Advertisement

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

  • Geoff Bardwell
  • Taylor Fleming
  • Alexandra B. Collins
  • Jade Boyd
  • Ryan McNeil
Article

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.

Keywords

Housing Single room occupancy hotels Risk environments Overdose response Safer environment interventions Peer naloxone programs 

Notes

Acknowledgements

We would like to thank study participants for their contributions to this research. We also thank current and past staff and peer research assistants at the British Columbia Centre on Substance Use for their research and administrative assistance. Thank you to the DTES SRO Collaborative and Vancouver Coastal Health for allowing us to conduct this research.

This study was supported by funding from the City of Vancouver and the US National Institutes of Health (R01DA044181). Geoff Bardwell is supported by a Mitacs Elevate Postdoctoral Fellowship from Mitacs Canada. Alexandra Collins is supported by a Mitacs Award through the Mitacs Accelerate Program. Ryan McNeil is supported by awards from the Michael Smith Foundation for Health Research and the Canadian Institutes of Health Research.

References

  1. 1.
    Government of Canada. Apparent opioid-related deaths. 2017; https://www.canada.ca/en/health-canada/services/substance-abuse/prescription-drug-abuse/opioids/apparent-opioid-related-deaths.html. Accessed November 20, 2017.
  2. 2.
    Rudd RA, Aleshire N, Zibbell JE, Gladden MR. Increases in Drug and Opioid Overdose Deaths—United States, 2000–2014. MMWR Morb Mortal Wkly Rep. 2016;64(50):1378–82.Google Scholar
  3. 3.
    King NB, Fraser V, Boikos C, Richardson R, Harper S. Determinants of increased opioid-related mortality in the United States and Canada, 1990-2013: a systematic review. Am J Public Health. 2014;104(8):e32–42.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Centers for Disease Control and Prevention Data Brief 294. Drug overdose deaths in the United States, 1999–2016. The United States: National Center for Health Statistics. Hyattsville, MD 2017.Google Scholar
  5. 5.
    Gladden RM, Martinez P, Seth P. Fentanyl law enforcement submissions and increases in synthetic opioid-involved overdose deaths—27 States, 2013-2014. MMWR Morb Mortal Wkly Rep. 2016;65(33):837–43.CrossRefPubMedGoogle Scholar
  6. 6.
    Compton W. Research on the use and misuse of fentanyl and other synthetic opioids. 2017; https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2017/research-use-misuse-fentanyl-other-synthetic-opioids. Accessed November 7, 2017.
  7. 7.
    Bode AD, Singh M, Andrews J, Kapur GB, Baez AA. Fentanyl laced heroin and its contribution to a spike in heroin overdose in Miami-Dade County. Am J Emerg Med. 2017;35(9):1364–5.CrossRefPubMedGoogle Scholar
  8. 8.
    O'Donnell JK, Halpin J, Mattson CL, Goldberger BA, Gladden RM. Deaths Involving Fentanyl, Fentanyl Analogs, and U‐47700‐10 States, July‐December 2016. Morbidity and Mortality Weekly Report. 2017 Nov;66(43):1197–202.Google Scholar
  9. 9.
    National Drug Early Warning System Coordinating Center. The increase in fentanyl overdoses. United States: National Drug Early Warning System Coordinating Center;2016.Google Scholar
  10. 10.
    Seal KH, Kral AH, Gee L, Moore LD, Bluthenthal RN, Lorvick J, et al. Predictors and prevention of nonfatal overdose among street-recruited injection heroin users in the San Francisco Bay Area, 1998–1999. Am J Public Health. 2001;91(11):1842–6.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Davidson PJ, McLean RL, Kral AH, Gleghorn AA, Edlin BR, Moss AR. Fatal heroin-related overdose in San Francisco, 1997-2000: a case for targeted intervention. J Urban Health : Bull N Y Acad Med. 2003;80(2):261–73.CrossRefGoogle Scholar
  12. 12.
    Galea S, Ahern J, Vlahov D, et al. Income distribution and risk of fatal drug overdose in New York City neighborhoods. Drug Alcohol Depend. 2003;70(2):139–48.CrossRefPubMedGoogle Scholar
  13. 13.
    Siegler A, Tuazon E, Bradley O’Brien D, Paone D. Unintentional opioid overdose deaths in New York City, 2005-2010: a place-based approach to reduce risk. Int J Drug Policy. 2014;25(3):569–574.Google Scholar
