What We Heard Report: Operating Grant: Evaluation of Harm Reduction Approaches to Address the Opioid Crisis in the Context of COVID-19 – Supervised Consumption Sites Evaluation
End-of-Grant Virtual Workshop

Workshop Date: October 28, 2022
Location: Virtual Meeting via MS Teams

Table of Contents

• Introduction
• Workshop Objectives and Agenda
• Message from the Scientific Director
• Project Findings
  • Prairies: A rapid assessment of the impact of the COVID-19 pandemic on supervised consumption services in Canada
  • British Columbia: Investigating access to and outcomes from supervised drug consumption services in British Columbia before and during the COVID-19 pandemic
  • Supervised consumption and COVID-19 in Ontario: An evaluation (SCCONE)
  • Changes in supervised consumption site use and emergency interventions in Montréal in the context of COVID-19
• Panel Reflections and Discussion
• Conclusion and Summary

Introduction

On October 28, 2022, the Canadian Institutes of Health Research (CIHR) hosted a virtual end-of-grant knowledge exchange workshop for four one-year supervised consumption sites (SCS) evaluation projects funded through the Operating Grant: Evaluation of Harm Reduction Approaches to Address the Opioid Crisis in the Context of COVID-19 funding opportunity. This report comprises a synthesis of the evidence presented by the four research teams and a summary of knowledge user and audience perspectives shared during a panel reflections and discussion session.

This funding opportunity supported a fifth multi-year project to assess the program implementation and short-term impact of Health Canada’s Substance Use and Addiction Program (SUAP) Safer Supply Pilot Projects (SSPP). This project was not included as part of this knowledge exchange workshop.

Disclaimer

The following information intends to summarize what we heard at the workshop. CIHR has made every effort to share this text with project participants for their review. Any errors or omissions are unintentional. This report should not be taken as a definitive account of research results. Readers are advised to follow up directly with grant recipients for the most current information on their projects.

The meeting book for this workshop is available upon request. Requests can be directed to the CIHR Contact Centre: support-soutien@cihr-irsc.gc.ca.

Workshop Objectives and Agenda

The primary objectives of the workshop were to:

• Share and discuss findings on the public health impacts of supervised consumption sites (SCS) on people who use SCS services, and also on the general population, to inform best practices and policies for the operation of SCS, taking into consideration the impact of the COVID-19 pandemic
• Foster cross-disciplinary discussion with researchers, decision makers and knowledge users to inform drug policy and advance evidence-based practices

Message from the Scientific Director

For over two years, Canada’s overdose crisis has been exacerbated by the effects of the COVID-19 pandemic. Throughout the country, harm reduction services, including supervised consumption sites (SCS), have been hampered by public health measures put in place to address COVID-19, including physical distancing, leading to, for example, facility closures and staffing limitations. As a result, there is an urgent need for data on the impact of the pandemic on harm reduction services provided by SCS.

To address this evidence gap, the Canadian Institutes of Health Research Institute of Neurosciences, Mental Health and Addiction (CIHR-INMHA) launched the Evaluation of Harm Reduction Approaches to Address the Opioid Crisis in the Context of COVID-19 funding opportunity in the fall of 2020.

Evaluation of both local and national contexts is key to understanding the impacts of SCS on people who use the services and the local community, as well as the pandemic’s impact on this harm reduction approach. Each of the country’s roughly 40 SCS contends with its own social and economic considerations, in addition to varying provincial public health responses to COVID-19. To that effect, this initiative provided funding to a team in each of CRISM’s (Canadian Research Initiative in Substance Misuse) four regional nodes. These four research teams have conducted critical and potentially life-saving work exploring the public health impacts of SCS on people who use SCS services and on the general population before, during and after the COVID-19 pandemic.

These four projects funded through this initiative evaluated several facets of the dual crises, including usage and uptake patterns, barriers to access, flexible formats, holistic and integrated care, advocacy, and resourcing. Through direct interviews, focus groups and questionnaires, several hundred knowledge users (including people who use drugs and SCS staff) were consulted.

In this end-of-grant workshop, research findings were shared alongside the perspectives and expertise of knowledge users — providing a comprehensive view of the topic and enhancing the potential impact of the findings. Knowledge shared through this event can be used to support evidence-based decisions to help ensure safe, consistent delivery of SCS in both regular and adverse public health environments.

