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Housing and overdose: an opportunity for the scale-up of overdose prevention interventions? Bardwell, Geoff; Collins, Alexandra B; McNeil, Ryan; Boyd, Jade Dec 6, 2017

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COMMENTARY Open AccessHousing and overdose: an opportunityfor the scale-up of overdose preventioninterventions?Geoff Bardwell1,2*, Alexandra B. Collins1,3, Ryan McNeil1,2 and Jade Boyd1AbstractBackground: North America is currently experiencing an overdose epidemic due to a significant increase offentanyl-adulterated opioids and related analogs. Multiple jurisdictions have declared a public health emergencygiven the increasing number of overdose deaths. In the province of British Columbia (BC) in Canada, people whouse drugs and who are unstably housed are disproportionately affected by a rising overdose crisis, with close to90% of overdose deaths occurring indoors. Despite this alarming number, overdose prevention and responseinterventions have yet to be widely implemented in a range of housing settings.Overdose prevention interventions: There are few examples of overdose prevention interventions in housingenvironments. In BC, for example, there are peer-led naloxone training and distribution programs targeted at somehousing environments. There are also “supervised” spaces such as overdose prevention sites (similar to supervisedconsumption sites (SCS)) located in some housing environments; however, their coverage remains limited and theimpacts of these programs are unclear due to the lack of evaluation work undertaken to date. A small number ofSCS exist globally in housing environments (e.g., Germany), but like overdose prevention sites in BC, little is knownabout the design or effectiveness, as they remain under-evaluated.Conclusions: Implementing SCS and other overdose prevention interventions across a range of housing sitesprovides multiple opportunities to address overdose risk and drug-related harms for marginalized people who usedrugs. Given the current overdose crisis rising across North America, and the growing evidence of the relationshipbetween housing and overdose, the continued implementation and evaluation of novel overdose preventioninterventions in housing environments should be a public health priority. A failure to do so will simply perpetuatewhat has proven to be a devastating epidemic of preventable death.Keywords: North America, Overdose crisis, Housing, Overdose prevention interventions, Supervised consumption sitesBackgroundDrug overdose deaths remain among the most pressingpublic health challenges in North America, which is cur-rently experiencing an overdose epidemic. The prolifera-tion of fentanyl-adulterated opioids and related analogshave given rise to an unprecedented overdose crisis, withopioid-related overdoses now the leading cause of acci-dental death in North America [1]. The overdose crisishas been particularly severe in the province of BritishColumbia (BC) in Canada, leading to the provincialdeclaration of a public health emergency in April 2016.That year, BC experienced approximately 1000 drug-related overdose deaths, which constitutes an 80% in-crease over 2015 [2]. In 2017, BC is on target to exceedthis number of overdose deaths, with an estimate of 31.3deaths per 100,000 individuals [2]. The public health re-sponse to the overdose epidemic in BC has proven to bechallenging, particularly given the proliferation offentanyl-adulterated opioids and related analogs that aredriving rising overdose mortality across Canada [3].People who use drugs (PWUD) and who are unstablyhoused have been disproportionally affected by the* Correspondence: gbardwell@cfenet.ubc.ca1British Columbia Centre on Substance Use, St. Paul’s Hospital, 608-1081Burrard Street, Vancouver, BC V6Z 1Y6, Canada2Department of Medicine, University of British Columbia, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Bardwell et al. Harm Reduction Journal  (2017) 14:77 DOI 10.1186/s12954-017-0203-9overdose crisis in British Columbia, as elsewhere [4]. Ac-cording to a recent provincial coroner’s report, 88.5% ofBC’s overdose deaths are occurring indoors, with menwho use alone being most affected [2]. Despite these sta-tistics, and the well-described aspects of housing environ-ments that shape overdose risk [5–7], overdoseprevention and response interventions have yet to bewidely implemented in a range of housing settings, includ-ing in those designed specifically for PWUD. Furthermore,research has largely focused on substance use and housingfor people experiencing homelessness rather than forthose who are housed [8–10]. However, a recent system-atic review of Housing First literature found an absence ofexplicit mention and discussion of harm reduction inter-ventions [11]. With the exception of managed alcohol pro-grams [12–14], there remains a lack of published researchon harm reduction interventions that target drug use inhousing environments specifically.Overdose prevention interventionsIn BC, a small