“We’ve lost a lot of lives:” the impact of the closure of North America’s busiest supervised consumption site on people who use substances and the organizations that work with them

Abstract

Background

Supervised Consumption Sites (SCS) are an evidence-based harm reduction intervention that reduces the risk of fatal drug poisonings. However, these approaches have faced political opposition in Canada, resulting in the closures of SCS in some provinces. Our study examines the aftermath of the closure of what was once North America’s busiest SCS, located in Lethbridge, Alberta, Canada, offering a contextualized exploration of regressive drug policies.

Methods

Our study adopts a descriptive qualitative design to explore the Lethbridge SCS closure and the city’s current state of harm reduction service provision. We conducted 37 interviews to understand the perspectives of people who use substances (PWUS) and staff members of organizations that provide harm-reduction services in Lethbridge. We chose to use reflexive thematic analysis, which allows for a critical realist and contextual approach to data analysis.

Results

We developed three themes based on our analysis. Our first theme speaks to the harms of SCS closures on PWUS and organizations that provide harm reduction services. Next, our second theme highlights participants’ perspectives on the political motivations behind the SCS closure. Our last theme explores how PWUS and organizations navigate the political opposition to harm reduction approaches while responding to the worsening unregulated drug poisoning crisis.

Conclusions

Our findings speak to the dangers of political decisions that restrict access to harm reduction services within the context of the current unregulated drug poisoning crisis.

Background

From January 2016 until September 2024, more than 50,000 people died from drug poisonings across Canada [39]. These deaths occur within a policy landscape that shapes the risks and violence associated with procuring and using unregulated substances, resulting in numerous other poor health outcomes such as infections, injuries, and non-fatal poisonings [14, 35, 53, 68, 70]. Ongoing drug prohibition has created an environment where illicit drugs have become increasingly toxic [10]. Despite this, safer supply projects, which allow PWUS to access substances of known composition, have been publicly and politically opposed and remain unavailable in many provinces of Canada [37, 56, 75].

These policy choices necessitate a range of government and grassroots harm reduction responses to address the unregulated drug poisoning crisis. Although harm reduction can be defined differently, it has often been conceptualized as any strategy that aims to reduce the risks of substance use without requiring abstinence [25, 51]. Supervised consumption sites (SCS) are an important harm reduction strategy in the context of a toxic drug supply, where PWUS can be observed consuming illicit drugs to ensure that potential drug poisonings are witnessed and effectively treated [18]. SCS are known to reduce the risk of infections, drug poisoning, and death in PWUS [49, 54].

Within these sites, PWUS can often also access a range of services to improve their overall health and wellbeing, including medical care, housing support, and referral to community-based services. The inclusion of health and social services differentiates SCS from overdose prevention sites (OPSs) that focus primarily on reducing the immediate risks of substance use, such as drug poisoning, and may be legally or illegally operated [18]. Conversely, SCS are federally sanctioned in Canada, though the way in which they are managed varies both within and between provinces, with some being operated directly by provincial health authorities and others facilitated by community organizations that receive funding through a variety of mechanisms, including government contracts [38]. As of November 2024, the Government of Canada lists 39 SCS currently in operation within five provinces, namely, Alberta, British Columbia, Ontario, Quebec, and Saskatchewan, with calls from PWUS, health professionals, and academics to scale up the implementation of this lifesaving harm reduction strategy (Canadian Drug Policy [16], Government of Canada [40]).

Despite the evidence of their effectiveness and research that suggests that most Canadians support this approach, SCS remain a contentious political issue in Canada [23, 73, 74]. In the media, some politicians have suggested a need to scale back the implementation of SCS, citing concerns about reduced public safety and public order in the surrounding community [44, 57, 71]. Although evidence from systematic reviews suggests that SCS do not cause increases in crime or public nuisances, some provincial governments in Canada have taken steps that limit PWUS ability to access SCS either through the failure to expand existing services to meet demands or by closing some sites [49, 54, 67]. In 2020, the Government of Alberta closed SCS in two communities (including Lethbridge, the focus of this study), with plans to close other sites and provincially operated OPSs by 2025 [65, 69]. In August 2024, the Government of Ontario paused all new approvals of SCS while banning sites near schools or daycares, potentially leading to the closure of 10 of the province’s 17 SCS [76]. To date, of the ten, one site is set to close, eight others have been denied provincial funding, which will likely result in their closure, and one site in Toronto will remain open until at least May 01, 2025, due to a temporary injunction granted by the Ontario Superior Court (Canadian Drug Policy [17]). The Alberta and Ontario governments justify these closures by citing concerns about public safety, public disorder, and criminal activity around SCS (Alberta [1, 41]).

