Spatial analyses of health services and drug-related harms in urban and rural settings

The Article by Indhu Rammohan and colleagues1Rammohan I Gaines T Scheim A Bayoumi A Werb D Overdose mortality incidence and supervised consumption services in Toronto, Canada: an ecological study and spatial analysis.Lancet Public Health. 2024; 9: e79-e87Summary Full Text Full Text PDF Google Scholar adds to a growing body of literature showing positive outcomes from supervised consumption services (SCS). To date, the focus of SCS research has been on individual experiences, health outcomes, and perspectives regarding the structuration of such services,2Potier C Laprévote V Dubois-Arber F Cottencin O Rolland B Supervised injection services: what has been demonstrated? A systematic literature review.Drug Alcohol Depend. 2014; 145: 48-68Crossref PubMed Scopus (338) Google Scholar, 3Ivsins A Warnock A Small W Strike C Kerr T Bardwell G A scoping review of qualitative research on barriers and facilitators to the use of supervised consumption services.Int J Drug Policy. 2023; 111103910 Crossref Scopus (8) Google Scholar, 4Taylor J Ober AJ Kilmer B Caulkins JP Iguchi MY Community perspectives on supervised consumption sites: insights from four U.S. counties deeply affected by opioids.J Subst Abuse Treat. 2021; 131108397 Summary Full Text Full Text PDF Scopus (5) Google Scholar with fewer studies on the broader population health implications of these services.5Caulkins JP Pardo B Kilmer B Supervised consumption sites: a nuanced assessment of the causal evidence.Addiction. 2019; 114: 2109-2115Crossref PubMed Scopus (0) Google Scholar Using a comprehensive spatial analysis, this study addresses the spillover outcomes of SCS location by showing that proximity to SCS is associated with reductions in overdose deaths. In Toronto, ON, Canada, where the study was conducted, the baseline rates of overdose deaths suggest that the SCS were—quite appropriately—located in existing high-risk neighbourhoods. Showing significant reductions in overdose deaths in these areas establishes important evidence to inform policy and service planning. These findings also set the stage for future research to address crucial questions about the relationships between physical environments, health services, and overdose morbidity and mortality across multiple jurisdictions, including in rural settings. This study, like the majority of research on SCS and other overdose prevention measures in Canada, is set in a large urban context and might not be generalisable to overdose prevention interventions in smaller and rural communities.6Bardwell G Lappalainen L The need to prioritize research, policy, and practice to address the overdose epidemic in smaller settings in Canada.Can J Public Health. 2021; 112: 733-736Crossref PubMed Scopus (0) Google Scholar Rural settings across Canada are disproportionately affected by overdose mortality,6Bardwell G Lappalainen L The need to prioritize research, policy, and practice to address the overdose epidemic in smaller settings in Canada.Can J Public Health. 2021; 112: 733-736Crossref PubMed Scopus (0) Google Scholar with findings from the province of British Columbia from 2015 to 2018 showing that people living in rural areas had 30–50% higher odds of a fatal overdose than those living in large urban centres.7Hu K Klinkenberg B Gan WQ Slaunwhite AK Spatial-temporal trends in the risk of illicit drug toxicity death in British Columbia.BMC Public Health. 2022; 222121 Crossref Scopus (8) Google Scholar Importantly, research is needed on what role, if any, the establishment of SCS and other overdose prevention measures has in decreasing overdose mortality across rural settings. Given the many different models of SCS, understanding model-based variations is also important. For example, some SCS are embedded within community health centres, where individuals have access to other health services, including opioid agonist treatment,3Ivsins A Warnock A Small W Strike C Kerr T Bardwell G A scoping review of qualitative research on barriers and facilitators to the use of supervised consumption services.Int J Drug Policy. 