Supervised inhalation sites: preventing overdose and reducing health inequities among people who use drugs

Abstract

Policy and research on the implementation of services for people who inhale drugs lag similar efforts for people who inject drugs, limiting access to adequate harm reduction resources for people who inhale drugs. This commentary considers why supervised inhalation sites (SIS) are needed and highlights operational characteristics of four existing services and the need for future research regarding SIS. Our hope is to encourage the expansion of SIS worldwide for overdose prevention and reduction of health inequities in drug use. Given the limited literature regarding SIS, more extensive study of these programs is warranted to incorporate inhalation into the implementation of supervised consumption sites to provide fair opportunities for all people who use drugs to do so safely without fear of stigma and overdose.

Introduction

Supervised consumption sites (SCS), also known as overdose prevention centers among other names, are an important, comprehensive approach to reducing drug-related morbidity and mortality. Subsets of SCS include supervised injection facilities (SIF) and supervised inhalation sites (SIS), which offer safe spaces to inject or inhale drugs, respectively. Given the increased potency of the illicit drug supply, namely the increased presence of fentanyl and xylazine in opioid and non-opioid drugs [1], scaling up interventions that mitigate the risk of fatal overdose for all PWUD, inclusive of those who inhale drugs, has never been more pressing [2,3]. Yet, there has been limited consideration of inhalation (inclusive of insufflation and smoking) in the existing harm reduction literature [3], especially in the United States, where the SCS literature was born out of preventing HIV and HCV from injection drug use. This necessitates greater attention to how people who prefer to inhale drugs can be better supported, as well as how SIS can be expanded and better implemented to promote health.

To further characterize the need for SIS expansion, the current case study summarizes and compare the implementation of four established sites: Canada’s Vancouver Area Network of Drug Users (VANDU) site, Germany’s Indro e.V., the Netherlands’ Pauluskerk, and Denmark’s Skyen. Among SIS with extensive documentation, sites were chosen based on their representation of a range of service delivery settings and operational constraints. We first discuss research around inhalation, summarize the special operational characteristics and considerations around SIS implementation, examine four established models of SIS, and conclude by identifying limitations in our current work that need to be addressed in future research.

Inhalation as a preferred method of drug consumption

Inhalation has become increasingly popular as a method of drug consumption. For example, in a study conducted in British Columbia, Canada, researchers found that 40% of participants exclusively smoked opioids, 28% smoked and injected opioids, and 19% exclusively injected opioids [4]. In recent years, some PWUD have also chosen to transition from injection to inhalation as their preferred mode of substance use [5]. A notable driver of these shifts in drug consumption method are perceptions among PWUD that, compared to injecting, inhaling reduces the risk of overdose, as well as soft tissue infections and infectious diseases (i.e., HIV, Hepatitis C) [6]. In addition, some PWUD inhale to address fears that injection drug use will cause chronic health problems, such as distorted veins and chemical dependency [7,8]. Lastly, while injecting drugs into the blood stream provides a more intense and immediate experience per unit of drug [7], the increased potency of the illicit opioid market may render injection drug use unnecessary in achieving the same effects.

Among people who inject drugs, difficulties accessing veins for injections may push people to transition from injecting to inhaling drugs [5]. While PWUD may request injection assistance from others, some prefer to use drugs on their own to have more control and autonomy over their drug consumption [9]. Moreover, injection assistance may place financial burdens on PWUD who are asked for financial compensation in exchange. Because injection drug use can produce scars at the site of injection, PWUD may also prefer inhalation to avoid visible signs of drug use and associated stigmatization and discrimination [10,11]. People who view drug use as a “moral shortcoming” could be hesitant to provide housing and job supports to people with visible signs of drug use [10]. Experiences of these types of discrimination are found to be greater among people who inject drugs than among people who use drugs via other consumption methods, such as inhalation [12,13].

