Design considerations for supervised consumption facilities (SCFs): Preferences for facilities where people can inject and smoke drugs

International Journal of Drug Policy 24 (2013) 156–163

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International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo

Research paper

Design considerations for supervised consumption facilities (SCFs): Preferences for facilities where people can inject and smoke drugs Tara Marie Watson a , Carol Strike b,∗ , Gillian Kolla b , Rebecca Penn b , Jennifer Jairam c , Shaun Hopkins d , Janine Luce e , Naushaba Degani c , Peggy Millson b , Ahmed M. Bayoumi c,f,g,h a

Centre for Criminology and Sociolegal Studies, University of Toronto, 14 Queen’s Park Crescent West, Toronto, Ontario, Canada M5S 3K9 Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario, Canada M5T 3M7 c Centre for Research on Inner City Health, The Keenan Research Centre in the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario, Canada M5B 1W8 d The Works, Toronto Public Health, 277 Victoria Street, Main Floor, Toronto, Ontario, Canada M5B 1W2 e Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Toronto, Ontario, Canada M5S 2S1 f Department of Medicine, University of Toronto, Medical Sciences Building, 1 King’s College Circle, Toronto, Ontario, Canada M5S 1A8 g Department of Health Policy, Management, and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, Ontario, Canada M5T 3M6 h Division of General Internal Medicine, St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario, Canada M5B 1W8 b

a r t i c l e

i n f o

Article history: Received 16 February 2012 Received in revised form 5 July 2012 Accepted 1 September 2012 Keywords: Harm reduction Drug consumption room Supervised consumption facility Supervised injecting facility Supervised smoking facility Crack cocaine Stakeholders

a b s t r a c t Background: Supervised consumption facilities (SCFs) aim to improve the health and well-being of people who use drugs by offering safer and more hygienic alternatives to the risk environments where people typically use drugs in the community. People who smoke crack cocaine may be willing to use supervised smoking facilities (SSFs), but their facility design preferences and the views of other stakeholders have not been previously investigated in detail. Methods: We consulted with people who use drugs and other stakeholders including police, fire and ambulance service personnel, other city employees and city officials, healthcare providers, residents, and business owners (N = 236) in two Canadian cities without SCFs and asked how facilities ought to be designed. All consultations were audio-recorded and transcribed. Thematic analyses were used to describe the knowledge and opinions of stakeholders. Results: People who use drugs see SSFs as offering public health and safety benefits, while other stakeholders were more sceptical about the need for SSFs. People who use drugs provided insights into how a facility might be designed to accommodate supervised injection and supervised smoking. Their strongest preference would allow both methods of drug use within the same facility with some form of physical separation between the two based on different highs, comfort regarding exposure to different methods of drug administration, and concerns about behaviours often associated with smoking crack cocaine. Other stakeholders raised a number of SSF implementation challenges worthy of consideration. Conclusion: Decision-makers in cities considering SCF or SSF implementation should consider the opinions and preferences of potential clients to ensure that facilities will attract, retain, and engage people who use drugs. © 2012 Elsevier B.V. All rights reserved.

“Risk environments” refer to the social and physical spaces in which multiple factors can converge to increase the potential for drug-related harm (Rhodes, 2002). People use illicit drugs in a variety of environments (e.g., at home, in communal drug-using spaces such as “crack houses” or “shooting galleries,” on the street, in alleys, abandoned buildings) that are associated with risks (e.g., overdose, injury, infection) depending on factors such as the drugs used, the availability of drug-use equipment, the presence of others, physical design, availability of public health programming, local

∗ Corresponding author. Tel.: +1 416 978 6292; fax: +1 416 978 2087. E-mail address: [email protected] (C. Strike). 0955-3959/$ – see front matter © 2012 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.drugpo.2012.09.003

policing practices, and broader criminal justice approaches to illicit drug use. Modifying risk environments – which are influenced by micro and macro elements and have physical, social, economic, and policy dimensions – presents complex challenges and involves situational and/or structural interventions (Rhodes, 2002, 2009). Supervised consumption facilities (SCFs) – also known as drug consumption facilities, drug consumption rooms, supervised injection facilities (SIFs), supervised smoking facilities (SSFs), and other applicable terms – are one example of an intervention aimed at improving the health and well-being of people who use drugs. SCFs are legally sanctioned facilities that permit the use of pre-obtained drugs under trained supervision (Kimber, Dolan, van Beek, Hedrich, & Zurhold, 2003) and are thus focused on modifying the micro

