Somerville SCS Report_FINAL_2021 — File 212153

Somerville Supervised Consumption Site Needs Assessment and Feasibility Report Final Report - June 16th 2021 Alexandra B. Collins, Juliet Flam-Ross, Sarah Casey, Tj Thompson, Stephen Kelley, Cassie Hurd, Dhruv Gaur, Abdullah Shihipar, and Brandon D.L. Marshall

Alexandra B. Collins, PhD Investigator Brown University School of Public Health Juliet Flam-Ross, BA Research Data Associate Boston Medical Center Sarah Casey, BA Sarah Casey, BA Harm Reduction Specialist ONESTOP Harm Reduction Center Tj Thompson Peer Research Associate Material Aid and Advocacy Program Stephen Kelley Peer Research Associate Peer Research Associate Material Aid and Advocacy Program Cassie Hurd, BA Executive Director Material Aid and Advocacy Program Dhruv Gaur, BA Research Assistant Brown University School of Public Health Brown University School of Public Health Abdullah Shihipar, MPH Research Associate, Narrative Projects & Policy Impact Initiatives Brown University School of Public Health Brandon D.L. Marshall, PhD Associate Professor Brown University School of Public Health This report was produced by the People, Place & Health Collective This report was produced by the People, Place & Health Collective (@pph_collective), a research collaborative at the Brown University School of Public Health that studies drug use and infectious disease epidemics. Study Team Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 2

External Reviewers We would also like to thank the following external reviewers who provided critical insights and feedback on this report. Thomas D. Brothers, MD Resident Physician/Fellow Department of Medicine, Dalhousie University Halifax, Nova Scotia, Canada Elaine Hyshka, PhD Elaine Hyshka, PhD Assistant Professor School of Public Health, University of Alberta Edmonton, Alberta, Canada We would like to thank all of the community members, participants, and organizations who participated in this study and provided guidance and feedback that informed this report. We are especially grateful for the individuals who were willing to share their experiences and opinions to inform this work and next steps. Additionally, we would like to acknowledge the invaluable and continued contributions of the Somerville SCS Task Force whose members have supported this assessment and provided significant overall guidance. The The study team would like to extend particular thanks to Miriam Harris, MD, for her ongoing consultations and guidance throughout this process. We would also like to acknowledge the tireless efforts of Aubri Esters in centering the needs and perspectives of people who use drugs. In addition to ongoing advocacy efforts, Aubri also led the focus groups interviews with people who use drugs included in this report. We would also like to thank William Goedel, PhD, for his support conducting spatial analyses for this project. Additionally, we would like to express our gratitude to Corey Davis, JD, for his feedback and guidance over the course of this project. Funding This evaluation was funded by the City of Somerville, Department of Health and Human Services. Disclaimer This needs assessment and feasibility report was prepared for the City of Somerville by Drs. Alexandra Collins and Brandon Marshall, with the support of Juliet Flam-Ross, Sarah Casey, Tj Thompson, Stephen Kelley, Cassie Hurd, Dhruv Gaur, and Abdullah Shihipar, and in partnership with the Somerville SCS Task Force. The views expressed in this report are those of the authors only and do not represent the official positions or policy of the City of Somerville nor the authors’ institutions. Acknowledgements Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 3

Study Team Acknowledgements External Reviewers Funding Disclaimer Contents Executive Summary Executive Summary Summary of Recommendations List of Figures List of Tables Introduction The overdose crisis in Somerville The public health response What is harm reduction? What is harm reduction? Supervised consumption sites A review of the evidence Impacts on mortality Impacts on morbidity Treatment impacts Neighborhood impacts Economic impacts SCS models Integrated sites Stand-alone sites Embedded sites Mobile sites Evaluation context: Somerville, MA Current harm reduction programming and response in Somerville Study objectives Methods Study design Study oversight Quantitative data Survey with people who use drugs Somerville community survey Qualitative data Secondary data Results Survey with people who use drugs Demographics Drug use patterns Drug use locations Previous Overdoses Supervised consumption site services Somerville community survey Demographics Familiarity and usefulness of SCS Opinions about SCS 2 3 3 3 3 4 6 8 9 10 11 11 12 12 12 12 13 13 13 14 14 14 14 15 15 16 16 16 17 17 17 17 18 18 18 19 19 19 19 20 20 21 21 21 21 22 22 22 23 24 24 25 25 Table of Contents Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 4

Location Additional Steps Focus groups with people who use drugs Demographics Facilitators Barriers SCS model and location SCS program and service needs Cost effectiveness analysis Analyses of existing data Study limitations Surveys with people who use drugs Somerville community survey Focus group data Town Hall Overview Recommendations Geographic location Design and operational model Consumption room design Post-consumption observation room design Staffing recommendations Hours of operation Policies and procedures Accessing the SCS Police involvement Post-consumption observation and monitoring Service and program recommendations Legal recommendations Task Force Recommendations Legislative and legal sub-committee Program development sub-committee Next steps References Appendix 1 - Results from the surveys with people who use drugs Appendix 2 - Results from the Somerville community survey Appendix 2 - Results from the Somerville community survey Appendix 3 - Preliminary SCS operational guidance document Appendix 4 - Survey instruments Table of Contents Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 5 26 27 27 27 27 28 29 29 29 30 30 33 33 33 34 34 35 36 36 38 38 38 39 39 39 40 40 40 41 41 42 42 43 43 43 44 46 54 63 63 70 78

Massachusetts currently has the 8th highest rate of overdose deaths in the country, with over 2,000 individuals having died from a fatal overdose in 2020. In Somerville, overdose rates increased more than fivefold between 2012 and 2018, and each year, the city’s first responders attend to more than 100 overdose calls. Currently, there are limited supports for people who use drugs in Somerville, with no fixed harm reduction services (e.g. syringe distribution programs) available in the city. In In September 2020, the Somerville Department of Health and Human Services released a call for applicants to conduct a needs assessment and feasibility study on supervised consumption sites (SCS) in Somerville to address the ongoing impacts of the overdose crisis in the city. Supervised consumption sites (SCS) are a public health intervention to prevent fatal overdose and reduce harms associated with drug use. SCS are hygienic environments where individuals can use pre-obtained drugs under the supervision of healthcare professionals or trained staff who can respond in the event of an overdose or medical emergency. event of an overdose or medical emergency. The purpose of this needs assessment and feasibility study was to determine the conditions under which an SCS would be used by people who use drugs; the feasibility of implementing an SCS in Somerville; and to identify concerns, challenges, and barriers that may be associated with opening an SCS. Surveys with people who use drugs A total of 47 participants were surveyed. The majority of participants (87%) reported being unstably housed, 72% reported daily drug use, and 51% of participants had experienced an overdose in the past year. Almost all participants (94%) said they would use an SCS. The most common reasons for using an SCS included: overdose prevention or treatment, safety from police, and safety from crime or violence. Reasons for not wanting to use an SCS included: concerns about police around the site and not wanting to disclose their drug use. Surveys with community members Surveys with community members A total of 615 community surveys were completed. Participants were asked on a scale from 1 (least) to 10 (most) how helpful an SCS would be in Somerville. The average response was an 8.23. The main benefits of an SCS participants noted included: connecting people to services and supports, reducing overdose deaths, and overall public benefits. Negative community impact, concerns about the site enabling drug use, and increasing the number of people who come to Somerville to use drugs were listed as the top three reasons an SCS would not be beneficial. Key Findings Executive Summary Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 6

The top neighborhoods participants selected for an SCS included East Somerville (45%), Davis Square (41%), and Winter Hill (33%). Among participants, 56% said they would have no concerns if an SCS were located in their neighborhood. Focus group interviews with people who use drugs Two Two focus group interviews were conducted with 17 participants. Participants highlighted four main facilitators for using an SCS: anonymity and discreteness, availability of wraparound service, an interdisciplinary staffing model, and support for multiple consumption methods. In addition to harm reduction services, participants underscored the importance of having social services, health services, and basic needs supports at an SCS. Barriers to using an SCS included: law enforcement interaction around the site and inaccessible location. Based Based on the findings of this needs assessment and feasibility study, we recommend that Somerville establish at least one integrated SCS in either Davis Square and/or East Somerville that includes harm reduction and wraparound support services for people who use drugs. We also recommend that people who use drugs be meaningfully included in the planning, implementation, and operational phases of opening and running an SCS. Lastly, we recommend that the City of Somerville engage in transparent, community-engaged planning and implementation efforts with a range of stakeholders. stakeholders. Recommendations Executive Summary Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 7

The city of Somerville would benefit from an integrated supervised consumption site (SCS). In In an integrated SCS, consumption services are one part of a broad range of harm reduction, health, and social services services offered in the facility. Primary and secondary data analyses underscore the need for an integrated SCS in Somerville to address morbidity, mortality, and social impacts of the overdose crisis, as well as increase access to health and ancillary services for people who use drugs in Somerville. Participants—including those who do and do not use drugs—were largely supportive of a SCS in the city to reduce fatal overdose risk. In addition to harm reduction services, wraparound health and social services need to be included in the SCS. We recommend that the lead lead organization of the site be an organization that already provides harm reduction services and/or supports people who use drugs to improve uptake, and be determined by a Community Advisory Committee that is inclusive of representatives from the Somerville SCS Task Force. We recommend the consumption room be open 24 hours a day if feasible, with the drop-in center open from 8am - 6pm. The city of Somerville should consider Davis Square or East Somerville for an integrated SCS. Data from the Somerville community survey, city overdose surveillance data, and focus group data point to Davis Square and/or East Somerville as being suitable locations for an integrated SCS. Over half of participants reported that East Somerville would be best suited for an SCS, followed by Davis Square. We recommend at least one SCS be established in either Davis Square or East Somerville, but ideally both locations would have an integrated SCS. Importantly, these neighborhoods are also easily accessible by transit, which was noted as important among people who use drugs. People People who use drugs should be meaningfully included throughout the planning, design, and implementation processes. Data from people who use drugs and the Somerville SCS Task Force underscored the importance of including people who use drugs in the planning, design, and operation of an SCS, as well as selecting the organization that will operate the SCS. To improve suitability and uptake, we recommend that a Community Advisory Committee be convened that includes a range of stakeholders (inclusive of people who use drugs) to guide these processes. The The City should undertake a transparent and community-engaged process with a range of stakeholders (e.g. people who use drugs, business owners, residents, health and social service providers, police) in the planning and implementation phases of a SCS. We recommend that the City organize a series of public forums that feature diverse perspectives and stakeholders, including local community members affected by the overdose crisis. The goals of such meetings might include addressing concerns, increasing public understanding and acceptance of needs for a SCS, and ensuring better integration into the community. Mechanisms should be established for ongoing monitoring and evaluation of an SCS. Mechanisms should be established for ongoing monitoring and evaluation of an SCS. Evaluation processes should be undertaken to document the impact of the site on morbidity and mortality of clients, fatal overdose rates, and community impact. Summary of recommendations Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 8

