Reaching Those Most at Risk for Drug-Related Harm: Potential Users of a Supervised Injection Service in Ottawa, Canada Ashley Shaw; Lisa Lazarus; Sean.

Reaching Those Most at Risk for Drug-Related Harm:

Potential Users of a Supervised Injection Service in Ottawa, Canada

Ashley Shaw; Lisa Lazarus; Sean LeBlanc ; June Cummings; Dolly Lin; Caleb Chepesiuk; Sheetal Patel; Mark Tyndall,

For the PROUD Community Advisory Committee

Epidemiology and Public Health May 2, 2014 - 15:00.

We have no conflicts of interest to declare.

Conflict of Interest Disclosure

BACKGROUND: Supervised Injection Services (SIS)

A controlled health care setting where PWUID can access clean injection equipment and inject pre-obtained drugs under the supervision of a healthcare professional (Health Canada, 2008)

Often includes: Harm reduction education Overdose management Referral to health and social services,

including drug and addictions counselling and treatment

Currently, there are over 90 SISs in operation around the world, with the majority located in European countries

THE EVIDENCE: SISs…Reach the most marginalised PWUID

Who face issues of homelessness, mental health illness, interactions with the law, HIV infection

Decrease high-risk injection practices Sharing injection equipment Rushed injecting Injecting in public Unsafe syringe disposal No alcohol swabbing of injection sites

Reduce harm Decreased incidence of overdose deaths Reduced infection rates (Injection-site and blood-borne) Improved timely access to services (wound care, addictions treatment)

No negative impacts on public order and safety

Potential Users of a Supervised Injection Service in Ottawa No new sites established in Canada since

Insite opened its doors in 2003

TOSCA recommended 2 SIS be opened in Ottawa

To determine the potential impact of an SIS in Ottawa, we set out to determine whether the people who face the highest risk of negative

health outcomes are likely to use an SIS

The Ottawa Context HCV prevalence is at 60% and HIV is at 11-20% among

PWUID in Ottawa

At least 35 people died of overdose in 2011 (Skinner, Regional Supervising Coroner)

2012 TOSCA Study: in the previous 6 months, 20% of PWUID surveyed had experienced non-fatal overdose and 14% had injected with used needles

Limited peer inclusion at all levels

PROUD was the community’s responseParticipatory Research in Ottawa; Understanding Drugs

The PROUD Study: GOALS1. To build community capacity and ownership in all

aspects of the PROUD study Empower the drug using population to develop

research that affects their own community

2. To better understand the HIV risk environment among people who use drugs in the Ottawa area

3. To support the development of improved health and harm reduction services Peer-based HIV testing, supervised injection services

The PROUD Study: METHODS Study Design:

Prospective cohort study grounded in a Community-based participatory research (CBPR) framework

Community Advisory Committee

Sampling and Recruitment: From March - December 2013,

862 participants were enrolled into the study using a targeted, street-based recruitment strategy

• Wave 1: 597 from Ottawa’s downtown core• Wave 2: 265 from other areas within Ottawa

Eligibility criteria: • Aged 16+ years old; used injection drugs or smoked crack cocaine in

the past year; lived in Ottawa for at least three months

The PROUD Study: METHODS Data collection:

The PROUD CAC developed a cross-sectional survey covering 8 themes of importance to their community

A trained peer or medical student volunteer administered a one-time iPad-based questionnaire, followed by an HIV POC test(570 HIV tests were administered)

Prospective follow-up will occur through data linkages to health care records available from the Institute for Clinical and Evaluative Sciences (ICES)

Statistical analysis: A descriptive analysis was conducted comparing HIV risk factors

among PROUD participants who indicated a willingness to use an SIS and those who did not

Sub-sample analysis of the first 597 participants recruited

RESULTSAmong the 272 participants who reported injecting drugs in the past 12 months75.4% reported a willingness to use an SIS in

OttawaAmong Potential SIS users: 24.9% had injected with a used needle in the past year 61.3% were unstably housed 74.6% reported a mental health diagnosis 14.2% were HIV positive18.5% had engaged in sex work in the past year