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elements of drug-using environments. Broader macro influences, including the legal and social settings in which drug use occurs, are important determinants of whether SCF implementation will be viable or restricted. Once implemented, SCFs arguably modify risk environments at a more structural level as well by expanding the range of services available to meet the needs of people who use drugs. Facilities typically supervise people who inject drugs, but some European sites have also allowed people to smoke or inhale drugs, such as in the Netherlands where most facilities offer separate rooms for injecting and smoking (Hedrich, 2004; Kimber, Dolan, & Wodak, 2005). Shared goals across types of SCFs include reducing infection transmission, reducing cases of overdose, minimising public order problems such as public drug use, providing respite from the street environment, and increasing contact between people who use drugs and health and social services (Bayoumi et al., 2012; Hedrich, 2004; Kimber et al., 2003). While the numerous health and safety benefits of SIFs have been reported in the international literature (e.g., Kerr, Tyndall, Li, Montaner, & Wood, 2005; Kimber et al., 2003; Marshall, Milloy, Wood, Montaner, & Kerr, 2011; Salmon, van Beek, Amin, Kaldor, & Maher, 2010; Wood, Tyndall, Zhang, Montaner, & Kerr, 2007; Zurhold, Degkwitz, Verthein, & Haasen, 2003), SSFs have not yet been rigorously evaluated (Collins, Kerr, Tyndall, & Marsh, 2005; Shannon et al., 2006; Strathdee & Navarro, 2010). People who smoke crack cocaine often face multiple health-related problems as well as marginalization which interfere with their access to health and social services (Boyd, Johnson, & Moffat, 2008; Malchy, Bungay, & Johnson, 2008). SIFs connect street-involved people who inject drugs to such services (Small, Fast, Krusi, Wood, & Kerr, 2009; Small, Van Borek, Fairbairn, Wood, & Kerr, 2009). It is plausible that SSFs could do the same for hard-to-reach people who smoke crack cocaine and thereby help address the harms that they encounter in their risk environments. SSFs may be even more controversial than SIFs. Because the causal links between HIV and hepatitis C (HCV) transmission and drug smoking are less well developed compared to the links to injection drug use, there are questions about whether or not these facilities should be implemented (DeBeck et al., 2009; Fischer, Powis, Cruz, Rudzinski, & Rehm, 2008; Macías et al., 2008; Porter, Bonilla, & Drucker, 1997; Scheinmann et al., 2007; Shannon et al., 2006). Insite, a well-known SIF in Vancouver, has a room with a ventilation system designed for smoking drugs like crack cocaine,1 but requests from the site’s operators for a federal health exemption to open that room have been denied (Dhillon, 2011). In some jurisdictions, harm reduction programs that specifically target people who smoke crack cocaine (such as safer crack kit distribution) have been resisted or difficult to sustain (“Calgary Addicts,” 2011; Haydon & Fischer, 2005; Leonard et al., 2008; Strike et al., 2011); such resistance might also extend to SSFs. Strike et al. (2011) reported that although best practice recommendations advised that needle and syringe programs (NSPs) distribute safer inhalation equipment, including crack pipes, most programs in Ontario, Canada were not distributing these supplies in accordance with the recommendations. NSP managers in that study alluded to encountering opposition to distributing safer inhalation equipment. Community and political opposition to crack kit distribution appear, in part, related to debates about whether such supplies can reduce bloodborne pathogen transmission (Leonard et al., 2008).

1 This ventilated room and operational SSFs in other parts of the world can accommodate people who smoke other types of stimulants such as crystal methamphetamine or who smoke opiates like heroin. In this paper, we focus on crack cocaine because it is a prevalent illicit stimulant in the two Canadian cities we examined and our questions and recruitment strategy were focused on people who smoke crack cocaine.

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Table 1 Key informant interview participants by city. Toronto Police Fire Ambulance City departments Healthcare providers Business owners Residents Total *

1 1 2 2* 5 0 2 13

Ottawa

Total

3 0 2 2 5 1 0

4 1 4 3 11 1 2

13

26

Key informant who worked for the provincial Ministry of Health.

