Addressing Intersecting Housing and Overdose Crises in Vancouver, Canada: Opportunities and Challenges from a Tenant-Led Overdose Response Intervention in Single Room Occupancy Hotels

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Abstract

We examined the acceptability, feasibility, and implementation of the Tenant Overdose Response Organizers program (TORO)—a tenant-led naloxone training and distribution intervention. This pilot project was implemented in privately owned single room occupancy (SRO) hotels that were disproportionately affected by overdose in Vancouver’s Downtown Eastside (DTES) neighborhood. Semi-structured qualitative interviews were conducted with 20 tenants who had participated in a TORO training session and administered naloxone to someone in their SRO hotel or had overdosed in their SRO hotel and received naloxone from another tenant. Focus groups were conducted with 15 peer workers who led the TORO program in their SRO building. Interviews and focus groups were transcribed and analyzed thematically. Ethnographic observation at SRO hotels involved in the intervention was also co-led with peer research assistants. Ten SROs were included in the study. The level of acceptability of the TORO program was high, with participants describing the urgency for an intervention amid the frequency of overdoses in their buildings. Overdose response training enhanced participants’ knowledge and skills, and provided them a sense of recognition. Additionally, the TORO program was feasible in some buildings more than others. While it provided important training and engaged isolated tenants, there were structural barriers to program feasibility. The implementation of the TORO program was met with some successes in terms of its reach and community development, but participants also discussed a lack of emotional support due to overdose frequency, leading to burnout and vulnerability. Our findings suggest that the TORO program was affected by social, structural, and physical environmental constraints that impacted program feasibility and implementation. Despite these constraints, peer-led in-reach overdose response interventions are effective tools in addressing overdose risk in SROs. Future housing interventions should consider the intersecting pathways of overdose risk, including how these interventions may exacerbate other harms for people who use drugs. Further research should explore the impacts of environmental factors on overdose response interventions in other housing contexts.

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Most cited references 27

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Fentanyl Law Enforcement Submissions and Increases in Synthetic Opioid-Involved Overdose Deaths - 27 States, 2013-2014.

R Matthew Gladden, Pedro Martínez Arbizu, Puja Seth (2016)

In March and October 2015, the Drug Enforcement Administration (DEA) and CDC, respectively, issued nationwide alerts identifying illicitly manufactured fentanyl (IMF) as a threat to public health and safety (1,2). IMF is unlawfully produced fentanyl, obtained through illicit drug markets, includes fentanyl analogs, and is commonly mixed with or sold as heroin (1,3,4). Starting in 2013, the production and distribution of IMF increased to unprecedented levels, fueled by increases in the global supply, processing, and distribution of fentanyl and fentanyl-precursor chemicals by criminal organizations (3). Fentanyl is a synthetic opioid 50-100 times more potent than morphine (2).* Multiple states have reported increases in fentanyl-involved overdose (poisoning) deaths (fentanyl deaths) (2). This report examined the number of drug products obtained by law enforcement that tested positive for fentanyl (fentanyl submissions) and synthetic opioid-involved deaths other than methadone (synthetic opioid deaths), which include fentanyl deaths and deaths involving other synthetic opioids (e.g., tramadol). Fentanyl deaths are not reported separately in national data. Analyses also were conducted on data from 27 states(†) with consistent death certificate reporting of the drugs involved in overdoses. Nationally, the number of fentanyl submissions and synthetic opioid deaths increased by 426% and 79%, respectively, during 2013-2014; among the 27 analyzed states, fentanyl submission increases were strongly correlated with increases in synthetic opioid deaths. Changes in fentanyl submissions and synthetic opioid deaths were not correlated with changes in fentanyl prescribing rates, and increases in fentanyl submissions and synthetic opioid deaths were primarily concentrated in eight states (high-burden states). Reports from six of the eight high-burden states indicated that fentanyl-involved overdose deaths were primarily driving increases in synthetic opioid deaths. Increases in synthetic opioid deaths among high-burden states disproportionately involved persons aged 15-44 years and males, a pattern consistent with previously documented IMF-involved deaths (5). These findings, combined with the approximate doubling in fentanyl submissions during 2014-2015 (from 5,343 to 13,882) (6), underscore the urgent need for a collaborative public health and law enforcement response.

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Hospitals as a 'risk environment': an ethno-epidemiological study of voluntary and involuntary discharge from hospital against medical advice among people who inject drugs.

Ryan McNeil, Will Small, Evan Wood … (2014)

People who inject drugs (PWID) experience high levels of HIV/AIDS and hepatitis C (HCV) infection that, together with injection-related complications such as non-fatal overdose and injection-related infections, lead to frequent hospitalizations. However, injection drug-using populations are among those most likely to be discharged from hospital against medical advice, which significantly increases their likelihood of hospital readmission, longer overall hospital stays, and death. In spite of this, little research has been undertaken examining how social-structural forces operating within hospital settings shape the experiences of PWID in receiving care in hospitals and contribute to discharges against medical advice. This ethno-epidemiological study was undertaken in Vancouver, Canada to explore how the social-structural dynamics within hospitals function to produce discharges against medical advice among PWID. In-depth interviews were conducted with thirty PWID recruited from among participants in ongoing observational cohort studies of people who inject drugs who reported that they had been discharged from hospital against medical advice within the previous two years. Data were analyzed thematically, and by drawing on the 'risk environment' framework and concepts of social violence. Our findings illustrate how intersecting social and structural factors led to inadequate pain and withdrawal management, which led to continued drug use in hospital settings. In turn, diverse forms of social control operating to regulate and prevent drug use in hospital settings amplified drug-related risks and increased the likelihood of discharge against medical advice. Given the significant morbidity and health care costs associated with discharge against medical advice among drug-using populations, there is an urgent need to reshape the social-structural contexts of hospital care for PWID by shifting emphasis toward evidence-based pain and drug treatment augmented by harm reduction supports, including supervised drug consumption services.

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Determinants of increased opioid-related mortality in the United States and Canada, 1990-2013: a systematic review.

Nicholas King, Veronique Fraser, Constantina Boikos … (2014)

We review evidence of determinants contributing to increased opioid-related mortality in the United States and Canada between 1990 and 2013. We identified 17 determinants of opioid-related mortality and mortality increases that we classified into 3 categories: prescriber behavior, user behavior and characteristics, and environmental and systemic determinants. These determinants operate independently but interact in complex ways that vary according to geography and population, making generalization from single studies inadvisable. Researchers in this area face significant methodological difficulties; most of the studies in our review were ecological or observational and lacked control groups or adjustment for confounding factors; thus, causal inferences are difficult. Preventing additional opioid-related mortality will likely require interventions that address multiple determinants and are tailored to specific locations and populations.