapse/ cessation, binge drug use) Kennedy et al., Curr HIV/AIDS Rep. 2017
Results – Objective 2: Connect PWUD w/addiction treatment & other services 13 studies: • 4/5 – increased uptake of addiction treatment – 1/5 – no association w/ inability to access treatment • 6/6 – increased use of other health and social services • 1/1 – drug checking more likely to reduce doses but not dispose of drugs • 1/1 – smoking cessation program smoking cessation care Kennedy et al., Curr HIV/AIDS Rep. 2017
Results – Objective 3: Improve public order and safety 11 studies: • 5/5 – improved public order (i.e., reductions in public drug use, publicly- discarded syringes/ litter) • 6/6 – no increases in crime (e.g., theft, robbery, drug dealing/ possession, incarceration rates) Kennedy et al., Curr HIV/AIDS Rep. 2017
Results – Other health and social impacts 8 studies: • 6/6 – cost effective – 5 of Insite ($200,000 - $6 million) – 1 of unsanctioned, peer-run SCF • 1/1 – not associated with employment • 1/1 – increased consistent condom use among PWUD with regular but not casual partners Kennedy et al., Curr HIV/AIDS Rep. 2017
Discussion • Reduce overdose-related harms • Reduce risk of infectious disease transmission • No impact on community drug use patterns • Increased uptake of addiction treatment and other health and social services • Improvements in public order & safety • No impact on crime • Cost effective Kennedy et al., Curr HIV/AIDS Rep. 2017
Discussion – Directions for future research • Long-term health impacts (e.g., sustained injection cessation) • Innovations in SCF programming – Assisted injection – Supervised inhalation rooms – Peer-run SCFs – Women-only SCFs – Mobile SCFs – Integrated SCFs Kennedy et al., Curr HIV/AIDS Rep. 2017
Acknowledgements • Participants of studies included in review • Co-authors : Mohammad Karmouzian and Thomas Kerr • BCCSU staff and administrative support : Deborah Graham, Tricia Collingham and the rest of the team • Community groups and others who support this work • Funders : Canadian Institutes of Health Research (CIHR), Social Sciences and Humanities Research Council (SSHRC), Mitacs Canada, Vanier Canada
Contact: mckennedy@alumni.ubc.ca
I NSITE S UPERVISED I NJECTION & N URSING P RACTICE Tim Gauthier, RN, BSN, MN RNAO January 30/18
H ISTORY S UPERVISED I NJECTION IN C ANADA Insite opened in 2003 Response to Public Health Emergencies & public pressures 1990’s HIV & OD Deaths Research Program Exemptions granted yearly based on evidence Supreme Court of Canada upheld right to exemption while there is demonstrated need Civil Disobedience: VANDU, PHS, Dr Peter’s, Nurses…
#T HEYTALKWEDIE
C URRENT C ONTEXT S UPERVISED CONSUMPTION Public Health Crisis: Opioid Overdose Overdose Prevention Sites: volunteers, peers, harm reduction workers and nurses. Supervised Consumption Sites: varied models most include nurses Lack of clarity over what nurse do
L IGHT F OOT E T A L . (2009) C ANADIAN N URSE J OURNAL
I NSITE ’ S P RIORITY P YRAMID OD & Inj. Emergencies HR ED Referrals Nursing Treatments
O VERDOSE AND I NJECTION R ELATED E MERGENCES Opioid OD Stimulant OD Other Toxicology Seizure Chest Pain Hypoglycemia Cotton Fever vs Sepsis Psychosis Arterial Injection
H ARM R EDUCTION E DUCATION Safer Vein Care / Location Injection Supplies and Equipment Infection Prevention Alternate Routes of Ingestion OD Prevention OD Response & THN Hygiene Opioid Replacement
N URSING IN THE IR
R EFERRALS Substance Primary Mental Use & Care Health Addictions Dental Housing Food Income and Emergency Social & Acute Specialists Assistance Care
N URSING T REATMENTS P RIMARY N URSING C ARE POC HIV STI Testing & Wound Care Testing Treatment Counselling & Primary Care Immunizations Management Complaints Plans Mental Health Trauma & Case Crises & Emergency Management Suicidality Management
B ROADER R OLE C LARIFICATION RNAO / HRNA / CNA / C OMMUNITY OF P RACTICE https://www.nursesforsis.com/uploads/2/5/3/6/25361002/nursing_pr actice_and_supervised_injection_final_draft.pdf
H ARM R EDUCTION N URSES ’ A SSOCIATION The mission of HRNA is to recognize and foster advance harm reduction nursing through practice, education, research, and advocacy
C ONTACT I NFORMATION Please feel free to contact me with questions or comments about nursing practice and supervised injection Tim Gauthier Clinical Coordinator Insite & Onsite Tim.Gauthier@vch.ca Thank you!
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