All right, thank you for coming, everyone. As you can likely see, I am not Dr. Kimmick today. I am standing in for her. And with us today, we have Dr. Brandon Marshall, who is a professor of epidemiology at the Brown University School of Public Health. He's also the founding director of the People, Place, and Health Collective at Brown University. Dr. Marshall's research focuses on substance use epidemiology with a specific emphasis on harm reduction and overdose prevention. He's passionate about conducting research that improves the health and well-being of people who use drugs. And I will let Dr. Marshall take it from here. Thank you so much for joining us. Thank you, Dr. Latronica. It's good to see everyone again. This is part two in a session on harm reduction. We're focusing on the Q&A portion today, so I don't have any slides for you. But I thought we could start with some of the questions that we didn't get to last week. And Dr. Kimmick then had some additional questions for me, which I'm happy to answer. And then Dr. Latronica and I can take additional questions from you as well. So should I just dive right in? Let's get to it. Yeah. Okay. So as you might recall, last week we were talking about harm reduction and overdose prevention centers specifically. And there were a few questions that I was not able to get to on some neighborhood level outcomes and whether these have been studied and observed in places where these facilities are located. So the first question was about research on changes in property values and whether those have changed as a result of supervised consumption facility or overdose prevention center opening. And in brief, I have not seen any of this research looking at property value changes specifically. That's actually something that we have proposed to evaluate as sites, more sites open in New York City and as we have our first sites open in Rhode Island. So that was something that we did identify as an unanswered question, at least as far as I'm aware in the literature. So that is something that we will evaluate as more sites open. But I will say that studies have examined other neighborhood level outcomes as a result of overdose prevention centers, looking at say measures of crime, public drug use, drug related disorder. And the vast majority of studies show that these kinds of neighborhood problems go down as a result of overdose prevention centers opening. In particular, drug related litter, right? Because all of that material, that paraphernalia is being used on site and remains in these sites, not out on the streets. And so we pretty quickly see typically when OPCs are implemented, significant reductions in syringes and other paraphernalia in the streets and in parks. And that's something that was noticed dramatically in New York City in particular, at some of the surrounding parks around the two OPCs in those sites. So we are hypothesizing that because of some of these improvements in neighborhood conditions that we will not see any impact or actual positive impacts on property values, but that's something that we will continue to research as new sites open. The other question was also around, you know, neighborhood level impacts on a crime. We talked about that last week, but this question was about whether overdose prevention centers impact DUIs in that area. And that's another thing that has not been examined. The vast majority of people who use these facilities do not drive, they walk or take public transportation to them. And so I would hypothesize that we do not see any impact on DUIs because the vast majority of people are not using vehicles to attend to them. It's important to keep in mind that these are neighborhood interventions. They are used by people who reside in or live in the immediate vicinity typically of these facilities. And the vast majority of instances, you know, they are not serving a population living in other neighborhoods or other cities. So that's important to keep in mind for some of these outcomes like DUIs and crime. It's also helpful, I always find, to just set expectations in terms of one site in say the city of Boston is unlikely to impact significantly overdose rates in the entire city. Where we see the most impact is in the immediate neighborhoods in which they're located. So at the end of the day, they are more of a local intervention to address the needs of a specific community in a specific neighborhood. So they have to be paired with broader interventions that address overdose risk at a community level as well, I would say. Let's see. I'm just looking at some of the other questions. I'm just going to get through the rest of the questions around overdose prevention centers. And then Dr. Latronica, we can get to some of the other questions around harm reduction more broadly, if that works for you. So another question that came up was, who are the typical clients of overdose prevention centers? This is kind of related to the previous question, which is that most often people who use these centers are experiencing housing instability, are experiencing homelessness, have long histories of drug use, trauma in many circumstances, and are currently at risk for overdose. You know, that is the experience in the two sites in New York City. That is typically what we see in Vancouver and in other sites in Canada as well. Many centers actually ask people when they register, this is another question we'll get to, and ensure