Opening Canada’s first Health Canada-approved supervised consumption sites

Abstract

Setting

In response to the opioid overdose crisis, a Public Health Emergency was declared in British Columbia (BC) in April 2016. There were 1448 deaths in BC in 2017 (30.1 deaths per 100,000 individuals).

Intervention

Approximately one third of all overdose deaths in BC in 2016 (333/993) and 2017 (482/1448) occurred within the region served by Fraser Health Authority (FH). We identified a need for a supervised drug use site in Surrey, the city with FH’s highest number of overdose deaths in 2016 (n = 122). In order to ensure low-barrier services, FH underwent an internal assessment for a supervised drug use site and determined that a supervised injection site was unlikely to meet the needs of individuals who consumed their drugs using other routes, choosing instead to apply for an exemption to the Controlled Drug and Substances Act in order to open a Supervised Consumption Site (SCS).

Outcomes

In assessing population needs, injection was identified as the mode of drug administration in only 32.8% of overdose deaths in FH from 2011 to 2016. Other routes of drug (co-) administration included oral (30.6%); smoking (28.8%); intranasal (24.2%); and unknown/other (17.1%). Interviews with potential service users confirmed drug (co-) administration behaviours and identified other aspects of service delivery, such as hours and co-located services that would help align the services better with client needs. With Health Canada’s approval, SafePoint in Surrey opened for supervised injection on June 8, 2017 and received an exemption to allow oral and intranasal consumption on June 26, 2017.

Implications

By assessing drug use practices, the evolving needs of people who use substances, and tailoring services to local context, we can potentially engage with individuals earlier in their substance use trajectory to improve the utility of services and prevent more overdoses and overdose deaths.

Setting

In April 2016, a public health emergency was declared in the province of British Columbia (BC), Canada, due to a rapid increase in opioid-related overdoses. There were 993 illicit drug overdose deaths in BC in 2016 (20.9 deaths per 100,000 individuals) and 1448 in 2017 (30.1 deaths per 100,000 individuals) (British Columbia Coroner’s Service 2018). Approximately one third of all overdose deaths in BC in 2016 (333/993) and 2017 (482/1448) occurred within the region served by Fraser Health Authority (FH) (British Columbia Coroner’s Service 2018).

In Surrey, the city with FH’s highest number of overdose deaths in 2016 (n = 122) and 2017 (n = 176), overdoses are highly clustered. Nearly one third (31.3%) of overdoses occurred within 500 m of an area with a high concentration of homelessness, illicit drug use, and public injection. This, along with the co-location of other harm reduction and treatment services at an adjacent primary care clinic, informed the location for a supervised drug use site.

Intervention

Evidence

Drug use administration practices differ in FH. Injection was identified by the BC Coroner’s Service as the mode of drug administration in only 32.8% of overdose deaths in FH from 2011 to 2016, compared to 39.7% of deaths in Vancouver Coastal Health—the jurisdiction containing the supervised injection site, Insite (British Columbia Coroner’s Service 2017). Other routes of drug administration or co-administration included oral (30.6%); smoking (28.8%); intranasal (24.2%); and unknown/other (17.1%) (British Columbia Coroner’s Service 2017).

Consultations

Recognizing that Coroner data focused on cases ending in death, FH also did qualitative interviews and community consultations with individuals who use substances in the area surrounding the proposed facility to identify drug use behaviours and community needs. These interviews were promoted by outreach and shelter staff, who assisted in identifying potential participants who may be likely to use such a service. Participants were offered a cash honorarium for consideration of their time and participation in the interview.

These interviews confirmed that supervision of other forms of drug administration (i.e., inhalation) would be helpful at the proposed site. Interviews also informed the site’s hours of operation and additional services at the site, such as harm reduction supply distribution and referral to other services (e.g., mental health and substance use services and opioid agonist treatment (OAT)). Of particular interest during these interviews was whether an RCMP command centre adjacent to the proposed site would serve as a barrier to individuals accessing the service. Respondents overwhelmingly reiterated the need for a supervised site and stated that the RCMP centre would not be a deterrent to using the site.

Based on regional Coroner statistics and our community consultations, we determined a supervised injection site was unlikely to meet the needs of individuals who consumed their drugs using other routes.

Application process

Based on evidence and findings from consultations, FH applied to open a Supervised Consumption Site (SCS) (allowing oral and intranasal consumption). The large and increasing number of deaths made this service an urgent priority in Surrey, BC.

A Supervised Injection Site provides a safe, clean space for a person to inject substances under the supervision of a healthcare professional and to engage in health and social services.

A Supervised Consumption Site expands upon this service, and allows access to those individuals who consume their substances in ways other than through injection (i.e., orally or intranasally).

The Controlled Drugs and Substances Act (CDSA), passed in 1996, is Canada’s federal drug control statute. A section 56 exemption to the CDSA is required from Health Canada in order to open a supervised drug use site. This exempts staff and clients from being charged with any criminal activity related to the operation of the site. Receiving this exemption entails a lengthy process involving community consultations; letters from municipal government, police force, and other stakeholders; data demonstrating need; and scientific evidence. FH was the first jurisdiction in Canada to submit an application to Health Canada to open a consumption site allowing oral and intranasal administration.