The reflections shared at this workshop will be invaluable to the countless lives touched by the ongoing overdose crisis nationally, and I am grateful to the researchers, knowledge users and people with lived and living experience who contributed to these projects and shared their work, perspectives, and ideas with us through this important virtual event.

Samuel Weiss, PhD, FRSC, FCAHS
Scientific Director, CIHR Institute of Neurosciences, Mental Health and Addiction

Project Findings

This session included findings from the four SCS evaluation projects and knowledge user implications as shared by the research team. A brief question and answer period followed each presentation if time allowed, and audience members were invited to make comments and ask questions using the MS Teams chat feature. The presentations and accompanying discussion are summarized below for each project.

Prairies: A rapid assessment of the impact of the COVID-19 pandemic on supervised consumption services in Canada

Presented by: Patrick McDougall, Dr. Peter AIDS Foundation, and Savannah Swann, Dr. Peter AIDS Foundation

Nominated Principal Investigator: Elaine Hyshka, University of Alberta

This project, which is still ongoing, seeks to describe SCS utilization patterns before and after the onset of the COVID-19 pandemic, analyze the impact of COVID-19 on SCS across different service models and regions, assess staff perspectives on how COVID-19 is shifting care for people who use drugs (PWUD), and describe staff-identified solutions for ensuring SCS access.

The researchers partnered with the Dr. Peter AIDS Foundation, which organizes a national community of practice for approximately 50 organizations that operate SCS and overdose prevention sites (OPS) in Canada. The researchers also convened a smaller advisory group of SCS stakeholders (i.e., SCS managers and staff, and people with lived and living experience) to provide in-depth feedback on the research protocols, data collection instruments, and recruitment within SCS. Knowledge shared at the workshop included data gathered from Health Canada-exempted SCS.

Preliminary administrative data gathered from 17 SCS demonstrate a dramatic and rapid shift in SCS utilization and outcomes in response to the COVID-19 pandemic. Although total visits to SCS decreased rapidly following the onset of pandemic response protocols, more unique clients visited SCS during the first year of the pandemic compared to the previous year. The researchers note that this could reflect the unpredictability in the drug supply at the time and highlight the corresponding increased need for SCS to ensure safety.

Organizational surveys with 22 SCS, while still preliminary, revealed that almost all sites implemented changes in operations or infrastructure in response to COVID-19. Almost all facilities implemented participant screening and personal protective equipment (PPE) requirements, and many made operational changes including but not limited to: physical distancing, occupancy limits, hygiene protocols, reducing services and adding physical barriers. In addition, overdose response protocol changes observed because of the pandemic included: requiring staff to wear additional PPE, removing people from a space where a participant was experiencing an overdose, modifying resuscitation practices, and increasing reliance on naloxone. Washroom access was limited to avoid isolated overdoses.

Through semi-structured interviews with 15 frontline SCS staff to date, participants described shifts in care for PWUD, including an inability to meet demand. Many sites operated with reduced capacity and clients were sometimes required to wait outside for long periods, including in extreme temperatures. There was also an increased demand for basic needs (e.g., food, clothing, shelter) resulting from the closure of other community services, and SCS staff were not adequately resourced to meet these needs. Participants also reported changes to SCS atmosphere in response to COVID-19 protocols. For example, having to act as “mask police” detracted from the ability to have supportive client-provider relationships, and having to control movement and gatekeep sterile supplies that used to be freely accessible resulted in a reduced sense of community and self-determination for PWUD.

Several staff participant-identified solutions were outlined to ensure optimal SCS service delivery and emergency response planning. Solutions included: 1) front-line staff and PWUD being included early and often when developing and evaluating programming; 2) maintaining paid sick leave for staff; 3) additional grief support for staff and clients; and 3) maintaining access to community health and social services throughout pandemics or other states of emergencies.

Question and answer period

• How can we better inform how these services should be provided?

  Funding is critical, as well as having policies that allow SCS operators to quickly adapt to the needs of clients. Offering services outside would have been useful, as well as indoor inhalation facilities. It was also extremely difficult to get PPE.

