'It's our safe sanctuary': Experiences of using an unsanctioned overdose prevention site in Toronto, Ontario.
BACKGROUND
Overdose prevention sites (OPSs) are spaces where people can consume drugs under the supervision of trained volunteers or staff and receive help in the event of an overdose. Unsanctioned OPSs are a grassroots response to the current opioid crisis in Canada.


METHODS
We used rapid evaluation methods to study the experiences of 30 individuals accessing the smoking and injection services at the first unsanctioned OPS in Toronto, Ontario using semi-structured interviews. Data were analyzed using an applied thematic analysis approach to identify emergent themes related to service user experiences, characteristics of the risk environment, and recommended changes to the service model.


RESULTS
The OPS represented a safe sanctuary and brought a sense of belonging to a community that often experiences discrimination. Valued aspects included: shelter; protection from violence; safety from overdoses; free equipment; information about health and social services; food and beverages; and socializing and connecting with others. Integrating peer workers in the design and delivery of services encouraged service users to visit the site. The OPS changed the risk environment by: providing access to the first supervised smoking service in Toronto; having few explicit rules and a communal approach to making new rules; allowing assisted injection, and negotiating with police to allow people to access the site with minimal contact. Service users noted the need to ensure a safe space for women and recommended extended hours of operation and moving to a more permanent space with heat and lighting for both smoking and injecting drugs.


CONCLUSION
The unsanctioned OPS in Toronto served an important role in defining new, community-led, flexible responses to opioid overdose-related deaths at a time of markedly increasing mortality. Providing harm reduction services in diverse settings and expanding services to include smoking and assisted injection may increase access for marginalized people who use drugs.
['Foreman-Mackey|Annie|A|', 'Bayoumi|Ahmed M|AM|', 'Miskovic|Miroslav|M|', 'Kolla|Gillian|G|', 'Strike|Carol|C|']
D000328:Adult D062787:Drug Overdose D005260:Female D040261:Harm Reduction D006801:Humans D008297:Male D008875:Middle Aged D018671:Needle-Exchange Programs D009864:Ontario D000080052:Opioid Epidemic D009293:Opioid-Related Disorders D062487:Social Marginalization D015819:Substance Abuse, Intravenous D055815:Young Adult
Overdose prevention Supervised smoking Assisted injection Harm reduction Community activism Qualitative research Supervised consumption