Introduction

Substance use and related harms have sharply increased across Canada over the past decade, and especially following the onset of the COVID-19 pandemic [1]. For example, since January 2016, there have been 36,442 accidental opioid toxicity deaths in Canada, and the average number of deaths per day has doubled between 2019 (prior to the COVID-19 pandemic), and 2022. Moreover, more than half (56%) of the opioid deaths in 2022 also involved a stimulant [1]. Available data suggest that there have also been over 13,000 apparent stimulant toxicity deaths between 2018 to 2022, with many involving cocaine (64%) and methamphetamine (53%) [1]. Several factors are contributing to the overdose crisis, including increases in the prevalence of opioid use and opioid use disorders, increases in risky drug use, such as using drugs while alone, fentanyl-laced stimulants, and increases in the toxicity of the illicit drug supply [1]. In particular, the province of Ontario has witnessed the highest number of opioid and stimulant overdose deaths in Canada, with 2,501 and 1,811 occurring during 2022 respectively. However, within Ontario, overdose deaths are not evenly distributed, and there have been stark increases in opioid-related overdoses in northern and rural areas since the COVID-19 pandemic began. For example, Greater Sudbury, which is the largest city in Northern Ontario, with a population of approximately 166,004, experienced an opioid-related mortality rate of 44.6 per 100,000 individuals in 2021, which was more than double the Ontario provincial rate of 19.6 per 100,000 [2, 3]. Data from the Greater Sudbury Community Drug Strategy (CDS) further highlights a drastic increase in opioid-related harms. For instance, paramedic services responded to 896 suspected opioid-related incidents in 2021, which was almost double that of 2019 (n = 468) [3, 4]. Additionally, there were 636 visits to emergency departments for confirmed opioid overdoses, representing a rate of 309.5 per 100,000 people, which is substantially higher than the rate for all of Ontario (115.4 per 100,000) [4]. Almost half of opioid deaths in Sudbury in 2022 involved cocaine and a third involved methamphetamines [5].

To address this ongoing crisis, governments across Canada and within Ontario have implemented several harm reduction measures such as supervised consumption services (SCS), with thirty-eight sites operational in Canada as of 2023, twenty-six of which are located in Ontario, and two of which are located in Northern Ontario (i.e., Thunder Bay and now Sudbury) [6]. SCS are evidence-based services that provide space for people who use drugs (PWUD) to safely use substances, typically under the supervision of trained healthcare providers or public health professionals who can also provide referrals to treatment services [7]. SCS allow PWUD to use pre-obtained drugs by way of injection, intranasal, and/or oral consumption [7]. SCS improve overall individual and public health outcomes by mitigating risky substance use behaviours such as sharing or reusing needles, improving access to other health and social services, and reducing the risk of hospitalization and death due to overdose [7, 8].

Although the literature on the benefits of SCS is well established and demonstrates many benefits for PWUD and their communities, these services are less available and accessible in northern and rural jurisdictions in Ontario despite the disproportionately elevated overdose rates in many of these communities [3, 4]. Historically, SCS application requirements have been administratively demanding, making it difficult for smaller communities with fewer resources to be granted approval compared to larger urban settings. In many smaller communities, stigmatization of PWUD is prevalent and contributes to difficulties securing community ‘buy-in’ for SCS, especially considering community consultations are a federal and provincial application requirement. This often results in unsuccessful applications and subsequent limited uptake [8]. For instance, smaller communities are more likely to encounter challenges with meeting Ontario provincial SCS requirements related to the establishment of permanent sites, including location restrictions, rigorous evaluations, the inclusion of on-site treatment services, and addressing community concerns on an ongoing basis, which have all been identified as barriers to operationalization [9, 10].