Survey with people who use drugs Figure 1 Frequency of drug use (page 21) Figure 2 Frequency of public drug use (page 22) Figure 3 Overdose experiences in the last year (page 22) Figure 4 How often would you use a SCS (page 23) Figure Figure 5 Participant agreement with the statement “How helpful a SCS would be in Somerville"” (page 25) Somerville community survey Figure 6 Top Most Important Outcome for SCS (page 26) Figure 7 Preferred Locations for a SCS in Somerville (page 26) Figure 8-13 Where overdose calls occur in Somerville (pages 30-31) Figure Figure 14 Map of density of QOL cals to the Somervile Police Department for hypodermic needles found in 2020 (page 32) Figure 15 - Davis Square-based integrated SCS (page 37) Figure 16 - East Somerville-based integrated SCS (page 37) List of Figures Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 9

Survey of people who use drugs Table 1 - Reasons for using a SCS (page 23) Table 2 - Reasons for not using a SCS (page 24) List of Tables Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 10

The overdose crisis in Somerville The New England region of the United States has been particularly hard hit by the nation’s overdose crisis. In 2019 the rate of overdose death reached 32.1 per 100,000 in the Commonwealth of Massachusetts, far exceeding the national average of 21.6 per 100,000 [1]. The state now has the eighth highest rate of overdose mortality in the country and the second highest in New England [2]. Although 2020 statistics are incomplete, provisional data indicate that the COVID-19 pandemic has greatly worsened the overdose crisis [3], with Massachusetts residents experiencing job loss, housing instability and homelessness, isolation, depression, anxiety, anxiety, and other stressors that increase overdose risk. While fentanyl continues to be involved in more than 90% of deaths, fatal overdoses involving cocaine and amphetamines have increased sharply during the COVID-19 pandemic [4]. Increasing overdose mortality rates among Black residents underscore the racial health inequities that have been exacerbated by the pandemic [4]. The City of Somerville has experienced firsthand the devastation wrought by overdose deaths, and the incalculable toll of preventable death on persons who use drugs, their friends, families, and loved ones. Between 2012 and 2018 the number of opioid-involved overdose deaths among Somerville residents increased more than fivefold. While some progress was noted in 2019 and 2020, these data are provisional and subject to change [5][6]. Fatal Fatal overdoses only represent the ‘tip of the iceberg’ in terms of the true burden of accidental overdose experienced by Somerville residents. According to SomerStat: The Mayor's Office of Innovation and Analytics, the Somerville police and fire departments have responded to more than 100 opioid-related overdoses each year since 2015 [7]. Since the majority of persons who experience a non-fatal overdose do not seek emergency services, this figure is likely an under-estimate. Most studies suggest that the non-fatal to fatal overdose ratio is anywhere between 20:1 to 40:1 [8,9], which suggests that Somerville residents experience between 340 and 680 non-fatal overdoses each year. The The Commonwealth of Massachusetts is also experiencing a rapid increase in HIV cases among people who use and inject drugs. Large outbreaks have occurred in the cities of Lawrence and Lowell. In addition, over 100 new HIV cases have been identified among people who inject drugs in the City of Boston since 2019, particularly among persons who are experiencing homelessness [10]. Introduction Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 11

The public health response A comprehensive public health approach to addressing the health and social needs of people who use drugs amid an overdose crisis and HIV epidemic involves the implementation, scale-up, and sustainment of coordinated measures focused on prevention, treatment, harm reduction, and recovery. A recent mathematical modeling study using data from Massachusetts found that no single intervention is expected to reduce overdose mortality by 40%, highlighting the need for a comprehensive set of interventions [11]. A summary of evidence-based approaches to reduce overdose death is beyond the scope of this report, and has been been reviewed elsewhere [12], but includes increased access to medications for the treatment of opioid use disorder, enhanced distribution of naloxone, and community-based recovery support. What is harm reduction? Harm reduction is a philosophy of care and set of principles and approaches that aim to reduce the harms associated with drug use, as well as the harms resulting from racialized and punitive drug policies. Importantly, harm reduction is grounded in social justice and prioritizes dignity, agency, and respect for people who use drugs. A range of evidence-based harm reduction interventions have been implemented across the US to address overdose risk and drug-related harms (e.g., transmission of HIV or hepatitis C), including expanded access to naloxone, drug checking services, scale-up of medications for opioid use disorder, disorder, and syringe service programs. Critically, most harm reduction interventions have been developed by and for people who use(d) drugs. Supervised consumption sites (SCS) are an additional public health intervention to mitigate fatal overdose and reduce harms associated with drug use. However, no sanctioned SCSs currently exist in the US, despite ongoing efforts across a number of states. Supervised consumption sites SCSs—also referred to as supervised injection facilities, drug consumption rooms, or overdose prevention sites—are hygienic environments where individuals can bring pre-obtained drugs to use under the supervision of health care professionals or trained staff who can respond with oxygen and naloxone in the event of an overdose. These services aim to reduce harms associated with drug use use by providing access to sterile drug use supplies, rapid emergency overdose response, and often wraparound health and ancillary supports. SCSs are also important for providing a space for people who otherwise use drugs alone, which significantly increases fatal overdose risk [13]. There is no evidence that establishing an SCS leads to an influx of clients from other communities. In fact, the majority majority of SCS clients and users of other harm reduction services reside within one mile of these programs [14]. The first sanctioned SCS was established in Switzerland in 1986 and there are now over 120 sites located in 11 countries [15]. While SCSs operate under a range of models, they are part of a larger continuum of care for people who use drugs and seek to connect with individuals who may not be readily engaged in existing healthcare settings. For additional information on SCS service environments, including tours of existing SCSs, please refer to Consumption room at the Dr. Peter Center. Source: https://www.catie.ca/sites/default/files/ catie-drpeter-ops-scs-11062019.pdf For additional information on SCS service environments, including tours of existing SCSs, please refer to the videos in the supplemental resource compendium. Introduction Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 12

A review of the evidence A considerable amount of research has examined the health and public safety impacts of SCSs, which has been summarized elsewhere [16,17]. This body of work has consistently documented the public health benefits of these interventions, including: reductions in harms associated with illicit drug use; connecting people who use drugs to health and treatment services; and improving neighborhood conditions and public order. A brief review of this evidence is included below. Impacts on mortality SCSs SCSs are an effective intervention that reduces overdose deaths. No fatal overdoses have ever been reported in sanctioned SCSs worldwide [17]. In Vancouver, Canada, Insite—North America’s first sanctioned SCS—is estimated to avert two to 12 overdose deaths per year among clients [9]. However, due to the proliferation of illicitly-manufactured fentanyl in the drug supply, Insite and other surrounding SCSs are likely to avert significantly more fatal overdoses in coming years. In Sydney, Australia, the opening of an SCS resulted in a 68% decrease in neighborhood ambulance calls for drug overdoses during the SCS operating hours [18]. Research Research has also demonstrated that frequent use of an SCS is associated with a reduced risk of death among people who inject drugs [19]. Importantly, SCSs have been shown to reduce population overdose mortality occurring in their immediate vicinity. In Vancouver, establishing a SCS led to significant reductions in accidental overdose deaths occurring within 500m (approximately 550 yards) of the facility [20]. Especially as fentanyl overdose deaths continue to drive overdose mortality in Massachusetts, this research demonstrates that SCSs are an effective way to reduce overdose deaths. Impacts on morbidity SCS SCS utilization reduces syringe sharing through the provision of sterile needles, syringes, and other paraphernalia, which lowers the risk of injection-related infections, such as HIV, hepatitis C (HCV), and skin and soft tissue infections [21]. Conservative models estimate that SCSs reduce short-term incident HIV infection rates by 6-11% each year [22,23]. In addition, SCSs can provide locations for people who use drugs to be connected with treatment for HIV and HCV [24], further reducing infectious disease transmission. Clients also more readily readily seek care for skin and soft tissue injuries—the leading cause of hospitalization among people who inject drugs [25]—at SCSs as compared to hospitals [26]. SCSs can lead to the long-term adoption of healthier drug use behaviors outside of the SCS setting. People who use SCSs reduce syringe sharing and report increased use of sterile materials, even when using drugs outside of an SCS [27]. SCS use may also lead to safer sex practices to reduce HIV transmission, such as increased condom use [28]. Urban network studies suggest that harm reduction behaviors such as those promoted by SCSs are often transferred through dense social networks [29,30]. As such, SCSs have the potential to foster foster harm reduction behaviors in a population larger than their baseline clientele. No fatal overdoses have ever been reported in sanctioned SCSs worldwide Introduction Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 13