The impact of SCS closures is only beginning to be understood. Greene et al. [43] explored PWUS perceptions and experiences of the SCS closure in Lethbridge, Alberta. They found that PWUS reported negative experiences related to the closure of the SCS, including the belief that there was an increase in drug poisoning. The study also highlighted concerns about the OPS that replaced the SCS, including its less central location, the absence of inhalation rooms, and a lack of comprehensive services. Our study aims to add to the understanding of the impact of SCS closures by including the perspectives of both PWUS and staff members of organizations that continue to provide harm reduction services. Although many studies explore the experiences of either PWUS or staff members within SCS [4, 11, 68], we believe our approach could strengthen this body of evidence by combining the perspectives of both groups in one narrative. In the aftermath of the defunding of the SCS, this study also explores barriers to implementing evidence-based harm reduction initiatives and what steps PWUS take to protect themselves from an increasingly toxic drug supply within the current service provision landscape.

Context

Our study was conducted in the community of Lethbridge, Alberta, Canada. Lethbridge is a mid-sized city located in the heart of the Blackfoot Confederacy territory of the Siksika, Kainai, Piikani, and Aamskapi Pikuni Nations (Blackfoot Confederacy Tribal [7, 19]). As a result of the harms of past and ongoing colonization, Indigenous people are disproportionately represented in the population of unhoused PWUS in Lethbridge [20]. The city has one of the highest per capita rates of drug poisonings in the province, with the neighbouring Blood Tribe declaring a local state of emergency due to the toxicity of the illicit supply in 2023 (Blood [8, 36]). Since 2016, at least 434 people in Lethbridge have died from drug poisonings [36].

Lethbridge also once contained the busiest SCS in North America, with an average of 663 visits/day, compared to the average of 45 visits/day (with a range of 0–412 visits/day) among Canadian sites (Canadian Drug Policy [15], Government of Canada [40]). Operated by the AIDS Outreach Community Harm Reduction Education and Support Society (ARCHES), the Lethbridge SCS opened near the downtown center in 2018 [2]. The site was the first in North America to offer supervised inhalation in addition to injection services, recognizing that PWUS who smoke want to use indoors in an environment that can provide some protection against violence while reducing the risk of fatal poisonings [9]. In addition to supervised consumption, ARCHES provided wrap-around services such as community education, walking and rural outreach, sterile supply distribution, clinical nursing services, justice advocacy and support, HIV and Hepatitis C testing and counselling, Housing First Initiatives, and Blackfoot cultural programming [2, 9].

Despite the apparent need for a SCS due to the high rates of drug poisonings in the community, the newly elected United Conservative Party of Alberta defunded both the site and most of the wrap-around programming operated by ARCHES in 2020 [45]. The defunding and closure of the Lethbridge SCS followed accusations of financial mismanagement in the organization (which were later disproven by a police investigation) and a commissioned report that focused on the harms of SCS (excluding any benefits of the site to PWUS or the surrounding community in their analysis), an approach that has been criticized for being methodologically flawed [55, 65].

Although the provincial government opened an OPS following the Lethbridge SCS closure, drug poisoning deaths increased from 56 deaths in 2020 to 125 in 2023 before declining to 42 deaths in 2024, reflecting a trend seen across Canada in that year [36, 39]. Only one of the 12 ARCHES-led services remains operational in Lethbridge, the Indigenous Recovery Coach Program, a “recovery-oriented, community-based and culturally informed program” funded by Indigenous Services Canada [46].

Methodology

Design and ethics

We chose a descriptive qualitative research design to guide this study, adding to the body of research that explores the impacts of SCS closures on PWUS and service providers. A descriptive qualitative approach is effective in exploring novel phenomena and was, therefore, appropriate to examine the impact of the closure of ARCHES-operated SCS in the unique context of Lethbridge [26, 66]. We used qualitative interviewing to generate the data in our study, as this method is useful for exploring perspectives on the complex landscape of the politics and practice of harm reduction.

The University of Alberta’s Research Ethics Board (Pro00120726) approved this study. We recognize that there are important considerations when conducting research with PWUS; however, we agree with others that PWUS deserve both ethical protection and rights through the research process, respecting the range of motivations that PWUS have for participating in research while also protecting their privacy and confidentiality [6, 32]. As reimbursement in the form of cash has long been considered an appropriate, ethical, and standard practice in research with PWUS, participants were given a $50 honorarium for their time and expertise [21, 28].

Participants provided both written and verbal consent prior to data generation. As others have identified, using substances does not inherently impair an individual’s capacity to provide informed consent [6],however, two (of 27) interviews with PWUS were ended early by the researcher when they determined that the participant could no longer provide ongoing consent because they became too tired to respond. As they were initially able to provide informed consent, and the onset of these participants’ tiredness was abrupt, we decided to include these interviews in our analysis.

