A Low-Barrier and Comprehensive Community-Based Harm-Reduction Site in Vancouver, Canada

Abstract

“The Molson” is a low-barrier, peer-staffed, supervised consumption site located in Vancouver, Canada. In addition to overdose response, this site offers drug checking and a colocated injectable hydromorphone treatment program, and it distributes tablet and liquid hydromorphone to service users at high risk of overdose. Our evaluation suggests benefits of this program in creating service continuums and preventing overdose deaths. From September 2017 to August 2019, the site had 128 944 visits, reversed 770 overdoses, and had no overdose deaths.

Supervised consumption sites provide safer spaces for people to consume drugs while monitored by staff trained in overdose response.¹ We describe a low-barrier, peer-staffed, supervised consumption site in Vancouver, Canada, novel for its integration of drug checking services and programs (1) providing injectable hydromorphone as a treatment of opioid use disorder and (2) distributing hydromorphone (in tablet and liquid form) as a harm-reduction measure to reduce the harms of fentanyl in the illicit opioid supply.

INTERVENTION

The Molson Overdose Prevention Site (OPS) and Learning Lab (“the Molson”) is operated by the Portland Hotel Society (PHS), a nonprofit organization providing housing, health care, and other services. The Molson is a provincially sanctioned low-barrier OPS (e.g., accommodates peer-to-peer assisted injections and drug sharing) staffed primarily by people who use(d) illicit drugs (“peers”). People may ingest, snort, or inject drugs on-site. During an overdose, staff administer oxygen and naloxone and may temporarily close the site to facilitate response or paramedic access. Drug checking using Fourier-transform infrared spectroscopy and immunoassay test strips are available twice weekly for people to check their drugs for potency and adulteration. Two nurse-run programs distribute physician-prescribed hydromorphone to PHS patients, including a medically supervised injectable opioid agonist treatment (iOAT) and a novel liquid or tablet hydromorphone distribution program.

PLACE AND TIME

Opened in September 2017, the Molson is located in Vancouver’s open-air illicit drug market.

PERSON

People who use drugs.

PURPOSE

In 2016, the provincial government issued a ministerial order directing regional health authorities to establish and fund OPSs to monitor and respond to overdoses.² The Molson aims to prevent overdose deaths and reduce drug-related harms (e.g., HIV).

IMPLEMENTATION

The Molson OPS is modeled after low-barrier sites initially established by local activists.² Peer staff are recruited primarily through PHS harm-reduction programs and receive training in overdose response. Open daily from 1 pm to 11 pm, the OPS accommodates up to 16 people at a time. A front-desk attendant greets people, records their pseudonym and drug being used, and assigns tables. The Molson operates with a “shared responsibilities code” that stipulates expectations about space use (e.g., no passing money or uncapped syringes). A flexible 15-minute time limit is implemented to prevent wait times, although people may remain in a “chill space” for as long as needed. Starting October 2018, Fourier-transform infrared spectroscopy drug checking became available on Tuesdays and Thursdays. Wait times for drug checking fluctuate but can reach an hour when there is high demand.

In December 2017, PHS began operating an iOAT program within the Molson, adjacent to the OPS. There are currently 60 people enrolled in iOAT. The program has a separate locked buzzer entrance, and is separated from the OPS by a partial wall with a door. In the iOAT treatment area, enrollees can receive two daily doses of hydromorphone (max = 200 mg/dose) in syringes, a maximum of 400 milligrams per day. Injections are self-administered, or administered intramuscularly by nursing staff. This program operates from 8 am until 5 pm. Full-time on-site staffing consists of nurses, a program coordinator–mental health worker, and peer workers. A physician and social worker are on-site one to two days a week.