  14. 14.
    Galea S, Ahern J, Vlahov D. Contextual determinants of drug use risk behavior: a theoretic framework. J Urban Health : Bull N Y Acad Med. 2003;80(4 Suppl 3):iii50–58.Google Scholar
  15. 15.
    Kerr T, Small W, Moore D, Wood E. A micro-environmental intervention to reduce the harms associated with drug-related overdose: evidence from the evaluation of Vancouver’s safer injection facility. Int J Drug Policy. 2007;18(1):37–45.CrossRefPubMedGoogle Scholar
  16. 16.
    Knight KR, Lopez AM, Comfort M, Shumway M, Cohen J, Riley ED. Single room occupancy (SRO) hotels as mental health risk environments among impoverished women: the intersection of policy, drug use, trauma, and urban space. Int J Drug Policy. 2014;25(3):556–61.CrossRefPubMedGoogle Scholar
  17. 17.
    Lazarus L, Chettiar J, Deering K, Nabess R, Shannon K. Risky health environments: women sex workers’ struggles to find safe, secure and non-exploitative housing in Canada’s poorest postal code. Soc Sci Med(1982). 2011;73(11):1600–7.CrossRefPubMedCentralGoogle Scholar
  18. 18.
    McNeil R, Small W, Wood E, Kerr T. Hospitals as a ‘risk environment’: an ethno-epidemiological study of voluntary and involuntary discharge from hospital against medical advice among people who inject drugs. Soc Sci Med(1982). 2014;105:59–66.CrossRefPubMedCentralGoogle Scholar
  19. 19.
    Pauly B, Reist D, Belle-Isle L, Schactman C. Housing and harm reduction: what is the role of harm reduction in addressing homelessness? Int J Drug Policy. 2013;24(4):284–90.CrossRefPubMedGoogle Scholar
  20. 20.
    Rhodes T, Watts L, Davies S, et al. Risk, shame and the public injector: a qualitative study of drug injecting in South Wales. Soc Sci Med(1982). 2007;65(3):572–85.CrossRefGoogle Scholar
  21. 21.
    Small W, Rhodes T, Wood E, Kerr T. Public injection settings in Vancouver: physical environment, social context and risk. Int J Drug Policy. 2007;18(1):27–36.CrossRefPubMedGoogle Scholar
  22. 22.
    Bardwell G, Collins AB, McNeil R, Boyd J. Housing and overdose: an opportunity for the scale-up of overdose prevention interventions? Harm Reduction J. 2017;14(1):77.CrossRefGoogle Scholar
  23. 23.
    Sherman SG, Gann DS, Scott G, Carlberg S, Bigg D, Heimer R. A qualitative study of overdose responses among Chicago IDUs. Harm Reduction J. 2008;5:2.CrossRefGoogle Scholar
  24. 24.
    Banjo O, Tzemis D, Al-Qutub D, Amlani A, Kesselring S. Buxton JA. A quantitative and qualitative evaluation of the British Columbia take home naloxone program. CMAJ Open. 2014;2Google Scholar
  25. 25.
    Bartlett N, Xin D, Zhang H, Huang B. A qualitative evaluation of a peer-implemented overdose response pilot project in Gejiu, China. Int J Drug Policy. 2011;22(4):301–5.CrossRefPubMedGoogle Scholar
  26. 26.
    Marshall C, Perreault M, Archambault L, Milton D. Experiences of peer-trainers in a take-home naloxone program: Results from a qualitative study. Int J Drug Policy. 2017;41:19–28.CrossRefPubMedGoogle Scholar
  27. 27.
    Mitchell K, Durante SE, Pellatt K, Richardson CG, Mathias S, Buxton JA. Naloxone and the Inner City Youth Experience (NICYE): a community-based participatory research study examining young people’s perceptions of the BC take home naloxone program. Harm Reduction J. 2017;14:34.CrossRefGoogle Scholar
  28. 28.
    Wagner KD, Davidson PJ, Iverson E, et al. “I felt like a superhero”: the experience of responding to drug overdose among individuals trained in overdose prevention. Int J Drug Policy. 2014;25(1):157–65.CrossRefPubMedGoogle Scholar
  29. 29.
    Rhodes T. Risk environments and drug harms: a social science for harm reduction approach. Int J Drug Policy. 2009;20(3):193–201.CrossRefPubMedGoogle Scholar
  30. 30.
    McNeil R, Small W. ‘Safer environment interventions’: a qualitative synthesis of the experiences and perceptions of people who inject drugs. Soc Sci Med(1982). 2014;106:151–8.CrossRefGoogle Scholar
  31. 31.
