Prevalence and factors related to public injecting in Ottawa, Canada: implications for the development of a trial safer injecting facility

Abstract

Background: In January 2003, the Canadian federal government announced its support of the scientific evaluation of safer injecting facilities (SIFs) in Canada. As emerging evidence from Europe and Australia has demonstrated that SIFs contribute significantly to reductions in the injection of drugs in public areas, the objective of this paper is to examine the nature of public injecting in Ottawa and its implications for a prospective SIF in the city. Methods: Between October 2002 and January 2003, street-recruited active IDUs consented to personal interviews. Multiple logistic regression was used to determine factors related to public injecting. Content analysis was undertaken of responses to an open-ended question regarding reasons for injecting in public locations. Findings: Overall, 65% of 506 participants reported injecting in any public place in the previous six months. Homelessness was the strongest predictor of public injecting (adjusted odds ratio: 6.6, 95% confidence interval (CI): 3.8–11.6). IDUs injecting in public locations were also significantly more likely to be males; to have initiated drug injecting at younger ages; to score higher on a severity of addiction scale; and to report sharing used needles, injecting most often with any opiate other than morphine, injecting with five or more different people in the previous six months, and trading sex with male clients. Receiving most income from welfare was protective. IDUs who injected predominantly in public places were in chronic need of a location offering privacy and safety, whereas casual public injectors tended to report injecting in public only when in immediate need of a drug fix. Conclusions: These findings suggest that the implementation of a SIF could help alleviate harms related to public injecting among IDUs in Ottawa by the provision of a clean, private, and safe place to inject, with access to sterile injection equipment and housing and addiction services.

Introduction

The injection of drugs in public and semi-public areas such as streets, public toilets, parks, abandoned buildings, and cars may present the injection drug user (IDU) with a myriad of health and social problems. Previous research has documented that the urgency of public injecting associated with IDUs’ fears of being seen by police and other community members can lead to unsafe injection practices (Dovey, Fitzgerald, & Choi, 2001; Klee & Morris, 1995; Latkin, Mandell, Vlahov, Oziemkowska, & Celentano, 1996; Latkin et al., 1994) and the unsafe disposal of used needles and syringes (Broadhead, Kerr, Grund, & Altice, 2002; Broadhead, van Hulst, & Heckathorn, 1999). The shared use of needles and other injecting equipment increases public injectors’ risks for acquiring blood-borne disease such as HIV (Friedman, Jose, Des Jarlais, & Neaigus, 1995), and the limited opportunities for cleanliness and hygiene while injecting in public locations can create other health problems such as abscesses (Darke, Kaye, & Ross, 2001; Fry, Fox, & Rumbold, 1999; Green, Hankins, Palmer, Boivin, & Platt, 2003; Klee & Morris, 1995). These challenges facing public injectors contribute to a greater reliance on the health care system, particularly for emergency care (Palepu et al., 1999, Palepu et al., 2001). Without access to nearby medical assistance or telephones, these IDUs are also at greater risk of fatal overdose (Darke, Ross, & Hall, 1996; McGregor, Darke, Ali, & Christie, 1998). In addition to the societal costs associated with these negative health outcomes, public injecting may also present further concerns for the wider community, such as perceived threats to personal safety, perceived negative image of the area, and exposure to the drug scene (Broadhead et al., 2002; Medically Supervised Injecting Centre [MSIC] Evaluation Committee, 2003).

As an integral component of a comprehensive strategy to reduce harms related to injection drug use, safer injecting facilities (SIFs) can directly address many of the problems associated with public injecting. Since the late 1980s, SIFs have been successfully established in several European cities with open drug scenes (Broadhead et al., 2002, Dolan et al., 2000) and more recently an 18-month SIF trial has been completed in Sydney, Australia (MSIC Evaluation Committee, 2003). SIFs allow IDUs to inject previously purchased drugs under clinical supervision in controlled settings, access needle exchange services, and receive emergency care to manage overdoses, primary health assessment and care, health education, and referrals to drug treatment and other health and social services (Broadhead et al., 2002; Schneider & Stöver, 1999), although the comprehensiveness of an individual SIF may depend on its service delivery model. SIFs currently in operation vary from facilities which are integrated into existing low-threshold service facilities, such as drop-in centres for people who are homeless or drug treatment agencies, to specialised facilities which operate separately from other care facilities, and informal SIFs which comprise indoor illicit drug dealing venues usually run by current or former drug users (Wolf, Linssen, & de Graaf, 2003). Although evaluations of informal SIFs are lacking, reported benefits of integrated and specialised facilities include greater utilisation of health and social services by IDUs; reductions in the number of publicly discarded needles, incidence of fatal overdose, and engagement in risky injection practices; and notably, significant shifts away from public injecting and injecting in open drug scenes among SIF clients (Anoro, Ilundain, & Santisteban, 2003; Broadhead et al., 2002, Dolan et al., 2000; MSIC Evaluation Committee, 2003; Ronco, Spuhler, Coda, & Schopfer, 1996; Zurhold, Degkwitz, Verthein, & Haasen, 2003).