A review of the evidence Treatment impacts SCSs SCSs are effective modalities for increasing access to treatment for substance use disorders. Closely integrating SCS services with referrals to addiction treatment programs and other social services has shown substantial signs of success. Previous studies have shown that SCS service utilization leads to increased uptake of detoxification services [31,32] and entry into evidence-based substance use disorder treatment programs [33,34], especially when referrals are facilitated by on-site counselors [35]. As such, researchers and clinicians propose including SCSs as part of the evidence-based continuum of care for people seeking treatment treatment for substance use disorders [36,37]. Finally, evidence suggests that establishing an SCS does not lead to increased drug use initiation [38,39]. Neighborhood impacts In addition to reducing local overdose mortality, SCSs enhance public safety, decrease public disorder, and improve the neighborhood conditions in which they are located [40]. SCSs contribute to public order by decreasing the number of people who inject drugs in public [40,41]. SCSs also decrease injection-related litter and publicly-discarded syringes by providing direct syringe disposal services for community members [40,41]. In reviewing the evidence on SCSs, the Massachusetts Harm Reduction Commission concluded that, “there is evidence that the neighborhood burden of drug use (e.g., public injections, discarded syringes, injection-related injection-related litter) is lessened after the establishment of a harm reduction site, especially when paired with outreach workers and syringe pick-up programs” [42]. Data from Canada and Australia demonstrate that the establishment of an SCS is not associated with local increases in crimes, such as drug dealing, drug possession, assaults or robberies [43–45]. In a recent analysis, documented criminal activity decreased rather than increased in the area around an unsanctioned SCS located in the US in the five years following the SCS opening [46]. Finally, there is no evidence that SCS have a negative impact on property values [47]. Economic impacts An An established evidence base from non-US settings indicates that SCSs are not only cost-effective, but can result in cost savings by reducing healthcare-related expenditures, averting emergency department visits, and preventing new cases of infectious diseases such as HIV and HCV [48,49]. Moreover, SCSs reduce the amount of outside medical care needed in the event of an overdose. Cost-effectiveness studies that model SCSs in a number of US cities, including New York City, San Francisco, Baltimore, and Seattle, consistently find that an SCS prevents overdose deaths and reduces healthcare costs by decreasing the need for overdose-related overdose-related ambulance rides, emergency department visits, and hospitalizations, and increasing clients’ uptake and retention of medications for the treatment of opioid use disorder [14,50–52]. Introduction Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 14

A review of the evidence Economic impacts Furthermore, Furthermore, SCSs generate cost savings beyond overdose-related health expenditures. By reducing syringe and needle-sharing among people who use drugs, SCSs reduce the incidence of HIV and HCV infections in the community, thereby reducing the need for costly, long-term medical treatment for these conditions [23]. In addition to the prevention of bloodborne diseases, skin and soft tissue infections currently represent the most common reason for hospitalization among people who use drugs [25]. Treating these infections can be a significant cost: in Florida, the average charge for a hospital admission for injection-related endocarditis was was over $64,000 in 2017 [53]. By providing a sterile injection environment and educating clients on safer injection practices, an SCS reduces the incidence of skin and soft tissue infections among clients [54], thereby further reducing hospital costs. In light of these other potential cost-savings, savings found due to reductions in overdose-related care represent a conservative estimate of the overall benefits of SCSs. SCS models Integrated sites Integrated Integrated SCSs are the most common SCS operational model. Under this model, SCSs are situated within an existing facility (e.g., a syringe exchange program, community health center) or network of services that provide health and social supports to people who use drugs as well as people who do not use drugs. In this capacity, integrated SCSs act as a ‘one-stop-shop’ on the continuum of care for people who use drugs, offering wraparound services such as counselling, housing case workers, basic basic medical services (e.g., HIV and HCV testing, wound care), food provision, and other harm reduction services (e.g., needle distribution, naloxone education), for people who use drugs and/or people who are unstably housed. In integrated facilities, the consumption room is generally located in a designated area and is only one of a range of services provided. This allows individuals who do not use drugs or who may be in recovery to still access additional services within the facility, while avoiding areas where drug use occurs. Integrated models are often implemented in locations where people who use drugs are more dispersed as it can facilitate the uptake of additional health and ancillary services and improve continuity in care for individuals. individuals. Examples of integrated SCSs include the Dr. Peter Center, an AIDS Service Organization in Vancouver, Canada [55] and the Queen West SCS located at the Parkdale Queen West Community Health Center in Toronto, Canada [56]. The Dr. Peter Centre facility in Vancouver, Canada. Source: Dr. Peter Centre facebook page Queen West SCS, Parkdale Queen West Community Health Center, Toronto, Canada. Source: https://pqwchc. org/programs-services/harm-reduction/ops/ Introduction Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 15

SCS models Stand-alone sites Stand-alone Stand-alone SCSs, also referred to as specialized SCSs, are distinct facilities whose primary focus is on supervised consumption within a sterile and non-judgemental environment. While some additional services may be provided within these sites, such as food and primary care services, they more typically refer clients to other health and ancillary service programs (e.g., counselling, medication for opioid use disorder, housing supports). Stand-alone sites are often larger than other SCS models and are typically located near open drug scenes or where there is a large concentration of people who use drugs. Since the main purpose is for supervised consumption, these sites primarily serve people who use drugs. supervised consumption, these sites primarily serve people who use drugs. Examples of specialized SCSs include Insite in Vancouver, Canada [57] and the Uniting Medically Supervised Injecting Centre (MSIC) in Sydney, Australia [58]. Embedded sites Embedded SCSs are located within existing services and care systems that do not typically allow non-medical drug use, such as hospitals, shelters, and supportive housing facilities. Offering supervised consumption services in hospital settings can reduce risk of harm associated with drug use among people in acute care (e.g., using drugs in locked bathrooms) and reduce the risk of people leaving against medical advice. Examples of hospital-based SCSs, including the Royal Alexandra Hospital in Alberta, Canada [59]; St. Paul’s Hospital in Vancouver, Canada [60]; and Gaïa-Paris in Paris, France [61]. Although Although embedded SCSs are less common, examples can be found in the Abrigado in Luxembourg City, Luxembourg [62], and the Eastside Facility in Frankfurt, Germany [63]. Notably, embedded SCSs have been increasingly implemented in shelters, hotels, and non-profit operated housing in Canada in recent years to address the increasing rates of fatal overdoses in these settings [64–66]. Mobile sites Mobile Mobile SCSs offer consumption services from specially outfitted vans, buses, recreational vehicles (RV) or trailers. Mobile models are often implemented when working within a setting where the drug scene is not centralized, but dispersed across broader geographic areas. However, mobile SCSs are typically implemented alongside stationary SCS and are complementary complementary to brick and mortar facilities. This model is often uncommon due to logistical considerations (e.g. expense, small size). To our knowledge, there are few mobile SCSs in operation. However, examples include mobile sites in Montréal, Canada [67]; Glasgow, Scotland [68]; Barcelona, Spain [69]; and Berlin, Germany [69]. A mobile SCS van in Vancouver, Canada. Source: https://bit.ly/3fZK8KU Introduction Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 16

Study context: Somerville, MA Somerville is located in Middlesex County, two miles northwest of Boston. The city is located on the traditional, unceded lands of the Wampanoag peoples. With a population of approximately 81,000 residents within four square miles, Somerville is one of the most densely populated communities in New England [70,71]. The city is culturally diverse, with 25% of the population born outside of the US [71]. As of 2019, approximately 68% of Somerville’s population was white, 12% were Hispanic or Latinx, 10% were Asian, Asian, 6% were Black or African American, with the remainder multi-racial and Indigenous [71]. Over the last decade, Somerville has continued to experience a housing affordability and availability crisis [72]. Between 2010 and 2017, average rents in Somerville increased by almost 30%, with almost 35% of renter households in the city cost-burdened [72]. Approximately 11.5% of Somerville residents were living in poverty [71] and during the 2018 point-in-time count, there were 134 unhoused individuals recorded in Somerville [73]. Current harm reduction programming and response in Somerville Harm reduction services are currently limited in Somerville. The city has several outpatient treatment services that provide medications for opioid use disorder. However, at present, there are no permanent harm reduction drop-in facilities, such as syringe exchange programs, located in Somerville. Street-based syringe distribution operated by the AIDS Action’s Access: Drug User Health Program (ACCESS) does occur in Somerville; however, they lack a brick-and-mortar presence. City-level City-level programming includes: the Community Outreach, Help and Recovery (COHR) program at the Somerville Police Department; the Office of Prevention at the Somerville Department of Health and Human Services; and naloxone training and distribution. Two other programs in the city operate on a limited basis and in partnership with Access: the Overdose Aftercare Community Teams Program and street-based harm reduction supply distribution. Study objectives The objective of the Somerville SCS needs assessment and feasibility study were to: 1) 1) Determine the conditions under which an SCS would be used or deemed suitable for use by people who use drugs in the City of Somerville; 2) Determine the feasibility of an SCS in Somerville, including operational model type, location, consumption methods supported, and programmatic features; and 3) Identify concerns, challenges, and barriers that may be associated with opening an SCS in Somerville and discuss strategies to address them among the Somerville community. Introduction Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 17