Following the submission of the application to Health Canada on December 30, 2016, there were numerous discussions with Health Canada in order to receive the necessary exemption to allow other forms of consumption. The main concern conveyed from Health Canada was the lack of evidence (specifically randomized controlled trials) surrounding the scientific benefit of supervising other forms of consumption.

The efficacy of supervised injection sites is known and has been well documented in the literature (Wood et al. 2006a, b; Tyndall et al. 2006; Kerr et al. 2006; Milloy et al. 2008). In order to receive their CDSA exemption, FH was asked to provide scientific evidence of the benefits of supervising other forms of consumption, for which there is a paucity of peer-reviewed literature. FH’s justification for a site included the rationale that (1) individuals consume substances by routes other than injection; (2) illicit substances being consumed may contain fentanyl or other opioids, putting individuals at greater risk of overdose due to potent analogues; (3) individuals have died from overdosing on orally consumed opioids; and (4) supervised consumption services prevent the acquisition of bloodborne pathogens, which can be spread through sharing intranasal equipment. Using this framework, the FH team responded to Health Canada that there was no reason to believe, nor evidence to suggest, that the well-documented benefits of a supervised injection site would not accrue to other forms of supervised consumption.

The health and safety protocols for the proposed site did not differ from those for supervised injection alone, as opioid overdose management is the same regardless of route. All other protocols, including cleaning and post-use observation, also remained the same.

Outcomes

With Health Canada’s approval, SafePoint in Surrey opened for supervised injection on June 8, 2017 and received an exemption to allow oral and intranasal consumption on June 26, 2017. A second, smaller site in Surrey opened one week later and also began allowing for oral and intranasal consumption on June 26.

Between June 8, 2017 and May 6, 2018, there were 55,554 visits to SafePoint by 1480 unique clients, and 577 overdoses managed. While demographics of the clients have remained relatively unchanged over time (Table 1), utilization of the site has steadily increased since opening (Fig. 1). In this time period, there were 211 referrals to other health and social services, with the most common being mental health and substance use services, including OAT. The site also provides harm reduction supplies to clients, regardless of whether or not they use the site to consume drugs, reflecting what was heard in initial consultations. While injection is the most frequent form of administration at the site, some clients use the site to consume intranasally, including one client using the site frequently for this purpose.

Table 1.

Demographics of clients at SafePoint (N = 1480)

Gender
Male	900 (60.8%) (60.3%)
Female	412 (27.8%)
Not available/not reported	168 (11.4%)
Age group
19–29	455 (30.7%)
30–39	496 (33.5%)
40–49	325 (22.0%)
50–64	192 (13.0%)
65+	12 (0.8%)
Ethnicity
Aboriginal	121 (8.2%)
Caucasian	778 (52.6%)
South Asian	17 (1.1%)
Other	69 (4.7%)
Not available/not reported	495 (33.4%)

Fig. 1.

Visits and overdose rate at SafePoint since June 8, 2017

Both a process and outcome evaluation of the sites are being conducted to assess the impact and effectiveness of the sites. As part of this evaluation, a client and “potential” client survey were conducted one month and six months after opening to assess satisfaction with the site, barriers to use, and recommendations. When asked to rate the quality of services offered at the site, 95% stated the services were “good” or “excellent.” “Potential” clients were individuals who accessed other services in the area, but stated that they did not use the SCS. From these potential clients, the number one reason individuals did not use the SCS was the lack of smoking allowed at the site, reiterating what was heard in the original consultations.

Smoking was not included in the initial application for the SCS, owing to space and inadequate ventilation systems to ensure a safe workplace. However, in order to continue to provide tailored services that address the needs of the population, and in response to results of the assessment and evaluation interviews, FH opened an overdose prevention site (OPS) adjacent to SafePoint on January 19, 2018. Overdose prevention sites operate under the authority of a Ministerial Order from the BC Minister of Health, and do not require an exemption to the CDSA. This overdose prevention site is an outdoor smoking tent to support those whose needs are not met by the consumption site. In the first 11 days of operation, the site saw 590 visits.

Implications

In assessing drug use practices, the evolving needs of people who use substances, and tailoring services to local context, we can potentially engage with individuals earlier in their substance use trajectory to prevent overdose and overdose death. FH continues to promote these expanded services among clients and is evaluating its ability to reduce overdoses and engage individuals in the health care system; however, these services are still new and information in this regard is still emerging. Many other jurisdictions in Canada are now applying or have already applied to open similar facilities given the expanding overdose crisis across Canada. With the passage of Bill C-37, simplifying the application process for a section 56 exemption, and the approval of supervised sites for additional modes of consumption, service providers are in a better position to address the opioid crisis by offering services and interventions that are responsive and tailored to community needs.