Review of: Nick Kerman, et al., “‘It’s not just injecting drugs’: Supervised consumption sites and the social determinants of health,” Drug and Alcohol Dependence 213 (Aug. 1, 2020), p. 108078.

Reviewed by: Stacey McKenna, PhD

As drug overdoses surge across the United States—2019 saw a record 72,000 deaths and 2020 is on track for even more—public health advocates in several communities are fighting to establish supervised injection sites and consumption facilities (SCSs). Approximately 120 SCSs operate across 10 countries, providing spaces where individuals can safely consume or inject off the streets, with access to clean equipment and health care professionals trained to help in case of overdose or other medical emergencies. Indeed, dozens of studies indicate that such sites are associated with reductions in direct drug-related harms such as overdose mortality and the prevalence of HIV infections.

But individuals who inject drugs also face a wide range of social inequities—such as homelessness, food insecurity or interpersonal violence—that negatively affect health. Thus, in a recent study published in Drug and Alcohol Dependence, Nick Kerman and colleagues explored if and how SCSs may impact the so-called social determinants of health (SDOH).

The researchers conducted qualitative interviews and focus groups with 28 injection drug users who had used an SCS in the past month, were at least 18 years of age, and spoke and understood English. They recruited participants from an SCS based in a downtown Ottawa community health center and collected data in two phases. In March 2019, they conducted in-depth interviews with 22 individuals. Then, in August 2019, following a preliminary analysis of the interview data, the researchers held two focus groups with seven participants (only one of whom also took part in the interviews) to confirm initial findings. One interviewee was excluded from the study due to non-responsiveness and problems understanding their speech, so findings were based on the responses of the other 27 participants.

Kerman and colleagues identified five themes based on their analysis of the interview and focus group data. According to the participants, SCSs played an important role in their sense of social connectedness; emotional support; safety and security; shelter status and search for housing; and health service access and use.

For example, participants widely viewed SCSs as places around which a community was built, providing injection drug users with the opportunity to interact with other service users and staff alike. The quality of the social connections varied according to different participants, and a handful of women and transgender participants felt excluded and even mistreated by other service users. Nonetheless, the researchers note that this finding suggests SCSs may serve an important function in preventing social isolation.

On a related note, a number of participants discussed at length how the presence of supportive and nonjudgmental staff benefitted them. Participants stated positive interactions with SCS staff—when staff knew service users’ names, welcomed them to the facility, listened and talked with them in a caring way—reduced harm to self-esteem, and reduced stress, especially that associated with using drugs in public. However, not all participants had such positive experiences to report. A handful did not spend much time interacting with staff, and one participant said she had been emotionally abused by other clients at the SCS.

In addition to psychological and emotional support, many participants described the SCS as providing a sense of safety and security. For those experiencing homelessness, the facility provided a safe place to consume drugs that would not disturb others, would protect them from legal consequences of using in public and allowed them to take more care—not rushing to avoid arrest, for example. A number of participants also explained that having on-site medical professionals made them feel safer. Staff were largely viewed as able to respond to overdoses, provide information about current drug trends (i.e., a growing presence of fentanyl) and enforce rules about violence. Despite these benefits, participants noted that there were still risks associated with consuming in an SCS. In particular, they reported having to worry about being hassled by other service users for drugs or having to remain vigilant to avoid theft or even assault.

A fourth theme Kerman and colleagues identified was how SCSs affected housing status for those who were experiencing homelessness. A common report was that having access to a safe space to use helped homeless individuals avoid being banned from emergency shelters, many of which do not permit drug or alcohol use. Further, SCS staff sometimes worked with service users to help them navigate housing and shelter resources, in one case advocating to overturn a service user’s ban from an emergency shelter.

Finally, the researchers wrote, participants consistently reported that, “SCSs had improved their access or engagement with healthcare.” Staff helped about half of the participants access services—such as primary care physicians, addictions medicine or psychiatric services—that they were not using previously. Some participants noted that this improved access was facilitated by the staff’s nonjudgmental, genuinely caring approach to inquiring about health. They turned service users onto resources they had not known were available and reduced barriers related to logistics by providing referrals, helping them obtain a health card and more.

Overall, the qualitative nature of the study provides important and nuanced insights into the service implications. For example, the research highlights the importance of enforcing rules on aggression or violence, hiring staff committed to providing social and resource-related support, and ensuring staff are well trained in relevant resources throughout the community. However, there are some limitations. As the authors recognize, participants were recruited using “convenience sampling” from just one SCS. As such, benefits described by users of this particular facility may not be as relevant at other facilities. Such an approach can make the findings difficult to apply to groups beyond the research participants themselves. However, the vast majority of participants reported using more than one site in the Ottawa area, and the researchers note that the participant demographics were similar to the general population of SCSs users. Furthermore, the intention of qualitative research is not to provide generalizable information. Rather, it seeks to illuminate the detailed patterns of experience in ways that can inform theory or application.

Thus, despite its limitations, this study adds a valuable perspective to the already strong body of evidence in support of SCSs. Kerman et al. posited that, in addition to reducing direct drug-related harms, SCSs potentially improve clients’ health through several pathways, bolstering social connectedness and enhancing access to and engagement with a wide range of housing and general health resources.

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