  There was a lack of relevant information designed for PWUD. The pandemic exacerbated existing disparities, and we observed structural violence (wherein social structures or institutions cause harm by preventing people from meeting their basic needs).

British Columbia: Investigating access to and outcomes from supervised drug consumption services in British Columbia before and during the COVID-19 pandemic

Presented by: Thomas Kerr, University of British Columbia (Nominated Principal Investigator), and Mary Clare Kennedy, University of British Columbia – Okanagan

This project aimed to identify the impacts of COVID-19 on SCS delivery, access, and outcomes in Vancouver and Surrey, to inform policy, practice and optimized delivery of SCS.

The team has completed data collection, which included conducting in-depth qualitative interviews with 22 SCS clients in Surrey and 21 SCS staff and operators in Surrey and Vancouver. In addition, more than 400 PWUD completed questionnaires that included measures to assess changes in the accessibility or use of SCS beginning in July 2020.

Of 428 PWUD surveyed between July and November 2020, 13.6% reported difficulty accessing SCS in the last six months. The most commonly reported reasons for experiencing difficulty were: the site being closed or having reduced hours due to COVID-19 (43%), long wait times (39%), the site being too hectic (14%) and fear of getting COVID-19 (9%). Individuals who reported difficulty accessing sites were generally younger and experiencing structural vulnerabilities, including daily crystal meth use, active injection drug use, recent overdose and unstable housing.

Survey results also revealed that 14.7% of PWUD reported a decreased frequency of SCS use since the onset of the COVID-19 pandemic. This decreased frequency of use was associated with self-reported exposure to fentanyl and with individuals’ perceptions that sites were more difficult to access.

Qualitative interviews revealed several key themes. Participants noted reduced quality and increased unpredictability of the drug supply, which motivated SCS use. For example, increased contamination of benzodiazepines in the drug supply motivated individuals to access an SCS for protection from harms, such as being heavily sedated and vulnerable in an unsecured environment. Increased benzodiazepine poisonings at SCS meant that individuals could be monitored at the site for several hours, however, this reduced the site’s capacity for others. Service closures, reductions in operating hours, capacity restrictions, and related increases in wait times impeded access to SCS, leading people to consume substances elsewhere, where they were more vulnerable to harms, including overdose-related harms and exposure to violence.

This study highlights the need for strategies to support SCS access, particularly in the context of future public health emergencies. This includes expanding the capacity of existing sites where there is a demonstrated need, creating temporary/makeshift sites, or enabling flexible episodic overdose prevention services (where providers can observe substance use anywhere and anytime), for example, in community settings.

The next steps for this project include further analysis of service provider interviews to qualitatively explore factors driving changes in SCS delivery, access and outcomes, and further analysis of cohort data to quantify changes in SCS use and outcomes in the COVID-19 era compared to pre-COVID-19.

Question and answer period

• Has there been any discussion about using flumazenil to respond to benzodiazepine overdoses?

  Through staff interviews, we are hearing that staff don’t have adequate support or training to provide this at SCS.

• Were there any aspects of disagreement between the quantitative and qualitative arms of the research, or were they complementary/in agreement?

  This is difficult to say exactly, because the study’s quantitative arm was focused on Vancouver and the qualitative work was focused on Surrey. There are some contextual differences between the sites, for example, a smaller site may have different barriers to access than a larger facility.

• “Benzo-dope” (benzodiazepine and opioid drug combination) was a major issue prior to COVID, with increased and prolonged somnolence (drowsiness). Was the supply more volatile during the pandemic, or were responses [to overdoses] more difficult due to services being curtailed during the pandemic?

  Benzodiazepines were contaminating the drug supply before COVID-19. The supply then became more volatile during the pandemic, with evidence suggesting that things like border closures were driving unpredictability in the supply. It was consistently reported that the COVID-19 pandemic resulted in more people buying and cooking drugs themselves, leading to more contamination and cross-contamination.

Supervised consumption and COVID-19 in Ontario: An evaluation (SCCONE)

Presented by: Ahmed Bayoumi, University of Toronto (Nominated Principal Investigator)

This project seeks to evaluate optimal service models and sustainability of SCS across Ontario during and after the COVID-19 pandemic and to describe the availability and use of SCS services during the pandemic.