Research has found that people who smoke crack cocaine, including people who both inject and smoke drugs, would be willing to access SSFs (Collins, Kerr, Kuyper, et al., 2005; DeBeck et al., 2011; Leonard & DeRubeis, 2008), although facility design preferences have not been investigated in detail. The literature contains very few mentions regarding why it might make sense for SCFs to have separate rooms for injecting and smoking and lacks an indepth exploration of this issue (de Jong & Weber, 1999; Stoever, 2002; Wolf, Linssen, & de Graaf, 2003). We sought to develop a better understanding of SCF design preferences among people who use drugs and other stakeholders. The perspectives of people who use drugs are particularly important in SCF implementation research because of the nuanced descriptions they are able to provide about their drug-using practices and environments (Bayoumi et al., 2012; Kerr et al., 2003). Our objectives were to examine the following: (1) What are the reasons that would warrant establishing SSFs in two Canadian cities, Toronto and Ottawa? (2) If so, should facilities be designed as separate or combined sites for supervised injection and supervised smoking? (3) What are SSF implementation challenges? Methods We conducted 26 one-on-one key informant interviews and 28 focus group discussions with 236 participants between December 2008 and January 2010. We consulted with people who use drugs (n = 95; 32 in Ottawa and 63 in Toronto) and other stakeholders including police, fire and emergency medical service (EMS) personnel, other city employees and city officials, healthcare providers, residents, and business owners (n = 141; 80 in Ottawa and 61 in Toronto). Please see Tables 1 and 2 for detail about participant numbers. People who used drugs in the past 30 days were recruited through NSPs and community health centres for one of three types of focus groups in each city: groups with people who injected drugs; groups with people who smoked crack cocaine; and mixed groups with people who injected drugs, smoked crack cocaine, or used drugs in both ways. All focus groups included both men and women except two (one in each city) that were conducted with women only. To recruit government employees who work with people who use drugs and/or are involved with drug-related issues (including the police, fire and ambulance services, public health and housing departments), we contacted senior managers. We requested key informant interviews with senior management personnel and assistance to recruit for focus group discussions frontline personnel who had experience providing services to drug-using or homeless populations. For healthcare providers, we recruited physicians and nurses who specialized in methadone prescribing, addictions treatment, emergency care, and community-based care for people who use drugs for one-on-one interviews. We also conducted focus group discussions with our project advisory group members. Advisory groups were comprised of

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Table 2 Focus group participants by city.

Police Fire Ambulance City departments Advisory groups Business owners Residents Community safety group People who inject drugs People who smoke drugs Mixed people who use drugs Total

Toronto

Ottawa

Total

# of focus groups

# of focus groups

# of focus groups

(# of focus group participants)

(# of focus group participants)

(# of focus group participants)

1 (7) 1 (7) 1 (7) 1 (7) 1 (3) 1 (6) 2 (11) 0 (0) 3 (23) 3 (23) 2 (17)

1 (7) 0 (0) 1 (8) 0 (0) 1 (17) 1 (7) 2 (14) 1 (14) 2 (13) 2 (13) 1 (6)

2 (14) 1 (7) 2 (15) 1 (7) 2 (20) 2 (13) 4 (25) 1 (14) 5 (36) 5 (36) 3 (23)

16 (111)

12 (99)

28 (210)

service providers and frontline workers with extensive experience working with drug-using populations. Included within these advisory groups were some members of drug user advocacy groups. To recruit residents and business owners, we contacted neighbourhood and local business improvement associations in areas of each city where drug use was a known concern. Some organizations recruited members for our study directly, while others passed on contact information to their members so that they could directly contact the research coordinators about participating. All participants received an information sheet and consent form prior to the interview or focus group. A research coordinator described the details of the consent form to any participant who needed assistance with reading. All participants were offered a $25CAD honorarium. Interviews were conducted in person or by telephone and lasted between 45 min and 1 h. Each focus group was moderated by at least two research team members—one of the principal investigators or a co-investigator and/or one or two of the research coordinators. We asked people who use drugs about their willingness to use SCFs; we asked all participants about perceived and observed drug use in their communities, the potential benefits and drawbacks of SCFs, where SCFs should be located, what services should be offered at an SCF if one were implemented, and alternative approaches that address illicit drug use. All participants were asked to complete a short demographic questionnaire immediately after completing the interview or focus group. Audio recordings were transcribed verbatim. All transcripts were verified for accuracy and uploaded to NVivo 8 qualitative software. We followed an iterative analytic procedure (Corbin & Strauss, 2008; Strauss & Corbin, 1998). A sub-team comprised of one of the principal investigators, a co-investigator, and three research coordinators selected transcripts to review for emergent themes. Sub-team members met to discuss and compare coding of transcripts. During these meetings, the sub-team developed a common coding structure comprised of major themes and subthemes. Once the coding structure was established, all remaining transcripts were coded by one sub-team member and coding was verified by another sub-team member. Any discrepancies in coding were discussed and resolved by consensus within the sub-team. New themes and any refinements to existing themes were incorporated into the coding structure as deemed appropriate and as agreed upon by members of the sub-team. Previously coded transcripts were reviewed to determine if they contained any new codes. Thematic memos were kept to describe, summarize, and analyse the content of each theme. We compared thematic content between and within cities and stakeholder groups to identify any consistencies and discrepancies. Focus group participants were