Participant sampling and recruitment

We used purposive sampling to recruit staff members from organizations that provide or have intimate knowledge of harm reduction services in Lethbridge, Alberta. We chose a broad understanding of harm reduction to identify organizations that we deemed to work towards minimizing the risk of substance use in any manner. These included organizations whose work was primarily aimed at improving access to the prerequisites of health, in addition to those that provided more traditional harm reduction services such as sterile supply distribution. In line with our qualitative research design, this purposive sampling strategy aimed to provide us with a deeper understanding of the closure of the Lethbridge SCS by capturing a range of experiences from the staff members of diverse community organizations [66]. 17 organizations were contacted with an email invitation to participate in the study.

Recruitment of PWUS occurred by self-selection through posters displayed at public spaces in the Lethbridge downtown area and at community organizations that work with people experiencing homelessness or who use substances. To be eligible, participants had to speak English, be over the age of 18, live in Lethbridge, and self-identify as having a history of substance use in the last six months.

Data generation

We conducted semi-structured interviews with all participants using a separate interview guide for staff members and PWUS that the research team developed collaboratively based on our research questions and experiences as service providers, educators, and researchers who work with PWUS and organizations that provide harm reduction services in Lethbridge. For PWUS, questions were designed to encourage participants to describe their experience with the Lethbridge SCS and how its closure impacted their ability to engage in practices intended to make substance use safer. Staff members were asked to discuss how the closure of the Lethbridge SCS impacted both their organization and the lives of the people who accessed their services. Both groups of participants were also asked about Lethbridge’s current harm reduction service provision landscape and to reflect on any current gaps or strengths within the community.

Staff member interviews were conducted virtually by three research team members (MM, SV, & TO) from September 2022 to January 2023. Interviews with PWUS were conducted in person in a private, convenient downtown location by MM and SV in August 2023. Most of the data generation with PWUS was conducted one-to-one, apart from two instances where participants with close relationships with each other were interviewed together at their request. All interviews were audio recorded and transcribed verbatim by MM and KD. Participants were given the opportunity to review and add information to their transcripts, with one staff member providing feedback. Rather than being viewed as necessary for increasing rigour through participant validation, a belief incompatible with our ontological orientation described below, we used this strategy to generate additional data for our analysis [12].

Data analysis

We analyzed the data generated through participant interviews using Braun and Clarke’s [13] six-phase approach to reflexive thematic analysis. Braun and Clarke [13] describe reflexive thematic analysis as a method for developing themes or reoccurring patterns, and sometimes sub-themes, which are a particularly important element of the theme, across a data set. This method was chosen for its theoretical flexibility, allowing for a critical realist and contextual approach to data analysis that understands that language communicates participants’ diverse experiences and worldviews, which are shaped by material, social, and political conditions.

Reflexive thematic analysis recognizes that knowledge is situated and shaped by the experiences and perspectives of the researcher. Although much of our coding was inductive, aligning with our descriptive qualitative approach and driven by our participant’s understanding of historical and contemporary events, we also recognize that our own backgrounds as service providers, educators, and researchers within the health and social fields working with PWUS influenced data generation. As such, our themes also reflect concepts we commonly employ in our research and practice, including the social determinants of health, social justice, and health inequities, as well as our belief that health is not primarily determined by genetics or behavioural choices. For example, our understanding that poor health arises from social and economic structures that determine material conditions shaped our understanding of how our participants’ experiences of accessing harm reduction services are linked to broader issues of power and politics.

We used Braun and Clark’s [13] guidelines for “good reflexive thematic analysis” to ensure transparency in our theoretical positioning, clarity in our role in data generation, and congruency between the data and our analysis. Each member of the research team initially read the interview transcripts ahead of the coding phase to become familiar with the data. After coding the data and developing initial themes independently, the research team met to discuss and revise themes while interrogating the role our assumptions and positionalities may play in data analysis. Rather than attempting to find consensus, this collaborative process aimed to increase the depth and quality of our data analysis by integrating the diverse perspectives of the researchers. Following this meeting, MM created a list of candidate themes and subthemes that were then reviewed in relation to the initial codes and the entire data set. Finally, to align with the reflexive thematic analysis process, the entire research team engaged in a refining and naming process to develop our final themes.

Results

Demographics

Out of the 17 organizations we identified, a total of 10 staff members from nine organizations participated in the study. All staff members reported working with PWUS in Lethbridge when the SCS closed, with four of the ten participants reporting that ARCHES previously employed them. No demographic data was collected for this group out of concern for participant confidentiality, given the relatively small size of Lethbridge and the limited number of organizations that provide harm reduction services in the city.

