Supervised Injection Services: Evidence and Practice Mary Clare - - PowerPoint PPT Presentation

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.

January 30th, 2018 12:00 p.m. – 1 p.m. (EDT)

Coming up…

Tim Gauthier MN-NP Insite Vancouver Mary Clare Kennedy MA, PhD (cand) University of British Columbia, BC Centre on Substance Use

Public health and public order

• utcomes 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

• f 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

• pportunities 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

• Population: PWUD and broader communities in

which SCFs are located

• Interventions: Use, establishment or operation of

SCFs

• Comparison: No exposure to SCFs
• Outcomes: All individual- or population-level

health or social outcomes

• Study 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

• rder 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

INSITE SUPERVISED INJECTION & NURSING PRACTICE

Tim Gauthier, RN, BSN, MN RNAO January 30/18

HISTORY SUPERVISED INJECTION IN CANADA

 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…

#THEYTALKWEDIE

CURRENT CONTEXT SUPERVISED 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

LIGHTFOOT ET AL. (2009) CANADIAN NURSE JOURNAL

INSITE’S PRIORITY PYRAMID

OD & Inj. Emergencies HR ED Referrals Nursing Treatments

OVERDOSE AND INJECTION RELATED EMERGENCES

Opioid OD Stimulant OD Other Toxicology Seizure Chest Pain Hypoglycemia Cotton Fever vs Sepsis Psychosis Arterial Injection

HARM REDUCTION EDUCATION

Safer Injection

Vein Care / Location Supplies and Equipment Infection Prevention Alternate Routes of Ingestion OD Prevention OD Response & THN Hygiene Opioid Replacement

NURSING IN THE IR

REFERRALS

Primary Care Substance Use & Addictions Mental Health Dental Housing Food Income and Social Assistance Emergency & Acute Care Specialists

NURSING TREATMENTS PRIMARY NURSING CARE

Wound Care POC HIV Testing STI Testing & Treatment Immunizations Primary Care Complaints Counselling & Management Plans Case Management Mental Health Crises & Suicidality Trauma & Emergency Management

BROADER ROLE CLARIFICATION RNAO / HRNA / CNA / COMMUNITY OF PRACTICE

https://www.nursesforsis.com/uploads/2/5/3/6/25361002/nursing_pr actice_and_supervised_injection_final_draft.pdf

HARM REDUCTION NURSES’ ASSOCIATION

The mission of HRNA is to recognize and foster advance harm reduction nursing through practice, education, research, and advocacy

CONTACT INFORMATION

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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