not individually identified in the transcripts, so we cannot provide proportions of respondents who mentioned a particular theme. Results Comparison of the data by city revealed few thematic differences; however, there were differences across stakeholder groups and these are examined in detail below. What are the reasons for establishing SSFs? Public drug use and safety People who use drugs in both cities gave multiple reasons for implementing SSFs. These reasons included the observed frequency of crack cocaine use (“Crack you find at every corner.” Ottawa person who uses drugs) and the potential to reduce the number of publicly discarded crack pipes. There’s not a time you can’t walk through that park and find two pipes, three pipes. . .It’s [a supervised facility is] going to make that park that’s right next door to our shelter a lot cleaner, maybe a lot more people use the park, and it will just be safer for us. (Toronto person who uses drugs) Unsanctioned, communal drug-using spaces (e.g., “crack houses” or “shooting galleries”) were often described by people who use drugs as unsafe and uncomfortable places: “I personally don’t like being in a crack house. I don’t feel comfortable. Too many things going on.” (Toronto person who uses drugs) Some participants mentioned that supervised facilities would provide more hygienic and safer settings in comparison to these risk environments. Although people who use drugs mentioned that smoking crack cocaine at an SSF would be more hygienic compared to using on the street, they rarely made connections between smoking crack cocaine and disease transmission or how an SSF may reduce transmission. Safety sometimes meant being safe from other people who use drugs; other times, safety meant respite from fear of being arrested by police. We’re always hiding in alleys or hiding in washrooms or hiding here and there, you know. Where safe consumption sites, you don’t have to worry about the cops arresting you or taking your drugs or go into crack houses where it’s unsafe sometimes. (Toronto person who uses drugs) They’re [supervised facilities are] good for the reason that they’re better than going to a crack house or a rock house because the

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reason is these places are monitored so whatever dope you bring in to hit is only yours. Won’t have somebody coming in to rip you off or intimidating you for it, you know what I mean? (Toronto person who uses drugs) Other stakeholders discussed considerations for staff safety at an SSF, a topic that did not often arise in our focus groups with people who use drugs. SSFs were seen as potentially introducing risk for staff. Healthcare providers, in particular, highlighted the need for high-quality ventilation systems at SSFs. I don’t know how you ventilate these spaces. And I was thinking in terms of my being a staff member, how that would look for my own safety, in terms of inhalation, right. So you’d have to have very well-ventilated rooms. (Toronto healthcare provider) Although people who use drugs generally endorsed the idea of having SSFs, a small subset questioned the utility of such facilities by noting that people would not want to be in a confined space or building after they have smoked crack cocaine: “I would want to just go in for a quick puff and then get out.” (Ottawa person who uses drugs) Further, some people who use drugs noted that smoking crack cocaine involves less preparation, takes less time, and is easier to conceal in public than injecting drugs: “The thing about a supervised using site is, realistically, people can do a toke of crack anywhere. You can pull your jacket up over your friggin’ face and do a toke in your coat.” (Ottawa person who uses drugs)

Evidence of health benefits Across other stakeholder groups, considerable scepticism was expressed about the public health need for SSFs (“What’s the goal? Crack – do they really need a safe house?” Toronto EMS participant). While the relationship between SIFs and disease prevention was understood by most, some stakeholders questioned whether there was enough evidence that SSFs would help reduce HIV or hepatitis C transmission: “You’re not getting, you know, AIDS, or any other communicable disease from smoking, you’re getting it from the needles, so why would you need a safe smoking site?” (Toronto fire services participant) A number of participants asked the interviewer or moderators if there was any evidence demonstrating health benefits from SSFs. A few stakeholders added their belief that SSFs would not bring additional benefit to existing harm reduction services. So are we doing a lot of harm reduction through prevention of disease transmission through crack smokers? I don’t think by having a supervised site or giving them a clean crack pipe, is really going to address that problem. There are services already out there, giving out [safer drug use] kits, that is mobile and I think works a lot better. (Toronto police participant) While not opposed to the idea of SSFs, even public health personnel expressed uncertainty about how an SSF should be designed due to a lack of empirical evidence. I don’t have a lot of information in terms of programs that have implemented the smoking component. But maybe I just didn’t read up enough on some of the research. Or if there’s countries or places where they have experience with that. But I think that’s an area that we’re lacking information, certainly I’m lacking information. I’m lacking sort of, what’s been the experience in the field, to help us sort of conceptualize how it would work here. Because most of the material I’ve been reading and hearing about is about injection. (Ottawa public health participant)