Study design This community-engaged needs assessment and feasibility study sought to document the perspectives of people who use drugs and community members on establishing an SCS in Somerville, Massachusetts. Needs assessments from similar-sized communities in Canada were reviewed in the development of survey questions for this study [74–76], as well as the British Columbia Centre on Substance Use SCS operational guidance document [77]. All information obtained was anonymous and recorded by the investigators in such a manner that the identity of participants cannot be readily ascertained directly or through identifiers linked to the participant. As such, this work was exempt from Institutional Review Board (IRB) approval. As such, this work was exempt from Institutional Review Board (IRB) approval. This assessment was multi-phased. Phase one included analyses of existing data and primary data collection, which was completed in April 2021. In phase two, public feedback was sought through a virtual community meeting held on June 10th, 2021. The final report with recommendations was submitted to the City of Somerville’s Department of Health and Human Services in June 2021, during phase three. The following primary data collection methods were used in this assessment: 1) A survey conducted with people who use drugs 2) An online community survey of Somerville residents 3) Focus groups conducted with people who use drugs Of note, all surveys were conducted in 2021 for this needs assessment. However, focus groups with people who use drugs were conducted in January 2020. As these focus groups were undertaken to understand the perspectives of people who use drugs in relation to an SCS in Somerville, the study team also conducted an analysis of these existing data. In In addition to these primary sources of data, secondary existing data sources on overdose rates, opioid-related deaths, etc. were also analyzed. Study oversight Oversight was provided by the Somerville SCS Task Force. The Task Force was formed in 2019 to examine the financial, legal, and operational considerations of opening an SCS in Somerville, as well as the potential community impacts. The Task Force was chaired by the Director of Health and Human Services from its inception until October 2020, at which point it was chaired by Dr. Alexandra Collins as part of this needs assessment. The The Task Force is comprised of a range of stakeholders, including: Somerville community members, people who use(d) drugs, activists, health and social service providers, legal and legislative experts, representatives from the Somerville Police Department and Somerville Fire Department, and representatives from City of Somerville departments (e.g., communications, legal, health and prevention) and City Council. The Task Force was divided into four subcommittees: legal and legislative committee; communications committee; community outreach and education committee; and program development committee. Task Force meetings occurred monthly with attendance attendance ranging from approximately 10 - 20 people per meeting, with sub-committees meeting on an ad hoc basis in the interim. Methods Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 18

Study oversight The Task Force provided feedback on study methodology, data collection tools, and recruitment methods. Four members of the Task Force administered the surveys with people who use drugs given their existing relationships with harm reduction and social service agencies. Each subcommittee also provided a series of recommendations that are included below. Additionally, the Task Force was provided a draft version of this report. Quantitative data Survey with people who use drugs A survey was conducted with people who self-identified as currently using drugs from February to April 2021. A total of 47 participants completed the survey. The survey instrument was adapted from the British Columbia Centre on Substance Use SCS operational guidance document [77] and aimed to assess: demographic information; substance use patterns and practices; overdose experiences; SCS location and operational preferences; facilitators and barriers to using an SCS; and SCS programmatic and service needs (see Appendix 4). Surveys Surveys were conducted by four staff and peer researchers from two Cambridge-based harm reduction and social service organizations who serve a large number of Somerville residents and people who use drugs. Participants were recruited using a verbal script during outreach and at each drop-in center space. Participants were eligible to complete the survey if they self-identified as a person who uses drugs, were at least 18 years of age, and were able to provide verbal consent. The survey contained 27 questions and took approximately 10 minutes to complete. Participants were compensated $10 cash for their time. Surveys Surveys were conducted in-person and facilitated by a peer researcher or staff member. Surveys were available digitally using Qualtrics software or were conducted using a paper copy and later entered into the Qualtrics software. Somerville community survey An An online community survey was developed in consultation with the Somerville SCS Task Force and was distributed by the City of Somerville through social media and listservs. Qualtrics software was used to design the survey which took approximately 10 minutes to complete. The survey was open for participation from March to April 2021. The survey was promoted through a range of outlets, including social media, emails to community networks and groups, and the City of Somerville’s website. Participants Participants were eligible to complete the survey if they lived in Somerville and were 16 years of age or older. However, given the online distribution method, individuals who did not meet these criteria were still able to access the survey. Where appropriate, data from non-residents are summarized separately. A total of 615 surveys were completed and were included in this analysis. The The survey aimed to assess community members’ perceptions and concerns of an SCS, recommended location of an SCS in Somerville, and implementation considerations. The survey also collected participants’ demographics and suggestions for addressing concerns or questions related to an SCS in Somerville (see Appendix 4). Methods Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 19

Quantitative data Two focus groups were conducted with people who use drugs in January 2020. Focus groups were conducted at two harm reduction and social service organizations in Cambridge, MA supporting socio-economically marginalized individuals and people who use drugs. Participants were recruited by flyers posted in each of the drop-in centers and verbal invitation. Participants could sign up in advance if interested, but this was not required for participation. Each Each focus group was led by a person who use(d) drugs with one of two drop-in center staff co-facilitating. A facilitation guide was used to guide discussions and sought to elicit perspectives on the acceptability, feasibility, and implementation considerations of SCS. Each focus group consisted of seven to 12 participants, all of whom self-reported current drug use at time of participation and lasted approximately 45-90 minutes. Focus groups were audio-recorded and notes were taken simultaneously during each interview by the co-facilitators. Recordings and notes were later transcribed. Focus group data and notes were analyzed thematically, with themes themes organized by question. All participants were provided a $15 gift card from the City of Somerville’s Department of Health and Human Services, and lunch from SIFMA Now!, a Massachusetts-based coalition advocating for the opening of an SCS. Secondary data In order to appropriately contextualize this report to the overdose crisis in Somerville, data was collected from state and local agencies monitoring the overdose crisis. Counts of overdose deaths used in this report were originally collected and reported by the Massachusetts Department of Public Health [5]. Data on police and fire department calls were acquired from SomerStat, a statistical department in the Mayor's Office of Innovation and Analytics in Somerville [7]. To To assess accessibility of the proposed locations, we obtained data on Somerville’s road network from the Massachusetts Department of Transportation (MassDOT) [78], and on Somerville’s public transit routes and schedules from the Massachusetts Bay Transportation Authority (MBTA)’s general transit feed specification [79]. Finally, data on quality of life calls to the Somerville Police Department where hypodermic needles were found in public for the 2020 calendar year were obtained from the City of Somerville Data Catalog [80]. The locations of these incidents were mapped in ArcGIS Pro 2.7.3 to create a kernel density map that identifies locations within Somerville where these incidents were more common. Somerville where these incidents were more common. Methods Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 20

Demographics Survey with people who use drugs A total of 47 participants who self-identified as people who use drugs were surveyed, of whom 77% were men, 17% were women (transgender-inclusive), 4% were non-binary or genderqueer, and 2% chose not to respond. Roughly half of participants identified as white (53%), 24% identified as Black, 14% identified as multi-racial and/or other, and 9% identified as Hispanic or Latinx. The median median age of participants was 40 years, with ages ranging from 19 to 71 years. Housing instability was prominent among participants, with 87% of participants unhoused at the time of survey. 87% of participants were unhoused at the time of the survey Drug use patterns All but one participant reported drug use in the 30 days prior to being surveyed, and the majority of participants (72%) reported daily drug use. The majority of participants (80%) reported consumption by either smoking or inhalation in the 30 days prior to being surveyed, followed by injection (63%), ingestion (55%), and snorting (55%). The most commonly used substances among participants in the previous 30 days were heroin (68%), followed by alcohol (64%), crack cocaine (62%), and fentanyl (62%). Frequency Frequency of using drugs alone varied across participants, with 31% of participants reporting using alone all or most of the time, 37% using alone sometimes, 20% using alone occasionally, and 13% never using alone. 72% of participants reported daily drug use Figure 1 Results Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 21

51% of participants reported haiving at least one overdose in the past year Drug use locations Survey with people who use drugs Notably, 65% of participants (n=46) reported typically using drugs outdoors, followed by public washrooms (48%), or where they were currently living or staying (46%). Of those who reported public use of drugs (n=37), 51% reported doing so daily (see Figure 2). Previous overdoses Half of participants (51%) reported having had at least one overdose in the past year (see Figure 3). Figure 2 Figure 3 Results Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 22

Supervised consumption site services Importantly, 94% of participants said they would use an SCS in Somerville. Of those who said they would use a Somerville SCS (n=44), 24% reported that they would access the site every time they used, 33% reported they would access the site most of the time they used, 25% said they would use it sometimes, 9% occasionally, and 9% unsure of how often (see Figure 4). 4). Participants Participants overwhelmingly reported wanting to use an SCS for overdose prevention or treatment (94%). Other reasons for using an SCS included, safety from police (74.5%), safety from crime or violence (70%), access to sterile supplies (66%), ability to inject indoors rather than in public (55.5%), and access to health professionals (55.5%) (see table 1). health professionals (55.5%) (see table 1). Table 1: Reasons for using a SCS Figure 4 94% of participants said they would use a SCS Survey with people who use drugs Results Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 23

Supervised consumption site services Despite widespread support for a SCS in Somerville, participants highlighted potential barriers that may impede their uptake of this service. The main concern for participants was related to potential police interference at the SCS, followed by not wanting to disclose their drug use (see Table 2). Participants Participants who use drugs were also asked about the acceptability of potential SCS policies. The top three policies seen as most acceptable, included: use supervised by trained staff (74%); having to stay at the site after use to be monitored (38%); and having to register each time they use the site (30%). Participants Participants were also asked about a range of potential services that could be incorporated in an SCS, and the level to which they found services to be important. The services deemed most important were: access to contraception (82%); HIV, hepatitis C, and STI testing (80%); and assistance with housing, social assistance, and other support services (74%). Somerville community survey Demographics A total of 615 community surveys were completed. Given the online distribution methods, the survey was accessible to Somerville residents and non-residents. Individuals who did not live in Somerville were included in this analysis given their range of relationships with the city (e.g., business owner, service user), which are important to consider in the development and implementation of an SCS. Of Of 615 completed surveys, 557 (91%) participants were Somerville residents. The majority of participants were women (55%), 36% were men, and 6% were non-binary, transgender, or genderqueer. Participants overwhelmingly identified as white (85%), followed by Asian (4%), mixed, bi-racial, or multi-racial (3%), Black (1%), and Hispanic or Latinx (1%). The median age of participants was 37 years, with ages ranging from 16-78 years. All but two neighborhoods had participant representation. Union Square had the highest number of participants (18%) of participants, followed by Davis Square (16%), Spring Hill (13%), Winter Hill (13%), and Teele Square (7%). About one quarter of participants had lived in Somerville 5-10 years. About one quarter of participants had lived in Somerville 5-10 years. For full results of the Somerville community survey, please see Appendix 2. Table 2: Reasons for not using a SCS Results Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 24