that they do in fact have a history of drug use. Typically, people are not permitted to use drugs for the first time at these sites. Those kinds of folks would be directed to other prevention services or other clinical programs. So that is typically the kinds of folks we see at overdose prevention centers. And that's, again, something to keep in mind, the reason why these facilities aren't necessarily a panacea, because we have a lot of populations at risk for overdose these days, particularly as fentanyl has entered into the stimulant supply. People who are housed are using more recreationally, using cocaine or methamphetamine on the weekends or around, you know, in vacation settings or more periodically. These are not typically the kinds of populations who are using harm reduction centers or overdose prevention centers, but may still be at risk for overdose and in need of other kinds of harm reduction tools like fentanyl test strips or naloxone. So we need a broad suite of overdose prevention and harm reduction strategies for the extremely heterogeneous population of people who are using drugs and who are at risk for overdose. And this intervention, overdose prevention centers, are typically meeting the needs of people who are, you know, street entrenched, have long histories of drug use treatment experiences, and continue to remain at risk for overdose. And that sort of gets to the one last question before I'll address some of the other questions around harm reduction tools more broadly, which was around why most OPCs would ask people to register. And that is done to collect some basic information like history of drug use, you know, age. Most centers will try to identify the number of unique people using the service and then the number of utilizations just for evaluative purposes. So some of that information is just important for like program and process measures. At the same time, they are designed to be low threshold. So you're also typically best practice is not collect a whole suite of identifiers. You don't typically even need to provide your name. It might be a handle or a username and then some basic information. And then you provide that username or handle each time you use the service to sort of track utilization over time. And then each time a person chooses to use an overdose prevention center, some additional basic information would be collected typically around, say, what drug the person intends to use or would like to use in that moment, because that will drive the response if something goes wrong, if there's an overdose or some other adverse response, if it's an opioid that someone's using or a stimulant that leads to very different responses. And so it's important to collect that information for every use event as well to guide the medical and overdose response. So I think that was all the questions I got on overdose prevention services. Is there anything, Dr. Latronica, you have or that our attendees have before I shift gears here? And I'll give a second here for students to type in the Q&A if they have questions. I don't see any right now. I'll give it a minute though. I guess I do have one for you, and this here in Pennsylvania, we do not even have outside of Pittsburgh and Philadelphia syringe service programs. So some might say sort of a step below overdose prevention sites. And what we hear sometimes in some of the testimony, even from some activists who may generally be in favor of harm reduction, they have thoughts or suggestions. The information is secondhand, essentially, well, these syringe service programs are functioning as overdose prevention sites, safer consumption sites. And so in terms of how that evolved over time, like in New York, was that an issue? Was that a barrier where people were saying, well, you're kind of trying to sneak in safer consumption site through the back door and how you address that both with sort of the lay public and policymakers and even healthcare professionals who aren't always the best allies? Yeah, I, you know, often syringe service program providers would be well suited to implement overdose prevention centers because they have experience working with the community. They have the rapport, they have the trust. That's important, right? People who use these facilities have been stigmatized, are criminalized, have long histories of negative experiences with law enforcement, and in some circumstances, the healthcare system. And so you can't just expect to open one one day and have the doors, you know, be pounded down and have the floodgates open. You need to build that trust. And so most SSPs, syringe service programs, have that with a community. And therefore, if this kind of service were added, would be able to engage that population from day one. But I do want to be clear that overdose prevention center services are distinct from SSPs. They require distinct skill sets and staffing models. You're talking about intervening on overdoses as they're happening in real time. That requires specific training skills and resources, you know, like oxygen tanks, naloxone on hand, other equipment that typically you might not see at an SSP. So it is distinct and, you know, is not something that, I'll just leave it there. It sort of is very distinct and requires, you know, a fair amount of expertise and staffing to implement. It's not something that is necessarily done overnight, like we might see or hear discussed. There was one