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Designing facilities for supervised injection and supervised smoking Compared to other stakeholders, people who use drugs tended to offer more detailed responses regarding how a facility should be designed; some other stakeholders advised that people who use drugs would have more useful insights on this topic because of their lived experience with drug-using risk environments. When asked about facilities that could accommodate supervised injection and supervised smoking, participants considered three main design options: • Different facilities (i.e., a facility for injection drug use and a facility for smoking crack cocaine). • Same facility with multi-use rooms or areas without separation between supervised injection and smoking. • Same facility with separation between supervised injection and smoking (e.g., different rooms for injection and smoking). Many people who use drugs that we spoke with had a history of both injecting drugs and smoking crack cocaine. These participants typically reported that they would like to see supervised injection and smoking in the same facility because they would like to have one place where they can use different drugs in different ways: “It would be nice to have it both in one setting. . .I know once I do the down [depressants such as opiates], sometimes I want to go up [use stimulants].” (Toronto person who uses drugs) This preference was linked to convenience and an unwillingness to travel from one facility to another, especially after having used drugs: “Say you get there with your drugs and say, ‘Oh, can I do some crack here?’ ‘No, no, no, you got to go across town to do your crack, ‘cause this is just for heroin here.’ You understand?” (Toronto person who uses drugs) Some other stakeholders also mentioned that having injection and smoking in the same facility would make more sense for people who use drugs: “So it seems kind of stupid, ‘Okay, I’m going to go inject my morphine here. Then I’m going to go walk somewhere else to smoke my crack.’ That’s never going to work.” (Ottawa healthcare provider) Other stakeholders generally agreed that having supervised injection and smoking in the same facility would make greater logistical sense and require fewer resources than having separate facilities (“I think it would be an excessive redundancy to have a separate one for each.” Toronto EMS participant). Thus, across stakeholder groups most participants seemed to agree that supervised injection and smoking should be permitted in the same facility. Only a small minority of people who use drugs expressed a preference for entirely separate facilities for supervised injection and smoking. Regarding how supervised injection and supervised smoking should be set up within a facility, we did not hear a lot of support for the option of having both in the same immediate space without separation between them. Most people who use drugs stated a strong preference for keeping supervised injection and smoking separate within a facility (“That, I think, would be the best. Same site, but in separate rooms.” Ottawa person who uses drugs). People who use drugs preferred separation within the same facility for three main reasons: (1) the different highs produced from different drugs; (2) exposure to different methods of administering drugs; and (3) concerns about behaviours often associated with smoking crack cocaine. First, recommendations for keeping injection and smoking areas separate within the same facility were often based on the types of drug being used. Different drugs produce different effects and highs. As people who use drugs explained, crack cocaine (typically smoked) “brings you up” while opiates like heroin (typically injected) “bring you down.”

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‘Cause it’s two totally different trips. You know, when you’re injecting there. You’re talking, when you say injecting, I’m thinking of down. You’re injecting down, it’s a totally different trip. After you do your hit, you usually just sit back, enjoying your rush, you know. (Ottawa person who uses drugs) Some people who use drugs said that having both experiences in the same physical space without some form of separation might become problematic (“Different highs, so it has to be separate.” Ottawa person who uses drugs). These participants expressed concern about mixing together people using different drugs because it might ruin their highs or “trips.” This is linked to perceived differences in users’ behaviours discussed below. This point was mentioned by a few other stakeholders as well: “The feedback I’ve gotten from users is that it wouldn’t mix well. So there needs to be either separate rooms or separate floors because up and down are different and the way you react is different.” (Ottawa advisory group participant) Second, separate areas for supervised injection and smoking in the same facility were endorsed because of different methods of administration. A few people who use drugs said that they would not want to be exposed to crack-cocaine smoke inside an SCF. Some also noted that if people who smoke crack cocaine see other people injecting drugs it might influence them to try it and transition to injecting: “Some people, they smoke but they don’t do needles. But if you have it together, needles and crack, this person might leave there to try the needle too. So it’s better people being separated.” (Toronto person who uses drugs) More frequently, people who use drugs – typically, those who mentioned that they have never injected or have not injected in a long time – said that they would not want to see others inject. Some of these participants explained that they feel uncomfortable or ill at the sight of needles or blood: “I don’t like to see blood and I don’t like to see shooting” (Ottawa person who uses drugs); “I don’t like it. Watching a movie and seeing needles, I turn the channel.” (Toronto person who uses drugs) Similarly, some people who inject drugs advised that they do not like to openly inject in front of others; they acknowledged that even other people who use drugs may not want to see injection, including other injectors but especially those who are non-injectors. Some participants said that they prefer to inject alone, noting that they perceive injection to be a private behaviour: “One is more intimate, when you’re shooting up in your body.” (Toronto person who uses drugs) Furthermore, people who inject drugs reported that the process to prepare for injection typically takes time. Some added that they sometimes have difficulty injecting themselves and would feel self-conscious or embarrassed if others were watching them inject. People who use drugs often connected their suggestions for SCF design to privacy considerations. Participants suggested that a facility that permits both supervised injection and supervised smoking should have curtains, cubicles, booths, or different rooms between the two forms of drug use: “They could have like, you know, how they have curtained off, little sort of like cubicles where it would be curtained off.” (Toronto person who uses drugs); “You could have walls and privacy booths, like voting booth thingies.” (Toronto person who uses drugs) Some said that a facility could even have separate floors for injection and smoking: “I think there should be like maybe a two-storey floor, maybe have people who are doing needles in the basement part of it, and then the main floor is for people who use crack.” (Toronto person who uses drugs). The third reason for designing a facility with separation between injection and smoking crack cocaine was based on types of users and perceived behaviours. A number of people who use drugs, including those who reported smoking crack cocaine, suggested that crack cocaine often causes feelings of paranoia: “Some people get