Weighing the risks and benefits of inhalation drug use

While there is a perception among PWUD that inhalation is safer [14], there is limited scientific literature regarding the actual safety of inhalation drug use. For example, Kral and colleagues found a simultaneous increase in overdose and fentanyl smoking trends from 2018 to 2020 in San Francisco [5]. As such, it is important to weigh both the risks and benefits of inhalation. Research has shown that inhalation of drugs provides several benefits compared to injection drug use, particularly a decrease in abscesses and soft tissue infections, which are well-documented consequences of injecting tar heroin and inadequate access to sterile syringes [15]. PWUD have additionally noted that inhalation provides greater control over the quantity and speed of substances absorbed; drugs that are injected are delivered directly into the bloodstream, facilitating rapid transport to the brain, but drugs that are inhaled are first filtered through the lungs and kidneys before reaching the brain, which allows PWUD to have more control over the speed of their drug consumption [16,17]. However, the health risks associated with smoking drugs are not minor, as smoking drugs can still lead to the potential spread of infectious diseases such as HIV and Hepatitis C through bodily fluids, though the risk is considerably lower compared to injecting [6]. Moreover, inhalation as a drug consumption method can also lead to increased risks of burns and cuts on one’s mouth, as well as cardiovascular and respiratory problems [18] due to the damage that smoking causes to a person’s lung and respiratory tract [6]. Complicating community-based responses is the presence of drug contaminants such as xylazine, a powerful sedative associated with hypotension, bradycardia, and increased soft tissue injuries, which can impact PWUD regardless of the method with which they use drugs [1,2]. Accordingly, SIS implementors will need to consider providing linkage to a wide range of healthcare services in these facilities.

SIS operational characteristics and considerations

The ease and success of SIS implementation vary substantially by staffing, ventilation, and the accessibility of sites to the target population. In this section, we outline general factors for operating SIS and optimizing services for PWUD. We also address any barriers that may inhibit smooth implementation and operation of these sites, such as community disapproval and lack of funding.

Site setting and auxiliary services

SIS exist in the form of indoor fixed-site locations, or outdoor services, such as vans or tents. Indoor sites typically offer a wider gamut of healthcare and social services in addition to supervised drug consumption [19]. Common services include HIV and Hepatitis C testing, counseling, housing assistance, and linkage to employment support, all of which can generally be accessed in a single facility, coining these indoor sites as one-stop shops [19]. Smaller indoor sites that do not have adequate funding or space within their facility offer a narrower range of auxiliary services but nonetheless provide referrals to external health and social services. On the other hand, SIS operating through mobile vans or outdoor tents typically provide 1–3 consumption booths and cater to fewer PWUD at a single time, given their limitation in the use of space compared to indoor SIS [19]. They are advantageous due to their geographic reach, including being more responsive to changing needs, and lower cost. Although outdoor sites offer limited services, they are able to link PWUD to nearby services.

Staff management, training, and experience

All staff at any of these sites should be qualified and trained to readily implement harm reduction interventions for people who inhale drugs (e.g., responding to cocaine overdoses). Staff should also be well equipped with managing a range of scenarios, documenting drug use events and any drug-related emergencies, and ensuring that all drug use equipment are properly disinfected [20]. Other key activities that staff should perform include naloxone and oxygen administration, evaluation of health and physiological needs, and resuscitations during drug-related emergencies [19]. PWUD have also indicated preferences for a staff cohort that is trained to link PWUD to social services and assist with outreach to disseminate information about SIS [21]. Staff should also adhere to policies, such as informing PWUD about their rights and responsibilities and treating PWUD with non-judgmental services, such as trauma-informed care [21]. Furthermore, staff should ensure that medical records and conversations with PWUD are kept confidential, providing the opportunity for PWUD to comfortably share personal information with staff [22]. It is additionally important to maximize staff retention by ensuring their rights and privacies are respected by PWUD and fellow staff, as well as regularly checking in with staff to address any concerns [22]. Establishing partnerships with colleagues affiliated with healthcare services may be beneficial [22]. While federal laws can hinder peer employment, it is important to promote equal opportunities by employing staff with a range of professional and personal experiences [22].

Ventilation considerations

It is important to consider ways to install proper ventilation systems, especially in indoor SIS, for the safety of PWUD and staff. A notable model of ventilation is that of ARCHES, an SIS in Alberta that incorporated ventilation systems in accordance with local tobacco ordinances, regulations, and a commercial heating, ventilation, and cooling (HVAC) company [18]. The ventilation system works by filtering incoming air through a rooftop vent, with each inhalation room having its own air flow to prevent smoke and airborne diseases from spreading to other parts of the facility [18]. To ensure smooth operation, there is uninterrupted power in the facility, as well as regular replacement and monitoring of air flow [18]. Though the ventilation system in ARCHES need not be exactly replicated in future indoor sites, consideration of how to improve ventilation systems as such will help reduce spread of respiratory diseases among clients and lessen the risk of health effects from secondhand smoke for staff. Indoor locations could consider converting an existing outdoor space onsite such as a rooftop, patio, or parking space. Since mobile outdoor models are usually in temporary locations, natural ventilation for supervised inhalation will likely be easier to implement.

