45 References 1. Drug Overdose Deaths [Internet]. 2021 [cited 2021 Apr 29]. Available from: https://www.cdc.gov/drugoverdose/data/statedeaths.html 2. 2019 Drug Overdose Death Rates [Internet]. 2021 [cited 2021 Apr 29]. Available from: https://www.cdc.gov/drugoverdose/data/statedeaths/drug-overdose-death-2019.html 3. National Center for Health Statistics. Vital Statistics Rapid Release - Provisional Drug Overdose Data [Internet]. 2018 [cited 2018 Oct 3]. Available from: https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm 4. DiGennaro C, Garcia G-GP, Stringfellow EJ, Wakeman S, Jalali MS. Changes in characteristics of opioid overdose death trends during the COVID-19 pandemic [Internet]. bioRxiv. medRxiv; 2021. Available from: http://medrxiv.org/lookup/doi/10.1101/2021.02.01.21250781 5. Massachusetts Department of Public Health. Number of opioid-related overdose deaths, all intents by City/Town 2015-2019 [Internet]. 2020 Nov. Available from: https://www.mass.gov/doc/opioid-related-overdose-deaths-by-citytown-november- 2020/download 6. National Health for Health Statistics. Products - Vital Statistics Rapid Release - VSRR No. 11 Dashboard [Internet]. 2021 [cited 2021 May 6]. Available from: https://www.cdc.gov/nchs/nvss/vsrr/vsrr11-dashboard/index.htm 7. SomerStat. Mapping Opioid Overdose in Somerville (2014-2020). City of Somerville; 2020 Feb. 8. Darke S, Mattick RP, Degenhardt L. The ratio of non-fatal to fatal heroin overdose. Addiction. 2003 Aug;98(8):1169–71. 9. Milloy M-JS, Kerr T, Tyndall M, Montaner J, Wood E. Estimated drug overdose deaths averted by North America’s first medically-supervised safer injection facility. PLoS One. 2008 Oct 7;3(10):e3351. 10. Commonwealth of Massachusetts. HIV Treatment Guidelines and Clinical Advisories [Internet]. [cited 2021 May 30]. Available from: https://www.mass.gov/lists/hiv-treatment- guidelines-and-clinical-advisories 11. Linas BP, Savinkina A, Madushani RWMA, Wang J, Eftekhari Yazdi G, Chatterjee A, et al. Projected Estimates of Opioid Mortality After Community-Level Interventions. JAMA Netw Open. 2021 Feb 1;4(2):e2037259. 12. Saloner B, McGinty EE, Beletsky L, Bluthenthal R, Beyrer C, Botticelli M, et al. A Public Health Strategy for the Opioid Crisis. Public Health Rep. 2018;133(1_suppl):24S – 34S. 13. Hagan H, Campbell JV, Thiede H, Strathdee SA, Ouellet L, Latka M, et al. Injecting alone among young adult IDUs in five US cities: evidence of low rates of injection risk behavior. Drug Alcohol Depend. 2007 Nov;91 Suppl 1:S48–55.

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46 14. Behrends CN, Paone D, Nolan ML, Tuazon E, Murphy SM, Kapadia SN, et al. Estimated impact of supervised injection facilities on overdose fatalities and healthcare costs in New York City. J Subst Abuse Treat. 2019 Nov;106:79–88. 15. Supervised Consumption Services [Internet]. [cited 2021 Apr 29]. Available from: http://www.drugpolicy.org/resource/supervised-consumption-services 16. Kennedy MC, Karamouzian M, Kerr T. Public Health and Public Order Outcomes Associated with Supervised Drug Consumption Facilities: a Systematic Review. Curr HIV/AIDS Rep. 2017 Oct;14(5):161–83. 17. Potier C, Laprévote V, Dubois-Arber F, Cottencin O, Rolland B. Supervised injection services: what has been demonstrated? A systematic literature review. Drug Alcohol Depend. 2014 Dec 1;145:48–68. 18. Salmon AM, van Beek I, Amin J, Kaldor J, Maher L. The impact of a supervised injecting facility on ambulance call-outs in Sydney, Australia. Addiction. 2010 Apr;105(4):676–83. 19. Kennedy MC, Hayashi K, Milloy M-J, Wood E, Kerr T. Supervised injection facility use and all- cause mortality among people who inject drugs in Vancouver, Canada: A cohort study. PLoS Med. 2019 Nov;16(11):e1002964. 20. Marshall BDL, Milloy M-J, Wood E, Montaner JSG, Kerr T. Reduction in overdose mortality after the opening of North America’s first medically supervised safer injecting facility: a retrospective population-based study. Lancet. 2011 Apr 23;377(9775):1429–37. 21. Kerr T, Tyndall M, Li K, Montaner J, Wood E. Safer injection facility use and syringe sharing in injection drug users. Lancet. 2005;366(9482):316–8. 22. Pinkerton SD. How many HIV infections are prevented by Vancouver Canada’s supervised injection facility? Int J Drug Policy. 2011 May;22(3):179–83. 23. Andresen MA, Boyd N. A cost-benefit and cost-effectiveness analysis of Vancouver’s supervised injection facility. Int J Drug Policy. 2010 Jan;21(1):70–6. 24. Belackova V, Salmon AM, Schatz E, Jauncey M. Drug consumption rooms (DCRs) as a setting to address hepatitis C - findings from an international online survey. Hepatol Med Policy. 2018 Aug 22;3:9. 25. Ebright JR, Pieper B. Skin and soft tissue infections in injection drug users. Infect Dis Clin North Am. 2002 Sep;16(3):697–712. 26. Small W, Wood E, Lloyd-Smith E, Tyndall M, Kerr T. Accessing care for injection-related infections through a medically supervised injecting facility: a qualitative study. Drug Alcohol Depend. 2008 Nov 1;98(1-2):159–62. 27. Stoltz J-A, Wood E, Small W, Li K, Tyndall M, Montaner J, et al. Changes in injecting practices associated with the use of a medically supervised safer injection facility. J Public Health . 2007 Mar;29(1):35–9.

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47 28. Marshall BDL, Wood E, Zhang R, Tyndall MW, Montaner JSG, Kerr T. Condom use among injection drug users accessing a supervised injecting facility. Sex Transm Infect. 2009 Apr;85(2):121–6. 29. Greer AM, Luchenski SA, Amlani AA, Lacroix K, Burmeister C, Buxton JA. Peer engagement in harm reduction strategies and services: a critical case study and evaluation framework from British Columbia, Canada. BMC Public Health. 2016 May 27;16:452. 30. Bouchard M, Hashimi S, Tsai K, Lampkin H, Jozaghi E. Back to the core: A network approach to bolster harm reduction among persons who inject drugs. Int J Drug Policy. 2018 Jan;51:95– 104. 31. Wood E, Tyndall MW, Zhang R, Stoltz J-A, Lai C, Montaner JSG, et al. Attendance at supervised injecting facilities and use of detoxification services. N Engl J Med. 2006 Jun 8;354(23):2512–4. 32. Wood E, Tyndall MW, Zhang R, Montaner JSG, Kerr T. Rate of detoxification service use and its impact among a cohort of supervised injecting facility users. Addiction. 2007 Jun;102(6):916–9. 33. DeBeck K, Kerr T, Bird L, Zhang R, Marsh D, Tyndall M, et al. Injection drug use cessation and use of North America’s first medically supervised safer injecting facility. Drug Alcohol Depend. 2011 Jan 15;113(2-3):172–6. 34. Kimber J, Mattick RP, Kaldor J, van Beek I, Gilmour S, Rance JA. Process and predictors of drug treatment referral and referral uptake at the Sydney Medically Supervised Injecting Centre. Drug Alcohol Rev. 2008 Nov;27(6):602–12. 35. Wood E, Tyndall MW, Montaner JS, Kerr T. Summary of findings from the evaluation of a pilot medically supervised safer injecting facility. CMAJ. 2006 Nov 21;175(11):1399–404. 36. Scheim A, Werb D. Integrating supervised consumption into a continuum of care for people who use drugs. CMAJ. 2018 Aug 7;190(31):E921–2. 37. Bruneau J, Ahamad K, Goyer M-È, Poulin G, Selby P, Fischer B, et al. Management of opioid use disorders: a national clinical practice guideline. CMAJ. 2018 Mar 5;190(9):E247–57. 38. Kerr T, Tyndall MW, Zhang R, Lai C, Montaner JSG, Wood E. Circumstances of first injection among illicit drug users accessing a medically supervised safer injection facility. Am J Public Health. 2007 Jul;97(7):1228–30. 39. Kerr T, Stoltz J-A, Tyndall M, Li K, Zhang R, Montaner J, et al. Impact of a medically supervised safer injection facility on community drug use patterns: a before and after study. BMJ. 2006 Jan 28;332(7535):220–2. 40. Salmon AM, Thein H-H, Kimber J, Kaldor JM, Maher L. Five years on: what are the community perceptions of drug-related public amenity following the establishment of the Sydney Medically Supervised Injecting Centre? Int J Drug Policy. 2007 Jan;18(1):46–53.