other question that came up that sort of related, oh, yeah, this is a great question from Nina. Do people provide their own drugs and if so, are they tested? Yes. So that's another, that's a great question, Nina, because that's something else I'd like to clarify. Overdose prevention centers are places where people consume pre-obtained controlled substances. So substances are not provided by staff on site. They are brought on site by people who obtain them elsewhere. Often there is drug checking available that might be fentanyl test strips, which we'll talk about a bit later, or other drug checking technologies like mass specs. But the substances are obtained off site and brought. There are other interventions in other countries, Europe and Canada, that focus more on the provision, the medical provision of diacetylmorphine, which is what we colloquially call heroin. Or other injectable opioids that might be given, sort of other treatments for opioid use disorder in particular. Those are typically distinct interventions around providing a broader array of treatments for people with opioid use disorder. So those have existed for decades in some European countries, randomized trials have been conducted to show their efficacy in Canada and the UK and other places, but again are distinct from overdose prevention centers, which involves the consumption of pre-obtained controlled substances. Did I answer your question, Dr. Latronica? No, yes, absolutely, and I dovetailed nicely with Nina's. Thank you. Great. Great. I do want to get to fentanyl test strips. That was another question that came up, which is another harm reduction tool that we talked about last week. These are almost like COVID-19 tests, rapid tests. It's an immunoassay, which can identify even micrograms, nanograms of fentanyl in an unregulated drug sample. And so these originally were designed for forensic use, testing in urine, but are increasingly used prior to consumption to identify fentanyl in a sample. And a question came up about how would a provider educate patients on how to use them, and where could they obtain fentanyl test strips? This is a great question. We actually have a website here in Rhode Island around fentanyl test strips. I'm going to put that in the... Oh, I don't know if I can put that in the chat. I put it to host some panelists. Maybe there's some way to send it to the attendees. I'll just say the website is preventoverdoseri.org. And then if you go to prevention overdose, you'll see an entire page dedicated to fentanyl test strips, how they're used, how to interpret results. And we get a lot of activity on this page. It's actually the busiest page on our entire state site. And there's resources on where to find fentanyl test strips. If you're in Rhode Island, harm reduction organizations distribute them, but also nationally, they're available from organizations like DanceSafe and DoseTest. Those links are on that page. So people can obtain them online as well. And some of the education around how to use them is provided on the site and is available on other harm reduction websites as well. In the research we've done here at Brown, we found that people find them very easy to use. It's fairly straightforward, honestly. The results are somewhat counterintuitive. They're kind of the opposite of a COVID test. One line is positive, two lines are negative. So that's actually where we find the most difficulty with these. So we actually affix a graphic that shows visually how to interpret the result of a fentanyl test strip and affix them to each package when we're distributing them. And those stickers are available as a link at the bottom of the site. So that's important. Otherwise, in research we've done, we don't typically find people have trouble using them. And they do take important overdose risk reduction practices, especially when people get results. They use less, they use with naloxone, have someone around to intervene, or discard the fentanyl-contaminated substance altogether. That's something that we've observed in prior studies. And I'm currently running a randomized clinical trial right now to determine whether the use of fentanyl test strips reduces overdose. So that's something I'm hoping we can report out over the next year or so. Thank you, Dr. Marshall. We had a couple other questions roll into the chat now here. The first is kind of going back briefly to overdose prevention centers. Do you use, so individuals who use substances, have any guarantee that they won't be picked up by police, searched, et cetera, in a few blocks around the site on their way to or from the OPC? Yeah, thanks, Melody. This is such a great question. And I was just on a panel earlier today with the operators of the site in New York City who spoke very eloquently about this. You know, it's very difficult to operate overdose prevention centers without support from local law enforcement. And at the end of the day, really, they should be implemented hand in hand with changes in the way police and law enforcement interact with people who use drugs. Because you're right, you know, if police are just standing right outside the facility and arresting people or hessing people as they come in and out, that's not going to be effective from a public health point of view. So in New York City, the organizers, the operators of the overdose prevention centers worked extensively with local law enforcement. They speak of law enforcement