Accessibility of sites and spaces

It is critical that sites consider limiting the capacity of inhalation rooms (or inhalation spaces, if the SIS is outdoors) to one person. This maximizes privacy for PWUD who prefer to smoke alone and mitigates the potential spread of airborne infections among PWUD. However, limited capacity raises the possibility of increased waiting times amidst heightened demand for use of the space. This problem may be resolved by enforcing time limits (though these set times should not restrict PWUD from consuming drugs safely and at their own pace) or increasing the number of available inhalation rooms to accommodate more PWUD. Conversely, increasing capacity in inhalation spaces could reduce waiting times, though proper ventilation should be considered to prevent the risk of spreading smoke and respiratory diseases within the space. Another logistical consideration for expanding access to SIS is extending hours of operation of the sites and their inhalation rooms. Some sites have increased their operational hours to permit 24/7 access for PWUD [18]. However, 24/7 operation often requires sufficient staffing, which is difficult to maintain especially with limited funds. Thus, it is important to ensure that staff training and retention is maximized. Moreover, outdoor sites experience extreme weather conditions that reduce accessibility of the sites by necessitating temporary closures and cancellation of staff shifts, making it harder for these sites to maintain stable operation for PWUD [23].

Implementation barriers

Though we have raised several operational considerations that highlight the difficulties of identifying a physical space that will accommodate the needs of people whose primary mode of consumption is inhalation, it is essential to consider and address the legal, political, and social barriers that make it difficult to implement SCS, such as “not in my backyard” (NIMBY) sentiments, opposition from lawmakers, and barriers to accessing funding. For example, increasing the accessibility of SCS is complicated by the lack of funding that these sites receive due to their oftentimes ambiguous legality and hesitancy or unsubstantiated opposition from community members [24]. Though some harm reduction organizations can secure initial funding from external sources beyond government funding to operate SCS, they are often underfunded [25], making it difficult to expand operations to include inhalation services and expand operation hours for PWUD. Moreover, it can be challenging to find appropriate locations for these sites to operate due to neighborhood resistance, including NIMBY sentiments [26]. NIMBYism is present in many communities where SCS are introduced due to long-held misconceptions that offering substance use or mental health services in their community will attract undesirable or dangerous people. Moreover, many community members have misconceptions that SCS promote drug use, pose a negative influence on children and schools, increase crime rates, and affect community health, increasing feelings of NIMBYism among community members [27]. Thus, strategies to confront NIMBYism and stigma through collaboration with a variety of stakeholders such as government agencies, healthcare providers, and community organizations will be critical. Furthermore, property owners are usually reluctant to lease their property for SCS due to liability concerns stemming from laws prohibiting the maintenance of sites that facilitate illicit drug use, such as the United States Code Section 856, known colloquially as the Crack House Statute, which has been unsuccessfully applied in Philadelphia but remains a threat [25]. Thus, it is imperative that we address these barriers by encouraging further research and awareness on the implication of supervised inhalation in harm reduction to promote equity among PWUD.

Case study of four different SIS

Consideration of aforementioned factors in SIS implementation is critical for accommodating a more inclusive range of drug consumption modalities. The following case study addresses some of the considerations and barriers described above. We selected four specific sites that are documented to provide supervised consumption services for both drug injection and inhalation [28]: Canada’s Vancouver Area Network of Drug Users (VANDU) site, Germany’s Indro e.V., the Netherlands’ Pauluskerk, and Denmark’s Skyen. It is worthwhile to examine how these existing sites operate, and how future SIS should be improved to provide optimal support and services for PWUD.

Site setting and auxiliary services

All four SIS noted in this case study are indoor sites that offer robust auxiliary services to PWUD and the broader community, in addition to overdose prevention and safer inhalation services. Canada’s VANDU started off as a grassroots democratic organization, with prominent roles in advocacy via public demonstrations to support the rights of PWUD [29]. While the VANDU site was closed after 3 years, notable auxiliary services included educational programs to promote awareness of drug use safety and overdose prevention, as well as support programs, such as for people living with hepatitis C [30]. During support group meetings, for example, group members were invited to discuss their experiences, and health professionals were invited to discuss health challenges and ways to address them and reduce stigmatization [30]. In VANDU’s former “Hospital Programme,” volunteers visited and provided emotional support for hospitalized PWUD [31]. Further, VANDU’s peer advocacy programs and housing committee helped PWUD with employment and safe housing opportunities [31].

