So, now we're going to talk about Safe Conception Spaces; both define what they are, gives some other names for them that people commonly talk about, and provide some evidence as to why they're an important public health intervention to abate the overdose, epidemic as well as HIV, hepatitis C and help people get into treatment. By definition, a safe consumption space is a space for people to safely consume previously purchased drugs under clinical supervision, and oftentimes receive health care counseling and referrals to health and social services including drug treatment. We know that it takes an average of six times for people to stop using drugs. So, there are many people who are actively using drugs who need interventions that are effective to keep them alive, to get to the place where they actually can make the choice of quitting drugs. Safe consumption spaces are actually the standard of care and a number of venues in over 100 locations worldwide in 60 cities in 11 countries including Canada, Austria, Germany, Switzerland, France, Spain, et cetera. I'm going to talk to you about the extensive evidence that have shown that save consumption spaces have a positive impact, keeping people alive, providing them with important treatment services, and are incredibly cost effective. What's in a name? Why am I using the term safe consumption space? You likely, if you've ever heard of these types of schemes, have heard of SIF or Safe Injection Facility. There are a number of names that are used to refer to these physical locations, whether they be in a mobile van, in a room that's an a building by itself or with other services. The reason that I'm calling it a safe consumption space is because I think it connotes some key aspects of the space. One that it's safe. It's safe because there are other people around, people who are supervising a person's injection, consumption of drugs. Secondly, ideally people are allowed to consume drugs in any matter in which they prefer. So, injection, smoking, snorting, et cetera are included in a safe consumption space. Some spaces that allow for injection only do so because their city ordinances against smoking inside. So, it's complicated to get the approval for people to smoke inside even in the context of a place where people can consume illicit drugs. Of course, injection drug uses the most efficient route of drug administration, has the highest risk of overdose, highest rates of HIV transmission, hepatitis C transmission. So, if a space is going allowed for any behavior, it's generally focused on safe injection. There's some new names that have come on the scene in the last few years. Seattle, which I'm going to talk to you about has improved two safe consumption spaces, and they're being referred to as community health engagement locations. In Vancouver, with incredibly high rates of overdoses resulting from a fentanyl tainted heroin supply, even though they're on the West Coast, they've establish pop-up sites overdose prevention sites, which oftentimes are tents or parts of homeless shelters where people can learn how to administer in a lock zone and also consume drugs. These places are called Overdose Prevention Sites, even though they're in essence safe consumption sites. There are three basic models of safe consumption spaces, and I'm going to describe them. The first is integrated, the second is specialized, and the third is mobile. So, this is a picture of an integrated safe consumption space in Bonn, Germany, and these spaces provide a range of services. This safe injection facility in Bonn, Germany is actually co-located with a drop-in center, their medical and mental health services provided including exam room and spaces for therapists, counselling sessions to occur. There's access to employment programs, so there's case management with referrals to employment programs there. There's a cafe, there's drug counseling and there's actually inpatient crisis intervention on the second floor. You can see this is a four-storey building, the services are provided on different levels. So, people who are interested in drug counseling and drug treatment are on another floor than the actual safe injection facility. Specialized models such as this picture in Frankfurt, Germany are locations that simply provide access to places where people can consume drugs. I this model in Frankfurt, Germany, this is located at the main railway station in Frankfurt, which has a lot of drug activity basically an open-air drug market behind it, and there is a space where people can come in, there's a front dress, they register or they're give an ID, and then they go into the space inject and leave. The biggest challenge of this is the missed opportunity to connect people to other services. The last model, and of course, there can be other models, but these are the predominant models are mobile services. So, as opposed to the first two services which are provided in fixed sites, mobile services are on a fitted out van, usually an RV that's been changed to have three to five stations, and it can travel around town having a fixed schedule. The benefit of this of course is you literally are bringing the service to people, but it has a much lower capacity to reach a higher number of people at one time. What happens in safe consumption spaces? Right now, I am going to start talking more about this as a picture from Vancouver's safe injection facility called Insite. It has 13 booths, you can't see, but on the left side of that top picture is a desk where somebody, a medical personnel is sitting at all times, and can see people injecting. There're mirrors in front of them at the stalls, they're 13 stalls where people inject. So, at anytime, if someone starts to nod off or slump, fall asleep or fallout from an overdose, someone is there to watch them and intervene. So, in these spaces, there is medical supervision. It's a PA, an RN, a nurse practitioner, a nurse who's watching people inject. They are provided sterile equipment, equipment includes syringes, cotton cookers to prepare the drugs, they're bins, sterile bins at each site for people to properly dispose of syringes. In Vancouver, there're services, there're treatment referrals available. Actually, the second floor of Insite is Onsite, which is a drug treatment program. There's overdose prevention in lock zone distribution. The lock zone is a partial, opioid antagonist, which reverses the effect of an overdose, and if people ingested after they fall out on an overdose and that's supplied at Insite, and other safe consumption spaces, safe injection facilities. There's injection education, how to inject safely, so people don't develop accesses where bacteria enters your skin from unclean injection, and you actually can get endocarditis from that. So, it's really important for people to inject safely, use, wash their hands, clean the spot before they inject in that spot. Then also, the most important thing about these spaces is that they develop relationships with people who are not judgmental about what they're doing, they're actually supporting them in an act that bring so much shame and distress in their lives. Distress from families, from injecting drugs, from using drugs, and are treating them with dignity and respect, and providing a foundation for them to seek other services, and hopefully, eventually enter drug treatment. So, I want to focus a bit on Insite because it's no small thing that this safe injection facility exists. It came into being under a lot of political duress and actually in the advent of a huge HIV epidemic among injection drug users in Vancouver concentrated in one area of town, which is called Downtown Eastside, which was a virtual open-air drug market. It's a very concentrated space where drugs are consumed in Vancouver, which is very