as partners. They've not had any challenges. Police actually, the local precincts asked for materials that they could distribute to people to say, you know, I see that you're using, there's a service available to you, please visit it. You know, and so that has gone really well, honestly, in New York City. And that might not always be the case in every jurisdiction, but I think it shows you that those conversations can happen, they should happen, and they lead to positive outcomes. At the end of the day, these services benefit law enforcement in that they address a problem that police don't want to deal with, which is, you know, street level drug use and overdose response. So what we see typically is once OPCs are implemented, police understand that this is a more appropriate environment in which to respond to overdoses. These are professional staff who do this, and it allows law enforcement to focus on other activities, you know, domestic violence, robberies, thefts, and so on. So rather than street level policing, they're able to focus on other issues. That being said, you know, as the site was open in New York City, the mayor did get buy-in from the district attorneys in each borough that they would not prosecute people who were planning to use or coming or going from the facility. So that was another incentive for police to say, you know, it's not worth hassling and arresting these people, the district attorneys will not prosecute these cases. So that's what I'm sort of talking about earlier, is that ideally, they're implemented in contexts in which there's a changing to the enforcement policies or the local policing practices. This next question, sort of more of a comment in a way, but sort of attesting to the prevalence of fentanyl and the potency in people's tolerance, suggesting, you know, about test strips. Unfortunately, some of my patients want fentanyl. They tell me heroin just does not, quote unquote, do it for me anymore. And so maybe if you don't mind speaking to the, you know, the importance of safe supply testing, even in the setting of people becoming more tolerant and seeking it out in certain cases. Yeah, I think, you know, that is a reality of many settings now. We see people who are fentanyl dependent and that might be a population for which fentanyl test strips might not be an effective harm reduction tool at this point. You know, that's one thing we're trying to study and others are researching as for whom is this harm reduction technology most likely to benefit. Kind of going back to what I was mentioning earlier, this extremely heterogeneous population of people who use drugs, a significant number do not want to be exposed to an opioid at all, or might be completely opioid naive and for those populations, fentanyl test strips could be extremely effective at preventing a fentanyl overdose as a result of having fentanyl contaminated cocaine, for example. So I, you know, completely want to emphasize that we need multiple harm reduction strategies to address the needs of people who use drugs broadly. The other thing I would add too is that fentanyl test strips, what we've found and what harm reduction organizations have found is that they're an engagement tool. So even if the goal is not, the goal might not be like behavior change or risk reduction per se, it's still a way to engage, to offer something to someone, to have that conversation about how volatile the unregulated drug supply is. And so there might still be benefit in that, that's not directly related to reducing overdose risk. And that might depend on the conversations that open up as a result of that engagement tool or other sort of downstream interactions that arise as a result of distributing strips. So that's something we're starting to see and we're trying to understand with more nuance is, you know, what are the harder to measure potential benefits of distributing fentanyl test strips, even among populations who are fentanyl dependent. I see another question here from Melody asking about legal liability for the sites, the people administering services there. I'll just, in the case of one individual using multiple substances and they overdose, everything is done to try to save the individual, individual dies anyway. So asking here about, you know, is there malpractice insurance or site insurance? If so, is there a prohibitive cost to that? That's a great question, Melody. And unfortunately one, I haven't been able to find the answer to yet. I get this a lot and I don't know how this is, how this is addressed or would be addressed in US context. It's very different in Canada with the universal healthcare system. And so people who work at these facilities, or at least the clinicians are, you know, nurses employed and doctors employed by the local health authority or provincial health authorities. So I need to do more learning on this, on what this looks like in a US context. So I'm sorry, I don't have the answer for you. And I think a lot of jurisdictions, including here in Rhode Island, are actively trying to work through some of these potentially sticky issues around legal liability and insurance. And I don't know what the operators of OnPoint have done in this case. I haven't had the chance to ask them yet. What I can address sort of the middle part of your question, which is that so far to date, there has never been an overdose death in any overdose prevention center anywhere in the world