    BC Coroners Service. Fentanyl detected in 81% of illicit drug deaths in B.C. in 2017. 2017; https://archive.news.gov.bc.ca/releases/news_releases_2017-2021/2017PSSG0049-001545.htm. Accessed November 7, 2017.
  32. 32.
    British Columbia Coroners Service. Illicit drug overdose deaths in BC, January 1, 2007 - December 31, 2017. Br Columbia 31, College Park, MD 2018.Google Scholar
  33. 33.
    BC Non-Profit Housing Association & M. Thomson Consulting. 2017 Homeless Count in Metro Vancouver. Burnaby, BC: Metro Vancouver Homelessness Partnering Strategy Community Entity;2017.Google Scholar
  34. 34.
    Ciccarone D, Bourgois P. Injecting drugs in tight spaces: HIV, cocaine and collinearity in the Downtown Eastside, Vancouver, BC Int J Drug Policy 2016;33:36–43.Google Scholar
  35. 35.
    Burnett K. Commodifying poverty: gentrification and consumption in Vancouver’s Downtown Eastside. Urban Geography. 2014;35(2):157–76.CrossRefGoogle Scholar
  36. 36.
    Tweddle A, Battle K, Torjman S. Welfare in Canada, 2015. Ottawa, ON: the Caledon institute of Social Policy;2016.Google Scholar
  37. 37.
    Klein S, Ivanova I, Leyland A. Long overdue: why BC needs a poverty reductin plan. Vancouver, BC: Canadian Centre for Policy Alternatives;2017.Google Scholar
  38. 38.
    Lee M. Getting serious about affordable housing: towards a plan for metro Vancouver. Vancouver, BC: Canadian Centre for Policy Alternatives;2016.Google Scholar
  39. 39.
    Evans L, Strathdee SA. A roof is not enough: unstable housing, vulnerability to HIV infection and the plight of the SRO. Int J Drug Policy. 2005;17(2):115–117.Google Scholar
  40. 40.
    Shannon K, Ishida T, Lai C, Tyndall MW. The impact of unregulated single room occupancy hotels on the health status of illicit drug users in Vancouver. Int J Drug Policy. 2006;17(2):107–14.CrossRefGoogle Scholar
  41. 41.
    DTES SRO Collaborative Society. Tenant Overdose Response Organizers Program. 2017; https://dtescollaborative.org/toro-project/. Accessed September 8, 2017.
  42. 42.
    Creswell JW, Miller DL. Determining validity in qualitative inquiry. Theory Pract. 2000;39(3):124–30.CrossRefGoogle Scholar
  43. 43.
    Corbin J, Strauss A. Basics of qualitative research: techniques and procedures for developing grounded theory. Thousands Oaks, CA: Sage Publications; 2015.Google Scholar
  44. 44.
    Harbottle T. Cracking down on grim SRO Hotels 2011; https://thetyee.ca/News/2011/06/30/GrimSROs/. Accessed October 30, 2017.
  45. 45.
    Hembree C, Galea S, Ahern J, et al. The urban built environment and overdose mortality in New York City neighborhoods. Health Place. 2005;11(2):147–56.CrossRefPubMedGoogle Scholar
  46. 46.
    Visconti AJ, Santos GM, Lemos NP, Burke C, Coffin PO. Opioid overdose deaths in the city and county of San Francisco: prevalence, distribution, and disparities. J Urban Health : Bull N Y Acad Med. 2015;92(4):758–72.CrossRefGoogle Scholar
  47. 47.
    Rowe C, Santos GM, Vittinghoff E, Wheeler E, Davidson P, Neighborhood-Level CPO. Spatial characteristics associated with lay naloxone reversal events and opioid overdose deaths. J Urban Health : Bull N Y Acad Med. 2016;93(1):117–30.CrossRefGoogle Scholar
  48. 48.
    Jenkins LM, Banta-Green CJ, Maynard C, et al. Risk factors for nonfatal overdose at Seattle-area syringe exchanges. J Urban Health : Bull N Y Acad Med. 2011;88(1):118–28.CrossRefGoogle Scholar
  49. 49.
    Bardwell G, Scheim A, Mitra S, Kerr T. Assessing support for supervised injection services among community stakeholders in London, Canada. Int J Drug Policy. 2017;48:27–33.CrossRefPubMedGoogle Scholar

Copyright information

© The New York Academy of Medicine 2018

Authors and Affiliations

  • Geoff Bardwell
    • 1
    • 2
  • Taylor Fleming
    • 1
  • Alexandra B. Collins
    • 1
    • 3
  • Jade Boyd
    • 1
    • 2
  • Ryan McNeil
    • 1
    • 2
  1. 1.British Columbia Centre on Substance UseSt. Paul’s HospitalVancouverCanada
  2. 2.Department of Medicine, St. Paul’s HospitalUniversity of British ColumbiaVancouverCanada
  3. 3.Faculty of Health SciencesSimon Fraser UniversityBurnabyCanada

Personalised recommendations