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48 41. Wood E, Kerr T, Small W, Li K, Marsh DC, Montaner JSG, et al. Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users. CMAJ. 2004 Sep 28;171(7):731–4. 42. Harm Reduction Commission [Internet]. [cited 2021 May 9]. Available from: https://www.mass.gov/orgs/harm-reduction-commission 43. Myer AJ, Belisle L. Highs and Lows: An Interrupted Time-Series Evaluation of the Impact of North America’s Only Supervised Injection Facility on Crime. J Drug Issues. 2018 Jan 1;48(1):36–49. 44. Freeman K, Jones CGA, Weatherburn DJ, Rutter S, Spooner CJ, Donnelly N. The impact of the Sydney Medically Supervised Injecting Centre (MSIC) on crime. Drug Alcohol Rev. 2005 Mar;24(2):173–84. 45. Wood E, Tyndall MW, Lai C, Montaner JSG, Kerr T. Impact of a medically supervised safer injecting facility on drug dealing and other drug-related crime. Subst Abuse Treat Prev Policy. 2006 May 8;1:13. 46. Davidson PJ, Lambdin BH, Browne EN, Wenger LD, Kral AH. Impact of an unsanctioned safe consumption site on criminal activity, 2010-2019. Drug Alcohol Depend. 2021 Jan 11;220:108521. 47. Pardo B, Caulkins J, Kilmer B. Assessing the evidence on supervised drug consumption sites. RAND Corporation; 2018. 48. Bayoumi AM, Zaric GS. The cost-effectiveness of Vancouver’s supervised injection facility. CMAJ. 2008 Nov 18;179(11):1143–51. 49. Enns EA, Zaric GS, Strike CJ, Jairam JA, Kolla G, Bayoumi AM. Potential cost-effectiveness of supervised injection facilities in Toronto and Ottawa, Canada. Addiction. 2016 Mar;111(3):475– 89. 50. Hood JE, Behrends CN, Irwin A, Schackman BR, Chan D, Hartfield K, et al. The projected costs and benefits of a supervised injection facility in Seattle, WA, USA. Int J Drug Policy. 2019 May;67:9–18. 51. Irwin A, Jozaghi E, Weir BW, Allen ST, Lindsay A, Sherman SG. Mitigating the heroin crisis in Baltimore, MD, USA: a cost-benefit analysis of a hypothetical supervised injection facility. Harm Reduct J. 2017 May 12;14(1):29. 52. Irwin A, Jozaghi E, Bluthenthal RN, Kral AH. A Cost-Benefit Analysis of a Potential Supervised Injection Facility in San Francisco, California, USA. J Drug Issues. 2017 Apr 1;47(2):164–84. 53. Coye AE, Bornstein KJ, Bartholomew TS, Li H, Wong S, Janjua NZ, et al. Hospital Costs of Injection Drug Use in Florida. Clin Infect Dis. 2021 Feb 1;72(3):499–502.

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49 54. Lloyd-Smith E, Wood E, Zhang R, Tyndall MW, Montaner JS, Kerr T. Determinants of cutaneous injection-related infection care at a supervised injecting facility. Ann Epidemiol. 2009 Jun;19(6):404–9. 55. Wood RA, Stewart P, Zettel W. Harm reduction nursing practice: the Dr. Peter Centre Centre supervised injection project. Canadian Nurse. 2003;99(5):20–4. 56. Supervised Consumption Services (SCS) – Parkdale Site [Internet]. 2018 [cited 2021 May 4]. Available from: https://pqwchc.org/programs-services/harm-reduction/ops/ 57. Insite [Internet]. 2020 [cited 2021 May 4]. Available from: https://www.phs.ca/program/insite/ 58. Uniting Medically Supervised Injecting Centre (MSIC) [Internet]. [cited 2021 May 4]. Available from: https://www.uniting.org/community-impact/uniting-medically-supervised-injecting- centre--msic 59. Dong KA, Brouwer J, Johnston C, Hyshka E. Supervised consumption services for acute care hospital patients. CMAJ. 2020 May 4;192(18):E476–9. 60. Overdose Prevention Site at St. Paul’s Hospital [Internet]. [cited 2021 May 4]. Available from: https://www.catie.ca/en/pc/program/ops-stpaul 61. Salle de consommation à moindres risques [Internet]. Gaïa Paris. [cited 2021 May 4]. Available from: https://gaia-paris.fr/salle-de-consommation-a-moindre-risque/ 62. Drogenhilfezentrum Abrigado [Internet]. Comité National de Défense Sociale. 2015 [cited 2021 May 4]. Available from: https://www.cnds.lu/abrigado/ 63. Das Eastside - Europas größte niedrigschweillige Drogenhilfeeinrichtung [Internet]. idh - Integrative Drogenhilfe e.V. [cited 2021 May 4]. Available from: https://www.idh- frankfurt.de/eastside 64. Bardwell G, Kerr T, Boyd J, McNeil R. Characterizing peer roles in an overdose crisis: Preferences for peer workers in overdose response programs in emergency shelters. Drug Alcohol Depend. 2018 Sep 1;190:6–8. 65. Collins AB, Boyd J, Hayashi K, Cooper HLF, Goldenberg S, McNeil R. Women’s utilization of housing-based overdose prevention sites in Vancouver, Canada: An ethnographic study. International Journal of Drug Policy. 2020 Feb 1;76:102641. 66. Victoria - Howard Johnson [Internet]. Island Health - Overdose Prevention & Supervised Consumption Locations. [cited 2021 May 4]. Available from: https://www.islandhealth.ca/our- locations/overdose-prevention-supervised-consumption-locations/victoria-howard-johnson 67. Kassam A. Montreal opens first mobile supervised injection clinic in North America. The Guardian [Internet]. 2017 Jun 19 [cited 2021 May 30]; Available from: http://www.theguardian.com/worldhttps://www.islandhealth.ca/our-locations/overdose- prevention-supervised-consumption-locations/victoria-howard- johnson/2017/jun/19/montreal-mobile-supervised-injection-clinic-north-america

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50 68. Busby M. Inside Glasgow’s Safer Drug Consumption Van. VICE World News [Internet]. 2020 Sep 14 [cited 2021 May 4]; Available from: https://www.vice.com/en/article/3azmpj/glasgow- safer-drug-consumption-van 69. Dietze P, Winter R, Pedrana A, Leicht A, Majó I Roca X, Brugal MT. Mobile safe injecting facilities in Barcelona and Berlin. Int J Drug Policy. 2012 Jul;23(4):257–60. 70. About Somerville [Internet]. City of Somerville. [cited 2021 May 3]. Available from: https://www.somervillema.gov/about 71. United States Census Bureau. QuickFacts: Somerville city, Massachusetts [Internet]. [cited 2021 May 3]. Available from: https://www.census.gov/quickfacts/somervillecitymassachusetts 72. City of Somerville. SomerVision 2040: Comprehensive Plan Update [Internet]. 2020 Dec. Available from: https://2xbcbm3dmbsg12akbzq9ef2k-wpengine.netdna-ssl.com/wp- content/uploads/2020/12/SomerVision-202012023.pdf 73. US Department of Housing and Urban Development. 2018 AHAR: Part 1 - PIT Estimates of Homelessness in the US [Internet]. HUD Exchange. 2018. Available from: https://www.hudexchange.info/resource/5783/2018-ahar-part-1-pit-estimates-of- homelessness-in-the-us/ 74. Region of Waterloo Public Health and Emergency Services. Waterloo Region Supervised Injection Services Feasibility Study [Internet]. 2018. Available from: https://www.regionofwaterloo.ca/en/regional-government/resources/Reports-Plans-- Data/Public-Health-and-Emergency-Services/SIS_FeasibilityStudy.pdf 75. T Kerr, S Mitra, B Krysowaty, Z Marshall, C Olsen, B Rachlis, J Bacon, K Murray, S Rourke. Ontario Integrated Supervised Injection Services Feasibility Study Study Report: Thunder Bay, ON [Internet]. 2017. Available from: https://www.ohtn.on.ca/wp- content/uploads/2017/02/OISIS-Thunder-Bay-Report-Online.pdf 76. Public Health Sudbury & Districts. A study to explore the need for and feasibility of implementing supervised consumption services in the City of Greater Sudbury [Internet]. 2020. Available from: https://www.phsd.ca/wp- content/uploads/2020/06/Need_for_and_feasibility_of_implementing_supervised_consumpti on_services_in_the_City_of_Greater_Sudbury_EN-3.pdf 77. British Columbia Centre on Substance Use. Supervised consumption services: Operational guidance [Internet]. 2017. Available from: https://www.bccsu.ca/wp- content/uploads/2017/07/BC-SCS-Operational-Guidance.pdf 78. Massachusetts Document Repository [Internet]. [cited 2021 May 9]. Available from: https://docs.digital.mass.gov/dataset/massgis-data-massachusetts-department- transportation-massdot-roads 79. Massachusetts Bay Transportation Authority. GTFS [Internet]. MBTA. [cited 2021 May 9]. Available from: https://www.mbta.com/developers/gtfs