The project is ongoing, and the workshop presentation focused on the results of two focus group sessions that identified factors explaining why clients had less access to sites during the pandemic, how this related to access to other clinical and harm reduction services, pressures faced by staff in delivering services, how programs responded, and how sites adapted to changing public and political responses.

Participants highlighted several contextual factors to describe SCS services during the pandemic. These included: staff shortages and burnout; limited access to PPE for staff and clients; clients believing that sites were closed or clients avoiding sites due to perceived risk of contracting COVID-19; increased wait times; ongoing grief and loss for both clients and staff, and a lack of space to gather and support mourning; fewer community mental health supports or group supports; people being moved to shelter hotels or encampments and being dispersed throughout the city where travel to SCS was more difficult; and increased deaths.

The focus groups also explored SCS COVID-19 responses, staff and program changes, and services affected by the pandemic. Examples that were highlighted included: decisions about the use of oxygen during overdoses were impacted (i.e., potential for increased COVID risk), there was a decrease in the number of booths due to physical distancing, people unwilling to follow COVID protocols were denied services, staff were redeployed to work on other public health COVID-19 measures and more inexperienced workers were hired, there was reduced access to extended carries and safer supply, ewer referrals were made to services such as residential treatment programs or violence prevention shelters, and drug checking was put on hold.

Focus group participants noted that during the pandemic, clients had less access to supports within SCS (e.g., “chill out spaces”), clients avoided sites because of their concerns about COVID-19, clients had adverse health outcomes due to decreased availability of other services, staff faced increased pressure and staff-client relationships became more transactional. In addition, services shifted to focus more on acute care and less on prevention and community services. Participants also noted that the uncertainty around whether SCS services were considered essential made planning difficult.

The next steps for this project include interviewing people who use drugs and staff who work at SCS, as well as quantitative analysis of outcomes related to SCS use, including calls to Toronto Emergency Medical Services and admissions to hospital.

Changes in supervised consumption site use and emergency interventions in Montréal in the context of COVID-19

Presented by: Sarah Larney, University of Montréal (Nominated Principal Investigator), and Camille Zolopa, University of Montréal

The aim of this project was to assess changes in the use of SCS in Montréal during the first 12 months of the COVID-19 pandemic. This study collected data from four SCS, including one mobile site. It looked at changes in first-time and total visits, emergency interventions, types of drugs being injected, and harm reduction materials distributed. Researchers compared data collected during the first year of the pandemic to the 24 months preceding the pandemic.

The researchers found a significant and abrupt decrease in total visits to SCS corresponding to the start of the pandemic, likely because of infection minimization protocols put in place that affected attendance. Prior to the pandemic, total visits per month were increasing, and this trend continued in the 12 months following the onset of the pandemic, despite the lower number of total visits. As of February 2021, the total number of visits had not rebounded to pre-pandemic levels. However, the trend of increasing visits over time suggests that these numbers may increase to pre-pandemic levels in the future. There was no change in the number of new SCS clients following the onset of the pandemic.

This study found an increasing proportion of clients required emergency intervention in the 12 months following the onset of the pandemic, including an increase in naloxone administration. This result is consistent with reports of an increasingly toxic drug supply heightening the risk of overdose during this period.

Changes in the drugs being injected were also observed. Clients were asked to self-report what they believed they were injecting, and results show that there were declines in traditional unregulated opioids (e.g., heroin), increases in fentanyl and its derivatives, and an increase in pharmaceutical opioids, possibly reflecting an increase in counterfeit pills and/or safer supply efforts. With respect to non-opioids, unregulated amphetamine injections declined, pharmaceutical stimulant use increased, and no changes were observed with cocaine or other drugs being injected.

When investigating changes in harm reduction materials distributed per month, an increase in needle-syringe distribution immediately following the onset of the pandemic was observed, followed by a declining trend over time. This may be the result of clients stocking up on supplies early on and levels may restabilize over time. Naloxone kit and fentanyl test strip distribution remained consistent in the first 12 months of the pandemic, suggesting that community health efforts were able to respond rapidly to maintain these services.

Overall findings suggest that despite rapid service adaptation intended to keep people safe, the pandemic increased overdose risk. There were changes in the way SCS operated, particularly regarding capacity restrictions to accommodate physical distancing requirements.