since they've opened in the mid 1980s. That's not to say it might never happen, but despite millions and millions of use events around the world, there has never been a fatality. And so overdose, as you probably know, overdose symptoms are becoming increasingly complex with a lot of the novel psychoactive substances out there. And they do require a fair amount of staffing and expertise to respond to them appropriately. And so it's complicated. It requires specific staffing, but it seems to be the case that so far all overdoses can be effectively reversed. In New York City, they just recently reversed the 500th overdose and have called for additional medical support through EMS eight times. And that was often because of some other medical issues that have arisen seizures, for example, or some other acute medical condition that is potentially related or unrelated to the overdose. So the vast majority of overdoses can be effectively managed and reversed on site with tools that are available, oxygen and naloxone primarily. So again, important in terms of preventing EMS calls and ED visits for overdose, that's 492 overdoses in New York City that these sites have effectively managed without any other medical intervention or ED visits. So the savings there are significant from a cost perspective, and also reducing the strain on the healthcare system, which is, as you all know, very much under stress and exhausted, honestly, as a result of two and a half years of the COVID-19 pandemic. So I hope that answered the middle part of your question there. And I will learn more about insurance and legal liabilities more as we move towards opening them here in Rhode Island. I had one sort of addition. When you were talking about fentanyl test strips and who they may be useful for, in terms of what we may be testing for, what we should be testing for, expanding testing beyond just fentanyl, do you have any background or thoughts on field testing for a much wider array of contaminants or poisons or things like that? And where is that in terms of viability as a public health tool, in the United States at least? Yeah, this is such an interesting area of research, and we're starting to see these kinds of programs being implemented. There's one in North Carolina. One of my colleagues has a project that is a mix of ethnographic and hospital-based toxicological work, where we're asking people to donate paraphernalia or used baggies, cookers, that are then brought to our hospital and tested with a QTOF, which I'm told is a very advanced machine that identifies potentially hundreds of substances. And we're seeing just a wide array of substances pop up, especially xylosine, which is a tranquilizer, a benzodiazepine-based substances, fentanyl analogs, tramadol, all sorts of things. And we're just starting to put that on our website publicly and report that out to the community and the goal of this study is to try to learn how do we do that effectively? How would it positively impact people who are exposed to these substances on a daily basis? So I think there's a lot of promise here, but we need to understand how to do this effectively. It's very complicated to interpret these drug testing results and then translate that information in terms of, so what? For a typical person using an illicit drug, what does that mean that xylosine or some other substances in the sample, how can they use that information, take that information and use the substance more safely? So that's where we're at. I think there's a lot of promise here, but also more research that needs to be done in this area. And I can put in the chat the pages that we're just starting to publish more publicly on some of the data that we're seeing. Here we go. So Dr. Latronik, if you could just repost this to everyone, that would be great. Yes, let me see, actually, I can only click, when I click my down arrow, it only says hosts and panelists as well. So I will check. I'll try to do that. Oh, okay. Thank you, thanks so much. Yeah. See another question here about the ages available or which age of people are permitted at these sites, specifically, who haven't reached the age of majority. Is that, has that ever been a concern? Is there an age limit, so to speak? It's the question in the chat. Yeah, that is another good question, Melody. In the vast majority of sites, they are not open to minors. You might see, you see, though, different age limits in Canada or other contexts. I've seen 18, I've seen 21. You know, at the end of the day, as I mentioned, primarily these sites are used by people with long histories of drug use. They're not perhaps the most appropriate intervention for young people. When I was living in Vancouver, we had a youth-focused harm reduction program that I actually worked at where the supervised consumption site would direct those young people to, and we could provide more age-appropriate harm reduction services in sort of more youth-focused settings. So I completely agree about your concern around the appropriateness of these sites to minors. In some countries, in Canada, for example, you will see sites that might be, or hours that are focused for women, for example, or gender minority folks. So there's other populations that we need to think about as well who might need specific services or specific hours to feel welcomed and to maximally benefit from the services. So you do see, in some circumstances, overdose prevention centers