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51 80. City of Somerville. Quality Of Life Incidents [Internet]. 2020 [cited 2021 May 9]. Available from: https://data.somervillema.gov/Public-Safety/Quality-Of-Life-Incidents/62z4-avqc 81. Institute for Clinical and Economic Review. Opioid Epidemic: Supervised Injection Facilities [Internet]. 2020 [cited 2021 May 4]. Available from: https://icer.org/assessment/opioids- supervised-injection-facilities-2020/ 82. Mallow PJ, Belk KW, Topmiller M, Strassels SA. Geographic variation in hospital costs, payments, and length of stay for opioid-related hospital visits in the USA. J Pain Res. 2018 Dec 4;11:3079–88. 83. Miller CL, Firestone M, Ramos R, Burris S, Ramos ME, Case P, et al. Injecting drug users’ experiences of policing practices in two Mexican-U.S. border cities: public health perspectives. Int J Drug Policy. 2008 Aug;19(4):324–31. 84. Ti L, Wood E, Shannon K, Feng C, Kerr T. Police confrontations among street-involved youth in a Canadian setting. Int J Drug Policy. 2013 Jan;24(1):46–51. 85. Small W, Rhodes T, Wood E, Kerr T. Public injection settings in Vancouver: physical environment, social context and risk. Int J Drug Policy. 2007 Jan;18(1):27–36. 86. Volkmann T, Lozada R, Anderson CM, Patterson TL, Vera A, Strathdee SA. Factors associated with drug-related harms related to policing in Tijuana, Mexico. Harm Reduct J. 2011 Apr 8;8(1):1–8. 87. Sarang A, Rhodes T, Sheon N, Page K. Policing drug users in Russia: risk, fear, and structural violence. Subst Use Misuse. 2010 May;45(6):813–64. 88. Wagner KD, Simon-Freeman R, Bluthenthal RN. The association between law enforcement encounters and syringe sharing among IDUs on skid row: a mixed methods analysis. AIDS Behav. 2013 Oct;17(8):2637–43. 89. Bardwell G, Strike C, Altenberg J, Barnaby L, Kerr T. Implementation contexts and the impact of policing on access to supervised consumption services in Toronto, Canada: a qualitative comparative analysis. Harm Reduct J. 2019 May 2;16(1):1–9. 90. Collins AB, Boyd J, Mayer S, Fowler A, Kennedy MC, Bluthenthal RN, et al. Policing space in the overdose crisis: A rapid ethnographic study of the impact of law enforcement practices on the effectiveness of overdose prevention sites. International Journal of Drug Policy. 2019 Nov 1;73:199–207. 91. Foreman-Mackey A, Bayoumi AM, Miskovic M, Kolla G, Strike C. “It”s our safe sanctuary’: Experiences of using an unsanctioned overdose prevention site in Toronto, Ontario. International Journal of Drug Policy. 2019 Nov 1;73:135–40. 92. Watson TM, Bayoumi AM, Hopkins S, Wright A, Naraine R, Khorasheh T, et al. Creating and sustaining cooperative relationships between supervised injection services and police: A qualitative interview study of international stakeholders. Int J Drug Policy. 2018 Nov;61:1–6.

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52 Appendix 1 - Results from the surveys with people who use drugs Data Notes In total, 47 surveys were completed with people who self-identified as a person who uses drugs from February to April 2021. Participants were not required to answer each question and some questions allowed for multiple responses. Please note that the number of participants who responded to each question are noted below. Percentages have been rounded to the nearest whole percent. To protect participants’ privacy, responses that have less than five counts have been suppressed. These are denoted with a “nr” (not reportable). Demographics Characteristic (number of responses) FREQUENC Y PROPORTION (%) Gender* (47) Woman Man Non-binary, transgender, or genderqueer Other 8 36 nr nr 17% 77% nr nr Average age (range) (47) 42 (19 - 71 years) Race and ethnicity* (50) Black, African, or African American White Mixed, bi-racial, or multi-racial Indigenous, Native American, Alaska Native Hispanic or Latinx Asian Native Hawaiian or Pacific Islander Missing 12 26 5 nr nr nr nr nr 24% 52% 10% nr nr nr nr nr Current living situation* (60) Apartment/house rented or owned Family or friend’s place, couch surfing Recovery or residential treatment center Transitional housing program Hotel/motel room 7 6 nr nr 5 15% 13% nr nr 11%

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53 Unsheltered, outside Car, abandoned building, or indoor public space Shelter Tent 13 nr 16 8 28% nr 34% 17% Connection to Somerville (47) Yes No Unsure 32 12 nr 68% 26% nr nr = not reported due to fewer than five responses *Participants could select more than one answer. As such, the total proportion for these questions can exceed 100%. Drug use patterns All but one participant reported drug use in the 30 days prior to being surveyed. QUESTION (number of responses) FREQUENCY PROPORTION (%) Substances used in previous 30 days* (265) Cocaine Crack cocaine Crystal methamphetamine Heroin Fentanyl Opioids Marijuana Alcohol Hallucinogens Benzodiazepines Other 18 29 28 32 29 15 28 30 nr 22 nr 38% 62% 60% 68% 62% 32% 60% 64% nr 47% nr Methods of use in previous 30 days* (116) Inject Smoke or inhale Snort Ingest or swallow 29 37 25 25 62% 79% 53% 53% Require help injectingx (29) Yes No Sometimes 9 18 nr 31% 62% nr

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54 Frequency of use (46) Daily Multiple times per day 1-3 times per week 4-5 times per week 1-3 times per month Less than once per month 14 19 nr nr 7 nr 30% 41% nr nr 15% nr Frequency of using alone (46) Always (100% of the time) Most of the time (>75%) Sometimes (26-74%) Occasionally (<25%) Never nr 10 17 9 6 nr 22% 37% 20% 13% Overdoses in the last year (47) 1 overdose 2 overdoses 3 or more overdoses None 9 5 10 23 19% 11% 21% 49% nr = not reported due to fewer than five responses *Participants could select more than one answer. As such, the total proportion for these questions can exceed 100%. XSkip logic resulted in only participants who reported this method of consumption being asked to respond. Locations of drug use QUESTION (number of responses) FREQUENCY PROPORTION (%) Drug use locations* (107) Where you’re currently staying Public washrooms Bus, metro, transportation depots Outside (e.g. park, alley) Friend’s place Public building (e.g. library) 21 22 9 30 15 7 45% 47% 19% 64% 32% 15% Public drug usex (37) Daily 3-4 times per week 1 or fewer times per week 19 7 11 40% 15% 23% nr = not reported due to fewer than five responses *Participants could select more than one answer. As such, the total proportion for these questions can exceed 100%.