The city of Sudbury, Ontario, is one such example of a community that has faced many challenges in their efforts to apply for a permanent SCS, underscoring the difficulties some Northern Ontario communities have endured in implementing a SCS. To meet application requirements and corresponding permanent site approval, the CDS undertook a needs assessment between 2019–2020 which consisted of a survey with 190 people who inject drugs (PWID), an online survey with 2,251 community members, focus groups with 52 community partners and stakeholders, and secondary data analysis [11]. The assessment noted that more than half (53.7%) of PWID surveyed reported experiencing an overdose, 58.8% of whom had experienced one or more overdoses in the last six months. Regarding risky substance use behaviors, 71.1% of PWID reported re-using their own needles, 32.6% reported using a needle previously used by someone else, 36.3% reported they had trouble obtaining enough sterile needles to suit their needs, 83.2% reported having injected alone, and 89% reported that they would be willing to use a SCS, if one were to become available in their community. Regarding the distance PWID indicated they would travel to access an SCS, 28% suggested they would walk for up to 20 minutes in the summer to access a SCS, 20% would walk for up to 30 minutes, while 19% would walk no more than ten minutes and 18% would walk no more than five minutes [11]. These results underscored the need for a SCS in the community, yet simultaneously uncovered community member and business owner apprehension, stigmatization, and not-in-my-backyard (NIMBY) sentiments in which residents typically supported the need for the service as long as the location of the service was far away [12, 13].

Following the needs assessment and the subsequent submission of a SCS application, in May 2022, Sudbury was granted a time-limited federal exemption from Health Canada to operate the community’s first federally sanctioned SCS. The temporary site, also known as ‘The Spot,’ opened on September 28, 2022, and provides an array of services such as distribution of harm reduction supplies, consumption services, and referrals to other social and health services. The site is run by the Réseau ACCESS Network, a non-profit, community organization committed to holistic and comprehensive approaches in promoting wellness, harm and risk reduction, and education, which operates in a different location than The Spot [14]. Although The Spot was federally approved, as of Fall 2023, it has not yet received provincial funding and is currently relying on $1.1 million in funding, provided over one year, from the Sudbury city council. Furthermore, the site and its location are currently temporary, with the site slated to close in December 2023, if long-term provincial funding is not granted.

Given the novelty of the service in the City of Sudbury after longstanding harms associated with drug use, and lack of certainty regarding the sustainability of the site, it is important to explore how the site is being experienced by PWUD within the community, including perceived benefits, challenges, and impacts. Gaining an understanding of such experiences and perceptions will be important to understand the site’s utility and ability to meet community needs. As such, we conducted a study to qualitatively examine client experiences of using the consumption service at The Spot through in-depth semi-structured interviews. This data were complemented by administrative site utilization data provided by The Spot staff which included overall uptake of the consumption service based on total number of visits and consumptions, as well self-reported substances consumed within the consumption room by clients. The results of the study can be used to demonstrate the benefits and challenges of the site as well as to inform decision-making practices regarding the sites’ sustainability and impact, including evidence of the community’s need for site permanency.

Methods

The study involved a brief in-person socio-demographic survey followed by a qualitative semi-structured one-on-one interview. The survey collected basic socio-demographics including the age, gender, ethnicity, living situation, and substance use profiles of each participant. The qualitative semi-structured interview guide was developed in collaboration with the primary research team and peer advisors. The interview questions explored participants’ initial perceptions of the site, including any benefits, challenges, and barriers to accessing the site, as well as any impact it has had on, or will potentially have on, drug use patterns and risks of associated harms, and whether, or to what extent, the site is meeting the needs of PWUD. In addition, aggregate site utilization data between September 28, 2022 and August 31, 2023 were provided by the site staff which included monthly totals of the number of consumptions, visits, new clients, as well as the number and types of drugs consumed by clients who accessed the consumption service to contextualize overall consumption room utilization.

Results

The first section of the results reports overall usage of the consumption room, based on administrative aggregate site utilization data retrieved from The Spot. This was used to identify overall uptake of the consumption room in addition to client substance use profiles. The second section of the results highlights participant data from the survey, documenting their socio-demographic characteristics and substance use profiles. This is followed by the qualitative findings.

Site utilization data

Between September 28, 2022, and August 31, 2023, a total of 470 unique clients accessed The Spot, representing 1,181 total visits, and 1,605 total consumptions (see Fig 1). All site visits are counted once, irrespective of whether the client has visited the site before or how many times a client may access the site in a day. Each individual consumption is counted as a unique consumption, whether or not it is the same individual utilizing the consumption room multiple times a day or using the service once but consuming multiple times in one visit. This can lead to instances where the number of consumptions exceed the number of visits.

