“We’ve lost a lot of lives:” The Impact of  the Closure of North America’s Busiest Supervised Consumption Site on People Who Use Substances and the Organizations that Work with Them

“We’ve lost a lot of lives:” The Impact of the Closure of North America’s Busiest Supervised Consumption Site on People Who Use Substances and the Organizations that Work with Them | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article “We’ve lost a lot of lives:” The Impact of the Closure of North America’s Busiest Supervised Consumption Site on People Who Use Substances and the Organizations that Work with Them Morgan Magnuson, Shannon Vandenberg, Tracy Oosterbroek, Kevin Dey This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5820964/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Jun, 2025 Read the published version in Harm Reduction Journal → Version 1 posted 13 You are reading this latest preprint version Abstract Background Supervised Consumption Sites (SCSs) are an evidence-based harm reduction strategy to reduce the risk of fatal drug poisonings. However, this approach has faced political opposition in Canada, resulting in the closures of SCSs in some provinces. Our study aims to add to the understanding of the impact of SCS closures by exploring the perspectives of both people who use substances (PWUS) and the staff members of organizations that continue to provide harm reduction services. Our study explores the aftermath of the closure of what was once North America’s busiest SCS, located in Lethbridge, Alberta, Canada, offering a contextualized exploration of regressive harm reduction policies. Methods To better understand the impact of the closure, our study adopts a descriptive qualitative design to explore this novel phenomenon within the unique context of Lethbridge, Alberta. We conducted 27 interviews with PWUS and 10 with Staff Members of organizations that provide harm-reduction services. We chose to use reflexive thematic analysis (TA), which allows for a critical realist and contextual approach to data analysis. Results We developed three themes based on our analysis. Our first theme speaks to the harms of SCS closures on PWUS and organizations that provide harm reduction services. Next, our second theme highlights the perspectives of participants on the political motivations behind the ARCHES closure. Our last theme explores how PWUS and organizations navigate the political opposition to harm reduction approaches while responding to the worsening drug poisoning crisis. Conclusions Our study highlights the continued need to expand harm reduction services and for ongoing advocacy to reverse regressive policy decisions. Supervised Consumption Sites Harm Reduction Policy Politics Background In Canada 47, 162 people died from drug poisonings between January 2016 and March 2024 (Government of Canada, 2024b ). These deaths occur within a policy landscape that shapes the risks associated with substance use. The ongoing war on drugs and a lack of regulated supply has created an environment where the illicit drug supply has become increasingly toxic, and people who use substances (PWUS) often have few options to access safe substances (Boyd et al., 2016 ). In Canada, the illicit supply features not only increasingly strong fentanyl analogues but is also more frequently adulterated with other substances, such as benzodiazepines and tranquillizers, heightening the risk of use (Russell et al., 2023 ; Zhu, 2023 ). Despite this, safe supply projects, which allow PWUS to access substances of known composition, have been publicly and politically opposed and remain unavailable in many provinces of Canada (Government of Canada, 2024a ; Michaud et al., 2024 ; Wilson et al., 2024 ). Safe supply programs currently in operation are often small in scale and have been criticized for strict eligibility requirements, failing to offer participants their preferred substances, and being overly medicalized (Ledlie et al., 2024 ; Macevicius et al., 2023 ). Ongoing drug prohibition and a lack of a regulated, safe supply have necessitated a range of government and grassroots harm reduction responses to the drug poisoning crisis. Although harm reduction can be viewed differently, it has often been defined as any strategy that aims to reduce the risks of substance use without requiring abstinence (Denis-Lalonde et al., 2019 ). Research supports that harm reduction strategies, such as naloxone and sterile supply distribution, are effective in improving health outcomes and reducing drug poisonings for PWUS (Clark et al., 2014 ; Fernandes et al., 2017 ). Harm reduction approaches are often first implemented by PWUS and their allies as pragmatic responses to the changing drug supply before they are established as formal government responses (Goodyear, 2021 ; Smith, 2016 ). However, research suggests that harm reduction approaches are more effective when PWUS are actively involved in their design and implementation (Greer et al., 2019 ; Ti et al., 2012 ). Supervised consumption sites (SCSs) are an important harm reduction strategy in the context of a toxic drug supply, where PWUS can be observed consuming illicit drugs to ensure that potential drug poisonings are witnessed and effectively treated (Canadian Research Initiative in Substance Misuse, 2023 ). Within these sites, PWUS can often also access a range of services targeted at improving their overall health and wellbeing, including medical care, housing support, and referral to community-based services. The inclusion of health and social services differentiates SCSs from overdose prevention sites (OPSs) that focus primarily on reducing the immediate risks of substance use, such as drug poisoning, and may be legally or illegally operated (Canadian Research Initiative in Substance Misuse, 2023 ). Conversely, SCSs are federally sanctioned in Canada, though the way in which they are managed varies both within and between provinces, with some being operated directly by provincial health authorities and others facilitated by community organizations that receive funding through a variety of mechanisms, including government grants and contracts (Government of Canada, 2024a ). SCSs are known to reduce the risk of infections, drug poisoning, and death in PWUS (Kennedy et al., 2017 ; Levengood et al., 2021 ). Using a SCS also increases the likelihood that PWUS access other health and social services, including addiction care (Levengood et al., 2021 ). Additionally, cost-benefit analyses of SCSs have demonstrated favourable outcomes related to the prevention of disease and the associated healthcare costs (Khair et al., 2022 ). As of November 2024, the Government of Canada lists 39 SCSs currently in operation within five provinces, namely, Alberta, British Columbia, Ontario, Quebec, and Saskatchewan, with calls from PWUS, health professionals, and academics to scale up the implementation of this lifesaving harm reduction strategy (Canadian Drug Policy Coalition, 2024 ; Government of Canada, 2024a ). Despite the evidence of their effectiveness and research that suggests that the majority of Canadians support this approach, SCSs remain a contentious political issue in Canada (Curtin et al., 2024 ; Watson et al., 2020 ; Wild et al., 2021 ). In the media, some politicians have suggested a need to scale back the implementation of SCSs, citing concerns about reduced public safety and public order in the surrounding community (Herring, 2020 ; Migneault, 2024 ; Taylor, 2024 ). Despite evidence from systematic reviews that suggests that SCS do not cause increases in crime or public nuisances, some provincial governments in Canada have taken steps to close SCS (Kennedy et al., 2017 ; Levengood et al., 2021 ). In 2020, the Government of Alberta closed SCSs in two communities, with plans to close other sites and provincially operated OPSs by 2025 (Salvalaggio et al., 2023 ; Smith, 2024 ). In August 2024, the Government of Ontario paused all new approvals of SCSs while banning sites near schools or daycares, potentially leading to the closure of 10 of the province's 17 SCSs by March 2025 (Woodward, 2024 ). Both the Alberta and Ontario governments cite concerns about public safety, public disorder, and criminal activity around SCSs (Alberta Health, 2020 ; Government of Ontario, 2024 ). The impact of SCS closures is only beginning to be understood. Greene et al. ( 2023 ) explored PWUS’ perceptions and experiences of the Lethbridge SCS closing. They found that PWUS reported negative experiences related to the closure of the SCS, including the belief that there was an increase in drug poisoning. The study also highlighted concerns about the OPS that replaced the SCS, including its less central location, the absence of inhalation rooms, and a lack of comprehensive services. This study aims to add to the understanding of the impact of SCS closures by including the perspectives of both PWUS and Staff Members of organizations that continue to provide harm reduction services. In the aftermath of the defunding of the SCS, this study also explores barriers to implementing evidence-based harm reduction initiatives and what steps PWUS take to protect themselves from an increasingly toxic drug supply within the current service provision landscape. Methodology Context Our study was conducted in the community of Lethbridge, Alberta. Lethbridge is a mid-sized city located on Treaty 7 land near two First Nations reserves (City of Lethbridge, 2019 ). As a result of the harms of past and ongoing colonization, Indigenous people are disproportionately represented in the population of unhoused PWUS in Lethbridge (City of Lethbridge, 2022 ). The city has one of the highest per capita rates of drug poisonings in the province and once contained the busiest SCS in North America, operated by the AIDS Outreach Community Harm Reduction Education and Support Society (ARCHES), a nonprofit organization (ARCHES, 2020 ; Government of Alberta, 2024 ). Despite the apparent need for SCS, in 2020, the United Conservative Party of Alberta defunded both the site and the majority of the wrap-around programming operated by ARCHES (Hudes, 2020 ). The defunding and closure of the ARCHES facility followed accusations of financial mismanagement in the organization (which were later disproven by a police investigation) and a commissioned report that focused on the harms of SCS (excluding any benefits of the site to PWUS or the surrounding community in their analysis), an approach that has been criticized for being methodologically flawed (Livingston, 2021 ; Salvalaggio et al., 2023 ). Despite the SCS being replaced by a smaller OPS, drug poisoning deaths increased from 56 deaths in 2020 to 125 in 2023 (Government of Alberta, 2024 ). Design and Ethics We chose a descriptive qualitative research design to guide this study, adding to the body of research that explores the impacts of SCS closures on PWUS and service providers. A descriptive qualitative approach is effective in exploring novel phenomena and was, therefore, appropriate to examine the impact of the closure of ARCHES and its SCS in the unique context of Lethbridge, Alberta (Doyle et al., 2020 ; Sandelowski, 2010 ). We used qualitative interviewing to generate the data in our study, as this method is useful for exploring perspectives on the complex landscape of the politics and practice of harm reduction. The University of Alberta’s Research Ethics Board (Pro00120726) approved this study. We recognize that there are important considerations when conducting research with PWUS; however, we agree with others that PWUS deserve both ethical protection and rights through the research process, respecting the range of motivations that PWUS have for participating in research while also protecting their privacy and confidentiality (Bell & Salmon, 2012 ; Fry et al., 2006 ). Participants provided both written and verbal consent prior to data generation. As others have identified, using substances does not inherently impair an individual’s capacity to provide informed consent; however, some interviews were ended early by the interviewer if the participant’s ability to ability to provide ongoing consent became impaired (Bell & Salmon, 2012 ). As PWUS have long advocated for appropriate compensation for their contributions to academic research, participants were given a $ 50 honorarium for their time (Bell & Salmon, 2011 ; Canadian HIV/AIDS Legal Network, 2005; Collins et al., 2017 ) Participant Sampling and Recruitment We used purposive sampling to recruit Staff Members from organizations that provide or have intimate knowledge of harm reduction services in Lethbridge, Alberta. We chose a broad understanding of harm reduction to identify organizations that we deemed to work towards minimizing the risk of substance use in any manner, including those whose work was primarily aimed at improving access to the prerequisites of health, in addition to those that provided more traditional harm reduction services such as safe supply distribution. In line with our qualitative research design, this purposive sampling strategy aimed to provide us with a deeper understanding of the closure of ARCHES by capturing a range of experiences from the Staff Members of diverse community organizations (Sandelowski, 2010 ). All identified organizations were contacted with an email invitation to participate in the study. Recruitment of PWUS occurred by self-selection through posters displayed at public spaces in the Lethbridge downtown area and at community organizations that served people experiencing homelessness or who use substances in the days prior to data collection. To be eligible, participants had to speak English, be over the age of 18, live in Lethbridge, and self-identify as having a history of substance use in the last six months. Data Generation We conducted semi-structured interviews with all participants, lasting between nine and 65 minutes. For PWUS, questions were designed to encourage participants to describe their experience with ARCHES and how its closure impacted their ability to engage in practices intended to make substance use safer. Staff Members were asked to discuss how the closure of ARCHES impacted both their organization and the lives of the people who accessed their services. Both groups of participants were also asked about the current harm reduction service provision landscape in Lethbridge and to reflect on any current gaps or strengths within the community. Staff Member interviews were conducted virtually by three members of the research team (MM, SS, & TO) from September 2022 to January 2023. Interviews with PWUS were conducted in person in a private, convenient downtown location by MM & SS in August 2023. Most of the data generation with PWUS was conducted one-to-one, apart from two instances where participants with close relationships with each other were interviewed together at their request. All interviews were audio recorded and transcribed verbatim by MM & KD. Data Analysis We analyzed the data generated through participant interviews using Clarke and Braun’s ( 2021 ) six-phase approach. Clarke and Braun’s ( 2021 ) reflexive thematic analysis (TA) was chosen for its theoretical flexibility, allowing for a critical realist and contextual approach to data analysis that understands that language communicates the diverse experiences and worldviews of participants, which are shaped by material, social, and political conditions. Much of our coding was inductive, aligning with our descriptive qualitative approach and driven by our participant’s understanding of historical and contemporary events. However, we also recognize that our own backgrounds as service providers within the health and social fields working with PWUS influenced data generation. As such, our themes also reflect concepts we commonly employ in our research and practice, including the social determinants of health, social justice, and health inequities, as well as our belief that health is not primarily determined by genetics or behavioural choices. For example, our understanding that poor health arises from social and economic structures that determine material conditions shaped our understanding of how our participants' experiences of accessing harm reduction services are linked to the broader issues of power and politics. Additionally, as we all work in the community where our research takes place and have witnessed the devastating impact of the unregulated drug poisoning crisis, we are advocates for the expansion of harm reduction services and understand that we are not neutral on this topic. We used Braun and Clark’s (2022) guidelines for “good reflexive TA” to ensure congruency between the data and our analysis, transparency in our theoretical positioning, and clarity in our role in data generation. Each member of the research team initially read the interview transcripts ahead of the coding phase to become familiar with the data. After coding the data and developing initial themes independently, the research team met to discuss and revise themes while interrogating the role our assumptions and positionalities may play in data analysis. Rather than attempting to find consensus, this collaborative process aimed to increase the depth and quality of our data analysis by integrating the diverse perspectives of the researchers. Following this meeting, MM created a list of candidate themes that were then reviewed in relation to the initial codes and the entire data set. Finally, to align with the reflexive thematic analysis process, the entire research team engaged in a refining and naming process to develop our final themes. Results Demographics Out of the 17 organizations we identified, a total of 10 staff members from nine organizations participated in the study. All staff members reported they were working with PWUS in Lethbridge when the SCS closed, with four of the ten participants reporting that ARCHES previously employed them. For our second group of participants, recruitment was completed after 27 PWUS were interviewed, and the research team determined through reflexive practice that the data that had been generated provided a rich description of events and adequately answered our research questions (Clarke & Braun, 2021 ). These participants ranged in age from 27 to 64. Of the participants who self-declared, 48% were Indigenous, 33% were Caucasian, and 4% were Metis. 41% of participants identified as male, 44% as female, and 7% as non-binary. Four of the 27 participants who use substances reported that they had accessed services at ARCHES when it was in operation. Themes Through the reflexive thematic analysis process, we developed three themes that deepened our understanding of the evolving local context of harm reduction in Lethbridge, Alberta. The first theme consists of two subthemes that explore the impacts of decisions about what types of harm reduction services are available within the community. The second theme also includes two subthemes that explore the politics of the ARCHES closure at both the municipal and provincial levels. Lastly, the final theme contains three sub-themes that explore how PWUS and community organizations are currently responding to the unregulated drug poisoning crisis and the ongoing opposition to harm reduction practices. Theme 1 : Life before and after ARCHES Subtheme 1.1: More than just a supervised consumption site Many PWUS and Staff Members suggested that ARCHES was more than just a physical site where harm reduction services were provided. Staff Members of organizations that provide harm reduction services spoke to the breadth of services provided at ARCHES, including its growth from an organization that primarily provided services related to sexually transmitted and blood borne infections to one that provided services to meet the diverse needs of PWUS in the community in the context of a worsening drug poisoning crisis. Participants noted that ARCHES facilitated many initiatives, such as HIV case management, naloxone training and distribution, sterile supply distribution, outreach, clinic services, and cultural programs. One of these programs was described by Staff Member 10: Hip Hop for Healing… it was right off supervised consumption. So, clients could come there, and they'd go and see this guy…he could like mix music, like record it and create a song. And it was unbelievable, the people that were lining up to lay down their tracks. And so, people were creating songs. And you know, it was unbelievable the amount of writing that our clients did, poetry….and so, the organization itself when we think of where it started from, which was HIV and Hepatitis C care, and then it kind of evolved into harm reduction... And then it just exploded into this multi-program organization. Participants also spoke of the nonjudgemental nature of these programs to people who accessed ARCHES programs. Some staff members suggested that ARCHES provided a safe space where PWUS were well supported, with one participant noting: I think that they could just go and be real. They had an opportunity to, maybe, be vulnerable with some of the counsellors and the addiction workers that were on site. They got medical care without discrimination for being a drug user. And it was just a safe place. Like it's our street-involved population that don't have a lot of safe places where they can go and just be. (Staff Member 7). The sentiment was echoed by other participants who had accessed services at ARCHES. For example, when asked about their experience with ARCHES, PWUS 9 reported, “It was it was good. It was going home to people.” Participants also spoke about the positive interactions with the staff at ARCHES; PWUS 1 noted that: The workers were really friendly. They're really passive. Really, like, non-judgmental…Right, so if you asked for something, there's no shame in asking for needles, or a pipe or anything. Like, it was just, they were wonderful. You know, you want something to eat, you