Why housing-based overdose prevention sites needs to be adaptable to people who smoke drugs

What is it about?

Housing-based overdose prevention sites (HOPS) are designated spaces within low-barrier housing facilities where residents can use drugs under supervision, with staff able to respond to overdoses. In British Columbia, where 83% of drug deaths now occur indoors and 71% involve smoking rather than injecting, HOPS have become a key part of the provincial harm reduction response. This rapid-ethnographic study, conducted over six weeks at a non-profit housing and emergency shelter facility in Vancouver, used over 200 hours of observation, three focus groups, 20 informal resident interviews and 10 staff interviews to examine how residents and staff experience a HOPS in practice. The central finding is that the facility's HOPS is significantly underused because it does not offer inhalation services, creating a structural mismatch between the service and the actual consumption practices of the people it is meant to serve. As a result, residents who smoke continue to use drugs in unsupervised areas inside the building and nearby outside, increasing overdose risk for themselves and creating challenges for staff trying to monitor the building.

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Why is it important?

Canada has recorded over 47,000 apparent opioid toxicity deaths since 2016, and the drug supply and consumption patterns that drive those deaths have shifted substantially. Fentanyl now dominates, and smoking has overtaken injection as the primary route of consumption in BC. HOPS were largely designed in an era when injection was the main concern, and this study provides direct qualitative evidence that the failure to adapt these services to include inhalation provision is actively undermining their purpose and leaving people who smoke drugs without safe, supervised consumption options in their own homes. The findings make a compelling, evidence-based case for urgent redesign of housing-based harm reduction services to reflect current drug use patterns, and carry direct relevance for any jurisdiction planning or operating HOPS, including the UK and Ireland where housing-based overdose prevention models are under consideration.