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55 XSkip logic resulted in only participants who reported this method of consumption being asked to respond. Frequency of using an SCS in Somerville The vast majority of participants (94%) reported that they would use an SCS if located in Somerville, with the remainder unsure. Of those who reported that they would use an SCS (n=42), 24% reported they would always use an SCS, 33% would use it most of the time (>75% of the time), 26% would use it sometimes (26-74% of the time), 10% would use it occasionally (<25% of the time), and 7% were unsure or preferred not to answer. Reasons for using an SCS Reason for wanting to use a SCS (222)* FREQUEN CY PROPORTION (%) Access to sterile injection and/or smoking equipment 31 66% Ability to inject indoors rather than in public 26 56% Safety from being seen and/or arrested by police 35 75% Safety from crime or violence 33 70% Access to health professionals and basic health services 26 56% Access to referrals for treatment or social services 25 54% Overdose prevention or treatment 44 94% Other nr nr nr = not reported due to fewer than five responses *Participants could select more than one answer. As such, the total proportion for these questions can exceed 100%. Reasons for not using an SCS Reason for not wanting to use a nSCS (63)* FREQUEN CY PROPORTION (%) Do not want to be seen/do not want people to know about my drug use 10 21% Lack of confidentiality 6 13% Prefer to use alone nr nr Already have access to sterile supplies nr nr

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56 Afraid SCS are not safe from crime or violence 7 15% Concerned about police around the site 21 45% Already have a place to use nr nr Too many rules or policies nr nr Legal consequences related to condition of probation or parole nr nr No concerns 5 11% Other 7 15% nr = not reported due to fewer than five responses *Participants could select more than one answer. As such, the total proportion for these questions can exceed 100%. Location and SCS model QUESTION (number of responses) FREQUEN CY PROPORTION (%) Distance willing to travel (walk, car, bike, or transit) to access a SCS (47) 5-15 min 15-25 min 25-35 min 35+ min Unsure/prefer not to answer 11 14 10 6 6 23% 30% 21% 13% 13% Willingness to access the SCS if located in the following places* (242) Community health center Walk-in clinic, hospital, or doctor’s office Social service agency (e.g. shelter) Harm reduction center (e.g. SSP) Trailer, RV, or mobile location Own, freestanding location Other 39 35 38 43 40 43 nr 83% 75% 81% 92% 85% 92% nr

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57 Factors that would help with access to a mobile SCS* (70) Located in the same location daily Located in the same location certain days/week Mobile text with location for that day Other (e.g. signage, word of mouth) Unsure/prefer not to answer 34 12 17 5 nr 73% 26% 36% 11% nr nr = not reported due to fewer than five responses *Participants could select more than one answer. As such, the total proportion for these questions can exceed 100%. SCS logistics Participants largely preferred having an SCS opened around-the-clock or open over spans of 8-12 hours from the morning (e.g. 8am) until early evening (e.g. 7pm). Further, there was a desire to have a range of inhalation and injection room designs - both communal and private - that allowed for flexibility of use. QUESTION (number of responses) FREQUENC Y PROPORTION (%) Preferred hours of operation (47) 12am-8am 8am-12pm 12pm-4pm 4pm-8pm 8pm-12am 24 hours Other Unsure/prefer not to answer nr 8 nr nr 5 14 12 nr nr 17% nr nr 11% 30% 26% nr Preferred set-up for injecting spacesx (29) Private cubicles Open plan with benches at a large table/counter Open plan with tables and chairs Couches and chairs with side tables Combination of above Other 9 nr nr nr 15 nr 31% nr nr nr 52% nr Preferred set-up for inhalation spacesx (37) Private cubicles inside Open plan room inside Private cubicles outside under roof Open plan outside under roof nr 5 nr nr nr 14% nr nr

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58 Combination of above Other Unsure/prefer not to answer 22 nr nr 59% nr nr nr = not reported due to fewer than five responses XSkip logic resulted in only participants who reported this method of consumption being asked to respond. Involvement of people who use drugs in SCS operations Most participants (68%) thought that people who use drugs should be involved in the SCS (32 out of 47 participants). The remainder either disagreed with peer involvement (15%, 7 out of 47) or were unsure (17%, 8 out of 47). How people who use drugs should be involved* (112) FREQUENCY PROPORTION (%) At the entrance/greeting clients 21 19% Registering clients 20 18% In the waiting area 19 17% Monitoring in the injecting room or smoking area 18 16% In the post-use room or chill-out room 24 21% Other 5 4% Unsure/prefer not to answer 5 4% *Participants could select more than one answer. As such, the total proportion for these questions can exceed 100%. Acceptability of SCS policies and guidelines Policy (number of responses) Very acceptabl e (%) Acceptabl e (%) Neutral (%) Unacceptabl e (%) Very unacceptabl e (%) Use is supervised by trained staff (47) 74% 19% nr nr nr 30-minute time limit for use (47) 23% 43% 11% 21% nr Have to register each time you use the site (47) 30% 32% 17% 15% nr Required to show government ID (47) 11% nr nr 40% 36%

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59 Required to show client number (47) 21% 55% 13% 11% nr Have to live in the neighborhood (47) nr nr nr 45% 36% Video surveillance cameras on site to protect clients (47) 19% 26% 19% 23% 13% Prohibited from smoking drugs (46) nr 20% 17% 37% 24% Prohibited from assisting others with injection preparations (44) nr 23% 18% 43% nr Prohibited from assisting others with injections (44) nr 20% 25% 41% nr Prohibited from sharing drugs (46) 15% 28% 17% 30% nr May have to wait until there is space available (47) 26% 49% 17% nr nr May have to stay 10-15 min after using so health can be monitored (47) 38% 51% nr nr nr Prohibited from using the site if pregnant (46) 30% 33% nr nr 22% Dedicated site hours for women to use (45) 29% 36% nr 24% nr Dedicated site hours for genderqueer, non-binary, and gender diverse persons to use (45) 29% 29% 13% 24% nr nr = not reported due to fewer than five responses Importance of SCS services Service (number of responses) Very important (%) Important (%) Slightly important (%) Not important (%) Nursing staff for basic medical care (47) 66% 30% nr nr Bathrooms (47) 70% 30% nr nr Showers (47) 53% 21% 13% 13% Food (including takeaway) (47) 70% 23% nr nr Social workers or counsellors (46) 59% 35% nr nr Peer support (47) 60% 32% nr nr

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60 Syringe distribution (45) 67% 29% nr nr Injection equipment (44) 73% 25% nr nr Smoking equipment (44) 64% 30% nr nr Drug checking (e.g. fentanyl testing strips) (46) 63% 33% nr nr HIV, hepatitis C, and STI testing (46) 80% 17% nr nr Access to contraception (45) 82% 13% nr nr Referrals to drug treatment or other services (46) 63% 28% nr nr Being able to start buprenorphine or methadone on site (46) 59% 26% nr nr Mental health services onsite or referrals (47) 66% 30% nr nr A ‘chill out room’ to hang out in after using (46) 70% 26% nr nr Assistance with housing, social assistance, etc. (46) 74% 22% nr nr Assistance with legal services or DCF (46) 65% 26% nr nr Harm reduction education (47) 66% 32% nr nr nr = not reported due to fewer than five responses

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61 Appendix 2 - Results from the Somerville community survey Data Notes In total, 615 surveys were completed from March to April 2021 by Somerville community members aged 16 and older. A total of 557 participants were Somerville residents, with non- Somerville participants including business owners, service providers, people accessing Somerville-based services (e.g. schools, religious/spiritual spaces, health and social services, shops, transit), individuals working or volunteering in Somerville, and individuals who have friends and/or family that live in Somerville. Participants were not required to answer each survey question. Additionally, some questions allowed for multiple responses; these are noted below alongside the total number of participant responses. Percentages have been rounded to the nearest whole percent. To protect participants’ privacy, responses that have less than five counts have been suppressed. These are denoted with a “nr” (not reportable). Demographics Characteristic (number of responses) Somerville resident (n=557) Non- Somerville resident (n=58) Overall (n=615) Gender* (603) Man Woman Non-binary, transgender, or genderqueer 202 (36%) 306 (55%) 28 (5%) 20 (35%) 30 (52%) 7 (12%) 222 (36%) 336 (55%) 35 (6%) Average age (range) (571) 37 (16-78 years) 33 (17-75 years) 37 (16-78 years) Race and ethnicity* (625) Black, African, or African American White Mixed, bi-racial, or multi-racial Indigenous, Native American, Alaska Native Hispanic or Latinx Asian Native Hawaiian or Pacific Islander 7 (1%) 474 (85%) 17 (3%) nr 5 (1%) 20 (4%) nr nr 50 (86%) nr nr nr nr nr 8 (1%) 524 (85%) 19 (3%) nr 7 (1%) 22 (4%) nr nr = not reported due to fewer than five responses *Participants could select more than one answer. As such, the total proportion for these questions can exceed 100%.