want some water or anything? It was a good place. Subtheme 1.2: The harms of regressive drug policies Most participants who were familiar with ARCHES spoke about the negative impact its closure had on PWUS. A common concern among Staff Members was that when ARCHES was defunded, the majority of its programs ceased operations in addition to the closure of the SCS. For example, Staff Member 1 stated: Again, because there were so many programs under that umbrella, like it wasn't just supervised consumption that was closed, the HIV programming was closed, peer-based programming was closed, the naloxone program, which is now operating under a different provider, but not within the City of Lethbridge. I can't even think of all the programs [that closed]. They had an outreach team . Some also spoke about a reduction in programs that served Indigenous people in the community following the closure. Staff Member 2 noted: But it was an Indigenous cultural group where they would bring elders in. There was a music group, and it was a good way to reconnect folks with their culture. So, with ARCHES shutting down it kind of limited the resources for that specific demographic of Indigenous folks that are using substances. As I said, there are a few more out there, but they were connected to that one in particular and felt comfortable talking without being judged. Both Staff Members and PWUS spoke about the initial gaps in ham reduction service provision following the closure of ARCHES. Staff Member 2 highlighted their concerns that there was no longer an organization that facilitated broad sterile supply distribution, “ Since it [ARCHES] closed, I mean, we hand out some supplies, but we only hand them out to our direct participants. We do have people that are asking for supplies, and unfortunately, we can't give them to them. ” In addition to a more targeted approach, some also noted how the closure meant fewer organizations were able to hand out supplies to meet the needs of people who inhale their substances. Staff Member 4 stated, “We are able to hand out and supervise people who use needles, but we're not able to provide the items to use safer inhalation, and we're not able to observe them while inhaling, as well.” PWUS spoke about the continued challenges of accessing sterile inhalation supplies in the face of organizational policies that limit distribution, including PWUS 25, who indicated, “ Yeah, once every three days, you can get one [bubble pipes]. And then straight shooter, well, straight shooter you can get more often and tin foil. Umm, other than that, I have to buy them.” In response to a question about the ease of accessing sterile supplies, PWUS 17 suggested, “ I mean, it is what it is, but a lot of people find that their bubbles are sacred. Like, there's fights and violence that break out because of it…” Some participants spoke about the differences between SCS and the AHS-operated OPS, noting how the OPS had less capacity to support PWUS. Staff Member 4 noted: Well, so they did throw together the OPS bus around the same time that the site [SCS] closed. The OPS bus… doesn't have anywhere for storage. It is not wheelchair accessible. It only has one nurse, one paramedic and an addictions counsellor on and peer support. And they only have two booths. So that went from a [SCS] site with, I think it was, 11 to 12 booths plus two inhalation rooms. The differences between the capacity of SCS versus the OPS were particularly notable in regard to their ability to support supervised inhalation. Staff Member 4 explained: Yeah. So, ARCHES also had inhalation rooms, which I think they were the first ones [to offer inhalation rooms] in North America or Canada; I could be mistaken. But they were pretty new to us. And we no longer provide those.” Similarly, PWUS 24 stated their concern for the lack of inhalation rooms in Lethbridge following the closure of ARCHES, “The people who use needles have a place that they can inject safely. People that smoke, I don’t know… Well, smokers have been left out.” In addition to reductions in the type and scope of harm reduction services offered in Lethbridge, participants suggested that the closure of ARCHES damaged relationships between service providers and PWUS. Many Staff Members highlighted the need for good rapport for harm reduction programming to be effective and the damage that can be created when trusted service providers are no longer able to follow through with commitments as a result of the eroding service provision landscape. Staff member 2 described, “ But yeah, I think a lot of people were lost. I think it created a lot of distrust in the system. I think the way that it was handled really demonized a lot of our participants and stigmatized them.” Participants from both groups suggested that the closure of ARCHES may have led to more deaths in the community from drug poisoning. Some PWUS suggested that the absence of SCS in the city may have resulted in more people using alone, with PWUS 15 noting, “ When that place [the ARCHES SCS] was up, it was being watched over. Right now, they just go somewhere by themselves, and they overdose, and they’ve lost a lot of them. ” When asked about the impact of the closure of ARCHES on the community, PWUS 25 noted simply, “ We've lost a lot of lives .” Similarly, Staff Member 9 noted in response to a question about whether the closure of ARCHES impacted PWUS’s ability to keep themselves safe: Yeah, so between us and the [Local Harm Reduction Organization] and the other place, or the other grassroots outreach people that were out there, we all noticed that there were a number of increases in overdoses that we had to manage and attend to… But my feeling is that, of course, they had no place to go. So, people were using on the street or using in seclusion, which is even worse. So, if they do overdose, there's nothing that can be done because people can't find them, right? Theme 2: The politics of the ARCHES closure Subtheme 2.1: NIMBYism in Action Many participants discussed the ways in which local politics may have influenced the decision to close the SCS and many of ARCHES’s other programs, which were located in the Lethbridge’s downtown area. Some participants drew on concepts such as not in my backyard (NIMBY) to highlight the backlash towards PWUS and the organizations that provide harm reduction services in Lethbridge, such as Staff Member 2, who suggested: So, I mean, when ARCHES was running, there was a lot of not in my backyard mentality. That mentality still exists . And, you know, ARCHES was set up where it was because of the close proximity to the shelter and where a lot of folks were already congregating downtown…I think, you know, a lot of people were like, oh, we'll put the SCS outside of town. That also wasn't necessarily a good option, either, because then how do people access it? Boxing everyone up and shipping them away doesn't solve the problem. Similarly, PWUS 21 suggested that PWUS were not welcome in the downtown area: I don't read the paper, but I came across something accidentally, and it's a roast and toast. They said all the addicts and people trying to help them should be moved, basically moved out to a compound outside the city and fenced off. And later, regarding the ARCHES SCS: Here in Southern Alberta, I find there to be a lot of NIMBY attitude. Not my problem, or not my backyard; I don't want him in my backyard…move it somewhere else, put it somewhere else, give it to somebody else. Tax the fuck out of them, so they go leave and go to a different city. Become somebody else’s problem. Don’t try to help them. Why? The belief that PWUS do not belong in the community was also discussed in relation to racism. As Indigenous people are disproportionately represented in the population of unhoused people who use drugs in Lethbridge, participants drew attention to how the intersecting discriminatory attitudes influence how PWUS are perceived. In response to a question about the difficulties of implementing harm reduction services in Lethbridge, Staff Member 2 suggested: In Lethbridge, I would definitely say a huge part of it is, almost all, I want to say, a lack of understanding from just the general community. But there definitely is a bit of a stigma attached, and the racism component as well is huge… In Lethbridge, unfortunately, it’s a tight-knit community. You're either in the community or you're out of the community. Some participants described how the disdain for both PWUS and ARCHES being present in the downtown led to dangerous situations for both people accessing harm reduction services and staff. Staff Member 10 described their experiences of violence while working with ARHCES: I remember working in reception at supervised consumption, and some lady came in filming, telling us we were all, you know, effing disgusting. And it was pre-, kind of political drama. It was just, she heard, we were doing supervised consumption, and “How could you?” That was consistent, and we had all sorts of terrible things happen. We had death threats. I had terrible messages on my voicemail. We had a staff who got shot up with a paintball gun on a night shift. And honestly, a lot of the violent stuff that happened to us or to clients. Subtheme 2.2: Unpacking the motives behind the ARCHES closure In addition to the local politics of harm reduction, participants described how the provincial government influenced the closure of ARCHES. Participants suggested that ARCHES became a scapegoat for perceived increases in disorder and risk to public safety within the community. Staff Member 7 noted: And I think the messaging was, you know, the supervised consumption site goes away, the problem, the drug problem in Lethbridge, goes away. And as we can now see, two years later, that's clearly not the case. And it's, in fact, worse now than it's probably ever been. Rather than being based on evidence or local needs, Staff Members suggested that the decision to defund ARCHES may have been ideologically motivated. Some participants suggested that ARCHES did not align with the provincial government’s preferred policy approach to the unregulated drug poisoning crisis. For example, when describing the provincial government’s approach to substance use, Staff Member 4 noted, “ We also seem to have a government currently that is very favourable for abstinence-only type of recovery .” Others described how the provincial government’s dislike for harm reduction contributed to the closure of ARCHES, like Staff Member 2, who stated: And, you know, from my perspective, a big part of that was because of politics and the government not liking supervised consumption sites at the time. They didn't, it felt to me anyway, really take into account all the other programs. They just said, oh, we don't like supervised consumption sites. The way in which the provincial government handled the accusations that ARCHES staff had mismanaged funds was framed by some participants as being both unusual and politically motivated. Staff Member 2 suggested: We [the provincial government] found some kind of mismanagement of funds. Let's not dig any further. Let's just shut the whole thing down. It wasn't, you know, oh, let's reevaluate. Let's change the staffing. Let's, you know, we'll see what we can do to fix this problem. It was more of we don't like it [the supervised consumption site]. So, we're just going to shut the whole thing down. That's what it seemed like to me, anyway, yeah, political. Similarly, Staff Member 1 noted: And ARCHES was, I think, a bit targeted in that. Not that there weren't things that needed to be addressed or fixed. There certainly was. But it very much felt, like, vindictive. It very much felt like this was targeted. It didn't feel evidence-based. It didn't feel rooted, in fact, or something that needed to happen… So, I think it's just been really frustrating. It feels like it's very rooted in morality and not in evidence. Some participants also spoke to the In addition to a more general rejection of harm reduction approaches, a former ARCHES employee, Staff Member 10, described how the poor relationship between the government and the organization played a key part in the closure of the ARCHES site: When you look at ARCHES, we did not do that right. Leadership was kind of abrasive, aggressive, us against them, and it should not have gone that way. And that's why everything fell apart. Too many enemies were made. It was just us versus them. You either are for harm reduction and people who use drugs, or you're a racist… It was just siloing us and making enemies, and then we made enemies with the government. And then that was the end of that [ARCHES]. Theme 3: Navigating the current harm reduction service landscape Subtheme 3.1: Surviving the Crisis: Strategies for responding to policy choices and the evolving unregulated drug poisoning crisis To navigate changing policy approaches and the worsening of the unregulated drug poisoning crisis, PWUS spoke about the ways in which they try to protect themselves from the toxic drug supply. When asked about how they kept themselves safe, many participants spoke about implementing commonly accepted harm reduction practices such as never using alone, not sharing supplies, consuming test doses, drug checking, and carrying naloxone. Most PWUS in our study indicated that they inhaled their substances, with some suggesting that they had transitioned to this route from injection to make their substance use safer. For example, PWUS 22 stated that they recently switched to smoking, “ Ah, because injection just seemed more riskier for me.” Participants also spoke about the challenges of an increasingly toxic drug supply. Some participants suggested that they now use methamphetamine, in addition to opioids, to help manage a riskier supply. PWUS 21 stated, “ And usually when I’m using fentanyl, I will mix it with side, because fentanyl isn’t usually fentanyl, it’s cut with, ah what is it? Benzo. Knocks you right out.” Similarly, when asked about their reason for using methamphetamine and opioids concurrently, PWUS 13 stated, “ So that you don't fall asleep ,” and PWUS 14 said, “ I usually mix it with meth, with it... Yeah, so your heart doesn’t just stop. Other participants suggested that they mixed methamphetamine and opioids together as a measure to reduce the risk of or to reverse a drug poisoning. When asked about how methamphetamine is used in response to the toxic supply, PWUS 14 suggested, “And then honestly, people use methamphetamine to try and wake you up. But it is honestly way better because when we get naloxone, we get so sick.” Subtheme 3.2: Funding Forces: How precarious contracts shape the harm reduction service landscape The current political landscape towards harm reduction also impacts the community organizations that work with PWUS. Many Staff Members noted the challenges of providing services under the current system of government contracts and grants. When asked to expand on how the current funding model impacts the provision of harm reduction services in the city, Staff Member 5 suggested that contract funding creates instability for both Staff Members and PWUS: It's always changing and so everybody's very vulnerable to funding. Like one day, this might be available to you, and then tomorrow, it isn't, because how the money has come down is through, you know, the government, to the municipal government. The municipal government is, you know, divvying out these funds to support this population… We have work and staff whose positions are very dependent on our harm reduction and permanent supportive housing relationships. And our clients get close to our staff. And we can't be sure that in six months staff will still be working because they're temporary. Staff Member 7 also raised concerns about how short-term funding arrangements impact PWUS: It's confusing. It's confusing for us, and it's confusing for clients. Because clients, as I'm sure you guys know, this population that we work with is incredibly difficult to engage... And when services change hands or contracts change hands, I mean, five years really isn't much time. By the time you develop a relationship and rapport with the client. If you don't get that grant again, someone else has to restart where you already were five years in. In addition to the challenges associated with this funding model, some Staff Members also spoke about the overall lack of funding for harm reduction in Lethbridge. Staff member 1 offered, “ Before I moved into harm reduction, I was in housing, and it was the same. It felt like Lethbridge was always being bypassed for significant funding .” When asked about the potential reasons Lethbridge may be overlooked for funding, the participant stated: And it's also really hard to think that this isn't rooted in racism, because I think Indigenous people are disproportionately impacted in Lethbridge. Yeah, it's just really hard. Between people who use drugs and Indigenous people, I just don't think they're a priority for the government. Subtheme 3.3: Evidence vs. Politics: A balancing act Many Staff Members discussed the challenges of providing comprehensive harm reduction services that meet the needs of PWUS in the current political landscape. Some staff members spoke about a shift in the willingness of community organizations to offer harm reduction in the aftermath of the closure of ARCHES. Staff Member 7 suggested: Politics is getting in the way of helping people access their human rights to harm reduction and health care… I have heard, and personally do not believe, that after what happened with ARCHES, any nonprofit in our community would be willing to become the next supervised consumption site or be known for becoming the next supervised consumption site. I think that there's a lot of fear amongst, you know, a lot of the agencies. In response to a question exploring potential challenges organizations might face if they chose to take up some of the harm reduction services that ARCHES had previously provided, Staff Member 2 similarly suggested, Um, well, I think with everything that ARCHES ran, a lot of organizations didn't want to go near that [harm reduction services] with a ten-foot pole for their own funding. And then being under the scrutiny of, you know, government organizations. In addition to these perceived barriers to organizations providing harm reduction services in Lethbridge, the need to balance politics and evidence was evident in the ways in which organizations describe the services they currently provide. When speaking about how their organization engages in sterile supply distribution, Staff Member 7 stated: We’re not just like raining them [sterile supplies] all over the street. Of course, we're very aware, I guess, of what we're handing out, how much we are handing out, who we're handing it out to, and making sure that every time we hand out supplies, we are having conversations about other addiction supports or community supports that they could engage in. When asked to explain how they decided on this approach, and after clarifying that their organization would not be named in final reports, they responded: We don't want the misunderstanding to be created that [the organization], you know, just gives bubble pipes out to everybody…. We don't want to be known as a distribution center; we don't want to be known as a distribution site… So I think that is a big piece is just that, we need to balance the political view of our agency as well, if that makes sense, and the community view of our agency for future, potential, you know, opportunities that we have for funding for serving other vulnerable populations, while still making sure that vulnerable people are getting what they need if they are using substances. Discussion Our findings are consistent with research that suggests harm reduction organizations improve the health and wellbeing of PWUS in ways that move beyond the proximal risks of substance use, such as infections and drug poisonings (Ivsins et al., 2023 ). ARCHES, like other SCSs, provided services that supported improvements in the quality of PWUS’ social determinants of health, such as medical care, housing support, and the provision of material resources such as food and clothing (Bardwell et al., 2020 ; Boyd et al., 2020 ; Ivsins et al., 2023 ; Kerman et al., 2020 ; Small et al., 2009 ). Additionally, our research supports the findings of Kerman et al. ( 2020 ) and Ivsins (2023) that SCSs act as an important point of connection between PWUS and other health and social services. Similar to other studies exploring the perceptions of PWUS who access harm reduction services, our study found that most people who accessed ARCHES felt welcomed, supported, and included (Boyd et al., 2020 ; Greene et al., 2023 ; Kerman et al., 2020 ; Oudshoorn et al., 2021 ). Taken together, our findings add to the body of research that suggests that SCSs are an important source of connection to a wide range of safe and judgement-free health and social services. Many of our participants who used substances believed that the closure of ARCHES, including its SCS, caused an increase in drug poisonings and a decrease in the ability of PWUS to protect themselves from a toxic unregulated drug supply, echoing the findings by Greene et al. ( 2023 ). The perception among PWUS that the reduced capacity or closures of SCSs leads to increased drug poisonings has also been reported in literature exploring the impacts of the COVID-19 pandemic on harm reduction services (Foreman-Mackey et al., 2023 ; Russell et al., 2021 ). Although there are likely many factors that have contributed to the increase in drug poisonings in Lethbridge since 2020, including increased toxicity in the illicit drug supply and the wide-reaching impacts of the COVID-19 pandemic, the inability for the majority of our participants to access services that support their preferred method of consumption is likely a contributing factor (Beesoon et al., 2022 ; Mitra et al., 2024 ). As many of our participants who use substances reported that smoking was their preferred route of consumption, the transition from ARCHES to the OPS, which lacked the infrastructure to support supervised inhalation, was identified as a significant obstacle to minimizing the risks associated with substance use. The shift towards inhalation rather than injection as the preferred method of consumption and the route most commonly associated with drug poisoning has been noted in other recent Canadian studies (Fischer et al., 2024 ; Kamal et al., 2023 ). Many of our participants voiced a willingness to access supervised inhalation facilities, something that has been noted in Gehring et al. ( 2022 )’s scoping review. Despite these trends, sites with the capacity to support supervised inhalation continue to be rare in Canada, with only two sites ever receiving a federal exemption (one being the now-closed ARCHES’s SCS and the other in Saskatoon that continues to operate) (Canadian Research Initiative in Substance Misuse, 2023 ). Although the cost of building or retrofitting the ventilation infrastructure necessary to support indoor supervised inhalation may be prohibitive, without these sites, our findings suggest that many PWUS will be unable to access this lifesaving harm reduction strategy (van Draanen et al., 2023 ). In addition to the impact of changes to the harm reduction service provision landscape, PWUS in Lethbridge reported modifying their drug consumption to respond to an increasingly toxic drug supply. Our participants reported adulteration in the supply of “down” (fentanyl or its analogues) with benzodiazepines and other sedatives and “side” (methamphetamine) with fentanyl, reflecting trends seen in other parts of the country (Russell et al., 2023 ; Wagner et al., 2023 ; Zhu, 2023 ). To respond to the dangers of the toxic supply, our participants altered both their route of consumption, favouring inhalation over injection, as well as the types of substances they consumed, including using “down” and “side” together, to combat the increase in depressive effects caused by substances such as benzodiazepines that are now common in the illicit supply. Although the deliberate concurrent use of “down” and “side” is not a new phenomenon, the idea that methamphetamine can be used to reduce the harms associated with using adulterated fentanyl (including those caused by the risk environment many unhoused PWUS face) may be a recent response to the changing illicit supply (Daniulaityte et al., 2020 ; Eger et al., 2024 ). As there are health-related harms associated with taking depressants and stimulants at the same time, it seems prudent to explore ways to increase the accessibility of substances of known contents and doses so that PWUS can reduce their risks. To meet the needs of PWUS in the community, Staff Members of organizations that provide harm reduction spoke about the necessity of expanding and improving the harm reduction services available in the city. However, many noted that the competitive landscape of contract funding was a barrier to effective program planning and implementation. The decline of the welfare state in Canada has led to a greater emphasis on nongovernmental organizations, such as ARCHES and many of the organizations whose staff members participated in our study, to provide necessary health and social services within their communities through what are often short-term and insecure funding arrangements with the government (Baines et al., 2014 ; Phillips & Wyatt, 2021 ). Although funding insecurity is not unique to organizations who work with PWUS, the current political opposition to harm reduction from many conservative political parties at all levels of government, including in Alberta, likely increases their funding precarity (Salvalaggio et al., 2023 ; Wilson et al., 2024 ). For organizations, insecure and insufficient funding impacted staff morale and turnover and prevented them from implementing robust programming to meet the needs of PWUS. Staff Members also described how funding arrangements prevented consistency in service provision as organizations competed for, secured, and then lost contracts within the timeframe of a few years. They noted that when service delivery changes hands between organizations, the relationships between service providers and PWUS are negatively impacted, which can create barriers to service utilization. In their systematic review of barriers and facilitators to the use of SCSs, Ivsins et al., ( 2023 ) noted that relationship-building is critical in promoting harm reduction service and, more broadly, healthcare utilization. Given the intersecting marginalizations many PWUS in Lethbridge experience, the potential damage to the relationships between health and social providers and the people in need of services in the aftermath of the ARCHES SCS’s closure likely led to further harm. More robust and stable funding would better support nongovernmental organizations' work in restoring trust with the community and addressing the needs of PWUS. Our participants spoke to their belief that the current approach to harm reduction in Lethbridge was driven by ideology rather than evidence. Dominant ideologies influence who is perceived to belong or pose a risk within a community, reflecting the racist, colonial, and capitalist history of Canada. Both PWUS and Staff Members noted that the decision to close ARCHES was supported by community members who believed that the SCS did not belong in the downtown area. The concept of NIMBYism has been identified as a barrier to the implementation and operation of SCSs, where people may express broad support for the sites as long as they are not located near them, citing concerns of public safety, needle debris, and the impact on businesses (Cran, 2022 ; Kolla et al., 2017 ; Ziegler et al., 2019 ). Our findings add to this body of research as our participants identified NIMBYism as a key driver behind the closure of ARCHES and its SCS. Staff Members also reported that the controversy surrounding the site was not only about the impact of the SCS but also the PWUS who accessed it. Participants noted how racism may have played a role in the opposition to the SCS because, like PWUS, Indigenous people face discrimination and marginalization within the city. These forces have been explored by other scholars who suggest that Indigenous people face increased policing, sometimes as a response to public substance use, and restricted access to public spaces in the downtown Lethbridge area (Granzow, 2017 ; Ozcan, 2023 ). These authors suggest that these strategies are part of the broader ongoing colonial project designed to marginalize and exclude Indigenous people (Granzow, 2017 ; Ozcan, 2023 ). Our study adds to this body of knowledge, suggesting that discrimination and racism shape policy responses in various ways, including by attempting to reduce the visibility of PWUS by limiting the availability of harm reduction services in certain areas. Ideology also shapes support for differing approaches to the issues that are often associated with substance use (Fischer et al., 2016 ; Marshall, 2015; Wilson et al., 2024 ). In Alberta, Wilson et al. ( 2024 ) have noted that the ideological position of the governing United Conservative Party supports an abstinence-based approach. The authors argue that an abstinence-based approach represents the provincial government’s narrative that the root cause of harm for PWUS is the “addiction crisis,” obscuring the role that public policy decisions have on the illicit drug supply and individualizing the unregulated drug poisoning crisis. This framing can then be used to justify their opposition to harm reduction approaches, which are blamed for enabling people to engage in risky behaviour, regardless of the potential harm to PWUS and their community. Our findings support literature from the political economy of health inequities field that public policy decisions are not driven primarily by the evidence base or the needs of the community but by powerful groups who have little interest in supporting the harm reduction work of nongovernmental organizations that is not easily commodified (Raphael, 2014 ). Given the current government's preference for abstinence-based approaches, many of the Staff Members in our study spoke about the need to balance evidence and politics in their provision of harm reduction services. For example, Staff Members suggested that their organization's reputation within the community influenced how they approached providing harm reduction services, seeking to limit the perception that they were contributing to public disorder. Staff Members also spoke to fears of potential backlash from the government for providing harm reduction services, fearing that, like ARCHES, their organization may be defunded. Staff Members described how these fears led them and their organization to either hide, limit, or discontinue the harm reduction services they provided. For example, some noted the reluctance of some organizations within the community to provide safer smoking supplies, leading to a decrease in access in the immediate period following the closure of ARCHES, as well as continued restrictions on distribution at the time of data collection. Although participants noted how organizational-level policies on smoking were a barrier to distributing safer smoking supplies, a phenomenon noted elsewhere in the literature (Public Health Ontario, 2023 ), they also suggested that the need to maintain a positive reputation also played a role. As safer smoking supplies are well known to reduce disease transmission, reports that organizations feel they are unable to follow best practice recommendations are concerning. These insights into service provision in a climate of intense political opposition to harm reduction add to concerns about how ideological positions of policymakers can cause harm to PWUS and the broader community. Calls to Action To remedy the root causes of harm that PWUS experience, they must be positioned to guide the policy decisions that affect them. PWUS, in our study, made it clear that unrestricted access to sterile supplies, SCSs with the capacity to support inhalation, and programs that support improvements in the quality of the social determinants of health, such as housing, are needed to improve their health and wellbeing and prevent drug poisonings. As SCS cannot prevent all the harms associated with the unregulated drug supply, PWUS must also be actively involved in policy discussions to end drug prohibition and increase the availability of a safe supply. To address the concerns of Staff Members, governments at all levels should explore funding mechanisms that allow for more stability and consistency in the provision of harm reduction services. As ideologies shape the acceptance of harm reduction interventions, PWUS, service providers, and academics should continue to challenge stigmatizing and racist narratives that create moral panic about illicit substances and the people who use them. Grassroots organizing will likely be necessary to resist the further denigration of harm reduction services, given the current political landscape. Limitations Our findings reflect the unique context of the closure of the ARCHES-operated SCS in Lethbridge, Alberta, but some limitations should be noted. First, only four PWUS we interviewed had accessed the services provided by ARCHES, meaning that our findings about the impact of its closure disproportionately represented the perspectives of Staff Members employed by harm reduction organizations. Although we cannot disregard the impact our sampling method may have had on the characteristics of study participants, this limitation may also attest to the volatile and harmful situation in Lethbridge, where drug poisoning rates remained high over the period from the 2020 ARCHES SCS closure and our data collection in 2023. Another key limitation was the delay in data collection between Staff Members and PWUS, given the constantly evolving harm reduction landscape. For example, at the time we interviewed staff members, few organizations were offering safe inhalation supplies; however, this situation changed six months later when we interviewed PWUS, with some organizations altering their approach to distribution, which increased availability. As such, it was challenging to compare the perspectives of PWUS and Staff Members directly, which may have limited our analysis. Conclusion This descriptive qualitative research study explored the impacts of SCS closures on PWUS and service providers, using semi-structured interviews with PWUS and harm reduction service providers in Lethbridge, Alberta. Our study adds to the literature that identifies power and politics as the root causes of harm experienced by PWUS. Dominant ideologies can prevent the implementation of evidence-based services, forcing PWUS to adopt new strategies to protect themselves from the toxic supply and Staff Members to consider the risks to their organization if they continue to provide harm reduction services. The work of grassroots organizations that support PWUS will continue to be important in filling in the gaps left by regressive policy decisions. Abbreviations PWUS People who use substances SCS Supervised Consumption Site Declarations Ethics approval and consent to participate This study was approved by the University of Alberta’s Research Ethics Board (Pro00120726). All participants provided written and ongoing verbal consent. A $ 50 honorarium was provided to study participants who use substances. Consent for publication Not applicable Competing interests The authors declare that they have no competing interests. Author Details Faculty of Health Sciences, University of Lethbridge, Lethbridge, Alberta, Canada. Funding This study was funded by the Canadian Institutes of Health Research through the Canadian Research Initiative in Substance Matters’s Prairie Node. Author Contribution MM, SV and TO conceptualized the study. All authors completed data analysis. MM wrote the initial draft of the manuscript. All authors reviewed the manuscript. Acknowledgements Not applicable Availability of data and materials Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. References Alberta Health. (2020). Impact: A socio-economic review of supervised consumption sites in Alberta . https://open.alberta.ca/publications/9781460147054 ARCHES. (2020). Our history . https://archesqueerhealth.ca/our-history/ Baines, D., Cunningham, I., Campey, J., & Shields, J. (2014). Not profiting from precarity: The work of nonprofit service delivery and the creation of precariousness. Just Labour , 22. https://doi.org/10.25071/1705-1436.6 Bardwell, G., Strike, C., Mitra, S., Scheim, A., Barnaby, L., Altenberg, J., & Kerr, T. (2020). "That's a double-edged sword": Exploring the integration of supervised consumption services within community health centres in Toronto, Canada. Health & Place , 61, 102245. https://doi.org/https://doi.org/10.1016/j.healthplace.2019.102245 Beesoon, S., Bakal, J. A., Youngson, E., Williams, K. P., Berzins, S. A., Brindle, M. E., & Joffe, A. M. (2022). Excess deaths during the COVID-19 pandemic in Alberta, Canada. IJID Regions , 5, 62-67. https://doi.org/https://doi.org/10.1016/j.ijregi.2022.08.011 Bell, K., & Salmon, A. (2011). What women who use drugs have to say about ethical research: Findings of an exploratory qualitative study. Journal of Empirical Research on Human Research Ethics , 6(4), 84-98. https://doi.org/10.1525/jer.2011.6.4.84 Bell, K., & Salmon, A. (2012). Good intentions and dangerous assumptions: Research ethics committees and illicit drug use research. Research Ethics , 8(4), 191-199. https://doi.org/10.1177/1747016112461731 Boyd, J., Lavalley, J., Czechaczek, S., Mayer, S., Kerr, T., Maher, L., & McNeil, R. (2020). "Bed bugs and beyond": An ethnographic analysis of North America's first women-only supervised drug consumption site. The International Journal on Drug Policy, 78, 102733-102733. https://doi.org/10.1016/j.drugpo.2020.102733 Boyd, S. C., Carter, C., & MacPherson, D. (2016). More harm than good: Drug policy in Canada . Fernwood. Canadian Drug Policy Coalition. (2024). Open letter: Supervised consumption services site closures due to lack of funding from Ministry of Health . https://drugpolicy.ca/supervised-consumption-services-site-closures-due-to-lack-of-funding-from-ministry-of-health/ Canadian HIV/AIDS Legal Network. (2005). “Nothing about us without us” greater, meaningful involvement of people who use illegal drugs: A public health, ethical, and human rights imperative . http://www.hivlegalnetwork.ca/site/wp-content/uploads/2013/04/Greater+Involvement+-+Bklt+-+Drug+Policy+-+ENG.pdf Canadian Research Initiative in Substance Misuse. (2023). National operational guidance for the implementation of supervised consumption services . Canadian Research Initiative in Substance Misuse. https://crism.ca/wp-content/uploads/2023/09/scs-og-final-20-sept-2023-1.pdf City of Lethbridge. (2019). Lethbridge community wellbeing: Needs assessment report . https://www.lethbridge.ca/media/0f3g2apj/community-wellbeing-needs-assessment-report.pdf City of Lethbridge. (2022). Lethbridge 2022 point-in-time count . https://static1.squarespace.com/static/64246b84b9ecca652aacc1b9/t/6446acc12934de23718de83c/1682353347303/2022+PiT+Count+Report+_FINAL.pdf Clark, A. K., Wilder, C. M., & Winstanley, E. L. (2014). A systematic review of community opioid overdose prevention and naloxone distribution programs. Journal of Addiction Medicine , 8(3). https://journals.lww.com/journaladdictionmedicine/fulltext/2014/05000/a_systematic_review_of_community_opioid_overdose.1.aspx Clarke, V., & Braun, V. (2021). Thematic analysis: A practical guide. Thematic Analysis, 1-100. Collins, A. B., Strike, C., Guta, A., Baltzer Turje, R., McDougall, P., Parashar, S., & McNeil, R. (2017). "We're giving you something, so we get something in return": Perspectives on research participation and compensation among people living with HIV who use drugs. The International Journal on Drug Policy, 39, 92-98. https://doi.org/10.1016/j.drugpo.2016.09.004 Cran, A. (2022). “Why do they treat us this way?”: Supervised consumption sites, racialized geographies, and notions of belonging in southern Alberta. Undergraduate Journal of Humanistic Studies , 12. https://www.carleton.edu/ujhs/past-issues/winter-2022/ Curtin, K. D., Thomson, M., Hyshka, E., Colman, I., Wild, T. C., Belon, A. P., & Nykiforuk, C. I. J. (2024). Assessing support for substance use policies among the general public and policy influencers in two Canadian provinces. Substance Abuse Treatment, Prevention, and Policy , 19(1), 40. https://doi.org/10.1186/s13011-024-00622-w Daniulaityte, R., Silverstein, S. M., Crawford, T. N., Martins, S. S., Zule, W., Zaragoza, A. J., & Carlson, R. G. (2020). Methamphetamine use and its correlates among individuals with opioid use disorder in a midwestern U.S. City. Substance Use & Misuse , 55(11), 1781-1789. https://doi.org/10.1080/10826084.2020.1765805 Denis-Lalonde, D., Lind, C., & Estefan, A. (2019). Beyond the buzzword: A concept analysis of harm reduction. Research and Theory for Nursing Practice , 33(4), 310. https://doi.org/10.1891/1541-6577.33.4.310 Doyle, L., McCabe, C., Keogh, B., Brady, A., & McCann, M. (2020). An overview of the qualitative descriptive design within nursing research. Journal of Research in Nursing , 25(5), 443-455. https://doi.org/10.1177/1744987119880234 Eger, W. H., Plesons, M., Bartholomew, T. S., Bazzi, A. R., Hauschild, M. H., McElrath, C. C., Owens, C., Forrest, D. W., Tookes, H. E., & Crable, E. L. (2024). Protective or potentially harmful? Altering drug consumption behaviors in response to xylazine adulteration. Research Square . https://doi.org/10.21203/rs.3.rs-4810429/v1 Fernandes, R. M., Cary, M., Duarte, G., Jesus, G., Alarcão, J., Torre, C., Costa, S., Costa, J., & Carneiro, A. V. (2017). Effectiveness of needle and syringe programmes in people who inject drugs – an overview of systematic reviews. BMC Public Health , 17(1), 309. https://doi.org/10.1186/s12889-017-4210-2 Fischer, B., Murphy, Y., Rudzinski, K., & MacPherson, D. (2016). Illicit drug use and harms, and related interventions and policy in Canada: A narrative review of select key indicators and developments since 2000. International Journal of Drug Policy , 27, 23-35. https://doi.org/https://doi.org/10.1016/j.drugpo.2015.08.007 Fischer, B., Robinson, T., & Jutras-Aswad, D. (2024). Three noteworthy idiosyncrasies related to Canada's opioid-death crisis and implications for public health-oriented interventions. Drug and Alcohol Review, 43 (2), 562-566. https://doi.org/https://doi.org/10.1111/dar.13796 Foreman-Mackey, A., Xavier, J., Corser, J., Fleury, M., Lock, K., Mehta, A., Lamb, J., McDougall, J., Newman, C., & Buxton, J. A. (2023). “It’s just a perfect storm”: Exploring the consequences of the COVID-19 pandemic on overdose risk in British Columbia from the perspectives of people who use substances. BMC Public Health , 23(1), 640. https://doi.org/10.1186/s12889-023-15474-5 Fry, C. L., Hall, W., Ritter, A., & Jenkinson, R. (2006). The ethics of paying drug users who participate in research: A review and practical recommendations. Journal of Empirical Research on Human Research Ethics , 1(4), 21-35. https://doi.org/10.1525/jer.2006.1.4.21 Gehring, N. D., Speed, K. A., Launier, K., O'Brien, D., Campbell, S., & Hyshka, E. (2022). The state of science on including inhalation within supervised consumption services: A scoping review of academic and grey literature. International Journal of Drug Policy , 102, 103589. https://doi.org/https://doi.org/10.1016/j.drugpo.2022.103589 Goodyear, T. (2021). (Re)politicizing harm reduction: Poststructuralist thinking to challenge the medicalization of harms among people who use drugs. Aporia , 13(1), 26-35. https://doi.org/https://doi.org/10.18192/aporia.v13i1.5272 Government of Alberta. (2024). Alberta substance use surveillance system https://healthanalytics.alberta.ca/SASVisualAnalytics/?reportUri=%2Freports%2Freports%2F1bbb695d-14b1-4346-b66e-d401a40f53e6§ionIndex=0&sso_guest=true&reportViewOnly=true&reportContextBar=false&sas-welcome=false. Government of Canada. (2024a). Interactive map: Canada's response to the opioid overdose crisis . https://health.canada.ca/en/health-canada/services/drugs-medication/opioids/responding-canada-opioid-crisis/map.html#table12 Government of Canada. (2024b). Opioid- and stimulant-related harms in Canada . https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants Government of Ontario. (2024). Ontario protecting communities and supporting addiction recovery with new treatment hubs. https://news.ontario.ca/en/release/1004955/ontario-protecting-communities-and-supporting-addiction-recovery-with-new-treatment-hubs Granzow, M. (2017). The production of public space in a small Canadian city: An analysis of spatial practices in the revitalizing of Galt Gardens. Space and Culture , 20(3), 344-358. https://doi.org/10.1177/1206331217707473 Greene, C., Maier, K., & Urbanik, M.