2023; 111103910 Crossref Scopus (8) Google Scholar which is known to have protective effects against overdose mortality.8Pearce LA Min JE Piske M et al.Opioid agonist treatment and risk of mortality during opioid overdose public health emergency: population based retrospective cohort study.BMJ. 2020; 368: m772Crossref PubMed Scopus (95) Google Scholar From a policy perspective, governments and health authorities would benefit from understanding if particular SCS models lead to greater reductions in overdose (eg, integrated vs stand-alone sites). We hypothesise that SCS that offer inhalation services would provide additional protective effects against overdose, given that the majority of overdose deaths in some Canadian provinces result from smoking toxic drugs.9British Columbia Coroners ServiceIllicit drug toxicity deaths in BC knowledge update: mode of consumption.https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/bccs_illicit_drug_mode_of_consumption_2016-2021.pdfDate: Oct 11, 2022Date accessed: December 7, 2023Google Scholar Including other interventions (eg, opioid agonist treatment and detoxification services) in future spatial analyses would also be of value, to understand the effects of these interventions on drug-related risks and harms across both urban and rural settings. Spatial methods are an important approach for evaluating drug policies, particularly as they relate to changes in built environments. Rammohan and colleagues1Rammohan I Gaines T Scheim A Bayoumi A Werb D Overdose mortality incidence and supervised consumption services in Toronto, Canada: an ecological study and spatial analysis.Lancet Public Health. 2024; 9: e79-e87Summary Full Text Full Text PDF Google Scholar used a comprehensive modelling approach to isolate the spatial hot and cold spots of overdose mortality based on estimated proximity to SCS. The granularity of location is always a challenge with spatial methods, particularly when balancing ethical issues regarding the identification of cases against greater precision in location. In reporting their limitations, Rammohan and colleagues1Rammohan I Gaines T Scheim A Bayoumi A Werb D Overdose mortality incidence and supervised consumption services in Toronto, Canada: an ecological study and spatial analysis.Lancet Public Health. 2024; 9: e79-e87Summary Full Text Full Text PDF Google Scholar state that a reliance on postal codes could limit geospatial specificity; however, they also suggest that postal codes are sufficient in densely populated jurisdictions. Although true for large metropolitan areas, this approach is limited in its application to less densely populated areas, including rural settings. Moving beyond traditional spatial analyses that rely purely on space and towards those that encompass space-time data, such as Bayesian spatiotemporal analysis,10Law J Quick M Chan P Bayesian spatio-temporal modeling for analysing local patterns of crime over time at the small-area level.J Quant Criminol. 2014; 30: 57-78Crossref Scopus (83) Google Scholar would benefit future research in identifying hot spots and variations across time, in which factors such as population rates of substance use might fluctuate. Additionally, as Rammohan and colleagues1Rammohan I Gaines T Scheim A Bayoumi A Werb D Overdose mortality incidence and supervised consumption services in Toronto, Canada: an ecological study and spatial analysis.Lancet Public Health. 2024; 9: e79-e87Summary Full Text Full Text PDF Google Scholar also suggest, inter-relationships between individual and geographical contexts such as how living arrangements, neighbourhood deprivation, and population density are associated with the effectiveness of SCS could be addressed through the use of multilevel spatial analyses. Finally, future research would benefit from mixed-methods approaches that include qualitative interviews and ethnographical observations to improve the understanding of the contexts of drug use and the effects of built environments on drug use-related harms and health service access. To conclude, SCS exist as one policy option on the continuum of care that should be considered for supporting health outcomes for people who use drugs. Given the ongoing debates across the USA, Canada, and Mexico on where SCS should be established, these decisions should necessarily be based in evidence. As such, spatiotemporal research will be crucial in informing SCS implementation. Alongside, research is needed to examine the interconnectedness of this service and other health and social services (eg, housing, mental illness, and addiction recovery supports) and monitor the balance across various approaches to drug use—encompassing harm reduction, treatment, and prevention services. We declare no competing interests. Overdose mortality incidence and supervised consumption services in Toronto, Canada: an ecological study and spatial analysisWe found that the period during which SCS were implemented in Toronto was associated with a reduced overdose mortality in surrounding neighbourhoods. The magnitude of this inverse association increased from 2018 to 2019, equalling approximately two overdose fatalities per 100 000 people averted in the square mile surrounding SCS in 2019. Policy makers should consider implementing and sustaining SCS across neighbourhoods where overdose mortality is high. Full-Text PDF Open Access

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