Research Paper
Sheltering risks: Implementation of harm reduction in homeless shelters during an overdose emergency

https://doi.org/10.1016/j.drugpo.2017.12.011Get rights and content

Abstract

Background

The current opioid overdose crisis in North America is heightening awareness of the need for and the challenges of implementing harm reduction, notably within complex and diverse settings such as homeless shelters. In this paper, we explore the implementation of harm reduction in homeless shelters during an emerging overdose emergency.

Methods

The objective of this qualitative study was to identify and understand micro-environment level factors within emergency shelters responding to homelessness and substance use, and the macro-level influences that produce and sustain structural vulnerabilities. We conducted eight focus groups with a total of 49 participants during an emerging overdose emergency. These included shelter residents (n = 23), shelter staff (n = 13), and harm reduction workers (n = 13).

Results

The findings illustrate the challenges of implementing an overdose response when substance use is prohibited onsite, without an expectation of abstinence, and where harm reduction services are limited to the distribution of supplies. In this context, harm reduction is partially implemented and incomplete. Shelters can be a site of risks and trauma for residents and staff due to experiencing, witnessing, and responding to overdoses.

Conclusion

The current overdose crisis heightens the challenges of implementing harm reduction, particularly within complex and diverse settings such as homeless shelters. When harm reduction is limited to the distribution of supplies such as clean equipment and naloxone, important principles of engagement and the development of trust necessary to the provision of services are overlooked with negative implications for service users.

Section snippets

Data collection

Focus groups exploring issues related to substance use and harm reduction in shelters were conducted from December, 2015 to January, 2016. A total of 49 participants participated in eight focus groups that included shelter residents (n = 23), shelter staff (n = 13) or harm reduction workers (n = 13). Each focus group lasted between 40 and 60 min, and was conducted by experienced researchers who have long-standing collaborations with individuals and agencies responding to homelessness and

Results

Overdoses were identified by all groups as the most significant concern associated with substance use in shelters. Below we outline four themes that describe the shelter as a micro-environment in which harms may be mitigated or exacerbated by policy and political processes in the macro-level environment.

Limitations

The qualitative focus groups for this research were limited to two homeless shelters within a single city. This study, of shelter staff and residents during an emerging opioid overdose crisis is uniquely positioned to gather rich and timely data on substance use issues. While generalizability is not the objective of qualitative research, one limitation of this study is that the findings may not reflect experiences within different contexts. Although our sampling sought to include a diversity of

Discussion

Our findings indicate the inadequacies of harm reduction responses that focus primarily on the distribution of supplies within settings prohibiting use. Risks related to incomplete implementation of harm reduction include concealing use within a setting that prohibits use, and tragically, frequent overdoses, notably within the shelter washrooms that become de facto unsupervised consumption sites (Wallace et al., 2016). A distribution model of harm reduction within shelters are micro

Conclusions

The current illicit drug overdose crisis heightens awareness of the challenges in fully implementing harm reduction responses, notably within complex and diverse settings such as homeless shelters. This study found a combination of low-threshold service delivery, and distribution of harm reduction supplies with prohibition of use on-site, which was described as a context of mixed messages and competing priorities. The shelter is identified as a site of risks and trauma, as experiencing,

Conflict of interest

The authors report no conflicts of interest to declare.

Acknowledgements

This work was supported by the Vancouver Foundation. The funding body had no role in the study design or preparation of the manuscript.

References (42)

  • B. Pauly

    Harm reduction through a social justice lens

    International Journal of Drug Policy

    (2008)
  • T. Rhodes et al.

    The social structural production of HIV risk among injecting drug users

    Social Science & Medicine

    (2005)
  • T. Rhodes

    The ‘risk environment’: A framework for understanding and reducing drug-related harm

    International Journal of Drug Policy

    (2002)
  • T. Rhodes

    Risk environments and drug harms: A social science for harm reduction approach

    The International Journal on Drug Policy

    (2009)
  • R.A. Rudd et al.

    Increases in drug and opioid overdose deaths—United States, 2000–2014

    American Journal of Transplantation

    (2016)
  • E. Tiderington et al.

    A qualitative analysis of case managers’ use of harm reduction in practice

    Journal of Substance Abuse Treatment

    (2013)
  • H. Wilson et al.

    Perceived discrimination and injecting risk among people who inject drugs attending Needle and Syringe Programmes in Sydney, Australia

    Drug and Alcohol Dependence

    (2014)
  • BC Coroners Service

    Illicit Drug Overdose Deaths in BC: January 1, 2007–December 31, 2016

    (2017)
  • BCCDC

    The BC public health opiod overdose emergency

    (2017)
  • D. Briggs et al.

    Injecting drug use and unstable housing: Scope for structural interventions in harm reduction

    Drugs: Education, Prevention and Policy

    (2009)
  • S. Darke et al.

    Heroin overdose: Research and evidence-based intervention

    Journal of Urban Health

    (2003)
  • Cited by (0)

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