Pockets of Safety: Implementing an Overdose Prevention Site into an Emergency Shelter During a Public Health Emergency




Elbassiouny, Katrina

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Background: In April 2016, after several months of increased numbers of unintentional drug toxicity deaths, British Columbia’s Provincial Health Offer declared a public health emergency in response to this prolonged spike. In December 2016, the BC Minister of Health released Ministerial Order 488, supporting the implementation and expansion of overdose prevention services. In response to the toxic drug policy crisis in BC, one such overdose prevention site (OPS) was implemented within an emergency shelter, in Victoria, BC, in December 2016. This research sought to understand the role of OPS in responses to substance use and harms for people who use drugs and alcohol from the perspective of people accessing the shelter. Interviews were conducted in the spring of 2018, approximately 1.5 years after the OPS was opened. The primary research questions for this study were: How has the implementation of an OPS contributed to responses to substance use and the uptake of harm reduction policy, philosophy, and practice within the shelter, from the perspective of people accessing the shelter? What were the impacts of implementing an overdose prevention site for people accessing the shelter? To answer these broader questions, my specific research questions were: 1. Has the implementation of an OPS influenced responses to substance use in a shelter setting? 2. Has the implementation of an OPS reduced the harms experienced by people accessing the shelter? 3. How have the policies and practices within the shelter and organization impacted the implementation of the OPS? 4. Has the implementation of an OPS influenced the broader uptake and implementation of harm reduction policy, philosophy, and practice within the shelter setting? Methods: This qualitative study utilized an Interpretive Description methodology and is aligned with a social constructivist paradigm. The applied, practice-based orientation of Interpretive Description balances hermeneutic interpretive tradition with descriptive approaches. Participants were recruited by a third party using purposive sampling. Twenty-one participants were interviewed, and all participants had lived experience of substance use (legal or illegal substances) and were accessing services at the emergency shelter at the time of data collection. Accessing the OPS was not a criterion for participation; as such, experience accessing the OPS varied across participants providing deep insights into the implementation and impacts of the OPS in a shelter setting. Qualitative interviews were audio recorded and transcribed verbatim. Data were organized using NVivo software and analyzed using Interpretive Description. Rhodes’ Risk Environment Framework was used to guide the interpretation of findings. Findings: The OPS provided important micro-level pockets of safety for PWUD within the broader organizational context of the shelter as part of the meso-level risk environment. There were many positive impacts of OPS implementation including saving lives, providing novel inhalation services, preventing harms and complications, reducing criminalization, reducing stigma, improving relationships with staff, improving quality of care, and facilitating connections to care. Primary implementation issues include hours of operation, physical space, and privacy. Informal policy and substance use rules, a constantly changing policy environment, inconsistency in the application of rules, consequences of inconsistent application of rules, and a desire for consistency in the application of rules were all aspects of the broader policy context of the shelter that impacted the implementation of the OPS. Several aspects of the broader shelter influenced and were influenced by the implementation of an OPS. These included an organizational culture in transition, staffing within a transitional culture, the criminalization of substance use, and stigma. Lastly, the meso-level economic context of the shelter identified opportunities to further support implementation, including a need for increased resources, and the intersections of economics and safety. Conclusions: The OPS had positive impacts for those accessing it; however, these impacts were largely limited to the OPS itself. While the OPS shifted the micro risk environment for individuals accessing the OPS, the meso environment remained a risk environment in several ways. The novel inhalation service provided important spaces for safety; however, some lingering risks remained. Peer witnessing and eOPS are important adjuncts to OPS services for people who are unable or unwilling to access traditional OPS. Implementing OPS into an organization that serves diverse populations with different substance use goals and needs presents unique challenges. Organizational and funder policies, aligned with principles of harm reduction, are important for the robust implementation of OPS services and the uptake of harm reduction policy, philosophy, and practice. Peers were critical to the success of the OPS, but the inclusion of peers must go beyond service delivery to also include service planning and design. Adequate resourcing is important for the successful implementation of services, and without adequate resources, risk environments can remain. Robust implementation planning is an essential component of successful service implementation and organizational culture change.



Overdose Prevention Site, harm reduction implementation, Overdose Prevention, Housing, Emergency Shelters, Homelessness, harm reduction, harm reduction policy