Germany’s Indro e.V., and the Netherlands’ Pauluskerk, which are documented to be in operation, offer a variety of auxiliary services such as medical care and referrals to specialized care, legal help, support groups, and job searches to assist PWUD beyond offering safe inhalation. In addition, Pauluskerk provides additional services that are accessible to not only site users but also the greater public, including a low-cost clothing store, low-cost food and shelter, cultural activities (such as art nights, writers workshops, music and crafts classes, and game nights), language classes, and religious services [32]. These services promote further community engagement and opportunities to reduce stigmatization against PWUD. Meanwhile, the lack of documented information on the services provided by Denmark’s Skyen site limits our understanding of the full breadth of services offered. However, one notable service of Skyen is referrals to drug treatment facilities, healthcare, and social service support [33]. Despite the variation in programs offered across these four sites, the shared goal of these auxiliary services is to not only reduce the health risks that come with drug use, but also improve PWUD’s quality of life, ultimately highlighting the importance of offering comprehensive services to complement safe drug consumption.

Staff management, training and experience

The staff at Germany’s Indro e.V. consists of two healthcare professionals, two social workers, and two medically trained workers [34]. The Netherlands’ Pauluskerk includes at least seven medical professionals on their team of staff and offers volunteer opportunities for community members [35]. VANDU was founded and led by peers with drug use experience and established relationships to the local community [30]. While there is no publicly available information on the number and specific qualifications of staff at VANDU’s SIS and Denmark’s Skyen, the various harm reduction and auxiliary services provided at these sites necessitate a trained team of staff. In 2006, VANDU comprised of three staff members, a 15-member board of directors, and over 1000 volunteers [31]. Staff at their site were required to have CPR and naloxone training. In particular, VANDU was granted funding during its operating years to extend staff working hours, which suggests that paid staff members also assisted with the operation of the site [30]. Given that there is high workload across these four sites for successful operation, it is important to ensure that all staff and volunteers are qualified, trained and compensated to provide adequate support for PWUD.

Ventilation considerations

VANDU’s ‘underground’ SCS, while beneficial to the Downtown Eastside community of Vancouver, Canada, did not originally have a designated SIS [36]. As a result, PWUD would often use the washroom to inhale crack, prompting implementers to officially designate the washroom as an SIS [36]. Because the washroom was not originally intended to be an inhalation room, however, its ventilation system initially consisted of one fan [36]. Thus, while the development of the inhalation room was practical and much needed, it was an incomplete solution that highlighted the urgent need for greater availability and sophisticated ventilation in SIS.

Germany’s INDRO e.V. and Denmark’s Skyen sites have more sophisticated ventilation systems for supervised inhalation: an air exhaust system, and a fully automatic air conditioner that operates if it senses that the oxygen levels are below a given value, respectively [34,37]. These two sites may have planned to include inhalation services when developing their operational plans and proactively installed ventilation systems before opening. As such, optimal ventilation is possible within the site. No known description about the ventilation situation in the Netherlands’ Pauluskerk is available.

Accessibility of sites and spaces

The number of inhalation rooms among SIS also varies. During its former operation, the VANDU site in Canada offered only one inhalation space. Similarly, Indro e.V. in Germany currently offers one inhalation space and consequently enforces time limits to minimize the amount of time that PWUD could use the space [34,36]. Although such time limits maximize the number of PWUD who can use the space in a given day, the limited number of inhalation rooms increases waiting times for individuals (e.g., 15–30 minutes at VANDU [36]). In contrast, the Netherlands’ Pauluskerk offers 20 inhalation spaces and Denmark’s Skyen offers 6 inhalation spaces [37,38]. Both the Netherlands’ site and Denmark’s site do not enforce time limits for individuals [38]. The increased number of inhalation rooms in these sites reduces waiting times while allowing for PWUD to safely use substances for longer periods of time. Hours of these sites vary slightly but operate during general work hours, with some sites having extended hours into the late evening.