very paranoid and they’d be afraid to go outside until they calm down.” (Ottawa person who uses drugs) In addition to paranoia, people who use drugs suggested that smoking crack cocaine leads some individuals to behave in ways that are disruptive to others. Perceived frequent behaviours of people who smoke crack cocaine included aggressively asking for drugs (“You can see people that are coming off crack and they’re jonesing [craving drugs]. They get violent, you know.” Toronto person who uses drugs) and compulsively searching for drugs (“That’s why you call it a ‘carpet crawler,’ ‘cause they’ll get down and crawl and pick that carpet until their fingers bleed, looking for more.” Ottawa person who uses drugs). Discrimination and negative perceptions between different groups of people who use drugs were noted. Some people who use drugs discussed their own stereotypes about “crackheads” and “junkies” and suggested that, on this basis, it would be better to keep different user groups separate within a facility: “Like, you know, a heroin addict really looks down on a crack addict, and a crack addict looks down on a heroin addict.” (Toronto person who uses drugs); “Crackheads aren’t going to want to sit there, tweaking out [in a drug-induced agitated state], watching somebody bleed all over themselves too, right, you know.” (Ottawa person who uses drugs) A few other stakeholders raised questions about bringing together people who inject drugs and people who smoke crack cocaine. But I’m just wondering if you’re talking about two different populations of people. Do they mix? And if they do mix, are they going to be encouraging each other to use their substance? I don’t know the answers. Those are just questions I raise. Certainly from my experience, the needle people, they’re a different crowd. (Toronto resident) SSF implementation challenges Across other stakeholder groups, implementation-related issues were raised more often compared to our discussions with people who use drugs. Overall, participants noted three potential implementation challenges for SSFs: political resistance, tobacco smoking bylaws, and preventing staff exposure to second-hand smoke. People who use drugs and other stakeholders noted political resistance to the provision of safer crack kits (especially in Ottawa). Such resistance makes SSF implementation seem less likely to happen. It’s a political scene and it’s [an SCF is] not going to happen in this city because of political views. The city alone started taking the crack pipes away from users. . .you know, government workers, the employees that didn’t want that. You know, the police chief went right on record stating that he didn’t feel it was. . .I mean, you know the reason they don’t want it is because they’re going to find broken crack pipes and syringes in parks and places where there’s, you know, kids and stuff. (Ottawa person who uses drugs) Across stakeholder groups, questions arose regarding how SSFs could be permitted under current legislation that prohibits tobacco smoking inside public places: “They are allowed to smoke inside? You can’t even smoke a cigarette inside.” (Toronto fire services participant) A few participants, notably some police, suggested that there would be an unfair discrepancy if people were allowed to smoke crack cocaine at an SSF while cigarette smokers would not be given the same consideration. I’ve tried to get my head around why you need a safe place to smoke. It would be like saying, ‘We need, you know, people are

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smoking outdoors, it’s cold out in the winter. We’re going to provide you with smoking rooms for cigarettes now. Because it’s warmer inside, and that way you are less likely to get frostbite or get a cold.’ We wouldn’t even consider it, right. (Ottawa police participant) Finally, as mentioned above, some stakeholders had questions about how SSFs can be properly ventilated to prevent staff exposure to second-hand crack smoke. Healthcare providers and public health personnel expressed some concerns about this aspect of staff safety.