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62 Connection to Somerville QUESTION (number of responses) FREQUENCY PROPORTION (%) Relationship to Somerville* (1414) Resident Business owner Work in Somerville Family and/or friends live in Somerville Attend church in Somervillex Attend school in Somerville Child/children attend school in Somerville Use healthcare services in Somerville Use substance use treatment services in Somerville Use housing/shelter services in Somerville Use social or community services in Somerville Other 557 23 135 323 17 7 90 145 nr nr 84 32 39% 2% 10% 23% 1% 1% 6% 10% nr nr 6% 2% nr = not reported due to fewer than five responses *Participants could select more than one answer. As such, the total proportion for these questions can exceed 100%. xThe omission of other forms of religious services and spiritual groups by using “church” was an oversight in survey development. The authors would like to apologize for this error.

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63 Somerville neighborhood of residence Question (number of responses) FREQUENCY PROPORTION (%) Neighborhood of residence (549) Hillside Teele Square Powderhouse Square Davis Square Ball Square Magoun Square Winter Hill Ten Hills Assembly Square Porter Square Spring Hill Duck Village Union Square East Somerville Boynton Yards Innerbelt North Point 11 37 29 86 31 30 74 5 nr 28 74 10 98 34 nr nr nr 2% 7% 5% 16% 6% 5% 13% 1% nr 5% 13% 2% 18% 6% nr nr nr Duration living in Somerville (556) Less than 1 year 1-2 years 2-5 years 5-10 years 11-20 years More than 20 years 33 68 120 131 106 98 6% 12% 22% 24% 19% 17% nr = not reported due to fewer than five responses SCS familiarity and support Characteristic (number of responses) Somerville resident (n=557) Non- Somerville resident (n=58) Overall (n=615)

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64 Familiarity with SCS (615) Very familiar Somewhat familiar Not familiar 112 (20%) 368 (66%) 77 (14%) 12 (12%) 39 (67%) 7 (21%) 124 (20%) 407 (66%) 84 (14%) SCS would be helpful in Somervillex (615) Average (SD) 8.14 (2.68) 9.53 (0.98) 8.28 (2.60) Most important ranked outcome of SCSy (611) Reduce drug paraphernalia Reduce crime in area surrounding SCS Prevent overdoses and save lives Reduce public use Help connect people to services Reduce HIV and HCV transmission Reduce burden on emergency rooms, police, fire, and EMS by reducing overdose-calls 22 (4%) 28 (5%) 434 (7%) 9 (1%) 38 (6%) 13 (6%) 9 (1%) nr nr 56 (97%) nr nr nr nr 23 (4%) 28 (5%) 490 (80%) 10 (2%) 38 (6%) 13 (6%) 9 (1%) nr = not reported due to fewer than five responses xParticipants were asked on a scale of 1 (strongly disagree) to 10 (strongly agree) how helpful an SCS would be in Somerville. yParticipants were asked to rank a list of 7 outcomes of having an SCS from most to least important. *Participants could select more than one answer. As such, the total proportion for these questions can exceed 100%. Participants were asked to describe why they thought an SCS would be helpful in Somerville. The top five themes documented, included: connecting people to services and supports (n=197); reducing overdose deaths (n=167); overall public health benefits (e.g. reducing drug paraphernalia litter, reduction of infection, provision of sterile supplies) (n=158); providing a safe place for people to use drugs (n=139); and implementing a harm reduction approach to addressing the overdose crisis (n=47). The five major themes documented as to why an SCS would not be beneficial in Somerville included: SCS would have a negative community impact (e.g. decrease property value, increase litter, increase violence and crime) (n=28); SCS enable drug use (n=16); SCS are not effective public health interventions (n=13); SCS would increase in the number of people who come to use drugs in the city (n=13); and there is a need for treatment, prevention, and wraparound services instead (n=12). SCS location and siting considerations Characteristic (number of responses) Somerville resident (n=557) Non-Somerville resident (n=58) Overall (n=615)

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65 Neighborhood where a SCS would be most helpful (490) Hillside Teele Square Powderhouse Square Davis Square Ball Square Magoun Square Winter Hill Ten Hills Assembly Square Porter Square Spring Hill Duck Village Union Square East Somerville Boynton Yards Innerbelt North Point 72 (16%) 71 (16%) 62 (14%) 229 (51%) 67 (15%) 101 (23%) 182 (41%) 84 (19%) 120 (27%) 124 (28%) 82 (18%) 56 (13%) 168 (38%) 255 (57%) 91 (20%) 147 (33%) 60 (14%) 6 (14%) 6 (14%) 7 (17%) 23 (55%) 6 (14%) 10 (24%) 20 (48%) 8 (19%) 7 (17%) 17 (40%) 9 (21%) 7 (17%) 18 (43%) 21 (50%) 9 (21%) 20 (48%) 5 (12%) 78 (16%) 77 (16%) 69 (14%) 252 (51%) 73 (15%) 111 (23%) 202 (41%) 92 (19%) 127 (26%) 141 (29%) 91 (19%) 63 (13%) 186 (38%) 276 (56%) 100 (20%) 167 (34%) 65 (13%) Most important factors to consider when siting the SCS (607) Proximity to local businesses Proximity to residential areas Convenience for potential clients Proximity to other support services Proximity to schools and playgrounds Proximity to public transportation Rate of overdose in the neighborhood Other 37 (7%) 102 (19%) 398 (72%) 326 (59%) 131 (24%) 307 (56%) 437 (80%) 26 (5%) nr nr 46 (81%) 38 (67%) 6 (11%) 41 (72%) 45 (79%) nr 37 (6%) 106 (17%) 444 (73%) 364 (60%) 137 (23%) 348 (57%) 482 (79%) 30 (5%) Concerns of a SCS located in own neighborhood (556) Yes No Unsure 114 (21%) 308 (55% 134 (24%) -- -- Preferred method for addressing SCS questions or concerns* (635) Community town hall or forum Information on the goals of the SCS Information on how SCS can help communities Evaluations of the SCS once established Other 128 (22%) 119 (20%) 112 (19%) 195 (33%) 35 (6%) 9 (20%) 10 (22%) 10 (22%) 16 (35%) nr 137 (22%) 129 (20%) 122 (19%) 211 (33%) 36 (6%)

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66 nr = not reported due to fewer than five responses xParticipants were asked on a scale of 1 (strongly disagree) to 10 (strongly agree) how helpful a SCS would be in Somerville. *Participants could select more than one answer. As such, the total proportion for these questions can exceed 100%. Survey participants were asked to describe their concerns if an SCS were located in their neighborhood. Top five concerns included: impact on safety and crime (n=75); how the SCS would be operated (e.g. procedures following use, site capacity and overflow protocols) (n=56); location of the SCS and neighborhood type (e.g. business vs. residential neighborhood) (n=45); impact on congestion and foot traffic outside the SCS (n=42); and a potential influx of people who use drugs coming to access the SCS in Somerville (n=38). Current Somerville supports Question (number of responses) Somerville resident (n=557) Non- Somerville resident (n=58) Overall (n=615) Knowledge of overdose-related programs in Somerville (615) Yes No Unsure 245 (44%) 245 (44%) 67 (12%) 25 (43%) 26 (45%) 7 (12%) 270 (43%) 271 (44%) 74 (12%) Have you ever accessed any of these programsX (269) Yes No Unsure 6 (2%) 237 (97%) nr nr 23 (92%) nr 8 (3%) 260 (97%) nr Do you know someone who has accessed these programsX (270) Yes No Unsure 62 (25%) 137 (56%) 46 (19%) 10 (40%) 11 (44%) nr 72 (27%) 148 (55%) 50 (19%) Satisfied with the City’s approach to combating the overdose crisis (612) Very satisfied Satisfied Unsure Dissatisfied Very dissatisfied 13 (2%) 80 (14%) 387 (70%) 60 (11%) 16 (3%) nr 10 (18%) 40 (71%) 5 (9%) nr 13 (2%) 90 (15%) 427 (69%) 65 (11%) 17 (3%) nr = not reported due to fewer than five responses XSkip logic resulted in only participants who reported “yes” to having knowledge of overdose-related programs in Somerville being asked to respond.