Funding

The lack of funding placed a burden on VANDU’s operations, including its ability to offer more than one inhalation space and a less robust quality of ventilation compared to other sites. As a result, the site was shut down due to threats of funding withdrawal by local health authority [39]. However, sites such as Denmark’s Skyen, and the Netherlands’ Pauluskerk, which are funded by government municipalities, offer significantly more inhalation spaces allowing more PWUD to utilize these sites. Germany’s Indro e.V., (managed by a nonprofit and nongovernmental advocacy organization) while only offering one inhalation space, utilizes a more sophisticated ventilation system allowing for increased safety among PWUD and staff members. These cases underscore the importance of funding to increase the capacity, quality, and sustainment of services.

Limitations in current work

There is a relative lack of literature focused on inhalation compared to injection drug use. For example, only 47 out of 130 SCS that were studied in a literature review permitted inhalation, and only 40 studies out of 25,000 potentially relevant records were identified, underscoring the extant literature’s inattention to drug inhalation [40]. This limits our ability to thoroughly discuss the operational characteristics of SIS in our work. Furthermore, the lack of available literature regarding the implementation of outdoor SCS limits our discussion of various settings of SCS.

Available literature on four notable SIS in Canada, Germany, the Netherlands, and Denmark did not provide sufficient information on the exact process of implementing ventilation systems, extent of auxiliary services provided, and the number and capacities of staff. Limited publications about these operational characteristics make it difficult to holistically compare site differences. Moreover, the information on these sites’ operational methods referenced in our work is mostly found on their respective websites, with some information cited from peer-reviewed articles. While the websites provide direct information regarding these sites’ services and logistical considerations, some of the information could be outdated or unreliable. Future studies should leverage a broad range of peer-reviewed and gray literature, as well as audiovisual media and targeted interviews, to support the success and quality of future SIS implementation and research.

Conclusion

Thus far, injection drug use has dominated the SCS literature; less is known about the implementation of sites that accommodate supervised inhalation. It is important to recognize that there are various drug consumption methods, such as inhalation, that equally warrant attention in research as well as implementation of safe spaces to consume drugs without fear of fatal overdose deaths. Expanded implementation of supervised inhalation sites, through strategic planning and partnerships with PWUD, is necessary to provide greater support for people who prefer to inhale and to reduce disparities between methods of drug consumption. While previous and existing SIS can serve as models for future implementation of SIS, the lack of overall understanding regarding inhalation is a significant barrier to optimally expanding SIS. Further research should not only discuss a greater range of operational logistics for SIS implementation but also focus on social factors that affect the success of SIS and the effects that SIS implementation has on PWUD and the surrounding community. Comprehensive knowledge of SIS and its implications in harm reduction is important to promote the expansion of SIS to inclusively cater to all PWUD and prevent marginalization of people who prefer inhalation over injection. We hope to see greater investment in SIS implementation research, given the prevalence of inhalation among PWUD.

Table 1:

Overview of Four Supervised Inhalation Sites

	Vancouver Area Network of Drug Users: Vancouver, Canada	Indro e.V.: Munster, Germany	Pauluskerk: Rotterdam, The Netherlands	Skyen: Copenhagen, Denmark
Drug Consumption Types Supported	Injection & inhalation	Injection & inhalation	Injection & inhalation	Injection & inhalation
Setting	Fixed-site, indoor	Fixed-site, indoor	Fixed-site, indoor	Fixed-site, indoor
Ventilation System	Yes	Yes	Unknown	Yes
Spaces Available	6 injection spaces	4 injection spaces	20 injection spaces	8 injection spaces
	1 inhalation space	1 inhalation space	20 inhalation spaces	6 inhalation spaces
Operation Hours	Weekday: 10 AM - 8 PM Weekend: 4 PM - 8 PM	M-Th: 10 AM - 5 PM Friday: 10 AM - 4 PM Saturday: 10 AM - 3 PM Sunday: Closed	Daily: 9 AM - 9 PM	Daily: 6 AM - 5 AM
Other Services Offered	Yes	Yes	Yes	Yes
Site Management	Community-run, unsanctioned	Nonprofit, nongovernmental	Run by Saint-Pauluskerk Church, financed by Dutch municipalities	Run by The Men’s Home (charity), financed by Danish municipalities
Current Operational Status	Closed due to threats of pulled funding by local health authority [39]	Currently operating	Currently operating	Currently operating
Official Website	https://vandureplace.wordpress.com/	https://indro-online.de/en/home/	https://www.pauluskerkrotterdam.nl/	N/A
Key Articles	[29,30,39]	[34]	[32,35]	[19,37,38]