For our second group of participants, recruitment was completed after 27 PWUS were interviewed, and the research team determined through reflexive practice that the data that had been generated provided a detailed description of events and adequately answered our research questions [12]. These participants ranged in age from 27 to 64. Of the 23 participants who self-declared, 48% were Indigenous, 33% were Caucasian, and 4% were Metis. 41% of participants identified as male, 44% as female, and 7% as non-binary. Four of the 27 participants who use substances reported that they had accessed services at the Lethbridge SCS when it was in operation.

Participant interviews lasted between nine and 65 min, with interviews with PWUS tending to be shorter than those with staff members. This trend may reflect the fact that only four of the 27 participants who used substances had accessed the Lethbridge SCS, while all staff members were employed by organizations supporting PWUS during the site’s operation. As a result, staff members may have been better positioned to answer interview questions focused primarily on the site and its closure.

Themes

To highlight the main organizing concepts within our data set while being attentive to the numerous interconnected elements that shape those patterns, we chose to present our findings as three themes and seven sub-themes [13]. The first theme, Life Before and After the Lethbridge SCS Closure, consists of two subthemes that explore the impacts of decisions about what types of harm reduction services are available within the community: More Than Just a SCS and The Harms of Regressive Drug Policies. The second theme, The Politics of the SCS Closure, also includes two subthemes, The Violence of NIMBYism and Unpacking the Provincial Government’s Motives Behind the SCS Closure, which explores how power and influence shaped the defunding of the Lethbridge SCS. Lastly, the final theme, Navigating the Current Harm Reduction Service Landscape, contains three sub-themes that explore how PWUS and community organizations are responding to the unregulated drug poisoning crisis and current sociopolitical context: Surviving the Crisis: Strategies for Responding to Harmful Policy Choices, How Funding Forces Shape Harm Reduction Service Provision and Evidence vs. Politics: A Balancing Act.

Theme 1: life before and after the Lethbridge SCS closure

Subtheme 1.1: more than just a SCS

Many PWUS and staff members suggested that the Lethbridge SCS was more than just a physical site where harm reduction services were provided. Staff members spoke to the breadth of services provided by ARCHES, emphasizing its growth from an organization that primarily focused on sexually transmitted and blood-borne infections to one that sought to meet the diverse needs of PWUS in the community in the context of a worsening unregulated drug poisoning crisis. One of these programs was described by staff member 10:

Hip Hop for Healing… it was right off supervised consumption. So, clients could come there, and they’d go and see this guy…he could mix music, like record it and create a song. And it was unbelievable, the people that were lining up to lay down their tracks. And so, people were creating songs. And you know, it was unbelievable the amount of writing that our clients did, poetry…

Participants suggested that the Lethbridge SCS provided a safe and welcoming space where PWUS were well supported. For example, when asked about their experience at the site, PWUS 9 reported, “It was good. It was going home to people.”

Another participant who had accessed services at the Lethbridge SCS highlighted their positive interactions with the staff. PWUS 1 stated:

The workers were really friendly. They’re really passive. Really, like, non-judgmental…Right, so if you asked for something, there’s no shame in asking for needles, or a pipe or anything. Like, it was just, they were wonderful. You know, you want something to eat, you want some water or anything? It was a good place.

Subtheme 1.2: the harms of regressive drug policies

Most participants who were familiar with the Lethbridge SCS spoke about its closure’s negative impact on PWUS. A common concern among staff members was that when the SCS closed, most wrap-around services provided by ARCHES were also defunded and remain unavailable in the city, including the HIV and Hepatitis C Prevention, Education and Support program. Other participants spoke about a reduction in programs that served Indigenous people in the community following the closure, with staff member 2 noting:

But it was an Indigenous cultural group where they would bring elders in. There was a music group, and it was a good way to reconnect folks with their culture. So, with ARCHES shutting down, it kind of limited the resources for that specific demographic of Indigenous folks that are using substances. As I said, there are a few more out there, but they were connected to that one in particular and felt comfortable talking without being judged.

Both staff members and PWUS spoke about the initial gaps in sterile supply distribution, with particular concerns about the lack of outreach and diminished access to sterile smoking supplies. PWUS 25 indicated, “Yeah, once every three days, you can get one [bubble pipe]. And then straight shooter, well, straight shooter you can get more often and tin foil. Umm, other than that, I have to buy them.”

Some staff members suggested the reduction in sterile smoking supply resulted directly from the diminished community capacity following the closure of ARCHES outreach programs but also due to policies within other organizations that limited distribution. Staff member 4 stated, “We are able to hand out and supervise people who use needles, but we’re not able to provide the items for safer inhalation, and we’re not able to observe them while inhaling, as well.”