-M. (2023). “It's just not the same”: Exploring PWUD’ perceptions of and experiences with drug policy and SCS services change in a Canadian city. The International Journal of Drug Policy, 111, 103934-103934. https://doi.org/10.1016/j.drugpo.2022.103934 Greer, A., Amlani, A., Burmeister, C., Scott, A., Newman, C., Lampkin, H., Pauly, B., & Buxton, J. A. (2019). Peer engagement barriers and enablers: Insights from people who use drugs in British Columbia, Canada. Canadian Journal of Public Health. Revue Canadienne de Sante Publique , 110(2), 227-235. https://doi.org/https://doi.org/10.17269/s41997-018-0167-x Herring, J. (2020). Province may relocate or close some safe consumption sites, Kenney says . Calgary Herald. https://calgaryherald.com/news/province-may-relocate-or-shutter-some-safe-consumption-sites-kenney-says Hudes, S. (2020). UCP pulls funding to Lethbridge supervised consumption site following audit . Calgary Herald. https://calgaryherald.com/news/politics/ucp-pulls-funding-to-lethbridge-supervised-consumption-site-following-audit Ivsins, A., Warnock, A., Small, W., Strike, C., Kerr, T., & Bardwell, G. (2023). A scoping review of qualitative research on barriers and facilitators to the use of supervised consumption services. International Journal of Drug Policy , 111, 103910. https://doi.org/https://doi.org/10.1016/j.drugpo.2022.103910 Kamal, A., Ferguson, M., Xavier, J. C., Liu, L., Graham, B., Lock, K., & Buxton, J. A. (2023). Smoking identified as preferred mode of opioid safe supply use; investigating correlates of smoking preference through a 2021 cross-sectional study in British Columbia. Substance Abuse Treatment, Prevention, and Policy, 18 (1), 27. https://doi.org/10.1186/s13011-023-00515-4 Kennedy, M. C., Karamouzian, M., & Kerr, T. (2017). Public health and public order outcomes associated with supervised drug consumption facilities: A systematic review . Current HIV/AIDS Reports , 14(5), 161-183. https://doi.org/10.1007/s11904-017-0363-y Kerman, N., Manoni-Millar, S., Cormier, L., Cahill, T., & Sylvestre, J. (2020). “It’s not just injecting drugs”: Supervised consumption sites and the social determinants of health. Drug and Alcohol Dependence , 213, 108078. https://doi.org/https://doi.org/10.1016/j.drugalcdep.2020.108078 Khair, S., Eastwood, C. A., Lu, M., & Jackson, J. (2022). Supervised consumption site enables cost savings by avoiding emergency services: A cost analysis study. Harm Reduction Journal , 19(1), 32. https://doi.org/10.1186/s12954-022-00609-5 Kolla, G., Strike, C., Watson, T. M., Jairam, J., Fischer, B., & Bayoumi, A. M. (2017). Risk creating and risk reducing: Community perceptions of supervised consumption facilities for illicit drug use. Health, Risk & Society , 19(1/2), 91-111. https://doi.org/10.1080/13698575.2017.1291918 Ledlie, S., Garg, R., Cheng, C., Kolla, G., Antoniou, T., Bouck, Z., & Gomes, T. (2024). Prescribed safer opioid supply: A scoping review of the evidence . International Journal of Drug Policy , 125, 104339. https://doi.org/https://doi.org/10.1016/j.drugpo.2024.104339 Levengood, T. W., Yoon, G. H., Davoust, M. J., Ogden, S. N., Marshall, B. D. L., Cahill, S. R., & Bazzi, A. R. (2021). Supervised injection facilities as harm reduction: A systematic review. American Journal of Preventive Medicine , 61(5), 738-749. https://doi.org/https://doi.org/10.1016/j.amepre.2021.04.017 Livingston, J. D. (2021). Supervised consumption sites and crime: Scrutinizing the methodological weaknesses and aberrant results of a government report in Alberta, Canada. Harm Reduction Journal , 18(1), 4. https://doi.org/10.1186/s12954-020-00456-2 Macevicius, C., Gudiño Pérez, D., Norton, A., Kolla, G., Beck-McGreevy, P., Selfridge, M., Kalicum, J., Hutchison, A., Urbanoski, K., Barker, B., Slaunwhite, A., Nosyk, B., & Pauly, B. (2023). Just have this come from their prescription pad: The medicalization of safer supply from the perspectives of health planners in BC, Canada. Drugs: Education, Prevention and Policy , 1-11. https://doi.org/10.1080/09687637.2023.2283383 Michaud, L., Kolla, G., Rudzinski, K., & Guta, A. (2024). Mapping a moral panic: News media narratives and medical expertise in public debates on safer supply, diversion, and youth drug use in Canada. International Journal of Drug Policy , 127, 104423. https://doi.org/https://doi.org/10.1016/j.drugpo.2024.104423 Migneault, J. (2024). Ontario's decision to close 10 supervised consumption sites draws mixed reaction in Sudbury . Canadian Broadcast Corporation. https://www.cbc.ca/news/canada/sudbury/supervised-consumption-closures-sudbury-reaction-1.7299953 Mitra, S., Bouck, Z., Larney, S., Zolopa, C., Høj, S., Minoyan, N., Upham, K., Rammohan, I., Mok, W. Y., Hayashi, K., Milloy, M. J., DeBeck, K., Scheim, A., & Werb, D. (2024). The impact of the covid-19 pandemic on people who use drugs in three Canadian cities: A cross-sectional analysis. Harm Reduction Journal , 21(1), 94. https://doi.org/10.1186/s12954-024-00996-x Oudshoorn, A., Sangster Bouck, M., McCann, M., Zendo, S., Berman, H., Banninga, J., Le Ber, M. J., & Zendo, Z. (2021). A critical narrative inquiry to understand the impacts of an overdose prevention site on the lives of site users. Harm Reduction Journal , 18(1), 6. https://doi.org/10.1186/s12954-020-00458-0 Ozcan, G. (2023). The colour of policing in Lethbridge. In C. Hodes & G. T. Bonifacio (Eds.), Racism in Southern Alberta and anti-racist activism for change . AU Press. Phillips, S. D., & Wyatt, B. (2021). Intersections and innovations: Change for Canada’s voluntary and nonprofit sector . Muttart Foundation. https://era.library.ualberta.ca/items/22cdae0a-2b50-457c-8cdf-2da90604e087/download/68eebf8a-93bc-45e5-863a-42ff8ec479c0 Public Health Ontario. (2023). Harm reduction services for anyone who smokes or inhales drugs . https://www.publichealthontario.ca/-/media/Documents/H/2023/harm-reduction-services-smoking-inhaling-drugs.pdf?rev=255f0227310e46448c8c30ace7b6ef02&sc_lang=en Raphael, D. (2014). Beyond policy analysis: The raw politics behind opposition to healthy public policy†. Health Promotion International, 30 (2), 380-396. https://doi.org/10.1093/heapro/dau044 Russell, C., Ali, F., Nafeh, F., Rehm, J., LeBlanc, S., & Elton-Marshall, T. (2021). Identifying the impacts of the COVID-19 pandemic on service access for people who use drugs (PWUD): A national qualitative study. Journal of Substance Abuse Treatment , 129, 108374. https://doi.org/https://doi.org/10.1016/j.jsat.2021.108374 Russell, C., Law, J., Bonn, M., Rehm, J., & Ali, F. (2023). The increase in benzodiazepine-laced drugs and related risks in Canada: The urgent need for effective and sustainable solutions. International Journal of Drug Policy , 111, 103933. https://doi.org/https://doi.org/10.1016/j.drugpo.2022.103933 Salvalaggio, G., Brooks, H., Caine, V., Gagnon, M., Godley, J., Houston, S., Kennedy, M. C., Kosteniuk, B., Livingston, J., Saah, R., Speed, K., Urbanoski, K., Werb, D., & Hyshka, E. (2023). Flawed reports can harm: The case of supervised consumption services in Alberta. Canadian Journal of Public Health. https://doi.org/10.17269/s41997-023-00825-x Sandelowski, M. (2010). What's in a name? Qualitative description revisited. Research in Nursing & Health, 33(1), 77-84. https://doi.org/https://doi.org/10.1002/nur.20362 Small, W., Van Borek, N., Fairbairn, N., Wood, E., & Kerr, T. (2009). Access to health and social services for IDU: The impact of a medically supervised injection facility. Drug and Alcohol Review , 28(4), 341-346. https://doi.org/10.1111/j.1465-3362.2009.00025.x Smith, C. (2016). “About nothing without us”: A comparative analysis of autonomous organizing among people who use drugs and psychiatrized groups in Canada. Intersectionalities: A Global Journal of Social Work Analysis, Research, Polity, and Practice , 5(3), 82–109. https://journals.library.mun.ca/ojs/index.php/IJ/article/view/1613/1332 Smith, M. (2024). Alberta government to close red deer overdose prevention site, add new recovery services . CBC. https://www.cbc.ca/news/canada/edmonton/alberta-government-to-close-red-deer-overdose-prevention-site-add-new-recovery-services-1.7333122 Taylor, S. (2024). Conservatives would scale back supervised drug consumption sites, Poilievre says . The Canadian Press. https://www.thecanadianpressnews.ca/business/conservatives-would-scale-back-supervised-drug-consumption-sites-poilievre-says/article_e31773a2-b747-580b-b8e1-70266f8aeda4.html Ti, L., Tzemis, D., & Buxton, J. A. (2012). Engaging people who use drugs in policy and program development: A review of the literature . Substance Abuse Treatment, Prevention, and Policy , 7(1), 47. https://doi.org/10.1186/1747-597X-7-47 van Draanen, J., Hamilton, J., Morgan, J., Maxwell, S., Taylor, T., Richardson, L., & Nolan, S. (2023). Supervised smoking facility access, harm reduction practices, and substance use changes during the covid-19 pandemic: A community-engaged cross-sectional study. Harm Reduction Journal , 20(1), 101. https://doi.org/10.1186/s12954-023-00825-7 Wagner, K. D., Fiuty, P., Page, K., Tracy, E. C., Nocera, M., Miller, C. W., Tarhuni, L. J., & Dasgupta, N. (2023). Prevalence of fentanyl in methamphetamine and cocaine samples collected by community-based drug checking services. Drug and Alcohol Dependence , 252, 110985. https://doi.org/https://doi.org/10.1016/j.drugalcdep.2023.110985 Watson, T. M., Kolla, G., van der Meulen, E., & Dodd, Z. (2020). Critical studies of harm reduction: Overdose response in uncertain political times. International Journal of Drug Policy , 76, 102615. https://doi.org/https://doi.org/10.1016/j.drugpo.2019.102615 Wild, T. C., Koziel, J., Anderson-Baron, J., Asbridge, M., Belle-Isle, L., Dell, C., Elliott, R., Hathaway, A., MacPherson, D., McBride, K., Pauly, B., Strike, C., Galovan, A., & Hyshka, E. (2021). Public support for harm reduction: A population survey of Canadian adults. PLoS ONE , 16(5), e0251860. https://doi.org/10.1371/journal.pone.0251860 Wilson, P., Colizza, K., & Hyshka, E. (2024). Safer supply and political interference in medical practice: Alberta's narcotics transition services. International Journal of Drug Policy , 133, 104600. https://doi.org/https://doi.org/10.1016/j.drugpo.2024.104600 Woodward, J. (2024). Many deaths predicted from Ontario’s plan to shut supervised consumption sites: Experts, data . CTV. https://toronto.ctvnews.ca/many-deaths-predicted-from-ontario-s-plan-to-shut-supervised-consumption-sites-experts-data-1.7013045 Zhu, D. T. (2023). Public health impact and harm reduction implications of xylazine-involved overdoses: A narrative review. Harm Reduction Journal , 20(1), 131. https://doi.org/10.1186/s12954-023-00867-x Ziegler, B. R., Wray, A. J., & Luginaah, I. (2019). The ever-changing narrative: Supervised injection site policy making in Ontario, Canada. International Journal of Drug Policy , 74, 98-111. https://doi.org/https://doi.org/10.1016/j.drugpo.2019.09.006 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5820964","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":401905637,"identity":"07f710df-af83-4128-8d91-2928ac91cdca","order_by":0,"name":"Morgan Magnuson","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBUlEQVRIiWNgGAWjYCgAOQZ2BgZmkrQYA9UzNpOkJbGBkBbd9t7HL37uYIjm7197TPJHxZ30DYeZjz8uYLCTx6XF7MxxM8veMwy5M268S5PmOfMsd8NhtsTmGQzJhg24tNxIYzPgbWPIbbhxxkyase0wUAuPYTMPwwFGfFoM/wK1zAdqkfzZdjjd4DD/R5AWezxamB+DbNlwvsdMgrftcILBYR5GkJZEnFrOHGNjlm2TyN14g8fYmufMYcOZh9kMZ/MYJCfj1HK8jfnj2zab3Hnnzxje/FFxWJ7vePODzzwVdra4tAABmwQDAwglIAsa4FYPBMwfwBT/AbyqRsEoGAWjYAQDAGNhWu45kkDiAAAAAElFTkSuQmCC","orcid":"","institution":"University of Lethbridge","correspondingAuthor":true,"prefix":"","firstName":"Morgan","middleName":"","lastName":"Magnuson","suffix":""},{"id":401905638,"identity":"716b09d6-74ee-43d8-9b5f-cb44471d9383","order_by":1,"name":"Shannon Vandenberg","email":"","orcid":"","institution":"University of Lethbridge","correspondingAuthor":false,"prefix":"","firstName":"Shannon","middleName":"","lastName":"Vandenberg","suffix":""},{"id":401905639,"identity":"80606305-b5da-41ba-b21c-ae45d8eeda5f","order_by":2,"name":"Tracy Oosterbroek","email":"","orcid":"","institution":"University of Lethbridge","correspondingAuthor":false,"prefix":"","firstName":"Tracy","middleName":"","lastName":"Oosterbroek","suffix":""},{"id":401905641,"identity":"5b6575e4-b319-4432-b5aa-b7daaa729331","order_by":3,"name":"Kevin Dey","email":"","orcid":"","institution":"University of Lethbridge","correspondingAuthor":false,"prefix":"","firstName":"Kevin","middleName":"","lastName":"Dey","suffix":""}],"badges":[],"createdAt":"2025-01-13 14:53:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5820964/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5820964/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12954-025-01251-7","type":"published","date":"2025-06-05T15:57:11+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":84242512,"identity":"9bd4903c-b06e-4d1d-8835-3400df459140","added_by":"auto","created_at":"2025-06-09 16:08:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":971255,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5820964/v1/c4d16866-4ab4-4281-bf6a-80f387ec2f51.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"“We’ve lost a lot of lives:” The Impact of the Closure of North America’s Busiest Supervised Consumption Site on People Who Use Substances and the Organizations that Work with Them","fulltext":[{"header":"Background","content":"\u003cp\u003eIn Canada 47, 162 people died from drug poisonings between January 2016 and March 2024 (Government of Canada, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2024b\u003c/span\u003e). These deaths occur within a policy landscape that shapes the risks associated with substance use. The ongoing war on drugs and a lack of regulated supply has created an environment where the illicit drug supply has become increasingly toxic, and people who use substances (PWUS) often have few options to access safe substances (Boyd et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). In Canada, the illicit supply features not only increasingly strong fentanyl analogues but is also more frequently adulterated with other substances, such as benzodiazepines and tranquillizers, heightening the risk of use (Russell et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Zhu, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Despite this, safe supply projects, which allow PWUS to access substances of known composition, have been publicly and politically opposed and remain unavailable in many provinces of Canada (Government of Canada, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2024a\u003c/span\u003e; Michaud et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Wilson et al., \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Safe supply programs currently in operation are often small in scale and have been criticized for strict eligibility requirements, failing to offer participants their preferred substances, and being overly medicalized (Ledlie et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Macevicius et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOngoing drug prohibition and a lack of a regulated, safe supply have necessitated a range of government and grassroots harm reduction responses to the drug poisoning crisis. Although harm reduction can be viewed differently, it has often been defined as any strategy that aims to reduce the risks of substance use without requiring abstinence (Denis-Lalonde et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Research supports that harm reduction strategies, such as naloxone and sterile supply distribution, are effective in improving health outcomes and reducing drug poisonings for PWUS (Clark et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Fernandes et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Harm reduction approaches are often first implemented by PWUS and their allies as pragmatic responses to the changing drug supply before they are established as formal government responses (Goodyear, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Smith, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). However, research suggests that harm reduction approaches are more effective when PWUS are actively involved in their design and implementation (Greer et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Ti et al., \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSupervised consumption sites (SCSs) are an important harm reduction strategy in the context of a toxic drug supply, where PWUS can be observed consuming illicit drugs to ensure that potential drug poisonings are witnessed and effectively treated (Canadian Research Initiative in Substance Misuse, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Within these sites, PWUS can often also access a range of services targeted at improving their overall health and wellbeing, including medical care, housing support, and referral to community-based services. The inclusion of health and social services differentiates SCSs from overdose prevention sites (OPSs) that focus primarily on reducing the immediate risks of substance use, such as drug poisoning, and may be legally or illegally operated (Canadian Research Initiative in Substance Misuse, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Conversely, SCSs are federally sanctioned in Canada, though the way in which they are managed varies both within and between provinces, with some being operated directly by provincial health authorities and others facilitated by community organizations that receive funding through a variety of mechanisms, including government grants and contracts (Government of Canada, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2024a\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSCSs are known to reduce the risk of infections, drug poisoning, and death in PWUS (Kennedy et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Levengood et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Using a SCS also increases the likelihood that PWUS access other health and social services, including addiction care (Levengood et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Additionally, cost-benefit analyses of SCSs have demonstrated favourable outcomes related to the prevention of disease and the associated healthcare costs (Khair et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). As of November 2024, the Government of Canada lists 39 SCSs currently in operation within five provinces, namely, Alberta, British Columbia, Ontario, Quebec, and Saskatchewan, with calls from PWUS, health professionals, and academics to scale up the implementation of this lifesaving harm reduction strategy (Canadian Drug Policy Coalition, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Government of Canada, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2024a\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the evidence of their effectiveness and research that suggests that the majority of Canadians support this approach, SCSs remain a contentious political issue in Canada (Curtin et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Watson et al., \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Wild et al., \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In the media, some politicians have suggested a need to scale back the implementation of SCSs, citing concerns about reduced public safety and public order in the surrounding community (Herring, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Migneault, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Taylor, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Despite evidence from systematic reviews that suggests that SCS do not cause increases in crime or public nuisances, some provincial governments in Canada have taken steps to close SCS (Kennedy et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Levengood et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In 2020, the Government of Alberta closed SCSs in two communities, with plans to close other sites and provincially operated OPSs by 2025 (Salvalaggio et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Smith, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In August 2024, the Government of Ontario paused all new approvals of SCSs while banning sites near schools or daycares, potentially leading to the closure of 10 of the province's 17 SCSs by March 2025 (Woodward, \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Both the Alberta and Ontario governments cite concerns about public safety, public disorder, and criminal activity around SCSs (Alberta Health, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Government of Ontario, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe impact of SCS closures is only beginning to be understood. Greene et al. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) explored PWUS\u0026rsquo; perceptions and experiences of the Lethbridge SCS closing. They found that PWUS reported negative experiences related to the closure of the SCS, including the belief that there was an increase in drug poisoning. The study also highlighted concerns about the OPS that replaced the SCS, including its less central location, the absence of inhalation rooms, and a lack of comprehensive services. This study aims to add to the understanding of the impact of SCS closures by including the perspectives of both PWUS and Staff Members of organizations that continue to provide harm reduction services. In the aftermath of the defunding of the SCS, this study also explores barriers to implementing evidence-based harm reduction initiatives and what steps PWUS take to protect themselves from an increasingly toxic drug supply within the current service provision landscape.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eContext\u003c/h2\u003e \u003cp\u003eOur study was conducted in the community of Lethbridge, Alberta. Lethbridge is a mid-sized city located on Treaty 7 land near two First Nations reserves (City of Lethbridge, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). As a result of the harms of past and ongoing colonization, Indigenous people are disproportionately represented in the population of unhoused PWUS in Lethbridge (City of Lethbridge, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The city has one of the highest per capita rates of drug poisonings in the province and once contained the busiest SCS in North America, operated by the AIDS Outreach Community Harm Reduction Education and Support Society (ARCHES), a nonprofit organization (ARCHES, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Government of Alberta, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Despite the apparent need for SCS, in 2020, the United Conservative Party of Alberta defunded both the site and the majority of the wrap-around programming operated by ARCHES (Hudes, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The defunding and closure of the ARCHES facility followed accusations of financial mismanagement in the organization (which were later disproven by a police investigation) and a commissioned report that focused on the harms of SCS (excluding any benefits of the site to PWUS or the surrounding community in their analysis), an approach that has been criticized for being methodologically flawed (Livingston, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Salvalaggio et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Despite the SCS being replaced by a smaller OPS, drug poisoning deaths increased from 56 deaths in 2020 to 125 in 2023 (Government of Alberta, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eDesign and Ethics\u003c/h3\u003e\n\u003cp\u003e We chose a descriptive qualitative research design to guide this study, adding to the body of research that explores the impacts of SCS closures on PWUS and service providers. A descriptive qualitative approach is effective in exploring novel phenomena and was, therefore, appropriate to examine the impact of the closure of ARCHES and its SCS in the unique context of Lethbridge, Alberta (Doyle et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Sandelowski, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). We used qualitative interviewing to generate the data in our study, as this method is useful for exploring perspectives on the complex landscape of the politics and practice of harm reduction.\u003c/p\u003e \u003cp\u003e The University of Alberta\u0026rsquo;s Research Ethics Board (Pro00120726) approved this study. We recognize that there are important considerations when conducting research with PWUS; however, we agree with others that PWUS deserve both ethical protection and rights through the research process, respecting the range of motivations that PWUS have for participating in research while also protecting their privacy and confidentiality (Bell \u0026amp; Salmon, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Fry et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Participants provided both written and verbal consent prior to data generation. As others have identified, using substances does not inherently impair an individual\u0026rsquo;s capacity to provide informed consent; however, some interviews were ended early by the interviewer if the participant\u0026rsquo;s ability to ability to provide ongoing consent became impaired (Bell \u0026amp; Salmon, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). As PWUS have long advocated for appropriate compensation for their contributions to academic research, participants were given a \u003cspan\u003e$\u003c/span\u003e50 honorarium for their time (Bell \u0026amp; Salmon, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Canadian HIV/AIDS Legal Network, 2005; Collins et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2017\u003c/span\u003e)\u003c/p\u003e\n\u003ch3\u003eParticipant Sampling and Recruitment\u003c/h3\u003e\n\u003cp\u003eWe used purposive sampling to recruit Staff Members from organizations that provide or have intimate knowledge of harm reduction services in Lethbridge, Alberta. We chose a broad understanding of harm reduction to identify organizations that we deemed to work towards minimizing the risk of substance use in any manner, including those whose work was primarily aimed at improving access to the prerequisites of health, in addition to those that provided more traditional harm reduction services such as safe supply distribution. In line with our qualitative research design, this purposive sampling strategy aimed to provide us with a deeper understanding of the closure of ARCHES by capturing a range of experiences from the Staff Members of diverse community organizations (Sandelowski, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). All identified organizations were contacted with an email invitation to participate in the study.\u003c/p\u003e \u003cp\u003eRecruitment of PWUS occurred by self-selection through posters displayed at public spaces in the Lethbridge downtown area and at community organizations that served people experiencing homelessness or who use substances in the days prior to data collection. To be eligible, participants had to speak English, be over the age of 18, live in Lethbridge, and self-identify as having a history of substance use in the last six months.\u003c/p\u003e\n\u003ch3\u003eData Generation\u003c/h3\u003e\n\u003cp\u003e We conducted semi-structured interviews with all participants, lasting between nine and 65 minutes. For PWUS, questions were designed to encourage participants to describe their experience with ARCHES and how its closure impacted their ability to engage in practices intended to make substance use safer. Staff Members were asked to discuss how the closure of ARCHES impacted both their organization and the lives of the people who accessed their services. Both groups of participants were also asked about the current harm reduction service provision landscape in Lethbridge and to reflect on any current gaps or strengths within the community.\u003c/p\u003e \u003cp\u003eStaff Member interviews were conducted virtually by three members of the research team (MM, SS, \u0026amp; TO) from September 2022 to January 2023. Interviews with PWUS were conducted in person in a private, convenient downtown location by MM \u0026amp; SS in August 2023. Most of the data generation with PWUS was conducted one-to-one, apart from two instances where participants with close relationships with each other were interviewed together at their request. All interviews were audio recorded and transcribed verbatim by MM \u0026amp; KD.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eWe analyzed the data generated through participant interviews using Clarke and Braun\u0026rsquo;s (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) six-phase approach. Clarke and Braun\u0026rsquo;s (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) reflexive thematic analysis (TA) was chosen for its theoretical flexibility, allowing for a critical realist and contextual approach to data analysis that understands that language communicates the diverse experiences and worldviews of participants, which are shaped by material, social, and political conditions.\u003c/p\u003e \u003cp\u003e Much of our coding was inductive, aligning with our descriptive qualitative approach and driven by our participant\u0026rsquo;s understanding of historical and contemporary events. However, we also recognize that our own backgrounds as service providers within the health and social fields working with PWUS influenced data generation. As such, our themes also reflect concepts we commonly employ in our research and practice, including the social determinants of health, social justice, and health inequities, as well as our belief that health is not primarily determined by genetics or behavioural choices. For example, our understanding that poor health arises from social and economic structures that determine material conditions shaped our understanding of how our participants' experiences of accessing harm reduction services are linked to the broader issues of power and politics. Additionally, as we all work in the community where our research takes place and have witnessed the devastating impact of the unregulated drug poisoning crisis, we are advocates for the expansion of harm reduction services and understand that we are not neutral on this topic.\u003c/p\u003e \u003cp\u003e We used Braun and Clark\u0026rsquo;s (2022) guidelines for \u0026ldquo;good reflexive TA\u0026rdquo; to ensure congruency between the data and our analysis, transparency in our theoretical positioning, and clarity in our role in data generation. Each member of the research team initially read the interview transcripts ahead of the coding phase to become familiar with the data. After coding the data and developing initial themes independently, the research team met to discuss and revise themes while interrogating the role our assumptions and positionalities may play in data analysis. Rather than attempting to find consensus, this collaborative process aimed to increase the depth and quality of our data analysis by integrating the diverse perspectives of the researchers. Following this meeting, MM created a list of candidate themes that were then reviewed in relation to the initial codes and the entire data set. Finally, to align with the reflexive thematic analysis process, the entire research team engaged in a refining and naming process to develop our final themes.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eDemographics\u003c/h2\u003e \u003cp\u003eOut of the 17 organizations we identified, a total of 10 staff members from nine organizations participated in the study. All staff members reported they were working with PWUS in Lethbridge when the SCS closed, with four of the ten participants reporting that ARCHES previously employed them.\u003c/p\u003e \u003cp\u003eFor our second group of participants, recruitment was completed after 27 PWUS were interviewed, and the research team determined through reflexive practice that the data that had been generated provided a rich description of events and adequately answered our research questions (Clarke \u0026amp; Braun, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). These participants ranged in age from 27 to 64. Of the participants who self-declared, 48% were Indigenous, 33% were Caucasian, and 4% were Metis. 41% of participants identified as male, 44% as female, and 7% as non-binary. Four of the 27 participants who use substances reported that they had accessed services at ARCHES when it was in operation.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eThemes\u003c/h3\u003e\n\u003cp\u003eThrough the reflexive thematic analysis process, we developed three themes that deepened our understanding of the evolving local context of harm reduction in Lethbridge, Alberta. The first theme consists of two subthemes that explore the impacts of decisions about what types of harm reduction services are available within the community. The second theme also includes two subthemes that explore the politics of the ARCHES closure at both the municipal and provincial levels. Lastly, the final theme contains three sub-themes that explore how PWUS and community organizations are currently responding to the unregulated drug poisoning crisis and the ongoing opposition to harm reduction practices.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1\u003c/b\u003e: \u003cb\u003eLife before and after ARCHES\u003c/b\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 1.1: More than just a supervised consumption site\u003c/h2\u003e \u003cp\u003eMany PWUS and Staff Members suggested that ARCHES was more than just a physical site where harm reduction services were provided. Staff Members of organizations that provide harm reduction services spoke to the breadth of services provided at ARCHES, including its growth from an organization that primarily provided services related to sexually transmitted and blood borne infections to one that provided services to meet the diverse needs of PWUS in the community in the context of a worsening drug poisoning crisis. Participants noted that ARCHES facilitated many initiatives, such as HIV case management, naloxone training and distribution, sterile supply distribution, outreach, clinic services, and cultural programs. One of these programs was described by Staff Member 10:\u003c/p\u003e \u003cp\u003e\u003cem\u003eHip Hop for Healing\u0026hellip; it was right off supervised consumption. So, clients could come there, and they'd go and see this guy\u0026hellip;he could like mix music, like record it and create a song. And it was unbelievable, the people that were lining up to lay down their tracks. And so, people were creating songs. And you know, it was unbelievable the amount of writing that our clients did, poetry\u0026hellip;.and so, the organization itself when we think of where it started from, which was HIV and Hepatitis C care, and then it kind of evolved into harm reduction... And then it just exploded into this multi-program organization.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eParticipants also spoke of the nonjudgemental nature of these programs to people who accessed ARCHES programs. Some staff members suggested that ARCHES provided a safe space where PWUS were well supported, with one participant noting:\u003c/p\u003e \u003cp\u003e \u003cem\u003eI think that they could just go and be real. They had an opportunity to, maybe, be vulnerable with some of the counsellors and the addiction workers that were on site. They got medical care without discrimination for being a drug user. And it was just a safe place. Like it's our street-involved population that don't have a lot of safe places where they can go and just be. (Staff Member 7).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe sentiment was echoed by other participants who had accessed services at ARCHES. For example, when asked about their experience with ARCHES, PWUS 9 reported, \u0026ldquo;It was it was good. It was going home to people.\u0026rdquo; Participants also spoke about the positive interactions with the staff at ARCHES; PWUS 1 noted that:\u003c/p\u003e \u003cp\u003e \u003cem\u003eThe workers were really friendly. They're really passive. Really, like, non-judgmental\u0026hellip;Right, so if you asked for something, there's no shame in asking for needles, or a pipe or anything. Like, it was just, they were wonderful. You know, you want something to eat, you want some water or anything? It was a good place.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 1.2: The harms of regressive drug policies\u003c/h2\u003e \u003cp\u003eMost participants who were familiar with ARCHES spoke about the negative impact its closure had on PWUS. A common concern among Staff Members was that when ARCHES was defunded, the majority of its programs ceased operations in addition to the closure of the SCS. For example, Staff Member 1 stated:\u003c/p\u003e \u003cp\u003e \u003cem\u003eAgain, because there were so many programs under that umbrella, like it wasn't just supervised consumption that was closed, the HIV programming was closed, peer-based programming was closed, the naloxone program, which is now operating under a different provider, but not within the City of Lethbridge. I can't even think of all the programs [that closed]. They had an outreach team\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eSome also spoke about a reduction in programs that served Indigenous people in the community following the closure. Staff Member 2 noted:\u003c/p\u003e \u003cp\u003e \u003cem\u003eBut it was an Indigenous cultural group where they would bring elders in. There was a music group, and it was a good way to reconnect folks with their culture. So, with ARCHES shutting down it kind of limited the resources for that specific demographic of Indigenous folks that are using substances. As I said, there are a few more out there, but they were connected to that one in particular and felt comfortable talking without being judged.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eBoth Staff Members and PWUS spoke about the initial gaps in ham reduction service provision following the closure of ARCHES. Staff Member 2 highlighted their concerns that there was no longer an organization that facilitated broad sterile supply distribution, \u0026ldquo;\u003cem\u003eSince it [ARCHES] closed, I mean, we hand out some supplies, but we only hand them out to our direct participants. We do have people that are asking for supplies, and unfortunately, we can't give them to them.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e \u003cp\u003eIn addition to a more targeted approach, some also noted how the closure meant fewer organizations were able to hand out supplies to meet the needs of people who inhale their substances. Staff Member 4 stated, \u003cem\u003e\u0026ldquo;We are able to hand out and supervise people who use needles, but we're not able to provide the items to use safer inhalation, and we're not able to observe them while inhaling, as well.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003ePWUS spoke about the continued challenges of accessing sterile inhalation supplies in the face of organizational policies that limit distribution, including PWUS 25, who indicated, \u0026ldquo;\u003cem\u003eYeah, once every three days, you can get one [bubble pipes]. And then straight shooter, well, straight shooter you can get more often and tin foil. Umm, other than that, I have to buy them.\u0026rdquo;\u003c/em\u003e In response to a question about the ease of accessing sterile supplies, PWUS 17 suggested, \u0026ldquo;\u003cem\u003eI mean, it is what it is, but a lot of people find that their bubbles are sacred. Like, there's fights and violence that break out because of it\u0026hellip;\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eSome participants spoke about the differences between SCS and the AHS-operated OPS, noting how the OPS had less capacity to support PWUS. Staff Member 4 noted:\u003c/p\u003e \u003cp\u003e \u003cem\u003eWell, so they did throw together the OPS bus around the same time that the site [SCS] closed. The OPS bus\u0026hellip; doesn't have anywhere for storage. It is not wheelchair accessible. It only has one nurse, one paramedic and an addictions counsellor on and peer support. And they only have two booths. So that went from a [SCS] site with, I think it was, 11 to 12 booths plus two inhalation rooms.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe differences between the capacity of SCS versus the OPS were particularly notable in regard to their ability to support supervised inhalation. Staff Member 4 explained:\u003c/p\u003e \u003cp\u003e \u003cem\u003eYeah. So, ARCHES also had inhalation rooms, which I think they were the first ones [to offer inhalation rooms] in North America or Canada; I could be mistaken. But they were pretty new to us. And we no longer provide those.\u0026rdquo;\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSimilarly, PWUS 24 stated their concern for the lack of inhalation rooms in Lethbridge following the closure of ARCHES, \u003cem\u003e\u0026ldquo;The people who use needles have a place that they can inject safely. People that smoke, I don\u0026rsquo;t know\u0026hellip; Well, smokers have been left out.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eIn addition to reductions in the type and scope of harm reduction services offered in Lethbridge, participants suggested that the closure of ARCHES damaged relationships between service providers and PWUS. Many Staff Members highlighted the need for good rapport for harm reduction programming to be effective and the damage that can be created when trusted service providers are no longer able to follow through with commitments as a result of the eroding service provision landscape. Staff member 2 described, \u0026ldquo;\u003cem\u003eBut yeah, I think a lot of people were lost. I think it created a lot of distrust in the system. I think the way that it was handled really demonized a lot of our participants and stigmatized them.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003eParticipants from both groups suggested that the closure of ARCHES may have led to more deaths in the community from drug poisoning. Some PWUS suggested that the absence of SCS in the city may have resulted in more people using alone, with PWUS 15 noting, \u0026ldquo;\u003cem\u003eWhen that place [the ARCHES SCS] was up, it was being watched over. Right now, they just go somewhere by themselves, and they overdose, and they\u0026rsquo;ve lost a lot of them.