Discussion Our findings suggest that the potential benefits of SSFs identified for people who smoke crack cocaine include access to safer crack kits and to services such as referrals for medical care, drug treatment, and social services. Furthermore, SSFs have the potential to modify risk environments (Rhodes, 2002) by offering safer and more hygienic alternatives to settings such as crack houses that can present dangers to personal safety and threat of arrest from the police. In line with the last suggestion, DeBeck et al. (2011) reported that a high proportion of people who smoke crack cocaine in public and who experienced a recent encounter with police would be willing to use an SSF. Other stakeholders in our study were sceptical about the potential public health benefits and wondered if there was sufficient evidence to support claims that SSFs could reduce HIV and/or HCV transmission. People who use drugs recommended that facilities be designed to accommodate both supervised injection and supervised smoking. Physical separation of smoking from injecting was the most favoured design as this option would separate clients experiencing different highs, reduce visibility of different modes of drug administration (i.e., clients smoking crack cocaine would not have to see others injecting drugs), and makes sense given perceived differences between types of users. Other stakeholders – including police, fire and emergency medical service personnel, city officials, healthcare providers, residents, and business owners – raised more questions regarding implementation issues and were less vocal about design issues. Some participants noted that seeing a different method of drug administration might influence a person to try something new, such as initiating injecting. This observation agrees with the finding from studies on initiation to injection drug use that observing the process of injection, and being exposed to the modelling of injection, can be a major factor in influencing someone to try injecting a drug for the first time (Khobzi et al., 2009; Small, Fast, et al., 2009; Stillwell, Hunt, Taylor, & Griffiths, 1999). This suggests that in addition to the preference of people who use drugs, there may be a strong public health benefit to separating injection from smoking within an SCF as a means to reduce the transition from one method of drug administration to another. However, more research on this topic is needed. The concerns we heard about mixing together different user groups may worry some stakeholders, particularly anyone concerned about the potential for violence or disorder in the area surrounding an SCF where people who use drugs may congregate. Where there have been brief mentions in the SCF literature about the need to separate people who inject drugs from people who smoke crack cocaine, there has also been mention of controllability and conflict prevention (de Jong & Weber, 1999; Stoever, 2002; Wolf et al., 2003). According to Wolf et al. (2003), the Dutch SCF clients they interviewed “believe that drug smokers and drug injectors are two separate groups of addicts who do not get on well together. Many smokers are said to look down on injectors, who

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are ranked at the bottom of the drug hierarchy” (p. 655). We heard about similar cases of discrimination between user groups from the people who use drugs we consulted. However, it should be pointed out that there is considerable overlap between types of users as many have reported recent drug-use histories that include opiates and stimulants (Bayoumi et al., 2012). Furthermore, heroin and cocaine are both commonly used by clients at SCFs (Dubois-Arber, Benninghoff, & Jeannin, 2008; MSIC Evaluation Committee, 2003; Scherbaum, Specka, Schifano, Bombeck, & Marrziniak, 2010). While our participants discussed tensions between these user groups, these groups are not always clearly distinct from each other and perhaps tensions between them should not be overstated. Careful identification of issues and development of response plans may help to reduce concerns about the effects of mixing different user groups. Both smoking and injecting cocaine can lead to episodes of paranoia and disruptive behaviours (Brands, Sproule, & Marshman, 1998) which may present barriers to SCF utilization. In a study involving people who inject cocaine, Kerr et al. (2003) documented participants’ discussion of how to manage “tweaking” situations including preparing people prior to injecting about experiencing cocaine-induced psychosis, having peers involved, and threatening potential expulsion from an SIF. Small, Shoveller, et al. (2011) also noted that the potentially disruptive behaviours associated with cocaine use may be managed via trained staff and operational decisions that help move traffic through a facility in a timely manner. These examples highlight how SCF design considerations intersect with facility rules and operational procedures. Decision-makers in cities contemplating SCF or SSF implementation should carefully consider the opinions and preferences of potential clients to ensure that facilities will attract, retain, and engage people who use drugs, including people who smoke crack cocaine. Street-involved people who use drugs are immersed in their own risk environments (Rhodes, 2002) and know a great deal about the safety risks encountered in these settings and how to minimise their own drug-related risk. Including their perspectives in SCF implementation research is thus vital to increase future utilization (Bayoumi et al., 2012; Kerr et al., 2003). Macro-level barriers to SSF implementation include legal and political opposition to safer crack smoking initiatives specifically and harm reduction more broadly. At the global level, commentators differ in their interpretation of the UN Drug Conventions; a number have concluded that SCFs do not contravene the Conventions and noted that various countries have still moved forward with implementation (Canadian HIV/AIDS Legal Network, 2006; Lloyd & Hunt, 2007). However, there is still room for alternative interpretation of the UN Drug Conventions and this could be used to prevent implementation. Canada can be used as an example of political opposition interfering with SCF implementation. The current federal government’s omission of a harm reduction pillar from its National Anti-Drug Strategy (http://www.nationalantidrugstrategy.gc.ca/nads-sna.html) and unsuccessful attempts to close Insite which resulted in a Supreme Court case (Small, 2010) highlight such opposition in action. Any future SSF implementation efforts in Canada and in other regions of the world that do not currently operate facilities will need to negotiate drug-law exemptions, wherever applicable. Given the federal opposition to harm reduction in Canada and mixed community stakeholder support for SSFs (Bayoumi et al., 2012), overcoming these macro barriers may prove difficult to achieve. As some stakeholders in our study noted, barriers also exist at intermediate levels including municipal politics and smoking bylaws. Existing harm reduction programs provide frameworks for how to serve the needs of people who use drugs. A growing number of NSPs are providing – in addition to their supplies for injection drug use – new, single-user smoking equipment (e.g., glass pipes and