Somerville community survey Familiarity and usefulness of SCS Approximately 86% of respondents stated that they were at least somewhat familiar with SCS, with the remainder not familiar. Survey participants were asked how helpful an SCS would be in Somerville on a scale from 1 (strongly disagree) to 10 (strongly agree). The overall average (mean) response was 8.23. Residents of Somerville gave an average agreement score of 9.53 and non-residents gave an average agreement response of 8.14. Opinions about SCS Participants Participants who ranked usefulness of a Somerville SCS between 5 and 10 were asked to describe why they thought a site would be beneficial. Participants could provide more than one reason in their responses. The top four themes that arose from participant text responses, included: connecting people to services and supports (32%, n=197); reducing overdose deaths (27%, n=167); overall public benefits (e.g., reducing drug paraphernalia litter, reduction of infection, provision of sterile supplies, 25.5%, n=158); and providing a safe place for people to use drugs (22.5%, n=139). Additional themes included, the importance of SCS as providing a space to treat addiction as a disease, addressing drug-related stigma, and the utility of SCS as being an alternative approach to addiction as a disease, addressing drug-related stigma, and the utility of SCS as being an alternative approach to addressing the overdose crisis. Additionally, participants who ranked potential usefulness of a Somerville SCS from 1-5 were asked to describe why they thought it would not be beneficial in Somerville. Participants could provide more than one reason in their responses. A total of 70 participants responded, with the main themes including: SCS would negatively impact the community (e.g., decrease property value, increase litter, increase violence and crime, 40%, n=28); SCS enable drug use (23%, n=16); SCS are not effective public health interventions (19%, n=13); and SCS would increase in the number of people who come to use drugs in the city (19%, n=13). Additionally, there was a focus on the need for expanded expanded access to treatment, recovery, and social supports for individuals before (or in lieu of) an SCS (17%, n=12). However, some participants reported that SCS were not needed in Somerville (16%, n=11) or that additional information would be needed before they could make a decision (13%, n=9). Strongly disagree 1 Strongly agree 8.23 mean response 9.53 average resident 8.14 average non-resident 10 Figure 5 - Participant agreement with the statement “How helpful a SCS would be in Somerville"” Results Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 25

Somerville community survey Respondents Respondents were asked to rank 7 potential outcomes of SCS from most to least important. The majority of respondents (78%) reported that the most important outcome of SCS is to prevent overdoses overdoses and save lives (see Figure 6). Figure 7 Figure 6 Location All All neighborhoods were represented when asked where an SCS would be most helpful. Among the neighborhoods, 45% of participants (n=276) selected East Somerville, followed by Davis Square (41%, n=252), Winter Hill (33%, n=202), Union Square (30%, n=186), and Innerbelt (27%, n=167) (see Figure 7). (27%, n=167) (see Figure 7). Among respondents (n=615), 56% of participants reported that they would have no concerns with an SCS located in their neighborhood, 19% reported that they would have concerns, and 25% were unsure. Top concerns (n=193) included: safety and impacts on crime; SCS implementation implementation considerations and protocols (e.g., supervision after use, size of the space, security); location of the SCS (i.e., business vs. residential neighborhood); increased foot traffic outside the SCS; and an increase of people who use drugs coming to Somerville. of participants reported they would have no concerns with a SCS in their neighborhood 56% Results Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 26

Somerville community survey Additional Steps While the City has undertaken a range of programming to address the overdose crisis, only 44% of participants had heard of these activities. Of these participants, 27% knew someone who had accessed these programs, but only 3% had ever accessed these programs themselves. Notably, the majority of participants (70%) were unsure how satisfied they were with the City’s approach to addressing the overdose crisis, with 13% dissatisfied and 17% satisfied. Survey Survey participants were asked what the City could do to better address the overdose crisis in Somerville. The top three themes included: removing police from the response (e.g., decriminalizing drugs, diverting police funding); increasing community awareness and engagement related to the overdose crisis, including increased transparency of City efforts; and funding treatment and prevention programs. Focus groups with people who use drugs Demographics A total of 17 participants took part in one of two focus group interviews. All but one participant was white and the majority of participants were cisgender, straight men. Participants ranged from 32-55 years of age. The majority of focus group participants were unhoused at the time of participation. The The primary themes from focus group discussions were related to social and structural factors that would impact engagement with an SCS in Somerville, and operational considerations. Importantly, participants from one focus group stressed the importance of including people who use drugs in the design and siting of an SCS to be effective. Facilitators Participants Participants noted four main factors that would increase their engagement with an SCS in Somerville. Ability to maintain discreteness within the SCS and providing wraparound services were noted as the two most important facilitators. Anonymity Anonymity Anonymity and discreteness were reiterated as key requirements to utilizing an SCS. Focus group participants stressed the need for a level of confidentiality and anonymity to be maintained for clients. However, participants also underscored the need for the SCS itself to be “discrete” to minimize stigma from the broader community. To achieve this, participants recommended that the SCS be located in a building where it could blend in with surroundings, such as a large office or multi-service building complex, and did not contain large signs denoting what the space space was on the exterior. Multiple exits were also noted as important to help maintain the anonymity of clients. Results Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 27

Focus groups with people who use drugs Facilitators Wraparound services Participants overwhelmingly agreed that the SCS should provide a range of wraparound health and social services on site, in addition to referrals. For many, having consumption being only one of many services offered would also help maintain some level of privacy for clients, in addition to meeting their co-occurring needs. Support for multiple consumption methods Support for multiple consumption methods Focus group participants expressed the need for an SCS to support both injection and inhalation methods so as to not exclude individuals. A lack of inhalation support was explicitly described as a barrier to future utilization. While some participants expressed the need for smoking rooms within the facility, others described having a private outdoor space to smoke would also be suitable. Interdisciplinary staffing model Having Having an SCS be operated by a mix of people who use drugs, health professionals, and staff at existing harm reduction services would create a more “welcoming” and “comfortable” facility. Importantly, participants wanted at least some SCS staff to be outreach workers and support staff with whom they already have relationships. Barriers Two main barriers to accessing an SCS in Somerville were identified by participants: risk of arrest and SCS location. Law enforcement The The risk of law enforcement interaction was noted as a major barrier. Focus group participants described concerns of police potentially ‘targeting’ SCS clients. Establishing legal rights to access the SCS, ensuring law enforcement did not enter the space, and providing a ‘safety zone’ (i.e. a predetermined area surrounding the SCS where individuals would not be arrested when entering or leaving the site) around the SCS was deemed critical to protect individuals using the space. Location The The siting of an SCS was also described as a potential barrier impacting the accessibility and utilization of the service. Participants described how proximity to public transportation would likely dictate engagement. Additionally, participants described how their engagement may also be shaped by the need to manage withdrawal symptoms. Results Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 28

Focus groups with people who use drugs SCS model and location When asked about how an SCS should be designed and operated, participants expressed a strong interest in a permanent, brick-and-mortar facility. In terms of siting, there was no consensus across focus groups. However, two main neighborhoods were described as potentially being ideal locations: Davis Square and Assembly Square. SCS program and service needs Focus Focus group participants expressed the need to integrate a range of services into an SCS. The ability to access services that met their health and social needs was seen as important for engagement. Participants focused on four main areas of service integration: harm reduction, health services, social services, and basic needs. Harm reduction services In In addition to the provision of sterile equipment (injection and inhalation supplies) and naloxone, participants expressed a desire to have advanced drug testing technologies (e.g., spectrometer) available within an SCS. This was seen as important for providing a better understanding of what individuals were consuming. Additionally, focus group participants expressed the need for educational workshops, including safer drug use practices, safer injection practices, and harm reduction education. Health services Health Health services were seen as an integral component of services that should be provided at an SCS and included drug treatment options. Focus group participants stressed the importance of having a range of health services accessible on-site, rather than referrals to services at other organizations. There was a preference for having a weekly clinic integrated into the site, where individuals could access a wider range of medical care. In particular, the following services were listed as important to include at the SCS: HIV and STI testing; wound care; foot care; access to medications for opioid use disorder (e.g. methadone, buprenorphine); and hepatitis C treatment. However, participants noted that methadone, buprenorphine); and hepatitis C treatment. However, participants noted that if the integration of treatment options was not possible, then it would be important for the SCS to include referrals to drug treatment and recovery supports. Social services Focus group participants denoted several social service supports that would be beneficial to include in an SCS such as: community support groups (e.g. grief group); an on-site social worker; and housing supports (e.g. housing clinic). Basic needs A range of services that meet individuals’ basic needs were expressed as key components of the SCS, including in the waiting area. These included: food provision; a nap room or quiet room; and storage and bike lockers for use while on-site. Results Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 29