\u003c/em\u003e\u0026rdquo; When asked about the impact of the closure of ARCHES on the community, PWUS 25 noted simply, \u0026ldquo;\u003cem\u003eWe've lost a lot of lives\u003c/em\u003e.\u0026rdquo; Similarly, Staff Member 9 noted in response to a question about whether the closure of ARCHES impacted PWUS\u0026rsquo;s ability to keep themselves safe:\u003c/p\u003e \u003cp\u003e \u003cem\u003eYeah, so between us and the [Local Harm Reduction Organization] and the other place, or the other grassroots outreach people that were out there, we all noticed that there were a number of increases in overdoses that we had to manage and attend to\u0026hellip; But my feeling is that, of course, they had no place to go. So, people were using on the street or using in seclusion, which is even worse. So, if they do overdose, there's nothing that can be done because people can't find them, right?\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eTheme 2: The politics of the ARCHES closure\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003eSubtheme 2.1: NIMBYism in Action\u003c/h2\u003e \u003cp\u003eMany participants discussed the ways in which local politics may have influenced the decision to close the SCS and many of ARCHES\u0026rsquo;s other programs, which were located in the Lethbridge\u0026rsquo;s downtown area. Some participants drew on concepts such as \u003cem\u003enot in my backyard\u003c/em\u003e (NIMBY) to highlight the backlash towards PWUS and the organizations that provide harm reduction services in Lethbridge, such as Staff Member 2, who suggested:\u003c/p\u003e \u003cp\u003e \u003cem\u003eSo, I mean, when ARCHES was running, there was a lot of not in my backyard mentality. That mentality still exists\u003c/em\u003e. \u003cem\u003eAnd, you know, ARCHES was set up where it was because of the close proximity to the shelter and where a lot of folks were already congregating downtown\u0026hellip;I think, you know, a lot of people were like, oh, we'll put the SCS outside of town. That also wasn't necessarily a good option, either, because then how do people access it? Boxing everyone up and shipping them away doesn't solve the problem.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eSimilarly, PWUS 21 suggested that PWUS were not welcome in the downtown area:\u003c/p\u003e \u003cp\u003e \u003cem\u003eI don't read the paper, but I came across something accidentally, and it's a roast and toast. They said all the addicts and people trying to help them should be moved, basically moved out to a compound outside the city and fenced off.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAnd later, regarding the ARCHES SCS:\u003c/p\u003e \u003cp\u003e \u003cem\u003eHere in Southern Alberta, I find there to be a lot of NIMBY attitude. Not my problem, or not my backyard; I don't want him in my backyard\u0026hellip;move it somewhere else, put it somewhere else, give it to somebody else. Tax the fuck out of them, so they go leave and go to a different city. Become somebody else\u0026rsquo;s problem. Don\u0026rsquo;t try to help them. Why?\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe belief that PWUS do not belong in the community was also discussed in relation to racism. As Indigenous people are disproportionately represented in the population of unhoused people who use drugs in Lethbridge, participants drew attention to how the intersecting discriminatory attitudes influence how PWUS are perceived. In response to a question about the difficulties of implementing harm reduction services in Lethbridge, Staff Member 2 suggested:\u003c/p\u003e \u003cp\u003e \u003cem\u003eIn Lethbridge, I would definitely say a huge part of it is, almost all, I want to say, a lack of understanding from just the general community. But there definitely is a bit of a stigma attached, and the racism component as well is huge\u0026hellip; In Lethbridge, unfortunately, it\u0026rsquo;s a tight-knit community. You're either in the community or you're out of the community.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSome participants described how the disdain for both PWUS and ARCHES being present in the downtown led to dangerous situations for both people accessing harm reduction services and staff. Staff Member 10 described their experiences of violence while working with ARHCES:\u003c/p\u003e \u003cp\u003e \u003cem\u003eI remember working in reception at supervised consumption, and some lady came in filming, telling us we were all, you know, effing disgusting. And it was pre-, kind of political drama. It was just, she heard, we were doing supervised consumption, and \u0026ldquo;How could you?\u0026rdquo; That was consistent, and we had all sorts of terrible things happen. We had death threats. I had terrible messages on my voicemail. We had a staff who got shot up with a paintball gun on a night shift. And honestly, a lot of the violent stuff that happened to us or to clients.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 2.2: Unpacking the motives behind the ARCHES closure\u003c/h2\u003e \u003cp\u003eIn addition to the local politics of harm reduction, participants described how the provincial government influenced the closure of ARCHES. Participants suggested that ARCHES became a scapegoat for perceived increases in disorder and risk to public safety within the community. Staff Member 7 noted:\u003c/p\u003e \u003cp\u003e \u003cem\u003eAnd I think the messaging was, you know, the supervised consumption site goes away, the problem, the drug problem in Lethbridge, goes away. And as we can now see, two years later, that's clearly not the case. And it's, in fact, worse now than it's probably ever been.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eRather than being based on evidence or local needs, Staff Members suggested that the decision to defund ARCHES may have been ideologically motivated. Some participants suggested that ARCHES did not align with the provincial government\u0026rsquo;s preferred policy approach to the unregulated drug poisoning crisis. For example, when describing the provincial government\u0026rsquo;s approach to substance use, Staff Member 4 noted, \u0026ldquo;\u003cem\u003eWe also seem to have a government currently that is very favourable for abstinence-only type of recovery\u003c/em\u003e.\u0026rdquo; Others described how the provincial government\u0026rsquo;s dislike for harm reduction contributed to the closure of ARCHES, like Staff Member 2, who stated:\u003c/p\u003e \u003cp\u003e \u003cem\u003eAnd, you know, from my perspective, a big part of that was because of politics and the government not liking supervised consumption sites at the time. They didn't, it felt to me anyway, really take into account all the other programs. They just said, oh, we don't like supervised consumption sites.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe way in which the provincial government handled the accusations that ARCHES staff had mismanaged funds was framed by some participants as being both unusual and politically motivated. Staff Member 2 suggested:\u003c/p\u003e \u003cp\u003e \u003cem\u003eWe [the provincial government] found some kind of mismanagement of funds. Let's not dig any further. Let's just shut the whole thing down. It wasn't, you know, oh, let's reevaluate. Let's change the staffing. Let's, you know, we'll see what we can do to fix this problem. It was more of we don't like it [the supervised consumption site]. So, we're just going to shut the whole thing down. That's what it seemed like to me, anyway, yeah, political.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSimilarly, Staff Member 1 noted:\u003c/p\u003e \u003cp\u003e \u003cem\u003eAnd ARCHES was, I think, a bit targeted in that. Not that there weren't things that needed to be addressed or fixed. There certainly was. But it very much felt, like, vindictive. It very much felt like this was targeted. It didn't feel evidence-based. It didn't feel rooted, in fact, or something that needed to happen\u0026hellip; So, I think it's just been really frustrating. It feels like it's very rooted in morality and not in evidence.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSome participants also spoke to the In addition to a more general rejection of harm reduction approaches, a former ARCHES employee, Staff Member 10, described how the poor relationship between the government and the organization played a key part in the closure of the ARCHES site:\u003c/p\u003e \u003cp\u003e \u003cem\u003eWhen you look at ARCHES, we did not do that right. Leadership was kind of abrasive, aggressive, us against them, and it should not have gone that way. And that's why everything fell apart. Too many enemies were made. It was just us versus them. You either are for harm reduction and people who use drugs, or you're a racist\u0026hellip; It was just siloing us and making enemies, and then we made enemies with the government. And then that was the end of that [ARCHES].\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTheme 3: Navigating the current harm reduction service landscape\u003c/h2\u003e \u003cp\u003e \u003cb\u003eSubtheme 3.1: Surviving the Crisis: Strategies for responding to policy choices and the evolving unregulated drug poisoning crisis\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTo navigate changing policy approaches and the worsening of the unregulated drug poisoning crisis, PWUS spoke about the ways in which they try to protect themselves from the toxic drug supply. When asked about how they kept themselves safe, many participants spoke about implementing commonly accepted harm reduction practices such as never using alone, not sharing supplies, consuming test doses, drug checking, and carrying naloxone.\u003c/p\u003e \u003cp\u003eMost PWUS in our study indicated that they inhaled their substances, with some suggesting that they had transitioned to this route from injection to make their substance use safer. For example, PWUS 22 stated that they recently switched to smoking, \u0026ldquo;\u003cem\u003eAh, because injection just seemed more riskier for me.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e Participants also spoke about the challenges of an increasingly toxic drug supply. Some participants suggested that they now use methamphetamine, in addition to opioids, to help manage a riskier supply. PWUS 21 stated, \u0026ldquo;\u003cem\u003eAnd usually when I\u0026rsquo;m using fentanyl, I will mix it with side, because fentanyl isn\u0026rsquo;t usually fentanyl, it\u0026rsquo;s cut with, ah what is it? Benzo. Knocks you right out.\u0026rdquo;\u003c/em\u003e Similarly, when asked about their reason for using methamphetamine and opioids concurrently, PWUS 13 stated, \u0026ldquo;\u003cem\u003eSo that you don't fall asleep\u003c/em\u003e,\u0026rdquo; and PWUS 14 said, \u0026ldquo;\u003cem\u003eI usually mix it with meth, with it... Yeah, so your heart doesn\u0026rsquo;t just stop.\u003c/em\u003e\u003c/p\u003e \u003cp\u003eOther participants suggested that they mixed methamphetamine and opioids together as a measure to reduce the risk of or to reverse a drug poisoning. When asked about how methamphetamine is used in response to the toxic supply, PWUS 14 suggested, \u003cem\u003e\u0026ldquo;And then honestly, people use methamphetamine to try and wake you up. But it is honestly way better because when we get naloxone, we get so sick.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 3.2: Funding Forces: How precarious contracts shape the harm reduction service landscape\u003c/h2\u003e \u003cp\u003eThe current political landscape towards harm reduction also impacts the community organizations that work with PWUS. Many Staff Members noted the challenges of providing services under the current system of government contracts and grants. When asked to expand on how the current funding model impacts the provision of harm reduction services in the city, Staff Member 5 suggested that contract funding creates instability for both Staff Members and PWUS:\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt's always changing and so everybody's very vulnerable to funding. Like one day, this might be available to you, and then tomorrow, it isn't, because how the money has come down is through, you know, the government, to the municipal government. The municipal government is, you know, divvying out these funds to support this population\u0026hellip; We have work and staff whose positions are very dependent on our harm reduction and permanent supportive housing relationships. And our clients get close to our staff. And we can't be sure that in six months staff will still be working because they're temporary.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eStaff Member 7 also raised concerns about how short-term funding arrangements impact PWUS:\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt's confusing. It's confusing for us, and it's confusing for clients. Because clients, as I'm sure you guys know, this population that we work with is incredibly difficult to engage... And when services change hands or contracts change hands, I mean, five years really isn't much time. By the time you develop a relationship and rapport with the client. If you don't get that grant again, someone else has to restart where you already were five years in.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn addition to the challenges associated with this funding model, some Staff Members also spoke about the overall lack of funding for harm reduction in Lethbridge. Staff member 1 offered, \u0026ldquo;\u003cem\u003eBefore I moved into harm reduction, I was in housing, and it was the same. It felt like Lethbridge was always being bypassed for significant funding\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e \u003cp\u003eWhen asked about the potential reasons Lethbridge may be overlooked for funding, the participant stated:\u003c/p\u003e \u003cp\u003e \u003cem\u003eAnd it's also really hard to think that this isn't rooted in racism, because I think Indigenous people are disproportionately impacted in Lethbridge. Yeah, it's just really hard. Between people who use drugs and Indigenous people, I just don't think they're a priority for the government.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme 3.3: Evidence vs. Politics: A balancing act\u003c/h2\u003e \u003cp\u003eMany Staff Members discussed the challenges of providing comprehensive harm reduction services that meet the needs of PWUS in the current political landscape. Some staff members spoke about a shift in the willingness of community organizations to offer harm reduction in the aftermath of the closure of ARCHES. Staff Member 7 suggested:\u003c/p\u003e \u003cp\u003e \u003cem\u003ePolitics is getting in the way of helping people access their human rights to harm reduction and health care\u0026hellip; I have heard, and personally do not believe, that after what happened with ARCHES, any nonprofit in our community would be willing to become the next supervised consumption site or be known for becoming the next supervised consumption site. I think that there's a lot of fear amongst, you know, a lot of the agencies.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn response to a question exploring potential challenges organizations might face if they chose to take up some of the harm reduction services that ARCHES had previously provided, Staff Member 2 similarly suggested,\u003c/p\u003e \u003cp\u003e \u003cem\u003eUm, well, I think with everything that ARCHES ran, a lot of organizations didn't want to go near that [harm reduction services] with a ten-foot pole for their own funding. And then being under the scrutiny of, you know, government organizations.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn addition to these perceived barriers to organizations providing harm reduction services in Lethbridge, the need to balance politics and evidence was evident in the ways in which organizations describe the services they currently provide. When speaking about how their organization engages in sterile supply distribution, Staff Member 7 stated:\u003c/p\u003e \u003cp\u003e \u003cem\u003eWe\u0026rsquo;re not just like raining them [sterile supplies] all over the street. Of course, we're very aware, I guess, of what we're handing out, how much we are handing out, who we're handing it out to, and making sure that every time we hand out supplies, we are having conversations about other addiction supports or community supports that they could engage in.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eWhen asked to explain how they decided on this approach, and after clarifying that their organization would not be named in final reports, they responded:\u003c/p\u003e \u003cp\u003e \u003cem\u003eWe don't want the misunderstanding to be created that [the organization], you know, just gives bubble pipes out to everybody\u0026hellip;. We don't want to be known as a distribution center; we don't want to be known as a distribution site\u0026hellip; So I think that is a big piece is just that, we need to balance the political view of our agency as well, if that makes sense, and the community view of our agency for future, potential, you know, opportunities that we have for funding for serving other vulnerable populations, while still making sure that vulnerable people are getting what they need if they are using substances.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur findings are consistent with research that suggests harm reduction organizations improve the health and wellbeing of PWUS in ways that move beyond the proximal risks of substance use, such as infections and drug poisonings (Ivsins et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). ARCHES, like other SCSs, provided services that supported improvements in the quality of PWUS\u0026rsquo; social determinants of health, such as medical care, housing support, and the provision of material resources such as food and clothing (Bardwell et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Boyd et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Ivsins et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Kerman et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Small et al., \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Additionally, our research supports the findings of Kerman et al. (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) and Ivsins (2023) that SCSs act as an important point of connection between PWUS and other health and social services. Similar to other studies exploring the perceptions of PWUS who access harm reduction services, our study found that most people who accessed ARCHES felt welcomed, supported, and included (Boyd et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Greene et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Kerman et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Oudshoorn et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Taken together, our findings add to the body of research that suggests that SCSs are an important source of connection to a wide range of safe and judgement-free health and social services.\u003c/p\u003e \u003cp\u003eMany of our participants who used substances believed that the closure of ARCHES, including its SCS, caused an increase in drug poisonings and a decrease in the ability of PWUS to protect themselves from a toxic unregulated drug supply, echoing the findings by Greene et al. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The perception among PWUS that the reduced capacity or closures of SCSs leads to increased drug poisonings has also been reported in literature exploring the impacts of the COVID-19 pandemic on harm reduction services (Foreman-Mackey et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Russell et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Although there are likely many factors that have contributed to the increase in drug poisonings in Lethbridge since 2020, including increased toxicity in the illicit drug supply and the wide-reaching impacts of the COVID-19 pandemic, the inability for the majority of our participants to access services that support their preferred method of consumption is likely a contributing factor (Beesoon et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Mitra et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs many of our participants who use substances reported that smoking was their preferred route of consumption, the transition from ARCHES to the OPS, which lacked the infrastructure to support supervised inhalation, was identified as a significant obstacle to minimizing the risks associated with substance use. The shift towards inhalation rather than injection as the preferred method of consumption and the route most commonly associated with drug poisoning has been noted in other recent Canadian studies (Fischer et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Kamal et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Many of our participants voiced a willingness to access supervised inhalation facilities, something that has been noted in Gehring et al. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u0026rsquo;s scoping review. Despite these trends, sites with the capacity to support supervised inhalation continue to be rare in Canada, with only two sites ever receiving a federal exemption (one being the now-closed ARCHES\u0026rsquo;s SCS and the other in Saskatoon that continues to operate) (Canadian Research Initiative in Substance Misuse, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Although the cost of building or retrofitting the ventilation infrastructure necessary to support indoor supervised inhalation may be prohibitive, without these sites, our findings suggest that many PWUS will be unable to access this lifesaving harm reduction strategy (van Draanen et al., \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn addition to the impact of changes to the harm reduction service provision landscape, PWUS in Lethbridge reported modifying their drug consumption to respond to an increasingly toxic drug supply. Our participants reported adulteration in the supply of \u0026ldquo;down\u0026rdquo; (fentanyl or its analogues) with benzodiazepines and other sedatives and \u0026ldquo;side\u0026rdquo; (methamphetamine) with fentanyl, reflecting trends seen in other parts of the country (Russell et al., \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Wagner et al., \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Zhu, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). To respond to the dangers of the toxic supply, our participants altered both their route of consumption, favouring inhalation over injection, as well as the types of substances they consumed, including using \u0026ldquo;down\u0026rdquo; and \u0026ldquo;side\u0026rdquo; together, to combat the increase in depressive effects caused by substances such as benzodiazepines that are now common in the illicit supply. Although the deliberate concurrent use of \u0026ldquo;down\u0026rdquo; and \u0026ldquo;side\u0026rdquo; is not a new phenomenon, the idea that methamphetamine can be used to reduce the harms associated with using adulterated fentanyl (including those caused by the risk environment many unhoused PWUS face) may be a recent response to the changing illicit supply (Daniulaityte et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Eger et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). As there are health-related harms associated with taking depressants and stimulants at the same time, it seems prudent to explore ways to increase the accessibility of substances of known contents and doses so that PWUS can reduce their risks.\u003c/p\u003e \u003cp\u003eTo meet the needs of PWUS in the community, Staff Members of organizations that provide harm reduction spoke about the necessity of expanding and improving the harm reduction services available in the city. However, many noted that the competitive landscape of contract funding was a barrier to effective program planning and implementation. The decline of the welfare state in Canada has led to a greater emphasis on nongovernmental organizations, such as ARCHES and many of the organizations whose staff members participated in our study, to provide necessary health and social services within their communities through what are often short-term and insecure funding arrangements with the government (Baines et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Phillips \u0026amp; Wyatt, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Although funding insecurity is not unique to organizations who work with PWUS, the current political opposition to harm reduction from many conservative political parties at all levels of government, including in Alberta, likely increases their funding precarity (Salvalaggio et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Wilson et al., \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). For organizations, insecure and insufficient funding impacted staff morale and turnover and prevented them from implementing robust programming to meet the needs of PWUS.\u003c/p\u003e \u003cp\u003eStaff Members also described how funding arrangements prevented consistency in service provision as organizations competed for, secured, and then lost contracts within the timeframe of a few years. They noted that when service delivery changes hands between organizations, the relationships between service providers and PWUS are negatively impacted, which can create barriers to service utilization. In their systematic review of barriers and facilitators to the use of SCSs, Ivsins et al., (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) noted that relationship-building is critical in promoting harm reduction service and, more broadly, healthcare utilization. Given the intersecting marginalizations many PWUS in Lethbridge experience, the potential damage to the relationships between health and social providers and the people in need of services in the aftermath of the ARCHES SCS\u0026rsquo;s closure likely led to further harm. More robust and stable funding would better support nongovernmental organizations' work in restoring trust with the community and addressing the needs of PWUS.\u003c/p\u003e \u003cp\u003eOur participants spoke to their belief that the current approach to harm reduction in Lethbridge was driven by ideology rather than evidence. Dominant ideologies influence who is perceived to belong or pose a risk within a community, reflecting the racist, colonial, and capitalist history of Canada. Both PWUS and Staff Members noted that the decision to close ARCHES was supported by community members who believed that the SCS did not belong in the downtown area. The concept of NIMBYism has been identified as a barrier to the implementation and operation of SCSs, where people may express broad support for the sites as long as they are not located near them, citing concerns of public safety, needle debris, and the impact on businesses (Cran, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Kolla et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Ziegler et al., \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Our findings add to this body of research as our participants identified NIMBYism as a key driver behind the closure of ARCHES and its SCS.\u003c/p\u003e \u003cp\u003eStaff Members also reported that the controversy surrounding the site was not only about the impact of the SCS but also the PWUS who accessed it. Participants noted how racism may have played a role in the opposition to the SCS because, like PWUS, Indigenous people face discrimination and marginalization within the city. These forces have been explored by other scholars who suggest that Indigenous people face increased policing, sometimes as a response to public substance use, and restricted access to public spaces in the downtown Lethbridge area (Granzow, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Ozcan, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). These authors suggest that these strategies are part of the broader ongoing colonial project designed to marginalize and exclude Indigenous people (Granzow, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Ozcan, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Our study adds to this body of knowledge, suggesting that discrimination and racism shape policy responses in various ways, including by attempting to reduce the visibility of PWUS by limiting the availability of harm reduction services in certain areas.\u003c/p\u003e \u003cp\u003eIdeology also shapes support for differing approaches to the issues that are often associated with substance use (Fischer et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Marshall, 2015; Wilson et al., \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In Alberta, Wilson et al. (\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) have noted that the ideological position of the governing United Conservative Party supports an abstinence-based approach. The authors argue that an abstinence-based approach represents the provincial government\u0026rsquo;s narrative that the root cause of harm for PWUS is the \u0026ldquo;addiction crisis,\u0026rdquo; obscuring the role that public policy decisions have on the illicit drug supply and individualizing the unregulated drug poisoning crisis. This framing can then be used to justify their opposition to harm reduction approaches, which are blamed for enabling people to engage in risky behaviour, regardless of the potential harm to PWUS and their community. Our findings support literature from the political economy of health inequities field that public policy decisions are not driven primarily by the evidence base or the needs of the community but by powerful groups who have little interest in supporting the harm reduction work of nongovernmental organizations that is not easily commodified (Raphael, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven the current government's preference for abstinence-based approaches, many of the Staff Members in our study spoke about the need to balance evidence and politics in their provision of harm reduction services. For example, Staff Members suggested that their organization's reputation within the community influenced how they approached providing harm reduction services, seeking to limit the perception that they were contributing to public disorder. Staff Members also spoke to fears of potential backlash from the government for providing harm reduction services, fearing that, like ARCHES, their organization may be defunded. Staff Members described how these fears led them and their organization to either hide, limit, or discontinue the harm reduction services they provided. For example, some noted the reluctance of some organizations within the community to provide safer smoking supplies, leading to a decrease in access in the immediate period following the closure of ARCHES, as well as continued restrictions on distribution at the time of data collection. Although participants noted how organizational-level policies on smoking were a barrier to distributing safer smoking supplies, a phenomenon noted elsewhere in the literature (Public Health Ontario, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), they also suggested that the need to maintain a positive reputation also played a role. As safer smoking supplies are well known to reduce disease transmission, reports that organizations feel they are unable to follow best practice recommendations are concerning. These insights into service provision in a climate of intense political opposition to harm reduction add to concerns about how ideological positions of policymakers can cause harm to PWUS and the broader community.\u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eCalls to Action\u003c/h2\u003e \u003cp\u003eTo remedy the root causes of harm that PWUS experience, they must be positioned to guide the policy decisions that affect them. PWUS, in our study, made it clear that unrestricted access to sterile supplies, SCSs with the capacity to support inhalation, and programs that support improvements in the quality of the social determinants of health, such as housing, are needed to improve their health and wellbeing and prevent drug poisonings. As SCS cannot prevent all the harms associated with the unregulated drug supply, PWUS must also be actively involved in policy discussions to end drug prohibition and increase the availability of a safe supply.\u003c/p\u003e \u003cp\u003eTo address the concerns of Staff Members, governments at all levels should explore funding mechanisms that allow for more stability and consistency in the provision of harm reduction services. As ideologies shape the acceptance of harm reduction interventions, PWUS, service providers, and academics should continue to challenge stigmatizing and racist narratives that create moral panic about illicit substances and the people who use them. Grassroots organizing will likely be necessary to resist the further denigration of harm reduction services, given the current political landscape.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eOur findings reflect the unique context of the closure of the ARCHES-operated SCS in Lethbridge, Alberta, but some limitations should be noted. First, only four PWUS we interviewed had accessed the services provided by ARCHES, meaning that our findings about the impact of its closure disproportionately represented the perspectives of Staff Members employed by harm reduction organizations. Although we cannot disregard the impact our sampling method may have had on the characteristics of study participants, this limitation may also attest to the volatile and harmful situation in Lethbridge, where drug poisoning rates remained high over the period from the 2020 ARCHES SCS closure and our data collection in 2023. Another key limitation was the delay in data collection between Staff Members and PWUS, given the constantly evolving harm reduction landscape. For example, at the time we interviewed staff members, few organizations were offering safe inhalation supplies; however, this situation changed six months later when we interviewed PWUS, with some organizations altering their approach to distribution, which increased availability. As such, it was challenging to compare the perspectives of PWUS and Staff Members directly, which may have limited our analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis descriptive qualitative research study explored the impacts of SCS closures on PWUS and service providers, using semi-structured interviews with PWUS and harm reduction service providers in Lethbridge, Alberta. Our study adds to the literature that identifies power and politics as the root causes of harm experienced by PWUS. Dominant ideologies can prevent the implementation of evidence-based services, forcing PWUS to adopt new strategies to protect themselves from the toxic supply and Staff Members to consider the risks to their organization if they continue to provide harm reduction services. The work of grassroots organizations that support PWUS will continue to be important in filling in the gaps left by regressive policy decisions.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePWUS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePeople who use substances\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSCS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSupervised Consumption Site\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003e This study was approved by the University of Alberta\u0026rsquo;s Research Ethics Board (Pro00120726). All participants provided written and ongoing verbal consent. A \u003cspan\u003e$\u003c/span\u003e50 honorarium was provided to study participants who use substances.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eAuthor Details\u003c/h2\u003e \u003cp\u003eFaculty of Health Sciences, University of Lethbridge, Lethbridge, Alberta, Canada.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study was funded by the Canadian Institutes of Health Research through the Canadian Research Initiative in Substance Matters\u0026rsquo;s Prairie Node.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMM, SV and TO conceptualized the study. All authors completed data analysis. MM wrote the initial draft of the manuscript. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eData sharing is not applicable to this article as no datasets were generated or analyzed during the current study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAlberta Health. (2020). \u003cem\u003eImpact: A socio-economic review of supervised consumption sites in Alberta\u003c/em\u003e. https://open.alberta.ca/publications/9781460147054\u003c/li\u003e\n\u003cli\u003eARCHES. (2020). \u003cem\u003eOur history\u003c/em\u003e. https://archesqueerhealth.ca/our-history/\u003c/li\u003e\n\u003cli\u003eBaines, D., Cunningham, I., Campey, J., \u0026amp; Shields, J. (2014). Not profiting from precarity: The work of nonprofit service delivery and the creation of precariousness. \u003cem\u003eJust Labour\u003c/em\u003e, 22. https://doi.org/10.25071/1705-1436.6 \u003c/li\u003e\n\u003cli\u003eBardwell, G., Strike, C., Mitra, S., Scheim, A., Barnaby, L., Altenberg, J., \u0026amp; Kerr, T. (2020). \u0026quot;That\u0026apos;s a double-edged sword\u0026quot;: Exploring the integration of supervised consumption services within community health centres in Toronto, Canada. \u003cem\u003eHealth \u0026amp; Place\u003c/em\u003e, 61, 102245. https://doi.org/https://doi.org/10.1016/j.healthplace.2019.102245 \u003c/li\u003e\n\u003cli\u003eBeesoon, S., Bakal, J. A., Youngson, E., Williams, K. P., Berzins, S. A., Brindle, M. E., \u0026amp; Joffe, A. M. (2022). Excess deaths during the COVID-19 pandemic in Alberta, Canada. \u003cem\u003eIJID Regions\u003c/em\u003e, 5, 62-67. https://doi.org/https://doi.org/10.1016/j.ijregi.2022.08.011 \u003c/li\u003e\n\u003cli\u003eBell, K., \u0026amp; Salmon, A. (2011). What women who use drugs have to say about ethical research: Findings of an exploratory qualitative study. \u003cem\u003eJournal of Empirical Research on Human Research Ethics\u003c/em\u003e, 6(4), 84-98. https://doi.org/10.1525/jer.2011.6.4.84 \u003c/li\u003e\n\u003cli\u003eBell, K., \u0026amp; Salmon, A. (2012). Good intentions and dangerous assumptions: Research ethics committees and illicit drug use research. \u003cem\u003eResearch Ethics\u003c/em\u003e, 8(4), 191-199. https://doi.org/10.1177/1747016112461731 \u003c/li\u003e\n\u003cli\u003eBoyd, J., Lavalley, J., Czechaczek, S., Mayer, S., Kerr, T., Maher, L., \u0026amp; McNeil, R. (2020). \u0026quot;Bed bugs and beyond\u0026quot;: An ethnographic analysis of North America\u0026apos;s first women-only supervised drug consumption site. The International Journal on Drug Policy, 78, 102733-102733. https://doi.org/10.1016/j.drugpo.2020.102733 \u003c/li\u003e\n\u003cli\u003eBoyd, S. C., Carter, C., \u0026amp; MacPherson, D. (2016). \u003cem\u003eMore harm than good: Drug policy in Canada\u003c/em\u003e. Fernwood. \u003c/li\u003e\n\u003cli\u003eCanadian Drug Policy Coalition. (2024). \u003cem\u003eOpen letter: Supervised consumption services site closures due to lack of funding from Ministry of Health\u003c/em\u003e. https://drugpolicy.ca/supervised-consumption-services-site-closures-due-to-lack-of-funding-from-ministry-of-health/\u003c/li\u003e\n\u003cli\u003eCanadian HIV/AIDS Legal Network. (2005). \u003cem\u003e\u0026ldquo;Nothing about us without us\u0026rdquo; greater, meaningful involvement of people who use illegal drugs: A public health, ethical, and human rights imperative\u003c/em\u003e. http://www.hivlegalnetwork.ca/site/wp-content/uploads/2013/04/Greater+Involvement+-+Bklt+-+Drug+Policy+-+ENG.pdf\u003c/li\u003e\n\u003cli\u003eCanadian Research Initiative in Substance Misuse. (2023). \u003cem\u003eNational operational guidance for the implementation of supervised consumption services\u003c/em\u003e. Canadian Research Initiative in Substance Misuse. https://crism.ca/wp-content/uploads/2023/09/scs-og-final-20-sept-2023-1.pdf\u003c/li\u003e\n\u003cli\u003eCity of Lethbridge. (2019). \u003cem\u003eLethbridge community wellbeing: Needs assessment report\u003c/em\u003e. https://www.lethbridge.ca/media/0f3g2apj/community-wellbeing-needs-assessment-report.pdf \u003c/li\u003e\n\u003cli\u003eCity of Lethbridge. (2022). \u003cem\u003eLethbridge 2022 point-in-time count\u003c/em\u003e. https://static1.squarespace.com/static/64246b84b9ecca652aacc1b9/t/6446acc12934de23718de83c/1682353347303/2022+PiT+Count+Report+_FINAL.pdf\u003c/li\u003e\n\u003cli\u003eClark, A. K., Wilder, C. M., \u0026amp; Winstanley, E. L. (2014). A systematic review of community opioid overdose prevention and naloxone distribution programs. \u003cem\u003eJournal of Addiction Medicine\u003c/em\u003e, 8(3). https://journals.lww.com/journaladdictionmedicine/fulltext/2014/05000/a_systematic_review_of_community_opioid_overdose.1.aspx \u003c/li\u003e\n\u003cli\u003eClarke, V., \u0026amp; Braun, V. (2021). Thematic analysis: A practical guide. Thematic Analysis, 1-100. \u003c/li\u003e\n\u003cli\u003eCollins, A. B., Strike, C., Guta, A., Baltzer Turje, R., McDougall, P., Parashar, S., \u0026amp; McNeil, R. (2017). \u0026quot;We\u0026apos;re giving you something, so we get something in return\u0026quot;: Perspectives on research participation and compensation among people living with HIV who use drugs. The International Journal on Drug Policy, 39, 92-98. https://doi.org/10.1016/j.drugpo.2016.09.004 \u003c/li\u003e\n\u003cli\u003eCran, A. (2022). \u0026ldquo;Why do they treat us this way?