so what

In this study, we investigated the influence of a local overdose prevention site on the day-to-day lives of site users. The photo-narrative research method employed gave participants an opportunity to become the photographers and narrators of their own stories that represent a point in time in their lives.

The photos they took reveal their suffering, their hopes, and their humanity. They also show that many of them are artistic and creative individuals. The participants were able to capture imaginative and thought-provoking photos that identified self-reflection on how the site influenced their lives. Accessing the services at the site allowed participants to derive a degree of safety. 

Our research found that the site enhanced participants’ physical safety through access to a safe space supporting harm reduction practices, such as clean facilities, new injection equipment, access to naloxone and access to harm reduction staff and health professionals. In addition to the physical safety offered at the site, participants clearly conveyed “feeling safe” at the site.

Participants poignantly told us that the site offered a stigma-free environment of acceptance, connection and belonging. The care participants received at the site was in direct contrast to their experiences of stigmatization, marginalization, violence, and the unpredictability that they endured elsewhere in the community.

Our research has contributed new understandings in two core areas; caring relationships as an intervention in and of themselves and the important roles for overdose prevention sites that extend beyond disease and overdose prevention.

Caring Relationships


Our research contributes to an enhanced understanding of how caring relationships with staff at the overdose prevention site impacted site users’ sense of self.
It is our assertion that caring relationships are an intervention in and of themselves, and that these relationships contribute to transformation that extends far beyond the public health outcomes of disease reduction. Prior to using the site, many participants felt that no one cared for or about them and they similarly did not care for themselves.

Participants knowingly engaged in risky substance use practices without consideration of the consequences. However, when participants perceived the site staff to be accepting and compassionate towards them, they started to feel valued, and their perception of themselves improved.

Over time, participants began to take steps towards a healthier future, a process that is often marked by incremental gains. The caring relationships at the site are thus a starting point for significant social changes.

Beyond disease and overdose prevention

The site is what we’re talking about, it’s about what saved my life basically …
They help me want to go in the right direction. That’s why the train tracks are there. So recently, and most of the time I’m here, it’s like positive energy you know. It makes you want to be better and go in the right direction, and just recently I chose, I want to go to rehab.

– Participant #23

Generating and Supporting Stability

The consistent care and compassion that the participants received at the site brought calm and stability to their lives, even if it was just for a brief period of time. The stability that the site offered created opportunities for healthier substance use practices and healthier or new relationships.

The ongoing connection with the site, combined with the caring relationships found there, supported a shift away from chaos and risk. The stories and photos shared by participants show how some participants have started to think about their future from a place of stability.

That showed me responsibility when I had to go to pick up dirty needles. . It’s a responsibility to show me some work ethic to … All my life it depends on doing drugs, doing drugs, doing drugs. At least I got to go out with some people and get to talk, we got to work and do something positive and do something that’s going to help the community because my goal, if I ever do become sober, I want to give back to the place I came from, to the people that helped me.

– Participant #20

Empowering Engagement in Community

As participants started caring for themselves, that caring extended to the communities in which they live. Our findings suggest that harm-reducing practices extended well beyond the doors of the site. Site users spoke of reversing overdoses in the community, encouraging proper disposal of used gear, and giving back to the site by participating in the needle recovery program.

Overdose prevention sites are in a unique position to engage people who use substances as allies in health promotion and may become a starting point for civic engagement.

Systematic Challenges

These findings highlight the transformational impact that overdose prevention sites can have on the lives of site users. That said, the micro-environment that exists within this site needs to extend beyond its walls for true transformative change to take place in the lives of site users.

Caring relationships with staff served to increase stability in the lives of site users and enhanced their relationships with their peers and beyond. However, when site users reentered the community, they were again confronted with oppressive systemic issues that continue to place blame and shame on them and create barriers to achieving the determinants of health.

For some, the marginalization and stigmatization they experienced outside of the site will remain a constant barrier to achieving stability in their lives. It is our hope that sharing their photos will encourage us all to contemplate the context of their lives and offer compassion and acceptance.

This just symbolized society and how they look in on the individuals and making assumptions and they may see something. This is a weed right … and that’s the way they look at us. We look at weeds as an annoyance, a nuisance, it’s ugly, but when it blooms it’s actually, when you actually really look at it, it’s not all that
bad, it looks good.

– Participant #27


While the site was established as a public health intervention to reduce harms caused by substance use, according to the participants, it has functioned as much more than this. In addition to the physical safety the site provided, the site helped participants feel safe because of the way service was delivered.

Through caring, supportive, and non-judgmental relationships, participants described a sense of connection and belonging. The caring relationships developed with staff helped participants feel valued. It is from this place of being valued that participants encountered what we have labeled as “unexpected transformations”.

For communities who are contemplating the introduction of an overdose prevention site, we provide the evidence of site users’ experiences of caring relationships, increased stability and community engagement as important considerations for a better future; not only for the site users, but also the community at large.



Michelle Sangster Bouck, MA
Middlesex-London Health Unit,

Abe Oudshoorn, RN, PhD
Western University,

Melissa McCann, MSW
Middlesex-London Health Unit

Shamiram Zendo, PhD
Western University

Helene Berman, RN, PhD
Distinguished University Professor Emerita, Western University
Academic Director, Centre for Research on Health Equity and Social Inclusion

Jordan Banninga, MSc
Middlesex-London Health Unit

Marlene Janzen Le Ber, PhD
Brescia Excellence in Research Professor, Chair School of Leadership & Social Change, Brescia University College

Zayya Zendo, BSc
Western University


Centre for Research on Health Equity and Social Inclusion (CRHESI) –

Middlesex London Health Unit (MLHU) –


Funding for this evaluation was provided by MLHU.

Additional in-kind contributions from both MLHU and CRHESI

Study Site
The site for this research was Ontario’s first legally sanctioned temporary overdose prevention site (TOPS) in London, Ontario. TOPS opened its doors in February 2018.
The site has since transitioned to a consumption and treatment services program, now named Carepoint.

“The report authors are deeply grateful to the staff and clients of TOPS for
sharing their time and opening their space to us for this research.”