Commentary on Brothers <i>et al</i>.: The role of safer environment interventions in addressing injecting‐related bacterial and fungal infections

Initiatives including supervised consumption services, access to regulated drug supply and decriminalization could facilitate prevention and improved management of bacterial and fungal injecting-related infections. Harnessing potential synergies between differing types of Safer Environment Interventions could address a broad range of drug-related harms. The examination of social-structural forces influencing incidence and treatment of bacterial and fungal injecting-related infections by Brothers et al. [1] illustrates how particular modifiable environments shape risk for injecting-related infections along a pathway from drug acquisition and injection to health outcomes following infections. This suggests adopting a more social-structural approach to managing bacterial and fungal injecting-related infections is promising, with prioritization of Safer Environment Interventions (SEIs) to reshape environmental drivers. Unsafe consumption spaces, unregulated drug quality and restricted access to risk-reduction equipment and programs are forces driving bacterial and fungal injecting-related infections. These also shape injecting-related harms like blood-borne virus transmission, therefore, the potential of supervised consumption services (SCS), access to regulated drug supply and decriminalization of currently illegal drugs is identified. These initiatives could influence multiple stages along the infection pathway and facilitate prevention and improved management of infections. Harnessing synergies between differing types of SEIs could address an even broader range of drug-related harms than the authors note, including overdose. Decriminalization is discussed as a promising macro-level structural SEI to reform prohibitionist frameworks criminalizing people who inject drugs (PWID) [1], which are implicated in the proliferation of injecting-related harm [2, 3]. Potential public health benefits of decriminalization (resulting from prioritizing public health over criminal justice system responses) include reductions in drug-related harm and increased access to risk-reduction programs and healthcare among PWID [4], partially through reduced stigma and discrimination within healthcare [5]. Healthcare access barriers critically shape suboptimal management of injecting-related infections [1], and this would facilitate improved treatment and reduce reluctance to seek care, which negatively impacts the progression of infections [6]. SEIs are constrained in their operation and coverage by regulatory barriers and prohibition [7], therefore, decriminalization could also support the scale-up of interventions with potential to reduce incidence and improve management of injecting-related infections, like syringe services programs and SCS [8, 9]. Enhanced coverage and optimized operation of SCS, through elimination of legal barriers to their establishment and regulations that impede PWIDs’ access [7], would further influence the infection pathway by preventing occurrence of infections and supporting improved identification and management [6]. Decriminalization may also facilitate efforts to reshape multiple environments identified in the synthesis, through further initiatives focused on hygienic consumption spaces, enhanced healthcare policies and practices and access to regulated drug supply. Unregulated drug quality significantly drives injecting-related infections [1], and regulated supply models for currently illegal psychoactive substances have been identified as a public health priority [10]. Although less ambitious than full regulation, providing restricted access to medically regulated drug supply is being piloted in some Canadian settings [11] to reduce drug-related poisoning fatalities stemming from the toxic drug supply. While cited evaluation research demonstrates reduced infection-related hospitalizations among individuals enrolled in pilot ‘safe supply’ initiatives [12], recent studies also report changes in injecting behavior, such as reduced injection frequency and transitions to oral consumption [13], as well as enhanced engagement and retention in other healthcare services [14]. Such programs may exert beneficial effect on the infection pathway through prevention (as pharmaceutical-grade substances intended for injection are provided) and facilitate prompt intervention to identify and treat injecting-related infections. Overlap in the risk environments relevant to infections and overdose suggests regulated drug supply programs may efficiently address a spectrum of harms, as current ‘safe supply’ initiatives can reduce exposure to the unregulated drug supply [11], and many incorporate supervised hygienic drug consumption settings (like SCS) [15]. The veterinary tranquilizer xylazine as an emerging additive in the unregulated drug supply illustrates how specific contaminants can dramatically increase the prevalence and severity of injecting-related infections [16]. Xylazine is now prevalent in some North American drug markets and is associated with serious soft tissue harm in addition to drug poisoning risks, as it contributes to the incidence and severity of abscesses, skin ulcers and infections through vasoconstriction and decreased skin perfusion [17]. Increasing unpredictability and volatility is now a core feature of the unregulated drug supply and novel additives are likely to appear in future [18], highlighting the potential of regulated drug supply to mitigate injecting-related infections, as well as poisoning risks, by reducing unintended exposure to current (and future) contaminants. Expanding SEIs represents a compelling opportunity to reduce a broad range of drug-related harms, including injecting-related infections, through public health-focused approaches to proactively prevent disease and death. This does not dismiss the necessity of clinical care for infections or challenges to the implementation of ambitious structural SEIs (like decriminalization and drug regulation) because of policy inertia and dependence on prohibition [19], but rather focuses on the potential of upstream interventions modifying risk environments and social-structural forces to reduce the incidence, prevalence and severity of diverse injecting-related harms. Will Small: Conceptualization (lead); writing—original draft (lead); writing—review and editing (equal). Sean O'Callaghan: Conceptualization (supporting); writing—original draft (supporting); writing—review and editing (equal). None. There are no funders to report. W.S. is an Associate Professor in the Faculty of Health Sciences at Simon Fraser University, and a Research Scientist at the British Columbia (BC) Centre on Substance Use. S.O. is an MPH candidate in the Faculty of Health Sciences and a Research Assistant at the BC Centre on Substance Use. Both authors declare no financial or other relevant links to companies with an interest in the topic of this article. N/A.

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