\u0026rdquo;: Supervised consumption sites, racialized geographies, and notions of belonging in southern Alberta. \u003cem\u003eUndergraduate Journal of Humanistic Studies\u003c/em\u003e, 12. https://www.carleton.edu/ujhs/past-issues/winter-2022/ \u003c/li\u003e\n\u003cli\u003eCurtin, K. D., Thomson, M., Hyshka, E., Colman, I., Wild, T. C., Belon, A. P., \u0026amp; Nykiforuk, C. I. J. (2024). Assessing support for substance use policies among the general public and policy influencers in two Canadian provinces. \u003cem\u003eSubstance Abuse Treatment, Prevention, and Policy\u003c/em\u003e, 19(1), 40. https://doi.org/10.1186/s13011-024-00622-w \u003c/li\u003e\n\u003cli\u003eDaniulaityte, R., Silverstein, S. M., Crawford, T. N., Martins, S. S., Zule, W., Zaragoza, A. J., \u0026amp; Carlson, R. G. (2020). Methamphetamine use and its correlates among individuals with opioid use disorder in a midwestern U.S. City. \u003cem\u003eSubstance Use \u0026amp; Misuse\u003c/em\u003e, 55(11), 1781-1789. https://doi.org/10.1080/10826084.2020.1765805 \u003c/li\u003e\n\u003cli\u003eDenis-Lalonde, D., Lind, C., \u0026amp; Estefan, A. (2019). Beyond the buzzword: A concept analysis of harm reduction. \u003cem\u003eResearch and Theory for Nursing Practice\u003c/em\u003e, 33(4), 310. https://doi.org/10.1891/1541-6577.33.4.310 \u003c/li\u003e\n\u003cli\u003eDoyle, L., McCabe, C., Keogh, B., Brady, A., \u0026amp; McCann, M. (2020). An overview of the qualitative descriptive design within nursing research. \u003cem\u003eJournal of Research in Nursing\u003c/em\u003e, 25(5), 443-455. https://doi.org/10.1177/1744987119880234 \u003c/li\u003e\n\u003cli\u003eEger, W. H., Plesons, M., Bartholomew, T. S., Bazzi, A. R., Hauschild, M. H., McElrath, C. C., Owens, C., Forrest, D. W., Tookes, H. E., \u0026amp; Crable, E. L. (2024). Protective or potentially harmful? Altering drug consumption behaviors in response to xylazine adulteration. \u003cem\u003eResearch Square\u003c/em\u003e. https://doi.org/10.21203/rs.3.rs-4810429/v1 \u003c/li\u003e\n\u003cli\u003eFernandes, R. M., Cary, M., Duarte, G., Jesus, G., Alarc\u0026atilde;o, J., Torre, C., Costa, S., Costa, J., \u0026amp; Carneiro, A. V. (2017). Effectiveness of needle and syringe programmes in people who inject drugs \u0026ndash; an overview of systematic reviews. \u003cem\u003eBMC Public Health\u003c/em\u003e, 17(1), 309. https://doi.org/10.1186/s12889-017-4210-2 \u003c/li\u003e\n\u003cli\u003eFischer, B., Murphy, Y., Rudzinski, K., \u0026amp; MacPherson, D. (2016). Illicit drug use and harms, and related interventions and policy in Canada: A narrative review of select key indicators and developments since 2000. \u003cem\u003eInternational Journal of Drug Policy\u003c/em\u003e, 27, 23-35. https://doi.org/https://doi.org/10.1016/j.drugpo.2015.08.007 \u003c/li\u003e\n\u003cli\u003eFischer, B., Robinson, T., \u0026amp; Jutras-Aswad, D. (2024). Three noteworthy idiosyncrasies related to Canada\u0026apos;s opioid-death crisis and implications for public health-oriented interventions. \u003cem\u003eDrug and Alcohol Review, 43\u003c/em\u003e(2), 562-566. https://doi.org/https://doi.org/10.1111/dar.13796 \u003c/li\u003e\n\u003cli\u003eForeman-Mackey, A., Xavier, J., Corser, J., Fleury, M., Lock, K., Mehta, A., Lamb, J., McDougall, J., Newman, C., \u0026amp; Buxton, J. A. (2023). \u0026ldquo;It\u0026rsquo;s just a perfect storm\u0026rdquo;: Exploring the consequences of the COVID-19 pandemic on overdose risk in British Columbia from the perspectives of people who use substances. \u003cem\u003eBMC Public Health\u003c/em\u003e, 23(1), 640. https://doi.org/10.1186/s12889-023-15474-5 \u003c/li\u003e\n\u003cli\u003eFry, C. L., Hall, W., Ritter, A., \u0026amp; Jenkinson, R. (2006). The ethics of paying drug users who participate in research: A review and practical recommendations. \u003cem\u003eJournal of Empirical Research on Human Research Ethics\u003c/em\u003e, 1(4), 21-35. https://doi.org/10.1525/jer.2006.1.4.21 \u003c/li\u003e\n\u003cli\u003eGehring, N. D., Speed, K. A., Launier, K., O\u0026apos;Brien, D., Campbell, S., \u0026amp; Hyshka, E. (2022). The state of science on including inhalation within supervised consumption services: A scoping review of academic and grey literature. \u003cem\u003eInternational Journal of Drug Policy\u003c/em\u003e, 102, 103589. https://doi.org/https://doi.org/10.1016/j.drugpo.2022.103589 \u003c/li\u003e\n\u003cli\u003eGoodyear, T. (2021). (Re)politicizing harm reduction: Poststructuralist thinking to challenge the medicalization of harms among people who use drugs. \u003cem\u003eAporia\u003c/em\u003e, 13(1), 26-35. https://doi.org/https://doi.org/10.18192/aporia.v13i1.5272 \u003c/li\u003e\n\u003cli\u003eGovernment of Alberta. (2024). \u003cem\u003eAlberta substance use surveillance system\u003c/em\u003e https://healthanalytics.alberta.ca/SASVisualAnalytics/?reportUri=%2Freports%2Freports%2F1bbb695d-14b1-4346-b66e-d401a40f53e6\u0026amp;sectionIndex=0\u0026amp;sso_guest=true\u0026amp;reportViewOnly=true\u0026amp;reportContextBar=false\u0026amp;sas-welcome=false. \u003c/li\u003e\n\u003cli\u003eGovernment of Canada. (2024a). \u003cem\u003eInteractive map: Canada\u0026apos;s response to the opioid overdose crisis\u003c/em\u003e. https://health.canada.ca/en/health-canada/services/drugs-medication/opioids/responding-canada-opioid-crisis/map.html#table12\u003c/li\u003e\n\u003cli\u003eGovernment of Canada. (2024b). \u003cem\u003eOpioid- and stimulant-related harms in Canada\u003c/em\u003e. https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants\u003c/li\u003e\n\u003cli\u003eGovernment of Ontario. (2024). \u003cem\u003eOntario protecting communities and supporting addiction recovery with new treatment hubs.\u003c/em\u003e https://news.ontario.ca/en/release/1004955/ontario-protecting-communities-and-supporting-addiction-recovery-with-new-treatment-hubs\u003c/li\u003e\n\u003cli\u003eGranzow, M. (2017). The production of public space in a small Canadian city: An analysis of spatial practices in the revitalizing of Galt Gardens. \u003cem\u003eSpace and Culture\u003c/em\u003e, 20(3), 344-358. https://doi.org/10.1177/1206331217707473 \u003c/li\u003e\n\u003cli\u003eGreene, C., Maier, K., \u0026amp; Urbanik, M.-M. (2023). \u0026ldquo;It\u0026apos;s just not the same\u0026rdquo;: Exploring PWUD\u0026rsquo; perceptions of and experiences with drug policy and SCS services change in a Canadian city. The International Journal of Drug Policy, 111, 103934-103934. https://doi.org/10.1016/j.drugpo.2022.103934 \u003c/li\u003e\n\u003cli\u003eGreer, A., Amlani, A., Burmeister, C., Scott, A., Newman, C., Lampkin, H., Pauly, B., \u0026amp; Buxton, J. A. (2019). Peer engagement barriers and enablers: Insights from people who use drugs in British Columbia, Canada. Canadian Journal of Public Health. \u003cem\u003eRevue Canadienne de Sante Publique\u003c/em\u003e, 110(2), 227-235. https://doi.org/https://doi.org/10.17269/s41997-018-0167-x \u003c/li\u003e\n\u003cli\u003eHerring, J. (2020). \u003cem\u003eProvince may relocate or close some safe consumption sites, Kenney says\u003c/em\u003e. Calgary Herald. https://calgaryherald.com/news/province-may-relocate-or-shutter-some-safe-consumption-sites-kenney-says\u003c/li\u003e\n\u003cli\u003eHudes, S. (2020). \u003cem\u003eUCP pulls funding to Lethbridge supervised consumption site following audit\u003c/em\u003e. Calgary Herald. https://calgaryherald.com/news/politics/ucp-pulls-funding-to-lethbridge-supervised-consumption-site-following-audit\u003c/li\u003e\n\u003cli\u003eIvsins, A., Warnock, A., Small, W., Strike, C., Kerr, T., \u0026amp; Bardwell, G. (2023). A scoping review of qualitative research on barriers and facilitators to the use of supervised consumption services. \u003cem\u003eInternational Journal of Drug Policy\u003c/em\u003e, 111, 103910. https://doi.org/https://doi.org/10.1016/j.drugpo.2022.103910 \u003c/li\u003e\n\u003cli\u003eKamal, A., Ferguson, M., Xavier, J. C., Liu, L., Graham, B., Lock, K., \u0026amp; Buxton, J. A. (2023). Smoking identified as preferred mode of opioid safe supply use; investigating correlates of smoking preference through a 2021 cross-sectional study in British Columbia. \u003cem\u003eSubstance Abuse Treatment, Prevention, and Policy, 18\u003c/em\u003e(1), 27. https://doi.org/10.1186/s13011-023-00515-4 \u003c/li\u003e\n\u003cli\u003eKennedy, M. C., Karamouzian, M., \u0026amp; Kerr, T. (2017). Public health and public order outcomes associated with supervised drug consumption facilities: A systematic review\u003cem\u003e. Current HIV/AIDS Reports\u003c/em\u003e, 14(5), 161-183. https://doi.org/10.1007/s11904-017-0363-y \u003c/li\u003e\n\u003cli\u003eKerman, N., Manoni-Millar, S., Cormier, L., Cahill, T., \u0026amp; Sylvestre, J. (2020). \u0026ldquo;It\u0026rsquo;s not just injecting drugs\u0026rdquo;: Supervised consumption sites and the social determinants of health. \u003cem\u003eDrug and Alcohol Dependence\u003c/em\u003e, 213, 108078. https://doi.org/https://doi.org/10.1016/j.drugalcdep.2020.108078 \u003c/li\u003e\n\u003cli\u003eKhair, S., Eastwood, C. A., Lu, M., \u0026amp; Jackson, J. (2022). Supervised consumption site enables cost savings by avoiding emergency services: A cost analysis study. \u003cem\u003eHarm Reduction Journal\u003c/em\u003e, 19(1), 32. https://doi.org/10.1186/s12954-022-00609-5 \u003c/li\u003e\n\u003cli\u003eKolla, G., Strike, C., Watson, T. M., Jairam, J., Fischer, B., \u0026amp; Bayoumi, A. M. (2017). Risk creating and risk reducing: Community perceptions of supervised consumption facilities for illicit drug use. \u003cem\u003eHealth, Risk \u0026amp; Society\u003c/em\u003e, 19(1/2), 91-111. https://doi.org/10.1080/13698575.2017.1291918 \u003c/li\u003e\n\u003cli\u003eLedlie, S., Garg, R., Cheng, C., Kolla, G., Antoniou, T., Bouck, Z., \u0026amp; Gomes, T. (2024). Prescribed safer opioid supply: A scoping review of the evidence\u003cem\u003e. International Journal of Drug Policy\u003c/em\u003e, 125, 104339. https://doi.org/https://doi.org/10.1016/j.drugpo.2024.104339 \u003c/li\u003e\n\u003cli\u003eLevengood, T. W., Yoon, G. H., Davoust, M. J., Ogden, S. N., Marshall, B. D. L., Cahill, S. R., \u0026amp; Bazzi, A. R. (2021). Supervised injection facilities as harm reduction: A systematic review. \u003cem\u003eAmerican Journal of Preventive Medicine\u003c/em\u003e, 61(5), 738-749. https://doi.org/https://doi.org/10.1016/j.amepre.2021.04.017 \u003c/li\u003e\n\u003cli\u003eLivingston, J. D. (2021). Supervised consumption sites and crime: Scrutinizing the methodological weaknesses and aberrant results of a government report in Alberta, Canada. \u003cem\u003eHarm Reduction Journal\u003c/em\u003e, 18(1), 4. https://doi.org/10.1186/s12954-020-00456-2 \u003c/li\u003e\n\u003cli\u003eMacevicius, C., Gudi\u0026ntilde;o P\u0026eacute;rez, D., Norton, A., Kolla, G., Beck-McGreevy, P., Selfridge, M., Kalicum, J., Hutchison, A., Urbanoski, K., Barker, B., Slaunwhite, A., Nosyk, B., \u0026amp; Pauly, B. (2023). Just have this come from their prescription pad: The medicalization of safer supply from the perspectives of health planners in BC, Canada. \u003cem\u003eDrugs: Education, Prevention and Policy\u003c/em\u003e, 1-11. https://doi.org/10.1080/09687637.2023.2283383 \u003c/li\u003e\n\u003cli\u003eMichaud, L., Kolla, G., Rudzinski, K., \u0026amp; Guta, A. (2024). Mapping a moral panic: News media narratives and medical expertise in public debates on safer supply, diversion, and youth drug use in Canada. \u003cem\u003eInternational Journal of Drug Policy\u003c/em\u003e, 127, 104423. https://doi.org/https://doi.org/10.1016/j.drugpo.2024.104423 \u003c/li\u003e\n\u003cli\u003eMigneault, J. (2024). \u003cem\u003eOntario\u0026apos;s decision to close 10 supervised consumption sites draws mixed reaction in Sudbury\u003c/em\u003e. Canadian Broadcast Corporation. https://www.cbc.ca/news/canada/sudbury/supervised-consumption-closures-sudbury-reaction-1.7299953\u003c/li\u003e\n\u003cli\u003eMitra, S., Bouck, Z., Larney, S., Zolopa, C., H\u0026oslash;j, S., Minoyan, N., Upham, K., Rammohan, I., Mok, W. Y., Hayashi, K., Milloy, M. J., DeBeck, K., Scheim, A., \u0026amp; Werb, D. (2024). The impact of the covid-19 pandemic on people who use drugs in three Canadian cities: A cross-sectional analysis. \u003cem\u003eHarm Reduction Journal\u003c/em\u003e, 21(1), 94. https://doi.org/10.1186/s12954-024-00996-x \u003c/li\u003e\n\u003cli\u003eOudshoorn, A., Sangster Bouck, M., McCann, M., Zendo, S., Berman, H., Banninga, J., Le Ber, M. J., \u0026amp; Zendo, Z. (2021). A critical narrative inquiry to understand the impacts of an overdose prevention site on the lives of site users. \u003cem\u003eHarm Reduction Journal\u003c/em\u003e, 18(1), 6. https://doi.org/10.1186/s12954-020-00458-0 \u003c/li\u003e\n\u003cli\u003eOzcan, G. (2023). The colour of policing in Lethbridge. In C. Hodes \u0026amp; G. T. Bonifacio (Eds.), \u003cem\u003eRacism in Southern Alberta and anti-racist activism for change\u003c/em\u003e. AU Press. \u003c/li\u003e\n\u003cli\u003ePhillips, S. D., \u0026amp; Wyatt, B. (2021). \u003cem\u003eIntersections and innovations: Change for Canada\u0026rsquo;s voluntary and nonprofit sector\u003c/em\u003e. Muttart Foundation. https://era.library.ualberta.ca/items/22cdae0a-2b50-457c-8cdf-2da90604e087/download/68eebf8a-93bc-45e5-863a-42ff8ec479c0 \u003c/li\u003e\n\u003cli\u003ePublic Health Ontario. (2023). \u003cem\u003eHarm reduction services for anyone who smokes or inhales drugs\u003c/em\u003e. https://www.publichealthontario.ca/-/media/Documents/H/2023/harm-reduction-services-smoking-inhaling-drugs.pdf?rev=255f0227310e46448c8c30ace7b6ef02\u0026amp;sc_lang=en\u003c/li\u003e\n\u003cli\u003eRaphael, D. (2014). Beyond policy analysis: The raw politics behind opposition to healthy public policy\u0026dagger;. \u003cem\u003eHealth Promotion International, 30\u003c/em\u003e(2), 380-396. https://doi.org/10.1093/heapro/dau044 \u003c/li\u003e\n\u003cli\u003eRussell, C., Ali, F., Nafeh, F., Rehm, J., LeBlanc, S., \u0026amp; Elton-Marshall, T. (2021). Identifying the impacts of the COVID-19 pandemic on service access for people who use drugs (PWUD): A national qualitative study. \u003cem\u003eJournal of Substance Abuse Treatment\u003c/em\u003e, 129, 108374. https://doi.org/https://doi.org/10.1016/j.jsat.2021.108374 \u003c/li\u003e\n\u003cli\u003eRussell, C., Law, J., Bonn, M., Rehm, J., \u0026amp; Ali, F. (2023). The increase in benzodiazepine-laced drugs and related risks in Canada: The urgent need for effective and sustainable solutions. \u003cem\u003eInternational Journal of Drug Policy\u003c/em\u003e, 111, 103933. https://doi.org/https://doi.org/10.1016/j.drugpo.2022.103933 \u003c/li\u003e\n\u003cli\u003eSalvalaggio, G., Brooks, H., Caine, V., Gagnon, M., Godley, J., Houston, S., Kennedy, M. C., Kosteniuk, B., Livingston, J., Saah, R., Speed, K., Urbanoski, K., Werb, D., \u0026amp; Hyshka, E. (2023). Flawed reports can harm: The case of supervised consumption services in Alberta. \u003cem\u003eCanadian Journal of Public Health.\u003c/em\u003e https://doi.org/10.17269/s41997-023-00825-x \u003c/li\u003e\n\u003cli\u003eSandelowski, M. (2010). What\u0026apos;s in a name? Qualitative description revisited. \u003cem\u003eResearch in Nursing \u0026amp; Health,\u003c/em\u003e 33(1), 77-84. https://doi.org/https://doi.org/10.1002/nur.20362 \u003c/li\u003e\n\u003cli\u003eSmall, W., Van Borek, N., Fairbairn, N., Wood, E., \u0026amp; Kerr, T. (2009). Access to health and social services for IDU: The impact of a medically supervised injection facility. \u003cem\u003eDrug and Alcohol Review\u003c/em\u003e, 28(4), 341-346. https://doi.org/10.1111/j.1465-3362.2009.00025.x \u003c/li\u003e\n\u003cli\u003eSmith, C. (2016). \u0026ldquo;About nothing without us\u0026rdquo;: A comparative analysis of autonomous organizing among people who use drugs and psychiatrized groups in Canada. \u003cem\u003eIntersectionalities: A Global Journal of Social Work Analysis, Research, Polity, and Practice\u003c/em\u003e, 5(3), 82\u0026ndash;109. https://journals.library.mun.ca/ojs/index.php/IJ/article/view/1613/1332 \u003c/li\u003e\n\u003cli\u003eSmith, M. (2024). \u003cem\u003eAlberta government to close red deer overdose prevention site, add new recovery services\u003c/em\u003e. CBC. https://www.cbc.ca/news/canada/edmonton/alberta-government-to-close-red-deer-overdose-prevention-site-add-new-recovery-services-1.7333122\u003c/li\u003e\n\u003cli\u003eTaylor, S. (2024). \u003cem\u003eConservatives would scale back supervised drug consumption sites, Poilievre says\u003c/em\u003e. The Canadian Press. https://www.thecanadianpressnews.ca/business/conservatives-would-scale-back-supervised-drug-consumption-sites-poilievre-says/article_e31773a2-b747-580b-b8e1-70266f8aeda4.html\u003c/li\u003e\n\u003cli\u003eTi, L., Tzemis, D., \u0026amp; Buxton, J. A. (2012). Engaging people who use drugs in policy and program development: A review of the literature\u003cem\u003e. Substance Abuse Treatment, Prevention, and Policy\u003c/em\u003e, 7(1), 47. https://doi.org/10.1186/1747-597X-7-47 \u003c/li\u003e\n\u003cli\u003evan Draanen, J., Hamilton, J., Morgan, J., Maxwell, S., Taylor, T., Richardson, L., \u0026amp; Nolan, S. (2023). Supervised smoking facility access, harm reduction practices, and substance use changes during the covid-19 pandemic: A community-engaged cross-sectional study. \u003cem\u003eHarm Reduction Journal\u003c/em\u003e, 20(1), 101. https://doi.org/10.1186/s12954-023-00825-7 \u003c/li\u003e\n\u003cli\u003eWagner, K. D., Fiuty, P., Page, K., Tracy, E. C., Nocera, M., Miller, C. W., Tarhuni, L. J., \u0026amp; Dasgupta, N. (2023). Prevalence of fentanyl in methamphetamine and cocaine samples collected by community-based drug checking services. \u003cem\u003eDrug and Alcohol Dependence\u003c/em\u003e, 252, 110985. https://doi.org/https://doi.org/10.1016/j.drugalcdep.2023.110985 \u003c/li\u003e\n\u003cli\u003eWatson, T. M., Kolla, G., van der Meulen, E., \u0026amp; Dodd, Z. (2020). Critical studies of harm reduction: Overdose response in uncertain political times. \u003cem\u003eInternational Journal of Drug Policy\u003c/em\u003e, 76, 102615. https://doi.org/https://doi.org/10.1016/j.drugpo.2019.102615 \u003c/li\u003e\n\u003cli\u003eWild, T. C., Koziel, J., Anderson-Baron, J., Asbridge, M., Belle-Isle, L., Dell, C., Elliott, R., Hathaway, A., MacPherson, D., McBride, K., Pauly, B., Strike, C., Galovan, A., \u0026amp; Hyshka, E. (2021). Public support for harm reduction: A population survey of Canadian adults. \u003cem\u003ePLoS ONE\u003c/em\u003e, 16(5), e0251860. https://doi.org/10.1371/journal.pone.0251860 \u003c/li\u003e\n\u003cli\u003eWilson, P., Colizza, K., \u0026amp; Hyshka, E. (2024). Safer supply and political interference in medical practice: Alberta\u0026apos;s narcotics transition services. \u003cem\u003eInternational Journal of Drug Policy\u003c/em\u003e, 133, 104600. https://doi.org/https://doi.org/10.1016/j.drugpo.2024.104600 \u003c/li\u003e\n\u003cli\u003eWoodward, J. (2024). \u003cem\u003eMany deaths predicted from Ontario\u0026rsquo;s plan to shut supervised consumption sites: Experts, data\u003c/em\u003e. CTV. https://toronto.ctvnews.ca/many-deaths-predicted-from-ontario-s-plan-to-shut-supervised-consumption-sites-experts-data-1.7013045\u003c/li\u003e\n\u003cli\u003eZhu, D. T. (2023). Public health impact and harm reduction implications of xylazine-involved overdoses: A narrative review. \u003cem\u003eHarm Reduction Journal\u003c/em\u003e, 20(1), 131. https://doi.org/10.1186/s12954-023-00867-x \u003c/li\u003e\n\u003cli\u003eZiegler, B. R., Wray, A. J., \u0026amp; Luginaah, I. (2019). The ever-changing narrative: Supervised injection site policy making in Ontario, Canada. \u003cem\u003eInternational Journal of Drug Policy\u003c/em\u003e, 74, 98-111. https://doi.org/https://doi.org/10.1016/j.drugpo.2019.09.006 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Supervised Consumption Sites, Harm Reduction, Policy, Politics","lastPublishedDoi":"10.21203/rs.3.rs-5820964/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5820964/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSupervised Consumption Sites (SCSs) are an evidence-based harm reduction strategy to reduce the risk of fatal drug poisonings. However, this approach has faced political opposition in Canada, resulting in the closures of SCSs in some provinces. Our study aims to add to the understanding of the impact of SCS closures by exploring the perspectives of both people who use substances (PWUS) and the staff members of organizations that continue to provide harm reduction services. Our study explores the aftermath of the closure of what was once North America\u0026rsquo;s busiest SCS, located in Lethbridge, Alberta, Canada, offering a contextualized exploration of regressive harm reduction policies.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eTo better understand the impact of the closure, our study adopts a descriptive qualitative design to explore this novel phenomenon within the unique context of Lethbridge, Alberta. We conducted 27 interviews with PWUS and 10 with Staff Members of organizations that provide harm-reduction services. We chose to use reflexive thematic analysis (TA), which allows for a critical realist and contextual approach to data analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe developed three themes based on our analysis. Our first theme speaks to the harms of SCS closures on PWUS and organizations that provide harm reduction services. Next, our second theme highlights the perspectives of participants on the political motivations behind the ARCHES closure. Our last theme explores how PWUS and organizations navigate the political opposition to harm reduction approaches while responding to the worsening drug poisoning crisis.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eOur study highlights the continued need to expand harm reduction services and for ongoing advocacy to reverse regressive policy decisions.\u003c/p\u003e","manuscriptTitle":"“We’ve lost a lot of lives:” The Impact of the Closure of North America’s Busiest Supervised Consumption Site on People Who Use Substances and the Organizations that Work with Them","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-15 10:57:43","doi":"10.21203/rs.3.rs-5820964/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-19T07:00:26+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-15T04:20:10+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-13T23:29:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-11T23:35:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-04T20:18:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"19967474448084699076670932166943307774","date":"2025-02-25T03:22:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79191050305707423052090394194393388570","date":"2025-02-20T15:10:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"208406846905879045752034753211196195458","date":"2025-02-19T17:00:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79556237761562510806179072731471010529","date":"2025-02-19T11:15:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-02-19T05:34:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-14T08:43:09+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-14T08:42:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"Harm Reduction Journal","date":"2025-01-13T14:44:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6459c496-3686-4c10-ae2a-1d4c165324f6","owner":[],"postedDate":"January 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-06-09T16:00:15+00:00","versionOfRecord":{"articleIdentity":"rs-5820964","link":"https://doi.org/10.1186/s12954-025-01251-7","journal":{"identity":"harm-reduction-journal","isVorOnly":false,"title":"Harm Reduction Journal"},"publishedOn":"2025-06-05 15:57:11","publishedOnDateReadable":"June 5th, 2025"},"versionCreatedAt":"2025-01-15 10:57:43","video":"","vorDoi":"10.1186/s12954-025-01251-7","vorDoiUrl":"https://doi.org/10.1186/s12954-025-01251-7","workflowStages":[]},"version":"v1","identity":"rs-5820964","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5820964","identity":"rs-5820964","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}