Some participants noted the limited capacity of the OPS, which has two injection booths, compared to the SCS, which contained 12 injection booths and two inhalation rooms. PWUS 24 stated their concern for the lack of inhalation rooms following the closure of the Lethbridge SCS, “The people who use needles have a place that they can inject safely. People that smoke, I don’t know… Well, smokers have been left out.”

In addition to reductions in the type and scope of harm reduction services offered in Lethbridge, participants suggested that the closure of the SCS damaged relationships between service providers and PWUS. Staff member 2 described, “But yeah, I think a lot of people were lost. I think it created a lot of distrust in the system. I think the way that it was handled really demonized a lot of our participants and stigmatized them.”

Finally, participants from both groups suggested that the closure of the SCS may have led to more deaths in the community from drug poisoning, suggesting that many PWUS have been forced to use alone. When asked about the impact of the closure of the Lethbridge SCS on the community, PWUS 25 noted simply, “We’ve lost a lot of lives.”

Theme 2: the politics of the SCS closure

Subtheme 2.1: the violence of NIMBYism

Many participants discussed how local politics may have influenced the decision to close the SCS and many of ARCHES’s other programs. Some participants drew on concepts such as “not in my backyard” (NIMBY) to highlight the backlash towards PWUS and the organizations that provide harm reduction services in Lethbridge, such as staff member 2, who suggested:

So, when ARCHES was running, there was a lot of not in my backyard mentality. That mentality still exists. And, you know, ARCHES was set up where it was because of the close proximity to the shelter and where a lot of folks were already congregating downtown…I think, you know, a lot of people were like, oh, we’ll put the SCS outside of town. That also wasn’t necessarily a good option, either, because then how do people access it? Boxing everyone up and shipping them away doesn’t solve the problem.

Similarly, PWUS 21 suggested:

Here in Southern Alberta, I find there to be a lot of NIMBY attitude. Not my problem, or not my backyard; I don’t want him in my backyard…move it somewhere else, put it somewhere else, give it to somebody else. Tax the fuck out of them, so they go leave and go to a different city. Become somebody else’s problem. Don’t try to help them. Why?

The belief that PWUS do not belong in the community was also discussed by participants in relation to racism, drawing attention to how intersecting discriminatory attitudes influence how PWUS are perceived. In response to a question about the difficulties of implementing harm reduction services in Lethbridge, staff member 2 suggested:

In Lethbridge, I would definitely say a huge part of it is, almost all, is a lack of understanding from just the general community. But there definitely is a bit of a stigma attached, and the racism component, as well, is huge… In Lethbridge, unfortunately, it’s a tight-knit community. You’re either in the community, or you’re out of the community.

Some participants described how the disdain for both PWUS and Lethbridge SCS presence in the downtown area led to dangerous situations for both people accessing harm reduction services and staff. Staff member 10 described their experiences of violence while working for ARCHES:

I remember working in reception at supervised consumption, and some lady came in filming, telling us we were all, you know, effing disgusting. And it was pre-, kind of political drama. It was just, she heard, we were doing supervised consumption, and “How could you?” That was consistent, and we had all sorts of terrible things happen. We had death threats. I had terrible messages on my voicemail. We had a staff who got shot up with a paintball gun on a night shift. And honestly, a lot of the violent stuff that happened to us or to clients.

Subtheme 2.2: unpacking the provincial government’s motives behind the SCS closure

In addition to the local politics of harm reduction, participants described how the provincial government influenced the closure of the Lethbridge SCS. Participants suggested that the site became a scapegoat for perceived increases in public disorder and risk to public safety within the community. Staff member 7 noted:

And I think the messaging was, you know, the supervised consumption site goes away, the problem, the drug problem in Lethbridge, goes away. And as we can now see, two years later, that’s clearly not the case. And it’s, in fact, worse now than it’s probably ever been.

Rather than being based on evidence or local needs, staff members suggested that the decision to defund the Lethbridge SCS may have been ideologically motivated. Some participants indicated that ARCHES programming did not align with the provincial government’s preferred abstinence-based approach. Additionally, the way the provincial government handled the accusations that ARCHES staff had mismanaged funds was framed by some participants as being both unusual and politically motivated. Staff member 2 suggested:

We [the provincial government] found some kind of mismanagement of funds. Let’s not dig any further. Let’s just shut the whole thing down. It wasn’t, you know, oh, let’s reevaluate. Let’s change the staffing. Let’s, you know, we’ll see what we can do to fix this problem. It was more of we don’t like it [the supervised consumption site]. So, we’re just going to shut the whole thing down. That’s what it seemed like to me, anyway. Yeah, political.

Similarly, staff member 1 noted:

And ARCHES was, I think, a bit targeted in that. Not that there weren’t things that needed to be addressed or fixed. There certainly was. But it very much felt, like, vindictive. It very much felt like this was targeted.