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Fig 1. The Spot consumptions, unique clients, and visits, based on site utilization data collected between September 28, 2022, and August 31, 2023.

https://doi.org/10.1371/journal.pone.0292862.g001

Of the drugs reported, fentanyl was the most commonly self-reported injected drug with 1,005 consumptions, followed by speedballs (i.e., a mixture of opioids, now most commonly fentanyl and stimulants, typically either cocaine or methamphetamine) (n = 286 consumptions), and methamphetamine (n = 111 consumptions). The Spot has reversed a total of 20 overdose events, nine of which required naloxone, the remaining seven required oxygen only as the intervention. No overdose required EMS.

Socio-demographic characteristics of participants

A total of 20 clients participated in the study (Table 1). The average age of participants was 37, with the majority aged 31–50 (n = 12; 60%). Nearly three-fourths identified as men (n = 14; 70%), and half (n = 10; 50%) identified as Indigenous. Almost half (n = 9; 45%) reported experiencing homelessness.

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Table 1. Participant demographic characteristics.

https://doi.org/10.1371/journal.pone.0292862.t001

Regarding substance use characteristics among participants, fentanyl was the most commonly self-reported substance used within the past 30 days (n = 19; 96%), followed by crack cocaine (n = 17; 85%), and methamphetamine (n = 15; 75%). In terms of routes of consumption, the most common route of illicit opioid consumption was injection (n = 18; 95%) followed by inhalation (n = 14; 78%). Of the 17 participants who used crack cocaine, the most common route of consumption was inhalation (n = 16; 94%) followed by injection (n = 4; 24%). Of the 15 people who used methamphetamine, injection was the most common route of consumption (n = 11;73%), followed by inhalation (n = 9; 60%). See Table 2 for participant substance use characteristics.

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Table 2. Participant substance use characteristics.

https://doi.org/10.1371/journal.pone.0292862.t002

Discussion

This qualitative study examined client experiences and perceptions regarding Sudbury’s first SCS. Data collected suggest that the site presents considerable benefits to PWUD in Sudbury. Participants discussed the importance of the site’s ability to potentially reduce public use, overall frequency of drug use, and stigma, as well as increase feelings of safety regarding drug use, particularly as it relates to overdose risk. Participants also provided thoughtful suggestions to improve the service, such as the site’s location, hours, and policies related to the lack of inhalation services and inability to split or share drugs.

The Spot utilization data further demonstrate a need for the sustainability of the site as there has been a relatively stable increase in uptake and utilization of the site since its inception. The number of consumptions and visits steadily increased month over month until around April, reaching a peak of 202 and 128 respectively. However, the site thereafter experienced a temporary drop in both visits and consumptions, with 118 consumptions and 79 visits in May and 114 consumptions and 77 visits in June. This was followed by a rapid increase in July and August 2023, to numbers surpassing those recorded in the initial months. The number of consumptions and visits in July of 2023 was 224 and 153 respectively and there was 241 consumptions and 201 visits in August of 2023. Research suggests that there may be seasonal impacts on substance use as drug initiation, overdose emergency room visits,police calls for overdoses, and overdoses themselves usually tend to spike in the summer months [16, 17]. In terms of new clients, it appears that this number peaked in December 2022, and has remained relatively consistent within the last five months, with a small reduction in May 2023. Possible explanations for this trend may be that PWUD who were acutely in need of the SCS may have signed up in the initial months of opening, or there is a need for continued awareness and education around the site. Notably, the site also reversed a total of 20 overdoses, underscoring its usefulness as a safe space for PWUD to consume their substances and be attended to in the event of an overdose. Given the disproportionate rates of overdoses and related harms that have occurred in Sudbury, the ability of the site to respond to overdoses is extremely important [3].