number of overdose prevention inter-ventions have begun to be implemented within housingenvironments that serve as models to inform overdoseresponses in other settings. These include housing-based overdose prevention sites, peer-led naloxonetraining and distribution, peer witness injection pro-grams, and shared-using rooms. Drug user organiza-tions (e.g., Vancouver Area Network of Drug Users,Downtown Eastside SRO Collaborative) and other com-munity groups have also scaled-up naloxone trainingand distribution within housing environments to ensurethat PWUD are properly equipped and trained toadminister naloxone in the event of an overdose [15].Further, a city-funded naloxone pilot project has alsobeen implemented in 12 low-income private housingbuildings with the highest overdose rates in Vancouver,BC’s Downtown Eastside neighborhood. In this project,tenants are hired in each building as peer workers toprovide naloxone training and distribution to residentsand guests in their buildings [16].Additionally, peer witness injection programs wereestablished in two temporary winter emergency sheltersin Vancouver from December 2016 to March 2017. Ineach shelter, a designated room was set up with a table,chairs, and harm reduction supplies (e.g., sterile water,syringes, and cookers) for shelter residents to injectdrugs. Peer staff were hired part-time and trained tomonitor drug use onsite and respond in the event of anoverdose. Finally, “shared-using” rooms have beenimplemented in select supportive housing sites inVancouver to expand witnessed injection programmingto tenants, particularly those who are socially isolated.Shared-using rooms are spaces separate from residents’personal rooms where they can go to inject drugs. Whilethese rooms vary between buildings in how they aremonitored (e.g., cameras or staff ) or designed (e.g., des-ignated rooms or hallways), they are intended to providea ‘supervised’ space for people to use drugs, as an alter-native to using alone in their rooms where they may beat greater risk of dying from an overdose [17]. Althoughthese interventions constitute a positive step towards re-ducing overdose deaths in housing environments, theircoverage remains context-specific and limited, they areoften not officially sanctioned, and the precise impactsof these programs are unclear due to the lack of evalu-ation work undertaken to date.Moreover, overdose prevention sites (OPS) have beenestablished in communities across BC and are similar tosupervised consumption sites (SCS) in that PWUD aremonitored by trained staff or volunteers to intervene inthe event of an overdose. Unlike SCS, which require anexemption to operate legally under current federal law,OPS operate under a provincial ministerial order giventhe public health emergency [18]. As such, OPS tend tobe simpler in design and operation, are more peer-driven, and offer no or fewer clinical services. Since theimplementation of OPS in BC, activists across Canadahave opened similar OPS, although the legality of suchsites remains unclear [19]. In BC, OPS exist in housingenvironments such as supportive housing and homelessdrop-in centers [20, 21], but they too have not been welldescribed. While some evaluations are currently under-way, findings have yet to be published.SCS currently exist in a variety of settings, with over90 located in eight countries [22]. SCS are health set-tings where people can consume pre-obtained drugsunder the supervision of medically trained staff [23].These services have been rigorously evaluated and havebeen shown to reduce adverse health-related outcomes,including morbidity and mortality associated with over-dose [24, 25]. Despite the overwhelming scientific evi-dence supporting SCS, there continues to be social andstructural barriers (e.g., drug-related stigma and anti-harm reduction policies) to the implementation of theselife-saving public health interventions in communitiesaround the globe. In settings across North America, alack of support by policymakers and governments tofund and implement evidence-based harm reduction in-terventions continue to pose major challenges to open-ing SCS. However, circumventing such political barriershas proven feasible within the context of a public healthemergency. For example, in Canada, a shift in govern-ment policies has made it significantly less onerous toopen SCS, given the severity of the overdose crisis [26].Consequently, there has been a rapid scaling up of SCS,with multiple sites having opened in Montréal, Toronto,Ottawa, Victoria, Surrey, Kelowna, Kamloops, andVancouver. Furthermore, provincial ministerial orders inBardwell et al. Harm Reduction Journal  (2017) 14:77 Page 2 of 4BC have aided in the implementation of OPS, includingfunding for these services, and yet, other regions inCanada continue to face political barriers. Despite thesechallenges, several other North American cities are alsoconsidering the implementation of SCS as a measure torespond to overdose and other harms associated with in-jection drug use (e.g., San Francisco and