providing services to specific groups of people, but not typically adolescents. Someone just mentioned in the chat that their video was freezing. I typed an answer. I'm not having that issue, but yes, this will be made available as a recording if you're having issues with the freezing. Great. Looking in the chat. This was a question that came up the other day. This is not specific to OPCs or fentanyl test strips in general, but sort of the philosophy of how we approach harm reduction and how there's sort of a lot of pushback until a wave of devastation happens, or there's a bunch of overdoses or an outbreak of hepatitis or something like that. And I don't know if there's, this is almost sociological research, but a way to create that change without having to have the antecedent, brutal losses beforehand. And I don't know if that's something you can even really comment on, but I figured I would bring it up because it sort of undergirds all of this. It's so true. I think that's such a good point. I like to think about where would we be ideally? Like where would harm reduction fit ideally? And many countries are far ahead of us in this regard. I think at the end of the day, it is part of a spectrum of care for people. And so it means, ideally we think about harm reduction in just an expanded spectrum of care for people, in this case, people who use drugs. So that is where I'd like to see us get when it's just one of the many tools, medical interventions and care that we're able to provide. I think if it were fully integrated into the way that we address health problems, we'd be in a much better place, but you're right. The way we kind of approach it now is that only after a crisis has happened, do we start to implement these harm reduction services. We have more than a hundred thousand people now dying every day of a drug overdose in this country. And I think tragically, that is why we're having these conversations and seeing jurisdictions seriously consider overdose prevention centers. But it's terribly sad that we had to get to this point in the crisis to seriously consider these programs that we know save lives. So I'm hopeful though, that over the next five years, 10 years, 15 years, we will start to see broader integration of harm reduction philosophy and programming into healthcare and public health more broadly. I am very encouraged by federally, we are starting to see glimmers of that. We've seen support for harm reduction in the national drug policy plan. We're seeing broader support for harm reduction research now at NIH. We're seeing a harm reduction focused language from SAMHSA, so CDC. So that I think is the beginning, right? Of a broader federal support for harm reduction and then integration into the way that we address drug related problems. Yeah, thank you. That wasn't a straightforward question. So I appreciate- A good one though. A good one. Yeah, yeah. Melody is asking here, if the sites, overdose prevention centers provide things like hepatitis C or HIV treatments. They do. Typically they do. Yep, not always, but in many cases, either referrals to HCV or HIV treatment providers or therapy on site. There are some places that are able to provide the medications, be it for HCV or HIV directly to people who are using the facility and that can be very effective and successful. There's less examples that I know of, of pre-exposure prophylaxis or PrEP access and provision in overdose prevention centers. So that's actually something I'd love to ask on point whether they're considering that, but typically treatment is either directly available or there are some sort of referral to a known provider in that circumstance. Yeah, so great question. Great question. Give it a second here. So this is slightly broader as well, but something that's come up with, again, there's a continuum of, we talked about where Canada's maybe ahead in terms of how they've viewed this and some certain states as you well know now are on different ends of the spectrum. With certain service programs, there are definitely concerted efforts from various groups. So I was curious whether it's whatever experience you may have had or research on the Canadian side and also in terms of New York, who were the opponents or the most common or the most vocal? I think of like real estate developers or were there subsections of government? Who was it that was really coming out against, not to say that they were all bad faith, but just out of curiosity, were there recurring characters in other words? Yes, I think so. NIMBYism is very strong and well and alive. And so the opposition can be very localized, neighborhood associations, specific businesses, individual residents, and what OnPoint's approach was, they did have some of that opposition. And what OnPoint's approach was, was to say, we hear you, we are hearing these concerns, come visit us, learn more about what we're actually doing. And often they were able to engage and pretty quickly change that person's or that organization's opposition or at least soften it significantly. So I think a lot of the opposition comes from just a lack of understanding around what these centers are actually doing and the benefits that they typically have to communities. And so I really love that approach. It's tempting to polarize these issues and to villainize these types of groups who might be opposed, but a more effective strategy is to try to engage and to explain, to educate, and