In addition to the site’s ability to reduce overdose-related harms during the ongoing overdose crisis, participants discussed the value of The Spot in its ability to potentially address issues related to public consumption and related community-level stigma. Although these sentiments were largely speculative in nature and any impact will likely be contingent on continued sustainability and uptake of the site, available evidence suggests that SCS can, in fact, reduce public stigma toward PWUD through the reduction of crime rates, drug use, and prevalence of discarded needles in public spaces [7, 8, 18]. Data further suggest that SCS can achieve dual goals of reducing public consumption and visibility of drug use while reducing stigmatizing attitudes against them [19]. Considering the evidence, The Spot has the potential to increase perceptions of community safety, which can ideally work to address stigmatization of drug use in Sudbury. This is important to note for other non-urban communities who may experience community-level stigma against PWUD which acts as a deterrent to implementing evidence-based interventions, such as SCS [20, 21]. Recognizing that there might be initial pushback from communities to implement harm reduction programs in their respective neighborhood, it has been demonstrated that emphasizing the importance of overdose prevention can help decrease negative perceptions regarding harm reduction services [22]. As such, stakeholders involved in the implementation of SCS should engage with the public and mobilize discussions around the importance of harm reduction services as a means to reduce visibility of drug use and littering of paraphernalia, as this has the potential to mitigate negative attitudes.

Despite these potential benefits, there were a number of suggestions for how the service could be improved. Participants described issues related to the site’s location and operational hours, and suggested that due to its current location, the site is not reaching its full potential. Evidence suggests that travel acts as a significant barrier for PWUD in accessing health and social services [23, 24], and previous research has emphasized the importance of location and ensuring that travel or distance does not influence one’s ability or decision to use at the site [25–28]. Studies have documented that when harm reduction sites are located far away from where PWUD commonly congregate or are in inconvenient locations, this can act as a significant deterrent for individuals to access the site, which subsequently results in low uptake [24]. Suggestions to relocate the site within the downtown area where people typically purchase and use their substances and extend the operational hours were provided by participants as this could increase accessibility and uptake. However, given there were a minority of participants who emphasized the importance of the discreetness of the site’s current location, this may not benefit all PWUD. Finding a suitable location that appeases both the public but also meets PWUD’ needs is an ongoing challenge. For instance, The Spot is located where it is currently sits due to difficulties finding a location for the site that community members and city council could both agree on. This was a particular challenge, with members of the CDS proposing twelve unsuccessful locations. Deliberations took many months and resulted in advocates opening an unsanctioned temporary site in the interim, where The Spot is currently situated [29]. A systematic review on SCS design suggests PWUD prefer SCS that are open 24 hours a day and seven days a week, and that are near areas with high levels of drug use, health facilities, emergency services, and public transportation [25]. Evidence has also suggested that, when possible, SCS should be implemented in existing harm reduction facilities that are already being utilized by PWUD. This is relevant for other remote or rural communities potentially considering implementing a SCS, which tend to be smaller in population size and where there is less anonymity in comparison to urban settings. Having a stand-alone SCS that is not integrated within other models of care can impact an individual’s decision to access the site given the potential for exposure and associated stigmatization if seen accessing the site. Therefore, having the site integrated within other existing services as a one-stop-shop for PWUD within Sudbury could facilitate connections and referrals to other services. In a study by Jackson et al., (2022), PWUD in Nova Scotia primarily believed a SCS should be located in the same place as their local needle exchange, indicating the importance of a centralized and easily accessible location [30]. Many participants also suggested that SCS should be mobile, which can also increase accessibility [30]. However, finding a suitable location that community members can agree on can also be a contentious issue, which may be particularly relevant for smaller more tight-knit communities, as was the case for The Spot. Balancing the importance of ensuring consumption services are locally accessible and integrated within other health and harm reduction facilities, as well as the concerns of the community, can be difficult, and underscores the importance of community education on the beneficial impacts of SCS.