different, for example, than Baltimore where drugs are consumed in many different spaces. So, in 1997, the Chief Medical Officer in Vancouver declared a public health emergency from injection drug use because of high rates of HIV, Hepatitis C, and overdose. After that time, a series of meetings took place and there was a commission that was convened to establish a policy that addresses this issue of all of the morbidities and mortality that's associated with injection drug use. The mayor induced what was recommended by this task force, a four pillar strategy which included drug prevention, drug treatment, law enforcement, and harm reduction services. This was fairly unique that law enforcement and people who worked at needle exchanges and supported the philosophy of harm reduction, which is meeting drug users where they are, wherever they are in their drug use, so that can be active use or ceased use, to come to talk together to develop a multiple pronged strategy to address all of the negative outcomes of drug use. In 2002 at the Dr Peter Centre, nurses implemented a small safe injection facility which was a hospice basically for people living with HIV, and clients there could inject drugs. So, that actually was the first injection facility that was established in North America. It was not sanctioned by the government but it was sanctioned by the nurses who felt like this was an important part of the provision of care. It was only open to the people who were in the same Peter Centre, a few who were residing there. But in 2003, Insite was established as a three-year pilot project. There was a capable and productive research team from the University of British Columbia who partnered with the Provincial Health Authority to evaluate the impact of this injection facility that was open to the public. Over the next eight years, there was a lot of political strife with a conservative government coming into power, wanting to shut down Insite. But ultimately in 2011, it was exciting actually was in Toronto during this time, the Supreme Court came down with unanimous vote of keeping the injection facility open. That was quite a coup for the facility and also the health of drug users in Vancouver and elsewhere now where in Montreal, Toronto, other places in British Columbia where injection facilities had been established. So, these are some statistics that are important about Insite from 2015. As of that time, over 3,400 people had been referred to a residential drug treatment program that was, as I mentioned, Onsite directly above the safe injection facility. Through mathematical modeling, there were an estimated 2,047 HIV cases averted. There are over two million injections occurred at Insite during the first 10 years, and over 2,600 lives had been saved from 2003 to 2011 through staff intervening in overdoses that occurred in the injection facility. There was a cost effectiveness analysis, and it was found that $1.8 million are saved each year in preventing HIV infections alone in Vancouver. It's really important to note in Insite and in every injection facility since 1986 when they began in Bern, Switzerland, there has been no death resulting from an overdose. I want to say that a lot of the research I'm presenting today is from Insite because in European countries, in the Netherlands, in Germany and France, in Spain, in Switzerland where safe injection facilities exist, there were a part of the standard of care provided to drug users and evaluations weren't conducted because they weren't necessary, they didn't feel that they needed to prove anything. We know much about safe injection facilities from Sydney, Australia, where there was debate over the existence of an injection facility that exists that's run by the state, as well as the state-sponsored space in Vancouver because they were under political duress and they really needed to prove themselves that they were promoting health and had positive rather than negative outcomes. So, again, the benefits of a safe consumption spaces. There have not been any overdose deaths, and it's important to say that amongst millions and millions and millions of objections that ever occurred in one of these spaces. At Insite, the benefits of reducing the fatal overdose rate was not only within the walls of Insite, but outside of the walls as well. A study that Brandon Marshall lead found that in the two years after Insite opened, there was a 35 percent reduction in overdose events, fatal overdose events within a quarter mile surrounding Insite, compared to a nine percent reduction in the rest of the city, with no other large public campaign that occurred during this time that would have accounted for this significant difference. It's not to be underestimated the number of HIV cases that had been averted and Hepatitis C, which not only can lead to eventual death to people but they're incredibly costly to treat. As I mentioned, there is drug treatment that's offered directly above Insite called Onsite. Vancouver has provided several important studies that have demonstrated how going to the safe injection facility is associated with uptake of drug treatment. In a cohort that over 1,000 people that were followed during the first year of Insite, they were 30 percent more likely to enter residential drug treatment compared to the year prior to attending Insite. Over 2,800 people who use drugs have entered the Onsite detox program since its opening in 2007. There are 252 people who completed the Onsite residential drug treatment just in 2015, and that's 54 percent of the people that began, which is a pretty high rate in the world of drug treatment entry and success. One of the biggest complaints and arguments against investing in safe injection facilities or safe consumption facilities is that, why invest in that? Why not just invest in drug treatment programs? So, I want to underscore some of the reasons why I think and others think that it's important to invest in safe consumption spaces. First, safe consumption spaces, as I mentioned, are often the first step of people interacting with service providers, with people who treat them with dignity and respect, don't have judgment, don't push them into treatment, and oftentimes that's the first connection that leads to other connections and services that people utilize. Not just drug treatment, but people often need to get their lives in order before they're ready to be in drug treatment. So, with Insite and other integrated models for exampling, there's access to housing services, there's access to case management that connect you with lawyers to talk about getting your children back, to work on getting expungement for older arrests off your records so you could get into a job. People who use drugs in places where drugs are illegal, often have really, really chaotic and unstable lives driven by their drug use. So, in order for them to get to the point of wanting to get treatment, getting other aspects of their life under control, help them in that pathway, and safe consumption spaces that provide these services really provide a number of touchpoints before people are ready to go into treatment. I can't overemphasize the importance of trusting relationships with providers at these spaces and also with peers, people who have lived experiences of currently or formerly using drugs. It's important to mention a number of outcomes that have not been found to be associated with safe injection facilities. Increased drug use among clients of Insite where studies have been done or the communities surrounding the space. Increased crime that would occur because more drug users are coming to the area where Insite is, for example, actually a reduction in nuisance crimes, and noise, and public injection has been associated with the establishment of the safe injection facility.