to invite them into the conversation. And in most circumstances, I've seen that be very effective and gets us to where we need to be. I'm trying to think any other, well, politicians, yeah, and then some politicians, not necessarily entirely to the right, sort of across the spectrum, you see varying degrees of support and opposition. But so that's sort of a separate issue. The approach that was taken here by advocates in Rhode Island who were successful at passing the nation's first state bill to authorize harm reduction centers also took the approach of, we're willing to engage with any politician. Like if you're opposed, we will come and sit with you and meet with you and answer to the best of our ability, any question or concern that you might have. And some of those concerns then went into the bill that was passed or the regulations that have now been finalized. So listening to people, spending that time to engage with them and listen to their concerns, be they a neighbor, a resident, or a policymaker, I think can go a long way on this particular issue. Makes sense. I see here, Melody's asking, parents are especially concerned about having these sites near schools, but there's schools everywhere. How do you convince parents or figure out placement with regard to schools? Is this a good idea? Do they try to avoid being right next to slash near school? And there was a question about zoning previously as well, zoning regulations, both in Rhode Island and how that works. So maybe if you could just touch on zoning and those concerns. Yeah, that's a great. So it depends on the locality. In some places there are regulations around their zoning or their placement in regards to public services or schools. Here in Rhode Island, the state law does not dictate any of that, but each city in which an overdose prevention center would be located needs to approve it before a state license is provided. And that's been a challenge actually for us. And that's where you start to get into these conversations around zoning and so on and so forth. So those conversations are honestly happening right now. Epidemiologically, you want to locate these centers where the need is greatest, where you have people who are experiencing overdose, who are experiencing homelessness. So that is epidemiologically the location where you're likely to have the most positive public health impact. So for me as a researcher, that's what I like to always highlight in these discussions is that there are communities across our state where you see that need, where you see extraordinarily high rates of overdose burden. And then it comes down to it and more within that community, where might be the most appropriate location. They can also, we often think about overdose prevention centers as large fixed sites. They can be very small. They can be integrated into existing health facilities or urgent care centers. So that's the other thing I like to say is that they don't need to be these large standalone facilities. They can be very hidden in some ways to the extent that you might not even notice that they're there. There's a site in Montreal that's on a major commercial street, and you honestly would not even know that it's there if you walk by. It's not a large site. It doesn't draw a lot of attention to itself. So that's just something to keep in mind as well is that there's different ways to structure these interventions and to scale them and to co-locate them that can address some of these issues. Does that answer the question, Dr. Latronica? I think so, certainly. Okay. Yeah, I appreciate it. Give it another second here. Yeah, and then Melody offered a follow up question, do they try to hide the entrances or not put up signs? Sometimes yes, sometimes they are designed to be very discreet, so to speak. You might not, again, you might not even know if you pass by that it is an overdose prevention centers. Other times, it might. If it's an existing syringe service program, you know that signage might have pre existed so it can depend based on the, the jurisdiction. Certainly, there's one that just opened in my hometown in Canada of about 150,000 people they did have a mobile site and then move to a fixed site and I would have to look to see what that actually looks like. It's one of the newer ones that I'm aware of. Let's see if they have any pictures of it. No, I can't, I can't find any off the top of my head but it you know it might say drop in center, or, you know, harm reduction program it might not necessarily say supervised consumption site if it. That's helpful. Another sort of broader question on, you know, again comparing Canadian response to the American response. Was there a time where opposition to harm reduction in Canada was more similar to sort of what it would be currently in large portions of the US, in other words more hostile and if that's the case, was there a tipping point a breaking point because clearly over the past several decades and I didn't know if you know historians or sociologists or epidemiologists have pinpointed what that was but I'd be interested to know. Yeah, you know, so it was controversial in Canada, and I see that same those same issues playing out honestly, you know, insight opened, actually, 19 years ago yesterday in 2003, and for a long time many years it was the only sanctions overdose prevention center in the country. It was, it faced numerous lawsuits just like safe house is