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67 Participants were asked to describe suggestions they had for better addressing the overdose crisis in Somerville. The top five themes included: removing police from the response (e.g. decriminalizing drugs, diverting police funding (n=60); increasing community awareness and engagement related to the overdose crisis, including increased transparency of City efforts (n=46); funding treatment and prevention programs (n=39); addressing the social determinants of health (e.g. poverty, homelessness) (n=35); and unsure due to a lack of information about the overdose crisis and current efforts (n=33)

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68 Appendix 3 - Preliminary SCS operational guidance document Please note: The following draft operational guidance document was developed by the Program Development sub-committee of the SCS Task Force. Somerville Supervised Consumption Site Conceptual Framework This document was created by a coalition convened by Mayor Joseph Curtatone and the City of Somerville Department of Health and Human Services with representation from community based organizations including Safe Injection Facilities Massachusetts Now! (SIFMA Now!); the Material Aid and Advocacy Program; Community Outreach, Help & Recovery Unit (COHR); Boston University; and people with lived experience of drug use. Contributors Miriam Harris, Assistant Professor, Boston University School of Medicine, Member, SIFMA Now!; Cassie Hurd, Executive Director, Material Aid and Advocacy Program, Member, SIFMA Now!; Tj Thompson, Organizer, Material Aid and Advocacy Program, Member, SIFMA Now!; Steve Kelley, Organizer, Material Aid and Advocacy Program, Member, SIFMA Now!; Jennifer Korn, LICSW, Co-Director MB CIT TTAC, COHR; Danielle O’Hearn, Somerville Fire Department Acknowledgements The British Columbia Centre on Substance Use (BCCSU) supervised consumption services operational guidance were used to help craft the much of the language and recommendations included in this document. The BCCSU guidelines are evidenced based and include a detailed list of research references that support specific recommendations included here. Mission statement “We aim to create an inclusive, human centric, peer driven, and above all else, safe environment to foster and encourage the progression of personal autonomy with a 'come as you are and take a welcomed seat at the table' type of ethos. The Somerville supervised consumption space should be a place where human life is valued with compassion and a place that dismantles stigma and the failing 'one size fits all' approach to criminalizing people who use drugs. Instead, the facility should value and respond to the multifaceted vast spectrum that encompasses the tapestry of experience within each individual human being. Our hope is to create an environment that brings harm reductionists, counselors, doctors, social workers, people with lived experience, and people that want to help people

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69 together with a unified goal of preserving life, dignity, and choice with the ever present cry that one death is too many, all life is valuable”. - Tj Thompson (identifies as a person with lived experience) - Stephen Kelley (identifies as a person with lived experience) 1. Introduction Supervised consumption sites (SCSs) provide safe environments in which people can use drugs under the supervision of a healthcare professional, a trained peer (i.e., person who formerly used or currently uses drugs), or a trained allied service provider without the risk of arrest for drug possession.1 SCSs are evidence-based programs that, when well-integrated within a broad continuum of services for people who use drugs, reduce morbidity, mortality, and public disorder, as well as promote access to health and social services.1 SCSs promote the dignity and well-being of people who use drugs. SCSs have also been found to be cost-effective and to reduce burden on emergency services.1 Here we describe the conceptual framework for a Somerville SCS based on a preliminary needs assessment and community consultation. This document was created by a coalition convened by Mayor Joseph Curtatone and the City of Somerville Department of Health and Human Services with representation from community based organizations including Safe Injection Facilities Massachusetts -Now! (SIFMA Now!), the Material Aid and Advocacy Program, Community Outreach, Help & Recovery Unit (COHR), Boston University, and people with lived experience of drug use from Somerville. This is designed to be a living document meant to be updated with ongoing community input. Specific operating procedures will evolve as the community, city, and state stakeholders needs are clarified and funding, and support mechanisms defined. 2. Goals The overall goals of the Somerville SCS are to: 1. To improve the dignity and safety of people who use drugs in Somerville. 2. To reduce rates of non-fatal overdose and overdose-related deaths, and associated ambulance calls and health care utilization. 3. To reduce rates of drug-related transmission of blood-borne infections among people who use drugs (i.e., viral hepatitis and HIV). 4. To decrease the rates of acute health complications that are related to injection drug use (i.e., soft tissue infections, infective endocarditis). 5. To improve uptake of and access to health and care services among people who use drugs. 6. To improve people who use drug’s knowledge and uptake of/access to harm reduction practices and services.

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70 7. To improve people who use drug’s knowledge and uptake of/access to drug treatment services, including recovery-oriented programs and a range of opioid agonist treatments, including injectable therapies. 8. To reduce drug use in public or semi-public spaces, including inappropriately discarded injection equipment and related litter. 3. Somerville Supervised Consumption Site Vision Three key areas that should guide the development of an SCS for the community. These include safety, inclusivity, and integration (Figure 1). Safety An SCS in Somerville must be accessible, safe, and hygienic. Therefore, people who use drugs must be able to safely access an SCS without fear of arrest from the police, or violence from the police or other community members. This will require close internal safety procedures and collaboration with the local police department. Inclusivity A Somerville SCS must be inclusive. People from different racial and ethnic backgrounds, particularly Black, Latinx, and Indigenous people should feel welcome and safe at the SCS. People of all sexual orientations and people of all genders (including Non-binary and Transgender People) should also feel safe and welcome at the SCS. Therefore, Somerville SCS staff must include representation from different racial and gender backgrounds to make all community members feel welcome. The Somerville SCS will consider establishing certain days or times for specific communities, for example a women’s only time, to concretely reach all Somerville community members depending on the communities’ needs. The Somerville SCS will also address the needs of different types of drug use. This includes people who sniff or smoke their drug of choice. Therefore, the Somerville SCS will need multiple spaces to support the needs of people who inject drugs, sniff drugs, or smoke drugs. Integration The Somerville SCS must be integrated into other social and health services to meet the needs of people who use drugs. The SCS will be integrated with other services including housing, primary care, sexual and reproductive health, domestic violence, child protection services, and substance use disorder treatment services, and income assistance and return to work programs. The aim of the Somerville SCS is to provide comprehensive health and medical care, as well as social services, acting as a “one-stop- shop” for people who use drugs to meet their self-identified needs. Figure 1. Supervised Consumption Site Vision

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71 PWUD; people who use drugs, HCV; hepatitis C virus, HIV; human immunodeficiency virus; SUD; substance use disorder 4. Ideal type of SCS for Somerville 4.a. Basic Components The basic components of Somerville’s SCS should include: 1. A welcoming reception area, distinct from where substances are consumed, where potential SCS participants can learn about the service and its operations, their rights and responsibilities in the space, and complete an intake; 2. Two dedicated drug consumption areas: a. A dedicated drug injection space, and injecting equipment, as well as a receptacle for the disposal of used equipment; b. A dedicated space for smoking drugs, which is equipped with smoking equipment and is well ventilated; 3. A drug checking area for people who plan to use drugs at the SCS and for those that do not. 4. A separate, private clinical space for participants to access medical care; 5. Areas for people to be after they consume substances: . A dedicated de-stimulating "chillout space" for people who use stimulants; a. A dedicated area for people who may require observation after using opioids; 6. A common area for aftercare where participants can access support from healthcare professionals and peer support workers and receive after-care, referrals, education, and counseling.

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72 4.b. Integrated Model The staffing for the service would be multidisciplinary and would offer a team-based approach to maintaining a safe environment. Using a team-based approach to meet the complex social and clinical needs of the individuals who use the space, the program would offer a continuum of services within a nonclinical and informal setting that is welcoming and person-centered. Building an integrated multidisciplinary team with a shared mission would ensure better communication among staff and participants and would foster different perspectives and approaches to operating the program that would be essential to making this service succeed. 4.c. Staffing The staffing model should balance budgetary concerns with patient safety and risk management, particularly in relation to possible scenarios of overdose and other emergencies. Ideal models should include both medical and non-medical personnel. For example, staffing should include a supervising registered nurse or psychiatric nurse, who can be supported by other allied health professionals. Non-medical personnel, such as community mental health workers, case managers or social workers, and individuals identified as peers (i.e., people who formerly used or currently use illegal drugs) also play important roles in the planning and operation of SCSs and should be involved wherever possible and compensated appropriately. We recommend that at least two staff members (clinical and/or non-clinical) are working at a time. The Somerville SCS peer staffing should include a variety of employment opportunities such as full-time, part-time, and flexible-time work. These should be appropriately compensated, and this includes reasonable pay and benefits. Given the sometimes challenging nature of this work, staffing considerations must include behavioral health and wellness supports for SCS staff to mitigate staff trauma, burnout, and turnover. 4.d. Clinical and Other Services The Somerville SCS should be integrated with other services that support the needs of people using the SCS. The SCS should aim to provide comprehensive health and medical care, as well as social services, as a “one-stop-shop” for harm reduction and health and social services. Including an SCS within a network of services offered within the same facility allows clients to access a range of services without having to travel outside of the facility premises, thereby helping to prevent loss to care, to decrease barriers in access to care, and to ensure continuity of care.