This growing body of evidence and the continuing epidemics of HIV and hepatitis C virus (HCV) infection among IDUs prompted Health Canada to issue a call for the scientific evaluation of pilot SIFs in Canada in January 2003. These trial facilities would operate under a Ministerial exemption from the application of certain provisions of the Controlled Drugs and Substance Abuse Act to eliminate the risk of criminal liability for SIF staff and clients (Jürgens, 2002). The city of Vancouver was well-poised for initiating the development of a trial SIF situated in a neighbourhood experiencing an on-going health crisis among IDUs (Kerr, 2000), as local researchers had previously assessed the potential impact of a SIF on high-risk injection practices including public injecting (Wood et al., 2001, Wood et al., 2003) and undertaken extensive stakeholder consultation (MacPherson & Rowley, 2001). Following the completion of a large feasibility study examining IDUs’ willingness to use and their specific needs for a SIF (Kerr et al., 2003, Kerr et al., 2003; Kerr et al., 2003, Kerr et al., 2003), the first federally approved SIF trial site was officially opened in Vancouver’s Downtown Eastside on 15 September 2003 (O’Brian & Bula, 2003).

To further progress towards a multi-site SIF trial in Canada, Green et al. (2003) assessed the burden of public injecting in Montréal. Their investigation revealed that public injecting was common but diffuse, occurring in several locations across the city rather than concentrated in a single area. Almost 60% of 650 study participants had recently engaged in public injecting, and a dose-dependent relationship was observed between the intensity of public injecting and several risk-related variables including unstable housing and income, injecting daily, injecting with strangers, and injecting with used needles or other equipment. Public injectors also reported experiencing an array of injection-related health conditions, including overdose (40%), liver problems/hepatitis (33%), abscesses (24%), and HIV-positive status (21%). Green and colleagues findings provide compelling evidence that, despite the absence of an open drug scene, Montréal IDUs are not immune to the harms related to public injecting.

Ottawa is the capital of Canada and the country’s fourth largest city at approximately 774,000 residents (Statistics Canada, 2002), with an estimated IDU population of 3000–5000 (Remis, Millson, & Major, 1997) and, like nearby Montréal, the city does not have an open drug scene. The regionally and provincially funded needle exchange programme was established in 1991 and offers services from a fixed office and mobile van every day and evening of the week, as well as through street outreach. Since 1998, satellite needle exchange services have been offered by 11 partner agencies including AIDS service organisations, shelters, drop-ins, and community health centres located in central neighbourhoods of the city. Needle and syringe sales and disposal also occur at a limited number of pharmacies throughout Ottawa. Despite the extensive provision of harm reduction services, however, these services are not placed adequately to address the issue of public injecting. In 2002, 454 discarded syringes were collected in public areas of Ottawa by the Health Department’s “Needlehunter” team and by other regional services, in addition to hundreds of syringe caps, syringe wrappers and dope bags (City of Ottawa, 2003). There were on average 31 fatal drug overdoses per year between 1995 and 1999, although the conditions surrounding these overdose episodes have not been reported (Provincial Health Planning Database, 2004). Furthermore, the levels of HIV infection among Ottawa IDUs are the highest in the province of Ontario (Remis et al., 2003) and among the highest in the country (Hankins et al., 2002). Between 1995 and 2000, the baseline prevalence of HIV among needle-exchange attenders in Ottawa was 20.1% (95% confidence interval (CI): 17.6–22.7), with an incidence rate of 7.0 per 100 person-years (95% CI: 4.1–9.8) (Hankins et al., 2002). In the context of these local conditions, the implementation of a SIF in Ottawa may therefore be a significant addition to existing harm reduction programmes, with the direct aim of reducing the harms related to public injecting.

As the success or failure of a SIF will be impacted by whether the facility is target group specific and lifestyle relevant (Schneider & Stöver, 1999), the overall purpose of this paper is to examine the nature of public injecting in Ottawa. Specifically, the prevalence of self-reported public injecting among IDUs in Ottawa, the socio-demographic characteristics, injection practices and sexual behaviours significantly associated with public injecting, and IDUs’ main reasons for injecting in public will be examined. The findings of the investigation will be discussed in relation to the potential impact of a safer injecting facility on the harms related to public injecting in Ottawa.