experiencing in Philadelphia. The case actually went to the Supreme Court of Canada. And that was where you at the end of the day saw the sea change, the Supreme Court ruled and insights favor that these kind of facilities. Do not violate the Canadian controlled substances act and provide what is termed the in the Canadian Charter of Rights and Freedoms. of life, liberty and security of the person. So once that lawsuit was settled in the Supreme Court ruled in insights favor it upset the legal framework for many more overdose prevention centers to operate across the country there are now 39 overdose prevention centers in five provinces that are approved by health Canada, so it did take many years so that was perhaps in 2013 I want to say so it took 10 years between insight opening and the framework in place federally for many more to open across the country So I sort of see where we are now in the US, sort of similar to where Canada wasn't 2003 honestly. So, you know, I'm not a lawyer, I don't know if we might be likely to take that same kind of legal trajectory obviously the countries are very different in terms of their legal frameworks but I'm going to be really interested to see over the coming years. If we run into the same problem in the United States where a handful of jurisdictions like New York City, Rhode Island, maybe San Francisco have these sort of services that they don't open in any other jurisdiction where the need is very great, you know, and that would not be in my view a positive outcome. You know, I, but I do not know how to get us there to the point where these kinds of more robust harm reduction services are broadly available in the US. Is it going to be a legal pathway is it going to be some other pathway. I'm honestly not sure, but, you know, it wasn't entirely straightforward or fast in Canada, either. So, for what it's worth, it may take some time. Now that is, first of all, incredibly interesting and thank you and also somewhat, I think, refreshing because, as you know, better than anyone here being in harm reduction you take a lot of steps back along the way so it's nice to see that there was a progression even if it took time. Yeah, and I always like to appeal to American innovation, you know, we have the opportunity to make these even more effective than they are. We could completely redesign the way that these services are provided, we could develop many more different types of modalities, how to design these services in a way that's more useful and accessible to rural populations, for example. There's a whole bunch of challenges that we have the opportunity to address that other countries have only begun to tackle. So I think it's easy to get just, you know, really disappointed and disillusioned by seemingly how far back the US is in harm reduction innovation, but at the same time, we have the opportunity to lead. Now, and I think we can, and we can be a model for other countries, we don't always have to follow in this circumstance. I, you know, I think with the incredible folks at OnPoint show us the way to do that and there are other incredible people working in many other places, urban environments, rural environments, red states, blue states who are doing similar really phenomenal and innovative work. So I just like to highlight that, Dr. Latronica, too, that, you know, we're, we're also in some ways on the forefront of this and doing, and in many cases doing groundbreaking work. So we're not, we're not always behind, if that makes sense, to sort of end on a positive note. Yeah, no, that is good to remember. Thank you. I'm scrolling here. I don't see anything else in the chat. Is there anyone else? Oh, maybe one popped up. Melody's asking, are you keeping records on people attending the site? That sort of came up earlier. Typically most sites will, you know, for process measures to keep track of how many unique people use, have registered for the facility, and then how many utilizations there are on a typical day or week. So that is typically tracked by most centers. The, the use patterns can vary a lot. You might see people who use overdose prevention services every day or even multiple times a day. There might be other people who use fairly infrequently when they feel like they might be at particularly high risk of overdose if they have a new dealer or are using a different type of substance. So you see all sorts of different use patterns when you start to look at the data sort of in more detail. So it's, I would argue as a researcher, it's helpful to collect that information to know those use patterns and to sort of tailor the services accordingly. Melody says thank you for your responses and time. And I would echo the same. Thank you so much. This was incredibly informative and a pleasure speaking with you. Thank you all. I'm feeling a little bit under the weather and I think I have a cold. Not COVID, I've tested negative twice now so apologies that I've been a bit on low energy or running on not all my full cylinders. So thanks for bearing with my cold here. I appreciate it. I don't think we would have noticed unless you mentioned it. Okay. But I do hope you feel better. Thank you so much, and have a good evening. And thanks for everyone for attending. Take care. Bye bye.

harm reduction

overdose prevention centers

neighborhood outcomes

property values

drug-related litter

public drug use

typical clients

fentanyl test strips

engagement tool