New York) [27].Given the known effectiveness of SCS in reducingoverdose morbidity and mortality, it is somewhat sur-prising that these services have yet to be widely imple-mented and evaluated in housing environments,especially given the disproportionate rate of fatal over-doses occurring in private housing environments [2].There are a small number of SCS within housing envi-ronments worldwide. For example, in Frankfurt,Germany, the “Eastside” facility is a large rehabilitationcenter that also offers SCS for its approximately 100residents. Additionally, Luxembourg City, Luxembourg,has the “Abrigado”––a low-threshold housing facilitythat offers SCS along with HIV testing, counseling, andprimary care services [28]. However, little is knownabout the design or effectiveness of these SCS, as theyremain under-evaluated.ConclusionsDespite SCS developments, there have been fewinterventions for PWUD who are unstably housed.Implementing SCS and other overdose prevention inter-ventions across housing models provides multipleopportunities to address overdose risk and drug-relatedharms for marginalized PWUD. For example, incorpor-ating SCS in emergency shelters or supportive housingwould provide services beyond the capacity of part-timestaff and volunteers. This integration could include hav-ing medically trained staff onsite to provide harm reduc-tion supplies and education, supervise drug use, makereferrals to health and social services, and respond tooverdoses and other health issues that may arise. Add-itionally, the rapid gentrification of urban areas highlightthe need for innovative programming (e.g., mobile SCSand mobile distribution of harm reduction supplies) thatextend support to displaced and vulnerably housedPWUD. Complementing fixed overdose prevention ser-vices, including those within housing environments, withmore flexible interventions may provide a more effectiveresponse to the various overdose risks faced by PWUDwho are vulnerably housed.Until we can achieve more large-scale legal and policy-based harm reduction goals (e.g., decriminalization), thescaling up of SCS and other novel overdose preventioninterventions in housing environments represents an in-novative public health opportunity deserving of immedi-ate attention. Further efforts should now be focused onthe ways in which such interventions can be embeddedin a range of housing and shelter environments to ad-equately respond to the overdose epidemic. These ser-vices should also be rigorously evaluated, including anexamination of their impacts on rates of using alone andfatal overdose, impacts on residents who do not usedrugs, effects on specific at-risk populations, and theircost effectiveness. Given the current North Americanoverdose crisis, and growing evidence of the relationshipbetween housing and overdose, the continued imple-mentation and evaluation of novel overdose preventioninterventions in housing environments should be a pub-lic health priority. A failure to do so will simply perpetu-ate what has proven to be a devastating epidemic ofpreventable death.AbbreviationsBC: British Columbia; OPS: Overdose prevention sites; PWUD: People who usedrugs; SCS: Supervised consumption sitesAcknowledgementsWe would like to thank Thomas Kerr for his feedback on an earlier version ofthis manuscript.FundingGeoff Bardwell is supported by a Mitacs Elevate Postdoctoral Fellowship fromMitacs Canada. Alexandra Collins is supported by a Mitacs award throughthe Mitacs Accelerate Program. Ryan McNeil is supported by a CanadianInstitutes of Health Research New Investigator Award and a Michael SmithFoundation for Health Research Scholar Award. This research was supportedby the US National Institutes for Health (R01DA044181) and CanadianInstitutes of Health Research.Availability of data and materialsNot applicable.Authors’ contributionsGB conceptualized the commentary, conducted the literature review, andwrote the first draft of the manuscript. All authors contributed to thedevelopment and editing of the manuscript. All authors have read andapproved the final version of the manuscript.Ethics approval and consent to participateNot applicable.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1British Columbia Centre on Substance Use, St. Paul’s Hospital, 608-1081Burrard Street, Vancouver, BC V6Z 1Y6, Canada. 2Department of Medicine,University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street,Vancouver, BC V6Z 1Y6, Canada. 3Faculty of Health Sciences, Simon FraserUniversity, 8888 University Drive, Burnaby, BC V5A 1S6, Canada.Bardwell et al. Harm Reduction Journal  (2017) 14:77 Page 3 of 4Received: 4 November 2017 Accepted: 28 November 2017References1. Centers for Disease Control and Prevention. 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Available from: www.bccsu.ca/wp-content/uploads/2017/07/BC-SCS-Operational-Guidance.pdf. Accessed 15Oct 2017.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Bardwell et al. Harm Reduction Journal  (2017) 14:77 Page 4 of 4

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