Supervised Injection Services: Evidence and Practice

Transcription

1 January 30 th, :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.

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

3 Current HIV/AIDS Reports. 2017; 14(5): Public health and public order outcomes associated with supervised drug consumption facilities: A systematic review Mary Clare Kennedy, Mohammad Karamouzian & Thomas Kerr

4 Background Supervised drug consumption facilities (SCFs) Supervised injection facilities (SIFs) Supervised inhalation rooms (SIRs)

5 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

6 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

7 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

8 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

9 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

10 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

11 Results 47 eligible studies included ( ) 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

12 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

13 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

14 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

15 Results Objective 3: Improve public order and safety 11 studies: 5/5 improved public order (i.e., reductions in public drug use, publiclydiscarded 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

16 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

17 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

18 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

19 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

20 Contact:

21 INSITE SUPERVISED INJECTION & NURSING PRACTICE Tim Gauthier, RN, BSN, MN RNAO January 30/18

22 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

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24 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

25 LIGHTFOOT ET AL. (2009) CANADIAN NURSE JOURNAL

26 INSITE S PRIORITY PYRAMID OD & Inj. Emergencies HR ED Referrals Nursing Treatments

27 OVERDOSE AND INJECTION RELATED EMERGENCES Opioid OD Stimulant OD Other Toxicology Seizure Chest Pain Hypoglycemia Cotton Fever vs Sepsis Psychosis Arterial Injection

28 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

29 NURSING IN THE IR

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

31 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

32 BROADER ROLE CLARIFICATION RNAO / HRNA / CNA / COMMUNITY OF PRACTICE actice_and_supervised_injection_final_draft.pdf

33 HARM REDUCTION NURSES ASSOCIATION The mission of HRNA is to recognize and foster advance harm reduction nursing through practice, education, research, and advocacy

34 CONTACT INFORMATION Please feel free to contact me with questions or comments about nursing practice and supervised injection Tim Gauthier Clinical Coordinator Insite & Onsite Thank you!

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