Theme 3: navigating the current harm reduction service landscape

Subtheme 3.1: surviving the crisis: strategies for responding to harmful policy choices

To navigate changing policy approaches and the worsening of the unregulated drug poisoning crisis, PWUS spoke about the ways in which they try to protect themselves from the toxic drug supply. When asked about how they kept themselves safe, many participants spoke about implementing commonly accepted harm reduction practices such as never using alone, not sharing supplies, consuming test doses, drug checking, and carrying naloxone.

Most PWUS in our study indicated that they preferred inhalation as their route of consumption, with 20 of 25 participants who used illicit substances (not predominately alcohol) stating they smoked their substances. When asked what strategies they engaged in to make their substance use safer, many responded similarly to PWUS 5, who commented, “I don’t inject.” Some participants reported transitioning to smoking from injection as a strategy to make their substance use safer. For example, PWUS 22 justified their recent switch to smoking by stating, “Ah, because injection just seemed more riskier for me.”

Out of the 19 participants who reported using down or fentanyl, 16 reported they also use side or methamphetamine. Some participants suggested that they recently started using methamphetamine in addition to opioids to help manage the increasingly toxic supply. PWUS 21 stated, “And usually when I’m using fentanyl, I will mix it with side, because fentanyl isn’t usually fentanyl, it’s cut with, ah what is it? Benzo. Knocks you right out.” Similarly, when asked about their reason for using methamphetamine and opioids concurrently, PWUS 13 stated, “So that you don’t fall asleep,” and PWUS 14 said, “I usually mix it with meth… Yeah, so your heart doesn’t just stop.”

Other participants suggested that they mixed methamphetamine and opioids together as a measure to reduce the risk of or to reverse a drug poisoning. When asked about how methamphetamine is used in response to the toxic supply, PWUS 14 suggested, “And then honestly, people use methamphetamine to try and wake you up. But it is honestly way better because when we get naloxone, we get so sick.”

Subtheme 3.2: how funding forces shape harm reduction service provision

The current sociopolitical landscape impacts the ability of community organizations to support PWUS. Many staff members noted the challenges of providing services under the current system of government contracts. When asked to expand on how the current funding model impacts the provision of harm reduction services in the city, staff member 5 suggested that contract funding creates instability for both staff members and PWUS:

It’s always changing and so everybody’s very vulnerable to funding… We have work and staff whose positions are very dependent on our harm reduction and permanent supportive housing relationships. And our clients get close to our staff. And we can’t be sure that in six months staff will still be working because they’re temporary.

In addition to the challenges associated with the current funding model, some staff members also spoke about the overall lack of funding for harm reduction in Lethbridge, with some suggesting that discriminatory beliefs uphold these policy decisions. For example, staff member 1 stated:

And it’s also really hard to think that this isn’t rooted in racism, because I think Indigenous people are disproportionately impacted in Lethbridge. Yeah, it’s just really hard. Between people who use drugs and Indigenous people, I just don’t think they’re a priority for the government.

Subtheme 3.3: evidence vs. politics: a balancing act

Many staff members discussed the challenges of providing comprehensive harm reduction services that meet the needs of PWUS in the current political context. Some staff members spoke about a shift in the willingness of community organizations to offer harm reduction services in the aftermath of the closure of the Lethbridge SCS. Staff member 2 suggested:

Um, well, I think with everything that ARCHES ran, a lot of organizations didn’t want to go near that [harm reduction services] with a ten-foot pole for their own funding. And then being under the scrutiny of, you know, government organizations.

In addition to these perceived barriers, the need to balance politics and evidence was manifested in how some participants described the services their organizations currently offer. When speaking about how their organization engages in sterile supply distribution, staff member 7 stated:

We’re not just raining them [sterile supplies] all over the street. Of course, we’re very aware, I guess, of what we’re handing out, how much we are handing out, who we’re handing it out to, and making sure that every time we hand out supplies, we are having conversations about other addiction supports, or community supports that they could engage in.

When asked to explain how they decided on this approach, and after clarifying that their organization would not be named in final reports, they responded:

We don’t want the misunderstanding to be created that [the organization], you know, just gives bubble pipes out to everybody…. We don’t want to be known as a distribution center; we don’t want to be known as a distribution site… So I think that is a big piece is just that, we need to balance the political view of our agency as well, if that makes sense, and the community view of our agency for future, potential, you know, opportunities that we have for funding for serving other vulnerable populations, while still making sure that vulnerable people are getting what they need if they are using substances.