In January 2019, the Molson launched a hydromorphone distribution program. Currently, 59 people receive tablets and 10 receive injectable liquid hydromorphone. Enrollees are prescribed a daily dose of nurse-administered hydromorphone from a station in the OPS. Tablet enrollees receive up to 16 milligrams (two 8-mg tablets) of hydromorphone each hour, for a maximum of 80 milligrams per day. Injectable liquid enrollees receive an equivalent amount. Hydromorphone must be consumed on-site under nurse supervision, and can be taken orally, intranasally, or by injection.

In both hydromorphone programs, patients receive their hydromorphone, concurrent oral therapies (e.g., methadone or sustained-release oral morphine), and any other medications they require (e.g., antiretrovirals).

EVALUATION

We drew from PHS program data and targeted qualitative data collection to characterize program implementation. From August 2018 to August 2019, we conducted 91 interviews with people about their experiences using services, five interviews with peer staff regarding program operations, and 200 hours of ethnographic observation. We thematically analyzed interview transcripts and field notes in NVivo, a qualitative analysis software program (QSR International, Melbourne, Australia).

From September 2017 to August 2019, there were 128 944 visits to the Molson OPS, and staff responded to and reversed 770 overdoses. No overdose deaths occurred on-site. With knowledge of and experience using illicit drugs, peer staff expressed confidence they could assess people’s tolerance and prevent overdoses by advising people to start with lower doses. Some peer staff viewed their employment as a form of harm reduction, as financial compensation alleviated pressure to engage in criminalized forms of income generation. The low-barrier model was preferred by people for whom more medicalized models are not desirable, particularly those requiring assisted injecting.

People accessing drug checking reported feeling more knowledgeable about the drugs they consumed and desired increased availability of and specificity from the drug-checking technology. People using opioids were primarily interested in the mixture analysis to determine fentanyl potency and adjust dosage. For people using stimulants (primarily methamphetamine), drug-checking results were used to avoid fentanyl exposure.

The colocation of the OPS and the iOAT program facilitated connections between treatment and OPS services given both the physical proximity and the connections between iOAT and OPS staff.

People enrolled in the hydromorphone distribution program described the convenience of having the program integrated within a service they already use. However, participants discussed the inconvenience of having to wait when the OPS was full or access was restricted during an overdose. Occasionally, OPS wait times resulted in delayed or missed doses. The operating hours of the OPS were difficult for participants who required opioids in the morning to avoid withdrawal.

The Molson’s overdose response extends beyond the site. Staff share information about adulterated drugs with the local health authority, who broadcasts this information to other service providers and people who use drugs through weekly Community of Practice meetings and an anonymous text-messaging service. Approximately 400 peer workers have received training in overdose response through the Molson’s learning lab.

ADVERSE EFFECTS

Clinical studies indicate that injectable opioid treatments confer greater risks of adverse effects than oral treatments; however, these risks are minimal compared with those of injecting illicit drugs, especially within the context of widespread fentanyl adulteration, and are mitigated through nurse supervision and treatment of postinjection reactions.^3,4 The integration of multiple services in one location presented the challenges of ensuring adequate space for all services, managing noise from the OPS, and maintaining patient confidentiality.

SUSTAINABILITY

Supervised consumption sites have proven cost-effective in preventing overdose deaths and blood-borne diseases.⁵ However, staff burnout and turnover undermine sustainability. As observed at other OPSs, peer workers experience stress and trauma related to poverty and criminalization that is compounded by overdose response, yet they receive minimal financial compensation and benefits.⁶ Peer supervisors receive a living wage (including benefits),⁷ and all staff have access to counseling. Further improvements in peer staff remuneration, job security, and benefits would enhance program sustainability.

PUBLIC HEALTH SIGNIFICANCE

This evaluation indicates benefits of a low-barrier and peer-staffed comprehensive harm-reduction service in preventing overdose deaths and creating a service continuum. It suggests that OPSs are promising sites for colocated iOAT, drug checking, and “safe supply” programs that distribute pharmaceutical drugs to people vulnerable to overdose. Such programs are needed to prevent overdoses, facilitate connections to treatment, and provide alternatives to the toxic illicit drug supply.