Cost effectiveness analysis Previous cost-effectiveness modelling considers the costs and benefits associated with a large, urban SCS, analogous to Insite in Vancouver, Canada. Because Somerville is considerably smaller than the cities considered in previous analyses, and may therefore benefit from different models of SCSs, an explicit cost-benefit analysis was not conducted for an SCS in Somerville. However, significant reductions in costs associated with overdose and infectious disease-related care are expected to reduce costs for the city. One One recent study conducted by the Institute for Clinical and Economic Review estimated the cost-effectiveness of a single standalone SCS in Boston. This analysis found that such a facility would prevent more than 700 ambulance rides, 550 emergency department visits, and 270 hospitalizations each year, resulting in cost savings in excess of $4 million annually [81]. Somerville and Boston share many of the same drivers of overdose-related costs, such as ambulance transportation, emergency department costs, and hospitalization costs [82]. These costs are significant, as Somerville Police Department and Somerville Somerville Fire Department responded to over 100 opioid-related overdoses in each year since 2015 [7]. Further, the reduced cost of commercial space in Somerville relative to Boston would reduce the operational costs of operating an SCS. By reducing the need for overdose-related ambulance transportation, emergency department visits, and hospitalizations, SCS could significantly reduce the cost of overdose deaths borne by the health system in addition to reducing overdose risk. Analyses of existing data The Somerville police and fire departments responded to 721 overdose-related calls from 2015 to 2020. Calls were categorized as overdose-related based on information available to first responders and were not validated against medical reports. While these data do not represent the full burden of drug overdose in Somerville, they offer some indication of where overdoses occur in the city. In a memorandum to the Somerville SCS Task Force, SomerStat reported the geographic distribution of where these overdose response calls were located, aggregated to 400 square meter blocks within the city [7]. Figures 8-9 Where overdose response calls occur in Somerville: Where overdose response calls occur in Somerville: fig 8. 2015 112 opioid-related overdose calls fig 9. 2016 152 opioid-related overdose calls Results Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 30

Analyses of existing data Moreover, quality of life call data from the Somerville Police Department highlights two primary neighborhoods (Davis Square and East Somerville) where hypodermic needles were found in public in 2020 (Figure 14). These data could reflect increased public injection drug use in these neighborhoods, and thus locations in which an SCS might have a particularly positive effect on public order, health, and safety. Figure 14: Map of density of QOL cals to the Somervile Police Department for hypodermic needles found in 2020 Areas in purple represent density of quality of life calls to the Somerville Police Department for hypodermic needles found in 2020, with the darker areas signifying more calls. Results Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 32

Analyses of existing data As shown in the figure, opioid-related overdose response calls are distributed spatially throughout Somerville, demonstrating that overdose prevention is a primary public health concern for residents throughout the city. The widespread burden of overdose has remained consistent for each year from 2015 to 2020. Despite this wide geographic spread, a few neighborhoods stand out as areas with higher overdose response needs. In particular, Teele Square, Davis Square, and Winter Hill have high counts of overdose response calls. fig 10. 2017 120 opioid-related overdose calls fig 11. 2018 100 opioid-related overdose calls fig 12. 2019 112 opioid-related overdose calls fig 13. 2020 152 opioid-related overdose calls Figures 10-13: Where overdose response calls occur in Somerville: Results Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 31

Study limitations This This study has several limitations that should be considered. First, this study began during the second wave of the COVID-19 pandemic in New England, which restricted in-person data collection by the researchers due to travel restrictions, and created challenges connecting with people who use drugs due to service closures. Additionally, several previously planned components of the project had to be adapted or postponed due to COVID-19 restrictions, including an in-person community meeting to discuss this study and door-to-door canvassing. Despite these challenges, we feel that the adaptations have provided sufficient sufficient data to guide recommendations and next steps for the City of Somerville to consider and are in line with methods used in other feasibility studies conducted prior to SCS implementation elsewhere. In addition to COVID-related study limitations, there are limitations to primary data collection methods that we have highlighted below. Surveys with people who use drugs The survey conducted with people who use drugs used convenience sampling, with most participants recruited through organizations who serve this population. While the majority of participants were clients at these organizations, peer researchers at these organizations also conducted street outreach in an effort to recruit people who use drugs that were not yet connected to their service organizations. As such, people who use drugs of lower socio-economic status are likely overrepresented in this survey. Additionally, Additionally, given the lack of existing harm reduction services in Somerville, data collected with people who use drugs was conducted in neighboring towns that house syringe exchange programs and other supports for this population. While these services supported a significant population of Somerville residents, the sample surveyed for this evaluation cannot be assumed to be representative of all people who use drugs in Somerville. Moreover, Moreover, surveys were interviewer-administered which may have introduced recall bias and/or social desirability bias. There was also an underrepresentation of women and gender diverse women surveyed. As such, gender-specific considerations, concerns, and needs may not be fully reflected. We recommend that more explicit attention to gender-specific needs be prioritized in the following planning and development phases. Somerville community survey Due Due to COVID-19 restrictions, community surveys only used online distribution methods through the City and Task Force networks and were only available in a digital format. Some community members may have been outside the network of people directly and indirectly contacted to complete the survey, and some community groups may therefore be underrepresented. Of note, people with limited digital literacy or lacking access to technology may have been unable to complete the survey. While we received a total of 844 surveys, 229 of those were incomplete and therefore excluded from the analysis. This suggests that while while we aimed to create a survey that was as concise as possible, some respondents may have found the survey to be too burdensome to complete. As such, results from this survey may not be representative of all Somerville community members. Results Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 33

Study limitations Somerville community survey Additionally, we found that white people accounted for 85% of respondents, while accounting for only 68% of Somerville residents. As such, individuals from other racial and ethnic backgrounds are therefore underrepresented in the survey as compared to census data for the city of Somerville [66]. Finally, while no duplicate surveys were identified, we cannot be fully confident that respondents did not submit multiple surveys. Focus group data Focus group data Focus group recruitment was open to any individuals accessing two harm reduction and social support organizations that work with people who use drugs. As such, individuals who face significant socio-economic marginalization are likely overrepresented in this data. Further, women and gender diverse individuals were underrepresented in focus group data, and therefore important, intersectional considerations may not be included here. Focus Focus group data was collected in January 2020 by a peer researcher and was re-analyzed by the study team. While we had access to all notes and transcriptions, we were unable to collect audio recordings of the focus groups. Results Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 34

A virtual community meeting was held June 10, 2021. The meeting was publicized on the City of Somerville’s website and through an email listserv. People were encouraged to submit questions through a Google Form ahead of the meeting which was open from May 21 until the start of the community meeting on June 10. A penultimate version of this report was made available on the City of Somerville’s website June 3, 2021. The meeting lasted 1.5 hours, was hosted on Zoom, and was available live on GovTV, RCN Channel 13, Comcast Channel 22, and on the City of Somerville’s YouTube page. The event was recorded and is posted on the City’s YouTube page. The The meeting consisted of a panel of researchers, outreach workers, and a City Council representative, including Drs. Alexandra Collins and Brandon Marshall, Tj Thompson, Stephen Kelley, Rachel Bolton, and Councilor Matthew McLaughlin who is the City Council President. The meeting was co-hosted by Mayor Joseph Curtatone and Doug Kress, the Director of Health and Human Services, with questions moderated by Meghann Ackerman, the Deputy Director of Communications at the City of Somerville. Following Following welcoming remarks from the Mayor and the City Council President, the panelists introduced themselves, and Drs. Collins and Marshall gave a brief presentation of the report with key findings and recommendations. This was followed by a moderated Q&A period. Questions addressed included topics related to: - Existing harm reduction services available in Somerville and how an SCS fits into harm reduction strategies - Outreach and connections to potential clients - Legislative outcomes and its impact on the implementation of an SCS - Legislative outcomes and its impact on the implementation of an SCS - Operational logistics of an SCS (e.g. funding for the site, operating agency, type of medical personnel present, location, number of sites) - Community impact (e.g. impact on businesses, increase in individuals coming to Somerville), outreach, and involvement - Limitations of the research in Somerville (e.g. lack of diversity of survey respondents) and on SCS (e.g. research from large cities) Due Due to time constraints, not all questions were answered during the virtual Community Meeting. Remaining questions have been compiled and answered in a supplementary document which is posted on the City’s website alongside this report. The City of Somerville and the Somerville SCS Task Force have scheduled three Community Listening and Dialogue events in July to cover additional perspectives related to the implementation of an SCS in the city, including people who use drugs and harm reduction specialists, families and the broader community, and businesses and neighbors. Community Meeting Overview Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 35

Geographic location Findings from our feasibility study support the need for at least one (but preferably two) integrated SCS that includes a range of health and social service supports to be established in Somerville. Survey data from both Somerville residents and people who use drugs point to the prioritized need to address fatal overdose risk through an SCS approach (78% and 94%, respectively). Our Our recommendation for an integrated SCS is further driven by the fact that just over half of participants surveyed who use drugs have experienced at least one overdose in the prior year, and 30% use drugs alone all or most of the time, which increases risk of fatal overdose [13]. Additionally, 65% of participants reported typically using drugs outdoors, underscoring the need for a safer environmental intervention. Importantly, 51% reported that they would use an SCS most or all of the time they use if available. These data represent a significant need for an SCS to reduce risk of fatal overdose amongst participants. In In what follows, we provide our specific recommendations regarding the location, operational model, policies, and services that would best meet the needs of potential clients. While our recommendations are driven by the assessment’s findings, we underscore the need for procedures and implementation considerations to be guided by the specific needs of clients. Therefore, we suggest the following as a starting point, but stress the importance of reshaping policies and procedures to better address clients’ needs if required. We recommend that at least one fixed, integrated SCS be located in Davis Square or East Somerville (see Figures 15 & 16), but that the City consider implementing an integrated SCS with broad wraparound services in both locations. These locations are not only reflective of the neighborhoods where an SCS would be most beneficial based on the surveys, but are also responsive to the areas that experience a significant amount of overdose-related EMS runs (see Figures 8-13 above) and quality of life calls to the Somerville Police Department for hypodermic needles found in public (denoted in purple on Figures 15 & 16). 16). Davis Square and East Somerville are also locations where street-based outreach was regularly conducted by ACCESS, further outlining the need for expanded supports in these neighbourhoods. In addition, these areas are generally accessible on the MBTA subway, a critical need reported by people who use drugs. While Winter Hill has also seen a significant rate of EMS-related overdose runs in recent years, it is further from rapid transit, which was noted as an important factor in locating an SCS by people who use drugs within focus groups. As such, we feel that an East Somerville location could support the need in Winter Hill as well. Overall, 56% of Somerville resident survey participants reported that East Somerville would be best suited for an SCS, followed by 51% for Davis Square. Within these two neighborhoods, approximately 53% of East Somerville residents (n=34) agreed that an SCS would be helpful in their neighborhood, and 44% of Davis Square residents (n=85) supported an SCS in their neighborhood. However, we also want to note that while Union Square was not one of the top three recommended locations for an SCS, it was tied with Davis Square for having the most in-neighborhood support (n=37). Recommendations Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 36