Discussion

Our findings are consistent with research that suggests harm reduction organizations improve the health and wellbeing of PWUS in ways that move beyond the proximal risks of substance use by providing services that improve the quality of PWUS’ social determinants of health, such as medical care, housing support, and the provision of material resources such as food and clothing [4, 11, 47, 50]. Like other studies exploring the perceptions of PWUS who access harm reduction services, our study found that most people who accessed ARCHES programs felt welcomed, supported, and included [11, 43, 50, 59]. Taken together, our findings add to the body of research that suggests that SCS are an important source of connection to a wide range of safe and judgement-free health and social services.

Many of our participants who used substances believed that the closure of the Lethbridge SCS caused an increase in drug poisonings and a decrease in the ability of PWUS to protect themselves from a toxic, unregulated drug supply, echoing the findings by Greene et al. [43]. The perception among PWUS that the reduced capacity or closures of SCS leads to increased drug poisonings has also been reported in literature exploring the impacts of the COVID-19 pandemic on harm reduction services [31, 68]. Although there are likely many issues that have contributed to the increase in drug poisonings in Lethbridge from 2020–2023, including increased toxicity in the illicit drug supply and the wide-reaching impacts of the COVID-19 pandemic, the reduced capacity to provide harm reduction services in the city was likely a contributing factor [5, 58].

As many of our participants reported that smoking was their preferred route of consumption, the transition from the SCS to the OPS was identified as a significant obstacle to minimizing the risks associated with substance use in Lethbridge. The shift towards inhalation rather than injection as the preferred method of consumption and the route most commonly associated with drug poisoning has been noted in recent Canadian studies [30, 48]. In our study, many PWUS voiced a willingness to access supervised inhalation facilities, something that has been noted in Gehring et al. [34]‘s scoping review. Despite these trends, sites with the capacity to support supervised inhalation continue to be rare in Canada, with only three sites ever receiving a federal exemption (one being the now-closed Lethbridge SCS, with the other two operating in Saskatoon, Saskatchewan and Toronto, Ontario) [40]. Our findings provide further evidence for the need to expand supervised inhalation services in Canada.

In addition to the impact of changes to the harm reduction service provision landscape, PWUS in Lethbridge reported modifying their drug consumption to respond to an increasingly toxic drug supply. Our participants reported adulteration in the supply of down (fentanyl or its analogues) with benzodiazepines and other sedatives and side (methamphetamine) with fentanyl, reflecting trends seen in other parts of the country [64, 72, 77]. To respond to the dangers of the toxic supply, our participants altered both their route of consumption, favouring inhalation over injection, as well as the types of substances they consumed, including using down and side together, to combat the increase in depressive effects caused by substances such as benzodiazepines that are now common in the illicit supply. Although the deliberate concurrent use of down and side is not a new phenomenon, the idea that methamphetamine can be used to reduce the harms associated with using adulterated fentanyl (including those caused by the risk environment many unhoused PWUS face) may be a recent response to the changing illicit supply [24, 27]. As there are health-related harms associated with taking depressants and stimulants at the same time, it seems prudent to explore ways to increase the accessibility of substances of known contents and doses so that PWUS can reduce their risks.

The closure of the Lethbridge SCS also impacted service organizations. The decline of the welfare state in Canada has led to a greater emphasis on non-profit organizations, such as ARCHES and many of the organizations whose staff members participated in our study, to provide health and social services within their communities [3, 33]. However, staff members described how precarious funding arrangements prevented consistency in service provision as organizations competed for, secured, and then lost contracts within the timeframe of a few years, damaging relationships they had made with PWUS. In their systematic review of barriers and facilitators to accessing SCS, Ivsins et al. [47] noted that relationship-building is critical in promoting harm reduction service and, more broadly, healthcare utilization. More robust and stable funding would better support non-profit organizations’ work in restoring trust with the community and addressing the needs of PWUS.

Staff members noted that short-term government contracts are a barrier to effective program planning and service delivery and prevented them from achieving their organizational mandates. Research suggests that funding regimes are increasingly technocratic, with short-term competitive contracts creating a significant drain on non-profit organizations’ time and resources [3, 33, 61]. Additionally, funding regimes are particularly problematic for organizations whose mandates are sometimes at odds with the preferred policy approaches of the government, as was the case in our study [61]. Participants suggested that their organization’s reputation within the community influenced how they approached harm reduction service provision, with some limiting the type and volume of sterile supplies they distributed. They noted these decisions were driven out of fear that, like ARCHES, their organization may be partially or entirely defunded if they lost the favour of the provincial government. Baines et al. [3] have described how the power the state exerts on non-profit organizations through their funding regime creates conditions where socially and politically engaged organizations are punished through defunding while other organizations experience an “advocacy chill” as they narrow their mandates to focus on politically palatable programming.