Another major drawback noted by participants was the lack of inhalation services within the site. Participants identified that in addition to injecting their substances, they would also inhale, some of whom noted doing so as a harm reduction measure. Many participants within our study expressed perceptions that smoking is safer than injection, with a few reporting that they would engage in smoking their drugs first to test them prior to injecting. Routes of consumption have been associated with distinct risks [31]. For instance, injection drug use is associated with increased risks for contracting blood borne viruses and bacterial infections compared to inhalation. However, in terms of risks for overdose, evidence suggests that PWUD who smoke opioids are more likely to use alone than those who use other routes of administration, which considerably increases the risk of overdose [31, 32]. Moreover, more individuals have been dying from opioid poisoning via inhalation than injection in Canada, and there has been a significant shift from injection as the primary route of administration [33–35]. For instance, reports from Alberta, British Columbia, and Ontario suggest that more PWUD experience overdoses due to inhalation than injection drug use, demonstrating the necessity of these services [34–36]. The rise in inhalation-related overdoses combined with perceptions that inhalation is inherently safer route of consumption among PWUD underscores the importance of offering inhalation services to clients. However, most existing SCS do not have inhalation services, aside from a few that were implemented in select jurisdictions within British Columbia and one recent location in Ontario. Although it is no longer in operation, North America’s first inhalation site was located in Alberta, Canada, and had seen an overwhelming response within the first months of its opening [37]. With its inhalation rooms constantly in use, the site had to expand its hours of operation to 24/7 and add more smoking rooms to keep up with demand and long lineups [37]. These findings indicate the necessity of inhalation services, and that PWUD will use these services if given the option to do so [37]. To ensure that The Spot is meeting the needs of all drug users in Sudbury, participants emphasized the importance of inhalation services. Allowing PWUD to smoke their substances in a safe space would enhance clients’ safety as medical personnel would be there to intervene. Further exploration on how administrative and logistical issues can be addressed to support the incorporation of such a vital service into The Spot, and in other SCS provincially, is warranted.

The issues discussed among participants indicate the need for The Spot to be reflective of PWUD diverse drug use patterns, needs, and lifestyles, including recognizing the increasingly common route of administration via inhalation [38, 39]. It is imperative to recognize that needs are different for each person, and policies must reflect this to ensure that The Spot achieves its goals of reducing overdose and related risks. To continue to meet the needs of PWUD in the City of Sudbury, it is imperative for the site to remain operational. Given the temporary nature of the site, the results of this initial exploration into client’s experiences can be drawn on to substantiate the need for site permanency within Sudbury, as well as the potential to relocate and integrate it into existing harm reduction services downtown. The results can also be used as an example for other rural, remote, or northern communities seeking to implement a SCS. In Ontario, securing long-term provincial funding and site permanency can be an uphill battle due to the multiple levels of approval and applications required. Sites must seek federal approval as well as provincial approval, both of which have similar onerous application processes (e.g., the need for extensive and ongoing community consultations, securing an optimal site location, etc.). Additionally, in Ontario, there is a provincial cap on the number of sites they will fund which sits at 21, and sites vying for this funding must demonstrate they can provide comprehensive wrap-around supports and community and city council support. This complicates the ability for communities to find the funding and support for SCS [10]. However, alternatives exist, including ‘urgent public health need sites’ (i.e., colloquially referred to as overdose prevention sites), which are temporary and can be implemented in the interim drawing on municipal funding as communities gather the data and support needed to submit a formal application to the government. For instance, Timmins, another small Northern Ontario community implemented an urgent public health needs site while awaiting federal and provincial approval to operate a permanent site [40]. These temporary sites are becoming more common as communities attempt to mitigate the burden of the opioid crisis and the difficulties involved in implementing SCS. As the policy and political landscape of SCS evolves in conjunction with the opioid crisis—which has disproportionately impacted smaller and northern communities in Ontario—it will be important to monitor the impact that these sites have on communities long-term. This underscores the need for a longer-term evaluation of the site’s uptake and ability to respond to overdoses and increase public safety.

Conclusion

This initial qualitative exploration of client experiences with Sudbury’s first SCS suggests that the site offers many benefits to PWUD within the community and can reduce fatal overdoses, underscoring its utility as a key harm reduction service that can potentially reduce community-level stigmatization. However, participants described issues regarding site operational policies that currently hinder site uptake and may not achieve the desired impact of the program. Suggestions to improve the site included the addition of inhalation services, relocating it to downtown Sudbury where PWUD congregate, and extending the operational hours. The results of this early study demonstrate the value and need for site permanency.