Among women who reported willingness, 43.1% had engaged in sex work in the past year

RESULTSTable 1: Characteristics associated with willingness to use a supervised injection service in Ottawa a

Intention to use an SIS in Ottawa;

No. (and %) of participants b

Characteristic c Yes n = 205

No n = 67

OR (and 95% CI)

Age 40.0 43.1 1.05 (1.0-1.1) Gender Female 54 (84.4) 10 (15.6) 2.02 (1.0-4.2) Male 150 (72.8) 56 (27.2) Sexual Identity LGBTQ 35 (94.6) 2 (5.4) 6.69 (1.6-

28.6) Straight 170 (72.3) 65 (27.7) Injects in public Yes 86 (81.9) 19 (18.1) 1.85 (1.0-3.4) No 115 (71.0) 47 (29.0) Injects with other people

Yes 178 (80.2) 44 (19.8) 3.27 (1.7-6.3) No 26 (55.3) 21 (44.7)

REACHING THOSE MOST AT RISK FOR DRUG RELATED HARM: POTENTIAL USERS OF A SUPERVISED INJECTION SERVICE IN OTTAWA, CANADA

Assistance to inject

Yes 82 (82.0) 18 (18.0) 1.85 (1.0-3.4) No 121 (71.2) 49 (28.8) Overdosed Yes 55 (85.9) 9 (14.1) 2.36 (1.1-5.1) No 145 (72.1) 56 (27.9) Last Hep C test d

Positive 131 (80.4) 32 (19.6) 2.17 (1.2-4.0) Negative 51 (65.4) 27 (34.6) Ever redzoned Yes 103 (83.7) 20 (16.3) 2.37 (1.3-4.3) No 100 (68.5) 46 (31.5) Note: OR = odds ratio, CI = confidence interval. a. Percentages are calculated on the basis of the sum across each row. b. Except where indicated otherwise. Because of missing responses, the data for some

characteristics do not sum to 272. c. For each categorical variable, the reference category is the second category. For age, the OR

reflects per year older, and for number of overdoses, the OR reflects per additional overdose. All drug use behaviour variables are reported for the previous 12 months unless otherwise specified

POLICY IMPLICATIONSCURRENT CONTEXT

Providers should be granted an exemption under section 56 of the Controlled Drugs and Substances Act

The Supreme Court of Canada granted a constitutional exemption to Insite in 2011 –> an opportunity for new sites to open

Bill C2 Respect for Communities Act; An Act to amend the Controlled Drugs and Substances Act was reintroduced in October, 2013

FUTURE ACTION A call for evidence-based policy that facilitates rather than

impedes the implementation of proven healthcare services

Support the rights of PWUID to health, safety and access to care

CONCLUSIONS AND NEXT STEPS PWUID continue to face significant drug-

related harms and barriers to accessing health and harm reduction services

An SIS in Ottawa would likely reach its target group of high-risk injection drug users

Evidence indicates that an SIS could make a significant contribution toward engaging hard-to-reach populations and reducing harm

NEXT STEPS

SPECIAL THANKS TO OUR:Community Advisory Committee: Kelly F., Chris D., Dan M., Rick S., Tyler P., Hana D., Alana M., Tarah H., Caleb C., Fred C., Sean L., June C., Christine L., Gilles D., Sharp DCommunity Partners: Thank you to Ottawa Public Health for their support of the HIV POC testing-component of the project, our medical student volunteers, and our community partners DUAL, OASIS, Ottawa Inner City Health, AIDS Committee of Ottawa, and the Shepherds of Good HopeFunding received from: The Canadian Institutes of Health Research (CIHR), the Ontario HIV Treatment Network (OHTN) and The Ottawa Hospital, Department of Medicine and Division of Infectious Diseases, University of Ottawa

For more information:

www.supervisedinjectionottawa.com Supporters

Ashley ShawE-mail: [email protected]

Sean LeBlancE-mail: [email protected]

Mark TyndallE-mail: [email protected]

Contact Information