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73 Harm reduction services beyond observed injection with sterile injection equipment should also be included. For example, harm reduction education and provision of sterile injection equipment (such as syringes, needles and other drug paraphernalia) for use outside the SCS. The Somerville SCS should include case management to support pathways to housing, as well as referrals to detoxification facilities and residential treatment programs. The SCS should also provide access to harm reduction-oriented legal services onsite, in addition to connections to external legal services when needed. Services for those experiencing violence or abuse should either be onsite or have a clear referral and support pathway. Urgent primary care services such as wound and abscess care management, HIV prevention, and contraception should be accessible at the SCS. Clinicians should also be able to help those interested to establish long term primary care, behavioral health services, HIV treatment, and HCV treatment through onsite care or designated referral pathways. A complete list of possible clinical and other services that could be integrated into the Somerville SCS include: • Primary care (e.g., immunization, STI screening, screening for other communicable diseases such as HIV and viral hepatitis C) • Naloxone provision and training • Residential services (e.g., overnight shelters, residential nursing care) • Chronic illness management • Psychosocial treatment interventions (i.e., cognitive behavioral therapy) • Counselors/social workers • Mental health care • Women’s health services • Off-site outreach program • Drug treatment programs (e.g., medically managed withdrawal management, opioid agonist treatment) • Employment programs • Peer support programs • Recreational activities • Meals, snacks, coffee/tea • Possibility to use phone/Internet • Shower, laundry • Lockers, postal addresses • Overnight shelter and other low-threshold housing • Support recovery housing

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74 4.e. Screening and Information of Participants It is important for SCSs to be low-threshold and low-barrier, but it is equally important for these facilities to establish eligibility criteria for services and to inform clients about drug use and harm reduction strategies, in order to ensure the safety of clients and staff and to minimize risks, such as overdose. Importantly, people must feel safe using the SCS with the knowledge that their personal health information will be protected and they will not face legal repercussions for using the SCS. Therefore, developing an intake system that ensures client anonymity while being used for screening/eligibility, tracking, linkage to care, and research purposes is key. Eligibility and user agreement There should be an intake procedure for first time clients to an SCS that includes: • Screening for eligibility • Informing the client about the risks of non-medical substance use • Informing the client about expectations, rules and protocols for using SCS • Informing the client about their rights and responsibilities when using SCS • Informing the client about any data collection for monitoring, evaluation or research purposes, as well as appropriate ethical considerations • Assessing clients for any need for specific physical care, their knowledge of harm reduction techniques and ability to apply these to drug-use, as well as their knowledge of harm reduction services 4.f. Security and the Safety of Participants and Workers Although the vast majority of people who use drugs pose no threat to others; behavioral health, trauma, stimulant use, withdrawal, and chaotic situations can cause emotional dysregulation and result in escalated and unsafe behaviors. Such behaviors may place staff and other participants at risk. Further, overdose can occur anywhere in an SCS. Therefore, proper visibility and monitoring of participants at all times are also critical to preventing overdose deaths. While ensuring that services are as accessible as possible, SCS operators should also ensure that the facility layout, staffing, training, and protocols minimize security issues and maximize safety. Participants should be made aware of the security features during their initial screening intake, in addition to being informed of the social norms and boundaries. It should be emphasized that these features help to ensure the safety of both participants and staff. Demonstration of adequate site security may also help to increase the confidence and

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75 buy-in of local stakeholders, such as neighbors, community groups and partners, police and policy makers. There may be instances where SCS staff are required to respond to a crisis situation and/or aggressive behavior by a participant. SCS should create a triage protocol for staff to identify appropriate supports at each stage of an incident. Each situation will be unique and all facility staff should be trained in crisis management and de-escalation techniques to ensure the safety of all participants and staff. For any SCS to be successful, people using the facility must not be targeted or penalized for using the service. The Somerville Police Department understands that addiction is a health condition, they are a member of Police Assisted Addiction Recovery Initiative and have implemented many programs to support individuals in active use including a partnership with ACCESS. The Somerville Police Department supports the goal of treatment over criminal pursuit for people who use drugs in most cases and as a law enforcement agency will work with SCS to create understanding with responsibilities to consider state and federal law. Legislative advocacy around the decriminalization of opioids at the state and federal level should continue in order to better align the goals of the SCS and the Somerville Police Department role to abide by these laws moving forward. References 1. British Columbia Centre on Substance Use. Supervised consumption services operational guidance. Published online 2017.

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76 Appendix 4 - Survey instruments Survey with people who use drugs Question Response options 1. What is your current gender? (check all that apply) Woman Man Non-binary or genderqueer Something else: [text entry] 2. Do you identify as transgender? Yes No 3. How old are you? [text entry] 4. What is your race or ethnicity (check all that apply) Black, African, or African American White Mixed, bi-racial, or multi-racial Indigenous, Native American, Alaska Native Latin American Asian Native Hawaiian or Pacific Islander Something else: [text entry] 5. Are you of Hispanic or Latinx descent? Yes No 6. What type of place are you currently living in? (check all that apply) Apartment/house that you rent or own Friend or family’s place Recovery or residential treatment center Transitional housing program Hotel/motel room rented on a daily, weekly, or monthly basis Unsheltered, outside, outdoor public space Shelter Tent Somewhere else: [text entry] 7. Do you have any connection to Somerville (e.g. have lived/stayed there)? Yes (If yes, what is the connection? [text entry]) No

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77 Unsure 8. Which of the following substances have you used in the past 30 days? (check all that apply) Cocaine (powder) Crack cocaine (rock) Crystal methamphetamine Heroin Fentanyl Opioids (not as prescribed, purchased off the street) Marijuana Alcohol Hallucinogens Benzos (e.g. Ativan, Valium) Something else: [text entry] 9. How often are you currently using drugs? Daily Multiple times per day 1-3 times per week 4-6 times per week 1-3 times per month Less than once per month 10. How often are you using drugs alone? Always (100% of the time) Most of the time (>75%) Sometimes (26-74%) Occasionally (<25%) Never 11. Where do you typically use drugs? (check all that apply) Where you’re currently living or staying Public washrooms Bus, metro, transportation depots Outside (e.g. park, alley) Friend’s place Public building (e.g. library) Somewhere else: [text entry] 12. How often are you currently using in public? Daily 3-4 times per week 1 or fewer times per week 13. What methods have you used to consume drugs in the past 30 days? (check all that apply) Inject Smoke/inhale Snort Ingest/swallow 14. [If Q13=inject] Do you ever need help injecting? Yes No

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78 Sometimes 15. In the last year, how many overdoses have you had personally? 1 overdose 2 overdoses 3 or more overdoses None [Read]: A supervised consumption site, or SCS, is a legally operated facility where people come to use their own drugs under the supervision of medically trained workers in safe and sterile conditions. At SCS, people can access sterile equipment (e.g. cotton, syringes, cookers, water), medical care, and/or be referred to health and social services. 16. How long would you be willing to travel (walk, car, bike, or transit) to access an SCS? 5-15 min 15-25 min 25-35 min 35+ min Don’t know, unsure, prefer not to answer 17. Would you use the SCS if located in: (check all that apply) A community health center A walk-in clinic, hospital, or doctor’s office Social service agency (e.g. shelter) Harm reduction center (e.g. syringe exchange program) Trailer, RV, or mobile location Own, freestanding location Somewhere else: [text entry] 18. If the SCS was a mobile site, what would help you access it? (check all that apply) Located in the same spot daily Located in the same spot on certain days each week Mobile text about where the site would be located that day Something else: [text entry] Don’t know, unsure, prefer not to answer 19. [Prompt] I am now going to ask you a few questions about a hypothetical SCS in Somerville. an SCS was available in Somerville, would you consider using this service? Yes No (If no, why not? [text entry]) Don’t know, unsure, prefer not to answer 20. [If Q19=yes] How often would you use an SCS in Somerville? Always when I use drugs (100%) Most of the time (>75%) Sometimes (26-74%) Occasionally (<25%) Don’t know, unsure, prefer not to answer