Geographic location This This map highlights streets that are within 20 minutes from a potential SCS location in East Somerville by foot, public transit, or a combination. combination. Areas in purple represent density of quality of life calls to the Somerville Police Department for hypodermic needles found in 2020, with the the darker areas signifying more calls. Figure 16: East Somerville-based integrated SCS Figure 15: Davis Square-based integrated SCS This map highlights streets that are within 20 minutes from a potential SCS location in Davis Square by foot, public transit, or a combination. Areas Areas in purple represent density of quality of life calls to the Somerville Police Department for hypodermic needles found in 2020, with the darker areas signifying more calls. Recommendations Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 37

Design and operational model Overall, participants who use drugs reported preferring an SCS be included within a harm reduction center (e.g., syringe service program) or in a freestanding location. Given the lack of existing harm reduction services in Somerville, we recommend an integrated SCS be established as a freestanding location that provides a range of health and social services to clients. SCSs typically have three main components: a reception area, a dedicated consumption area, and a communal, post-consumption observation area. We recommend that in addition to these spaces, a Somerville SCS also have a dedicated drop-in space where individuals can access health and social service supports, harm reduction supplies supplies (e.g. condoms, syringes, alcohol swabs), and other necessary resources (e.g. food, harm reduction education). However, discreteness of an SCS was a key priority among focus group participants so as to minimize stigma from the broader community. To increase discreteness and to maximize accessibility of the site, including for individuals facing a range of structural vulnerabilities (e.g., housing instability, food insecurity) but who may not use drugs, we recommend that the SCS be designed to have multiple entrances, including one specific to access consumption services and one for the drop-in resource area. This will likely increase reach of the service and address clients’ concerns of community-based stigma. Additional recommendations for confidentiality are included in the policy and procedures section. Additional recommendations for confidentiality are included in the policy and procedures section. Importantly, we recommend that the SCS be designed to support inhalation, in addition to other methods of consumption (e.g. snorting, injection, ingestion), given that 79% of participants reported using this method of consumption used in the 30 days prior to being surveyed. We therefore strongly recommend that the SCS be inclusive of individuals whose preferred method is inhalation, as well as those who consume through other methods of use (e.g. injecting, snorting, swallowing), so as to increase the reach and accessibility of the site. Consumption room design To meet the diverse needs of clients, we recommend that the consumption room be dynamic in design, including both private booths/private smoking stalls and more communal tables for use based on comfort and preference. More than half of survey participants who use drugs (52%) expressed a desire to have a range of options that allowed them to be more or less social if accessing the injection area, and 59% expressed having this flexibility when accessing inhalation services in the space. For For smoking stalls, we recommend that these be located indoors with specialized ventilation so as to increase accessibility during the winter months. Post-consumption observation room design We We recommend that a post-consumption observation room be developed where clients can be further monitored in case of a medical emergency. While the specific design considerations were not captured in this evaluation, we recommend that this area be designed in collaboration with potential clients and informed by existing post-consumption observation spaces elsewhere. However, we do recommend that this area provides clients with access to food, beverages, and peer support, among other services. Recommendations Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 38

Design and operational model Staffing recommendations We We recommend that the SCS include a range of staff who can support clients on their clinical, mental health, and social needs, including nurses or healthcare professionals, counsellors, and peer support workers. However, we suggest that efforts be undertaken to include harm reduction and social service workers with whom people who use drugs in the community have existing relationships and trust. This is likely to improve engagement and facilitate uptake among individuals. We would also encourage the planners of a Somerville SCS to consider factors such as staff-to-client ratios to inform their staffing decisions. Survey Survey and focus group participants who use drugs overwhelmingly felt that people who use drugs (or peers) should be meaningfully included in the design and operation of the SCS. As such, we recommend that people who use drugs are included across all phases of design, implementation, and operation of the site. While no one space of an SCS was noted as being preferred for peer involvement, participants who use drugs did express interest in having peers involved in greeting and registering clients, supporting clients in the waiting area, monitoring the consumption room, and in providing support in the post-consumption room. Hours of operation Hours of operation While there was some variation in preferred hours of operation among people who use drugs, we recommend that the consumption area of an SCS be accessible 24 hours a day and the drop-in service area operate on more traditional ‘business’ hours, ranging from 8am - 6pm. Approximately 30% of participants who use drugs reported wanting an SCS open around-the-clock. As such, having access to the consumption area around-the-clock may increase engagement as it can meet the ongoing needs of individuals. However, However, we recognize the logistical and staffing challenges of operating an SCS 24 hours a day. If around-the-clock access is prohibited by these limitations, then we recommend that the operational hours be responsive to clients’ needs (e.g., 8am - 5pm and 8pm - 1am) and consider extended hours of operation during spikes in overdose events as revealed by overdose surveillance data. It It is important to note that women and gender diverse persons who use drugs were underrepresented in survey data. As such, gender-specific considerations for SCS operations may not be fully reflected. However, we recommend that the SCS is designed to be attentive to the diverse needs of individuals based on their gender, sexuality, and culture, as well as other intersecting social locations (e.g., ability). For example, women and gender diverse-only hours may increase accessibility for women and address safety concerns. We suggest that these needs be further explored in the SCS development phase. Please see Appendix 3 for more details on potential design and operational considerations. Recommendations Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 39

Policies and procedures Accessing the SCS Confidentiality Confidentiality was reiterated across participants who use drugs as an important factor in shaping their engagement with an SCS. Program policies and procedures must ensure the privacy of clients accessing the service and this must be transparent to clients. We recommend that clients need not provide their legal name, but can use an alias. Further, government issued IDs should not be required for accessing the space; this is often prohibitive for many individuals and may undermine the accessibility of an SCS. Rather, we recommend that no ID be required for use, with clients registering on their first visit and being provided a client ID number to use on subsequent visits. While While we recognize the community concerns related to a potential influx of people who use drugs in Somerville, we recommend that the SCS be open to anyone who uses drugs, including individuals who do not live in Somerville. This will be imperative for supporting clients in nearby areas (e.g., Cambridge). Data has demonstrated that individuals often do not travel more than one mile to access an SCS [14]. As such, eliminating the need for Somerville residency will likely have no adverse impact on the Somerville community. Police involvement Notably, Notably, concerns about police presence around the site was a primary driver for not wanting to use an SCS by participants who use drugs (see Appendix 1). Given these dynamics, it is imperative that the implementation and operation of a SCS involve transparent communication between the site and law enforcement so as to alleviate concerns among clients. Importantly, we recommend that the SCS and the police department develop a memorandum of understanding, in which participants going to, or leaving, the SCS will not be stopped or arrested. A large body of research documents the negative impact of drug enforcement and policing activities (e.g. confiscation of drug paraphernalia, intensive surveillance) on the health and wellbeing of people who use drugs [83–88]. Research has also demonstrated how police presence and surveillance in areas surrounding SCSs act as a barrier to uptake, undermining programs aimed at providing public health services to these populations [89–91]. As such, we recommend that mechanisms for ongoing dialogue between the City, the SCS operating organization, and the police be established as soon as possible. This will will be critical to developing cooperative relationships between these entities, which will be integral to the success of an SCS. Specifically, we recommend that police liaisons be established, as these have been shown to be effective in other locations [89,92]. Within these relationships, dedicated officers would act as liaisons with the SCS to provide ongoing communication and dialogue to address challenges that may arise, as well as processes for resolving disputes. Recommendations Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 40

Policies and procedures Police involvement We We also recommend that a boundary agreement be developed between the police and the SCS. Under this agreement, we recommend that procedures and protocols be developed to establish a “safe zone” around the SCS in which police do not arrest or target individuals who are engaging in public drug use [92]. Rather, procedures could be developed to direct a person injecting drugs within the vicinity of an SCS (e.g., four block radius) to access the SCS instead so as to avoid future contact with the police. While the specifics of a “safe zone” should be developed between the police and the SCS, having a clear and consistently adhered to boundary is critical for building trust and security for clients. consistently adhered to boundary is critical for building trust and security for clients. Post-consumption observation and monitoring Data from the Somerville community survey pointed to concerns regarding procedures following use in the SCS, including an increase in public intoxication and transportation concerns (e.g., driving under the influence). We therefore recommend that clear policies be developed regarding the length of time that clients should stay in the post-consumption observation area for monitoring in the event of an emergency. We also suggest that the recommended observation time be evaluated post-implementation and altered as needed. Service and program recommendations Notably, 88% of participants who use drugs were unstably housed at the time of their survey, underscoring the need for an SCS to include supports that address clients’ basic needs (e.g., food, bathrooms), in addition to their health and social needs. The The data overwhelmingly underscores the need for wraparound health and social services to be provided at the SCS in addition to consumption services. Specifically, access to a range of contraception, HIV, HCV, and STI testing, and assistance with housing and social assistance onsite were the top three most important services noted by participants, followed by access to sterile injection equipment, bathrooms, food services, and a post-consumption room. This highlights that while overdose prevention and response is the leading reason for utilizing utilizing an SCS, this public health intervention can be a critical space to support clients in meeting other health and basic needs. In addition to basic health and medical services (e.g., STI testing, wound care), we recommend that medications for the treatment of opioid use disorder be accessible in the SCS drop-in area. Approximately 60% of participants who use drugs reported that being able to initiate treatment services on-site was very acceptable. This integration would also help solidify the SCS as part of the continuum of care for people who use drugs. We also recommend that the SCS provide the following services and programs: Harm reduction supply access (e.g. condoms, pipes, syringes, alcohol swabs) Naloxone training and distribution Naloxone training and distribution Harm reduction education Drug testing technologies (e.g. fentanyl testing strips, mass spectrometry) Social service supports, including housing (e.g. housing referrals, support with applications), social support with applications), social assistance and disability (e.g. application support) supports, and employment programs Basic food provision Mental health support services onsite; and Peer-led support groups groups Recommendations Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 41