Our participants spoke to their belief that policy decisions related to harm reduction in Lethbridge were driven by ideology rather than evidence. Dominant ideologies influence who is perceived to belong or pose a risk within a community, reflecting the racist, colonial, and capitalist histories of Canada [22, 63]. Both PWUS and staff members noted that the decision to close the Lethbridge SCS was supported by community members who believed that the SCS did not belong in the downtown area. The concept of NIMBYism has been identified as a barrier to the implementation and operation of SCS, where people may express broad support for the sites as long as they are not located near them, citing concerns of public safety, needle debris, and the impact on businesses [52, 78]. Our findings add to this body of research as our participants identified NIMBYism as a key driver behind the closure of the Lethbridge SCS.

Staff members also reported that the controversy surrounding the site was not only about the impact of the SCS but also the PWUS who accessed it. Participants noted how racism may have played a role in the opposition to the SCS because, like PWUS, Indigenous people face intense discrimination and marginalization within the city. These forces have been explored by other scholars who suggest that Indigenous people face increased policing, sometimes as a response to public substance use, and restricted access to public spaces in the downtown Lethbridge area [42, 60]. These strategies can be understood as a part of the ongoing colonial project designed to kill, disappear, and supplant Indigenous people [53]. Similarly, our study suggests that discrimination and racism shape policy responses in various ways, including those that limit the availability of harm reduction services.

Ideology also shapes support for drug policy approaches, including those that relate to harm reduction services [29, 75]. In Alberta, Wilson et al. [75] have noted that the ideological position of the governing United Conservative Party supports an abstinence-based approach that frames harm reduction interventions, such as safe supply, as contributing to, rather than addressing, the harms of the unregulated toxic drug supply. Similarly, our participants suggested that the provincial government justified their decision to close the Lethbridge SCS by framing the services provided by ARCHES as harming both the people who accessed them and the community broadly. Using harm reduction interventions, such as SCS, as a scapegoat obscures the structural determinants of health that drive the unregulated drug poisoning crisis [10].

Our study also adds to the body of knowledge that suggests public policy decisions are often not driven primarily by the evidence base or the community’s needs. Instead, the political economy of health literature suggests that those with power and influence shape public policy in ways that maintain the status quo and existing inequities [62]. Although it was outside the scope of this study to explore what sectors of society benefitted from the closure of the Lethbridge SCS, research that examines how political and economic structures shape regressive drug policies may provide important insights about the barriers to implementing evidence-based harm reduction interventions.

Limitations

Our findings reflect the unique context of the closure of the ARCHES-operated SCS in Lethbridge, Alberta, but some limitations should be noted. First, only four PWUS we interviewed had accessed the services provided by ARCHES, meaning that our findings about the impact of its closure disproportionately represented the perspectives of staff members employed by harm reduction organizations. Although we cannot disregard the impact our sampling method may have had on the characteristics of study participants, this limitation may also attest to the volatile and harmful situation in Lethbridge, where drug poisoning rates remained high over the period from the 2020 Lethbridge SCS closure and our data collection in 2023. Another key limitation was the delay in data collection between staff members and PWUS, given the constantly evolving harm reduction landscape. For example, when we interviewed staff members, few organizations offered sterile inhalation supplies; however, this situation changed six months later when we interviewed PWUS, with some organizations altering their approach to distribution, which increased availability. As such, it was challenging to compare the perspectives of PWUS and staff members directly, which may have limited our analysis.

Conclusion

This descriptive qualitative research study explored the impacts of an SCS closure, using semi-structured interviews with PWUS and harm reduction service providers in Lethbridge, Alberta. Our findings highlight the harms of regressive drug policy decisions for PWUS, who experienced a significant disruption in their ability to protect themselves from the toxic drug supply following the SCS closure. We also underscored how the legacy of the Lethbridge SCS closure continues to impact organizations in the city, which may minimize their harm reduction service provision to avoid suffering the same fate. We also suggest that dominant ideologies can prevent the implementation of evidence-based harm reduction services, forcing PWUS to adopt new strategies to protect themselves from the toxic supply. Overall, our findings speak to the dangers of political decisions that restrict access to harm reduction services within the context of the current unregulated drug poisoning crisis.

Abbreviations

PWUS

People who use substances

SCS

Supervised consumption site

Author contributions

MM, SV and TO conceptualized the study. All authors completed data analysis. MM wrote the initial draft of the manuscript. All authors reviewed the manuscript.

Funding

This study was funded by the Canadian Institutes of Health Research through the Canadian Research Initiative in Substance Matters’s Prairie Node.

Availability of data and materials

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This study was approved by the University of Alberta’s Research Ethics Board (Pro00120726). All participants provided written and ongoing verbal consent. A $50 honorarium was provided to study participants who use substances.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.