Next steps for this project include additional data analysis and drug supply monitoring beyond self-report data and extending the work to look at SCS utilization over future COVID-19 waves.

Question and answer period

• Was there any difference in activities between brick-and-mortar sites and mobile sites?

  This wasn’t a part of the study but could be investigated in the future.

• Why was there more opioid use and less stimulant use at the SCS?

  The data is presented as a proportion/ratio, and we observed that the proportion of visits with opioids increased. In absolute numbers, there was an increase in synthetic opioids and fewer stimulant consumers visiting the SCS. This could be because people were using stimulants outside and didn’t feel it was necessary to go inside the SCS. In contrast, with the increased fentanyl in the drug supply and increased contamination with benzodiazepines, people may have thought it was safer to use opioids inside.

Panel Reflections and Discussion

In this session, panelists reflected on the research results presented and discussed the implications and applications of the findings. Panelists included treatment providers, harm reduction providers, and peer workers. Audience members from various backgrounds, including PWLLE, peer support and clinicians, also shared comments.

Below is a summary of the facilitated discussion, including the perspectives and experiences of panelists and workshop participants as they relate to SCS in Canada.

Moderator:

Leigh Chapman, Chief Nursing Officer, Health Canada

Panelists:

• Nicholas Boyce, Senior Policy Analyst, Canadian Drug Policy Coalition, Simon Fraser University
• Cheyenne Johnson, Executive Director, BC Centre on Substance Use
• Matt Johnson, Health Promoter – Supervised Consumption Services, Parkdale Queen West Community Health Centre
• Jammy Lo, Lead Peer Investigator, Keeping Six/HAMSMaRT
• Jean-François Mary, Executive Director, CACTUS Montréal
• Patrick McDougall, Director of Knowledge Translation and Evaluation, Dr. Peter AIDS Foundation

Summary of Discussion

Many people prefer inhalation over injection of substances, yet most SCS do not permit smoking. Indoor supervised inhalation facilities are difficult and expensive to set up, and federal regulations are not flexible enough to allow simpler, less expensive outdoor sites.

• At the time of writing, 38 SCS in Canada offer services, and of those, only two are authorized to permit the use of substances by inhalation (smoking).
• In British Columbia, over 64% of people report they are now smoking their drugs, and smoking fentanyl is on the rise across Canada.
• Lower overdose rates have been observed among people who smoke opioids compared to those who inject opioids. People who use substances report that it is easier to manage their drug dosage with smoking than injecting, and they feel smoking is safer.
• In colder climates, outdoor injecting is difficult.
• Indoor inhalation sites require dedicated HVAC systems in individual booths. People who use these sites report that the booths feel isolating and are not enjoyable to hang out in.
• Provincial anti-smoking regulations and municipal bylaws can make establishing inhalation sites difficult.
• Outdoor inhalation sites are more visible in the community, which may lead to opposition from neighbouring residents and businesses.
• Federal exemptions to section 56.1 of the Controlled Drugs and Substances Act need to be more flexible to enable SCS to expand into outdoor spaces (such as tents).
• It is easy and inexpensive to set up an outdoor site, such as a tent in a small, designated area.
• People with lived experience report that SCS can feel “like a slap in the face” because SCS are not offering support for smoking substances, therefore not meeting the community’s needs.

“Here’s this one space you can use drugs and not die, but only if you use drugs in this way. Everywhere else you use, you risk arrest.”

The exemption process to establish an SCS is complicated, inflexible, burdensome, and time-consuming. Overdose prevention sites (OPS) do not require a federal exemption and may be a low-barrier alternative to SCS.

• The process of obtaining and maintaining a federal exemption [to section 56.1 of the Controlled Drugs and Substances Act] needs to be more flexible and less complicated.
• Services such as drug checking, safe consumption including inhalation, and splitting and sharing substances should be included.
• The process is not nimble enough to respond to immediate needs and constantly changing drug supply.
• If these services were legalized, health authorities could offer them where they are needed, like other health services. Simple sites could be set up very quickly and for low cost (e.g., drug checking as a basic service offered in shelters).

“Only a few of us in the country have gone through the exemption process and know how to deal with the burden. When you try to scale up services, the burden becomes too much, and we miss opportunities. We could do more if [the exemption process] was easier.”