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screens) and services for people who smoke crack cocaine (Strike et al., 2011). By doing so, NSPs integrate and make more convenient harm reduction services for people who inject drugs, people who smoke crack cocaine, and those who do both. Further, existing SCFs and heroin-assisted treatment programs can provide frameworks for how to establish supervised injection and smoking crack cocaine in the same facility. A few SCFs in Europe are exclusively smoking facilities (and those that are may see more “chasing the dragon,” smoking heroin, than smoking crack cocaine), while some are combined facilities for injection and smoking drugs (Hedrich, 2004). In the Netherlands, heroin-assisted treatment programs offer clients injectable or inhalable heroin (Blanken, Hendriks, van Ree, & van den Brink, 2010; Lintzeris, 2009) and people who opt to smoke do so in ventilated rooms where staff observe them through windows, but are not physically in the same space (Trépos, 2007). It would be instructive to examine the costs of running properly ventilated rooms for smoking crack cocaine and how existing facilities have operated in accordance with anti-smoking laws. There are several limitations to our study. Participants were recruited by program staff at NSPs and community health centres in the case of people who use drugs and recruited by contacts within departments or organizations for other stakeholders. Healthcare providers were recommended by members of the research team. Thus, our sample was not random and we cannot determine how representative it is of each target stakeholder group. The perspectives of people who use drugs and other stakeholders in our study may not be generalizable to other locations, particularly places where SCFs are already situated. Many participants in the study had little, if any, direct experience with SCFs which renders some of their responses hypothetical. Nevertheless, recent research suggests that reported intentions to use a facility are good predictors of subsequent utilization (DeBeck et al., 2012). Throughout our questions, we defined SCFs as facilities that could permit supervised injection and/or supervised smoking of illicit drugs. We did not use the term “SSF” in our questions though it was clear from participants’ responses when they were discussing issues that pertain to these facilities. However, we might have elicited different responses (or generated more discussion of SSFs) had we asked about SIFs and SSFs separately. In this manuscript, we focus on the design features of SSFs; future work will be devoted to analysing additional insights offered by participants about the types of rules and regulations to implement within an SSF. Understanding how operational issues (including wait times and rules prohibiting drug sharing) might influence utilization is an important feasibility issue to which people who use drugs can contribute many insights (Small, Ainsworth, et al., 2011). For example, given how quickly crack cocaine can be consumed when smoking the drug, future SSFs will need to accommodate quick client turnover to ensure optimal utilization. There remain many unanswered questions about SSF implementation. Our study contributes an important piece of information – that people who use drugs prefer the convenience of having supervised injection and crack cocaine smoking in the same facility and also offer cogent reasons for maintaining a physical separation between the two.

Acknowledgements We are very grateful to our participants who offered their time and perspectives as part of this study. We would like to extend our thanks to the full Toronto and Ottawa Supervised Consumption Assessment (TOSCA) team including the following co-investigators and team members: Patricia O’Campo and Richard Glazier from the Centre for Research on Inner City Health, St. Michael’s Hospital; Benedikt Fischer from Simon Fraser University and the Centre for

Addiction and Mental Health; Susan Shepherd from the Toronto Drug Strategy Secretariat; Gregory Zaric from the University of Western Ontario; Christopher Smith from the University of Pennsylvania; Lynne Leonard from the University of Ottawa; Margaret Brandeau and Eva Enns from Stanford University. This project was funded by the Ontario HIV Treatment Network. Dr. Bayoumi is supported by a Canadian Institutes of Health Research/Ontario Ministry of Health and Long-Term Care Applied Chair in Health Services and Policy Research. The Centre for Research on Inner City Health is supported in part by a grant from the Ontario Ministry of Health and Long-Term Care. For the first two years of this study, salary and infrastructure support for Dr. Strike were provided by the Ontario Ministry of Health and Long-Term Care. The views expressed in this article are those of the authors and no official endorsement by supporting agencies is intended or should be inferred.

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