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79 21. What are the most useful hours of operation for an SCS? 12am-8am 8am-12pm 12pm-4pm 4pm-8pm 8pm-12am Other: [text entry] Don’t know, unsure, prefer not to answer 22. [If Q13=inject] What would be the best set-up for injecting spaces in an SCS? Private cubicles Open plan with benches at one large table/counter Open plan with tables and chairs Couches and chairs with coffee tables or side tables Combination of above Something else: [text entry] Don’t know, unsure, prefer not to answer 23. [If Q13=smoke/inhale] What would be the best set-up for smoking spaces in an SCS? Private cubicles inside Open plan room inside Private cubicles outside under roof Open plan outside under roof Combination of above Something else: [text entry] Don’t know, unsure, prefer not to answer 24. Do you think people who use drugs should be involved in running the SCS? Yes No Don’t know, unsure, prefer not to answer 25. [If Q24=Yes] How do you think people who use drugs should be involved? (check all that apply) At the entrance/greeting clients Registering clients In the waiting area Monitoring in the injecting room or smoking area In the post-use room or chill-out room Something else: [text entry] Don’t know, unsure, prefer not to answer 26. What reasons would you use an SCS? (check all that apply) Access to sterile injection and/or smoking equipment Able to inject indoors rather than in public Safety from being seen and/or arrested by police Safety from crime or violence

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80 Access to health professionals (e.g. basic medical care) Access to referrals for treatment or social services Overdose prevention or treatment Something else: [text entry] 27. What reasons would you not use an SCS? (check all that apply) Don’t want to be seen/don’t want people to know about use Lack of confidentiality Prefer to use with friends, family, or partner Prefer to use alone Already have access to clean supplies Afraid SCS aren’t safe from crime or violence Concerned about police around the site or getting caught by police Already have a place to use Can’t wait for a space to open up Too many rules or policies Age limit Legal consequences related to condition of probation or parole (e.g. mandated abstinence) Something else: [text entry] 28. SCS can have numerous policies and guidelines. For each of the following, please let me know if these would be very acceptable, acceptable, neutral, unacceptable, or very unacceptable to you Very acceptable Acceptable Neutral Unacceptable Very unacceptable Use is supervised by trained staff who can respond to overdoses 30-minute time limit for use Have to register each time you use the site

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81 Required to show government ID Required to show client number Have to live in the neighborhood Video surveillance cameras are on site to protect clients Prohibited from smoking drugs Prohibited from assisting others with injection preparations Prohibited from assisting others with injections Prohibited from sharing drugs May have to wait until there is a space available to use May have to stay 10-15 min after using so your health can be monitored Prohibited from using the site if pregnant Dedicated site hours for women to use Dedicated site hours for

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82 genderqueer, non- binary, and gender diverse persons to use 29. Various services are being considered to provide in an SCS. For each of the following, please let me know if these would be very important, important, slightly important, or not that important to you. Very important Important Slightly important Not that important N/A Nursing staff for basic medical care Bathrooms Showers Food (including takeaway) Social workers or counsellors Peer support Syringe distribution Injection equipment Smoking equipment Drug checking (e.g. fentanyl testing strips) HIV, hepatitis C, and STI testing Access to contraception (condoms, birth control, etc.) Referrals to drug treatment (methadone,

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83 buprenorphine, or other services) Being able to start buprenorphine or methadone on site Mental health services onsite or referrals A ‘chill out room’ to hang out in after using Assistance with housing, social assistance, etc. Assistance with legal services or DCF Harm reduction education Somerville community survey Thank you for agreeing to provide your thoughts about a supervised consumption site (otherwise known as an overdose prevention site) in Somerville. Please keep in mind that the specifics of what a supervised consumption site means for Somerville have not been decided. This survey is part of the process to determine the needs and concerns of the community. We want to understand your perceptions and questions so they can be addressed in the future. Question Response options 1. How familiar are you with supervised consumption sites (sometimes called overdose prevention sites or drug consumption rooms)? Very familiar Somewhat familiar Not familiar at all 2. [If Q1=Somewhat familiar or Not familiar] Supervised consumption sites are public health interventions where people can use pre-obtained drugs in a sterile environment with

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84 access to sterile equipment under the supervision of health professionals who can respond in the event of an overdose. There are over 120 of these sites across the world, but no sanctioned supervised consumption sites exist in the US. On a scale from 1 (strongly disagree) to 10 (strongly agree), please indicate the extent to which you think a supervised consumption site would be helpful in Somerville. By helpful, we mean preventing overdose deaths, limiting the spread of HIV and hepatitis C, connecting people to treatment, reducing public drug use, and reducing drug-related litter. 0 10 4. [If Q3=6-10] Please explain why you think a supervised consumption site would be beneficial in Somerville. [text entry] 5. [If Q3=1-5] Please explain why you think a supervised consumption site would not be beneficial in Somerville. [text entry] 6. Supervised consumption sites have many proven public health and public safety outcomes in their communities. Please rank the following outcomes in order of their importance to you, with 1 being the most important and 7 being the least important. To rank your answers, drag and drop each option Reduce drug paraphernalia (e.g. needles, pipes) in public Reduce crime in the area surrounding the supervised consumption site Prevent overdoses and save lives Reduce the number of people using drugs outdoors and in public spaces Help connect people to drug treatment and health and social services Reduce HIV and hepatitis C transmission due to syringe sharing Reduce burden on emergency rooms, police, fire, and EMS by reducing overdose-related calls

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85 7. What Somerville neighborhood(s) do you think a supervised consumption site would be most helpful in? Please select all that apply. Hillside Teele Square Powderhouse Square Davis Square Ball Square Magoun Square Winter Hill Ten Hills Assembly Square Porter Square Spring Hill Duck Village Union Square East Somerville Boynton Yards Innerbelt North Point 8. Potential supervised consumption site locations in Somerville have not been selected yet. What do you think are among the most important factors when considering a location for a supervised consumption site? Please select all that apply. Proximity of the facility to local businesses Proximity of the facility to residential areas Convenience for potential clients Proximity of the facility to other support services and agencies Proximity to schools and playgrounds Proximity to public transportation Rate of overdose in the neighborhood Other: [text entry] 9. Would you have any concerns if a supervised consumption site was located in your neighborhood? Yes No Unsure 10. [If Q9=Yes or Unsure] What concerns or questions would you have if a supervised consumption site was located in your neighborhood? [text entry] 11. [If Q9=Yes or Unsure] How would you want your questions or concerns about supervised consumption sites addressed? Please select all that apply. Community town hall or community forum

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86 Information on the goals of the supervised consumption site Information about how supervised consumption sites can help communities Evaluations to determine what is or is not working if a supervised consumption site was established in Somerville Other: [text entry] 12. Current programs aimed at addressing the overdose crisis in Somerville include: the Community Outreach, Help and Recovery (COHR) program; the Overdose Aftercare Community Teams Program in partnership with ACCESS; ACCESS harm reduction supply distribution; the Office of Prevention at the Department of Health and Human Services; and naloxone trainings and naloxone distribution. Have you heard of any of these programs? Yes No Unsure 13. [If Q12=Yes] Have you ever accessed any of these programs? Yes No Unsure 14. [If Q12=Yes] Do you know anyone who has ever accessed any of these programs? Yes No Unsure 15. How satisfied are you with the City of Somerville’s approach to combating the overdose crisis? Very satisfied Satisfied Unsure Dissatisfied Very dissatisfied 16. [If Q15=Unsure, Dissatisfied, or Very Dissatisfied] What else do you think the City of Somerville could do to better address the overdose crisis in your community? [text entry] 17. What is your age? [text entry] 18. What is your current gender? Please select all that apply. Woman Man

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87 Non-binary, transgender, or genderqueer Something else: [text entry] 19. What is your race or ethnicity? Please select all that apply. Black, African, or African American White Mixed, bi-racial, or multi- racial Indigenous, Native American, Alaska Native Hispanic or Latinx Asian Native Hawaiian or Pacific Islander Something else: [text entry] 20. What is your relationship to Somerville? Please select all that apply. Resident Business owner Work in Somerville Family and/or friends live in Somerville Attend church in Somerville Attend school in Somerville Child/children attend school in Somerville Use healthcare or mental health services in Somerville Use substance use treatment services in Somerville Use housing/shelter services in Somerville Use social or community services in Somerville Something else: [text entry] 21. [If Q20=Resident] How long have you lived in Somerville? Less than 1 year 1-2 years 2-5 years 5-10 years 11-20 years Greater than 20 years

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88 22. [If Q20=Resident] What Somerville neighborhood do you live in? Hillside Teele Square Powderhouse Square Davis Square Ball Square Magoun Square Winter Hill Ten Hills Assembly Square Porter Square Spring Hill Duck Village Union Square East Somerville Boynton Yards Innerbelt North Point