Legal Recommendations To ensure the success of an SCS in Somerville, we recommend that the City work alongside the Middlesex County District Attorney’s office to ensure that no individuals who might be arrested in conjunction with an SCS are prosecuted. We also recommend that the City work with probation and parole offices to ensure that individuals on probation or parole are not penalized for accessing the SCS. The City should also ensure that judges and staff of the Middlesex County Superior Court understand the benefits of the SCS and the importance of not discouraging justice-involved individuals from accessing it. Additional Additional recommendations have been provided by the SCS Task Force legislative and legal sub-committee (see below) and are also described in the Next Steps section at the end of this document. Recommendations Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 42

Task Force Recommendations Legislative and legal sub-committee The Legislative and Legal sub-committee recommends that a Somerville-based SCS offers referral and wraparound services, and includes a staffing model inclusive of peers, health navigators, and at least one medical professional when consumption services are being offered. Key areas of focus included: property ownership and authorization; collaboration with local, state, and federal entities; and ongoing evaluation. Specifically, the sub-committee recommends: 1) 1) The SCS is operated on City-owned property if state authorization for an SCS is not provided and/or private landowners are not protected from civil forfeiture under the Commonwealth’s authorizing legislation; 2) The SCS is authorized by the City of Somerville through its Board of Health if state authorization for an SCS is not provided. However, if SCS are sanctioned at the state-level, we recommend that no local authorization be required; 3) 3) There is outreach to local law enforcement officials to ensure that the operation of the SCS is not impeded by arrests or other law enforcement action, and that law enforcement direct individuals who use drugs to the SCS; and 4) The City maintains ongoing discussion with state and federal officials related to its City-level authorization and support of an SCS in the event that statewide legislation does not pass. Program development sub-committee The The Program Development sub-committee recommends that any SCS be developed with careful attention paid to three key areas: safety, inclusivity, and integration. There are six basic components they suggest be included in the SCS: 1) A welcoming reception area; 2) Two supervised consumption areas: one for injections and a well-ventilated smoking area; 3) Drug-checking mechanisms available for people regardless of on-site consumption 4) Private clinical spaces; 5) 5) Two post-consumption areas: a de-stimulating space for after stimulant consumption, and an observation area for use after consuming opioids; and 6) A common area where participants can receive support from support staff including social workers, clinicians, and peer support workers. Please see Appendix 3 for the sub-committee’s preliminary draft operational guidance document developed for the SCS. Recommendations Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 43

Development of advisory and oversight committees. We recommend that the City convene a community advisory committee to oversee the subsequent phases of this initiative. The community advisory committee should be composed of diverse stakeholder groups, including people who use drugs, health and social service providers, residents, business owners, and police. This committee should be responsible for overseeing community engagement processes and developing mechanisms to address community concerns as they arise. We also recommend that the community advisory committee develop procedures for maintaining transparency of the planning process within the larger community. All plans, procedures, and documents should be available to the public. procedures, and documents should be available to the public. Determine the organization(s) that will implement and operate the SCS. A transparent process determining which service provider(s) will operate the SCS should be established. The SCS should be part of a comprehensive strategy to address the overdose crisis and should therefore be integrated into a continuum of services and supports for people who use drugs. We therefore recommend that organizations considered should ideally have existing relationships with potential clients, which will be important for client uptake. Establish ongoing dialogue between the operating organization, the City of Somerville, and the police department. Engaging police in discussions about opening an SCS in Somerville is a necessary step and should be established early in the process. Protocols should be developed and implemented that clarify the role of the police in relation to the SCS. This dialogue should be transparent and ongoing, with decisions made available to the public. We recommend that these policies and procedures include determinations on how the community will be policed (e.g., developing “safe zones” around the site), mechanisms mechanisms for diversion, plans outlining procedures for addressing potential emergencies within the SCS and outside the SCS, conflict resolution steps in the event a procedure is not adhered to, and other elements that will be necessary for successful implementation. SCS site selection. A transparent site selection process should be undertaken to identify potential locations for an integrated SCS in Somerville. This process should include a range of stakeholders, including people who use drugs, to ensure the appropriateness of the space. Once potential locations are identified, we recommend that the City engage in targeted canvassing and community outreach to businesses and residents in the immediate vicinity to garner support and answer any questions or concerns. This support will be critical for a successful implementation. Implementation Implementation and evaluation plans should be developed. Ongoing evaluation should be undertaken throughout the design and implementation process, as well as following implementation to ensure that the services offered are relevant and responsive to the needs of clients. This evaluation will also be important for measuring community impacts. The implementation and evaluation plans should be developed by the agency that will operate the SCS, with input from other stakeholders (e.g., service providers, people who use drugs), and be led by a group with expertise in conducting mixed-methods research with people who use drugs. We recommend that evaluations primarily measure client-centered outcomes. outcomes. For example, it will be important to capture data on factors such as ease of access, operational facilitators/barriers of use, and whether programs are meeting clients’ needs, in addition to neighborhood-level impacts. Focusing evaluations on health and social factors related to people who use the site will be imperative to allow for program modifications to better meet the needs of those individuals. Next steps Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 44

Community education and communication strategy. A comprehensive approach to community engagement should be designed and implemented to ensure Somerville community members are well-informed about the need for a SCS in Somerville, the benefits of these services, and the SCS operational protocols and procedures. Improved communication between the City and the community was highlighted as a key theme in the community survey. These strategies should also explicitly provide information that addresses community concerns of public safety. The community engagement strategy should be an ongoing endeavor targeting potential clients, local residents and business, service providers, elected elected officials, police, and the broader public. These efforts will be critical to increase broader community support for a SCS, which is imperative for a successful integration. Develop a legal strategy. We recommend that the City consider developing memoranda of understanding with the SCS operating agency related to City-level support that could be provided if requested by the SCS (e.g. city-funded medical equipment and biohazard waste disposal). We also recommend that the City seek pathways that allow the SCS to operate under the City’s liability insurance. Additional administrative and logistical systems that aid in the SCS operations should be developed alongside the SCS operating agency. Importantly, Importantly, we recommend that the City of Somerville work with their legal department to develop an alternative approach to implementing an SCS in the event that state legislation on SCS (H.2088) is not passed. Specifically, we recommend that the City works with its legal team to consider establishing a system for authorization for SCS operation through the Department of Health and Human Services and/or Board of Health. As part of this plan, we also recommend that the City work with their legal team to take steps that ensure the protection of staff and clients of an SCS from police action and potential civil and/or disciplinary issues in the absence of state authorization. Identify Identify sustainable lines of funding. Prior to opening an SCS, we recommend that the City and operating agency identify sustainable lines of funding to support an integrated SCS and the range of services provided. Additional funding sources should be identified to operate a mobile SCS as well. We recommend that the City seek out a range of financial support through granting mechanisms, private donors, and City resources. Next steps Somerville Supervised Consumption Site // Needs Assessment and Feasibility Report 45

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49 46 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. 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.

50 46 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. 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.

51 46 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 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

52 46 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 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.

53 46 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.

54 46 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%

55 46 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

56 46 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%.

57 46 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

58 46 Already have access to sterile supplies nr nr 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

59 46 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 nr 5 nr nr 14% nr

60 46 Open plan outside under roof Combination of above Other Unsure/prefer not to answer nr 22 nr 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

61 46 Required to show government ID (47) 11% nr nr 40% 36% 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%

62 46 Food (including takeaway) (47) 70% 23% nr nr Social workers or counsellors (46) 59% 35% nr nr Peer support (47) 60% 32% nr nr 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

63 46 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

64 46 *Participants could select more than one answer. As such, the total proportion for these questions can exceed 100%. 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.

65 46 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)

66 46 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)

67 46 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%)

68 46 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.

69 46 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)

70 46 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.

71 46 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 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).

72 46 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. 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

73 46 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 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;

74 46 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. 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

75 46 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. 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

76 46 • Shower, laundry • Lockers, postal addresses • Overnight shelter and other low-threshold housing • Support recovery housing 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.

77 46 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 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.

78 46 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])

79 46 No 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

80 46 14. [If Q13=inject] Do you ever need help injecting? Yes No 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%)

81 46 Sometimes (26-74%) Occasionally (<25%) Don’t know, unsure, prefer not to answer 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

82 46 Safety from being seen and/or arrested by police Safety from crime or violence 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

83 46 Have to register each time you use the site 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

84 46 Dedicated site hours for women to use Dedicated site hours for 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

85 46 (condoms, birth control, etc.) Referrals to drug treatment (methadone, 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

86 46 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 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

87 46 Reduce HIV and hepatitis C transmission due to syringe sharing Reduce burden on emergency rooms, police, fire, and EMS by reducing overdose-related calls 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

88 46 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 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

89 46 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 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]

90 46 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 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