• OPS could be one tool for reframing the federal exemption process. Episodic OPS have been established quickly and successfully, for example, to support participants at a substance use conference.

Provinces and territories are responsible for delivering health services, yet provincial rules and ideologies can represent additional barriers to SCS.

• Even with federal exemptions in place, provincial/territorial restrictions can make harm reduction services, including SCS difficult to establish and maintain.
• Directly funding municipalities or individual sites may be helpful, however, it is still important that municipalities, provinces/territories, and the federal government work together.
• Mayors across the country are reporting that it is only possible to do something with the support of provincial/territorial health and social services.
• There could be a very small window for change before the next federal election, where there could be a change in government.

It is critical to listen to PWLLE of substance use to remain proactive and nimble, and to know what services are needed and where.

• Paying attention to what is happening on the street and meeting people where they are will enable services to be the most effective.
• The drug supply changes rapidly and needs a flexible and rapid response. If we listen to PWLLE, we should be able to stay with the wave.
• Not all people will use an SCS; there are many individuals who need different services.
• People who use substances are experts and are telling us what is needed. We need to respond.

More funding is needed to support harm reduction, including SCS and to save lives.

“We are struggling to keep the lights on. We shouldn't have to run fundraisers to provide essential services.”

Conclusion and Summary

This workshop featured four projects and a panel session with an open discussion among policy makers, health care and substance use health care providers, people with lived and living experience of substance use and harm reduction and peer support workers.

The four projects highlighted in this workshop evaluated the impact of SCS on public health, both in populations who use the services and in the general population — comparing their effects before, during and after the immediate COVID-19 crisis.

A high-level summary of overarching themes from the workshop follows below:

• Visits to SCS decreased following the onset of the pandemic. Service closures, reductions in operating hours, capacity restrictions, and related increases in wait times all impeded access to SCS. Some clients avoided sites out of fear of contracting COVID-19.
• The pandemic caused increased unpredictability in the drug supply, which affected SCS use and the safety of PWUD. Increased contamination with benzodiazepines motivated people to access SCS to ensure safety. There was an increase in fentanyl in the drug supply, an increase in the number of clients requiring emergency intervention and an increase in deaths.
• SCS experienced operational changes because of the pandemic. It was difficult to obtain PPE. Services were limited, shifted to acute care rather than prevention, and were impacted by occupancy limits, hygiene protocols and physical barriers.
• Infection control measures contributed to a reduced sense of community and self-determination among people accessing SCS. Clients could no longer access supplies on their own and reported feeling more isolated. Staff-client relationships became more transactional.
• Staff faced increased pressure and required additional support. Staff reported feeling like “mask police.” Paid sick leave was important, and additional grief support for both staff and clients was needed but not available.
• The pandemic exacerbated existing disparities. There was an increase in demand for basic needs and decreased availability of health and social services. SCS staff were unable to meet the demand and there was an increase in adverse health outcomes.
• There is a need for disaster response planning to support people who use substances during future public health emergencies. Planning must be done in collaboration with PWUD and service providers. Maintaining access to health and social services should be prioritized.
• Supervised inhalation sites are needed. There has been an increase in drug inhalation in many places and many people prefer smoking over injecting substances. Lower overdose rates have been observed among people who smoke opioids compared to those who inject. There are benefits and challenges to both indoor and outdoor inhalation sites.
• The federal exemption process can make it difficult to establish and/or expand SCS. More flexibility is needed. Overdose prevention sites may be a useful tool and can be set up quickly.
• All levels of government (federal, provincial/territorial, and municipal) must work together to support effective harm reduction services.
• More funding is needed. Harm reduction should be recognized and funded as an essential service.
• It is critical to listen to the voices of PWUD and harm reduction workers to stay nimble and responsive to the needs of people who use substances.

Thank you to all who participated in this knowledge exchange event.

The meeting book for this workshop is available to the public upon request. Requests can be directed to the CIHR Contact Centre: support-soutien@cihr-irsc.gc.ca.

More information on CIHR’s Research in Substance Use initiative can be found online.

For more information, visit CIHR’s Institute of Neurosciences, Mental Health and Addiction webpage or email INMHA-INSMT@cihr-irsc.gc.ca.

Date modified:

2023-05-09