Rationale for evaluating North America's first medically supervised safer-injecting facility

doi:10.1016/S1473-3099(04)01006-0

The Lancet Infectious Diseases

Volume 4, Issue 5, May 2004, Pages 301-306

https://doi.org/10.1016/S1473-3099(04)01006-0 Get rights and content

Summary

Many cities throughout the world are experiencing ongoing infectious disease and overdose epidemics among illicit injection drug users (IDUs). In particular, HIV and hepatitis C virus (HCV) have become endemic in many settings and bacterial infections, such as endocarditis, have become extremely common among this population. In an effort to reduce these public health concerns, in September 2003, Vancouver, Canada, opened a pilot medically supervised safer-injecting facility (SIF), where IDUs can inject pre-obtained illicit drugs under the supervision of medical staff. Before and since the facility's opening, there has been a substantial misunderstanding about the rationale for evaluating SIF as a public-health strategy. This article outlines the evidence and rationale in support of the Canadian initiative. This rationale involves limitations in conventionally applied drug-control efforts, and gaps in current public-health policies in controlling the spread of infectious diseases, and the incidence of overdose among IDUs.

Section snippets

Safer-injecting facilities

SIFs typically have several primary objectives including: the reduction of public drug use, fatal and non-fatal overdose, and infectious disease risk; improving contact between a highly marginalised “at-risk” population and the health-care system; and enhancing recruitment into medical care and addiction treatment.9, 10, 22 Within SIFs, IDUs are provided with sterile injecting equipment, medical attention in the event of an overdose, as well as access to or referral to primary health care and

Problems with conventional North American drug strategies

In public-health circles, it is well recognised that conventional enforcement-based drug-control strategies have not been sufficient to reduce the spread of infectious diseases, the incidence of overdoses, and the prevalence of other community harms of injection drug use.29, 30, 31 The limitations and problems stemming from conventional North American drug strategies provide the first rationale to support SIF evaluations.

Limitations of conventional public-health strategies for injection drug use

Along with the problems stemming from the over-reliance on criminal justice-based interventions, the limitations of conventional public-health strategies for IDUs are also increasingly being recognised. The limitations of conventional public health strategies provide the second rationale to support SIF evaluations.

Uptake of primary health care and addiction treatment services

Finally, although previous studies have demonstrated that services for IDUs, such as syringe exchange, may have substantial potential to engage IDUs and refer them to ancillary services such as drug treatment,65, 66 other reports have suggested that contact with exchange clients is often fleeting in nature and offers only limited opportunity to engage IDUs and offer them additional services.¹⁰ With regards to infectious disease treatment, we have recently demonstrated high rates of death among

The Vancouver SIF evaluation

In light of the lack of existing quantitative data addressing the efficacy of SIFs, the existence of ethical concerns,⁶⁸ and an awareness that a non-randomised study may be vulnerable to substantial selection biases,⁶⁹ the Vancouver SIF evaluation is structured around a prospective cohort design. In brief, the study involves random recruitment from within the SIF, and prospective serial measures of risk behaviour and venous blood samples to assess HCV and HIV incidence. Due to concerns around

Conclusion

A pilot study of a SIF in Canada will provide an opportunity to evaluate the efficacy of SIFs to address ongoing public-health and community harms resulting from illicit injection drug use, including their potential for infectious disease prevention. A rigorous review of the literature suggests that these harms stem from the limitations and problems relating to the over-reliance on conventional enforcement-based drug strategies including: the failure of supply reduction,³³ unsustainable levels

Search strategy and selection criteria

PubMed databases were searched for published reports on the health impacts of illicit injection drug use and/or supervised injecting facilities (under their various names: “consumption rooms”, “alley rooms”, etc,) with no language or date specified, and by examining references from relevant articles. In addition, key abstracts presented at international meetings were reviewed as long as the findings provided novel insights into issues not covered in peer-reviewed papers. Articles and

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Cited by (90)

Between zero risk and harm reduction: An ethnography of Montreal supervised injection services as a public policy instrument
2022, International Journal of Drug Policy
While much has been written about the positive individual and collective effects of Supervised injection services (SIS), notably on health and drug-related harm, little research focuses on their operational context and constraints. Building on Lascoumes and Le Gales's “public policy instrument and instrumentation” framework (2007), this article analyzes the implementation of Montreal SIS and discusses how the organizational aspects of SIS produce the contexts for drug injection.
Using an ethnographic approach, this article draws on three types of data: 10 months of participant observation in a SIS (700 h); 19 semi-structured interviews with staff members (social workers, peers, heads of staff, management); and analysis of organizational documents (protocols, staff notebooks).
First, this article examines how political context and advocacy coalitions produced Montreal SIS as a public policy instrument, affecting both the philosophy and the implementation of the service. It shows that Montreal SIS were developed under a health care network blueprint rather than a community organization harm reduction framework. Then, it analyzes how SIS as a policy instrument defines what constitutes appropriate injection practices, trying to supervise injection as an individual and technical act, rather than a broader social practice composed of pleasure, rituals, routines, and group dynamics.
Montreal SIS were conceptualized under a “health banner” and through alliances between regional public health administration and local well-known community organizations. They were then developed mostly under a health care administration blueprint, although operated at a ground-level by local community organizations. It created tensions between the logics of “zero risk” and “harm reduction”, and ambiguity about how injection should be supervised and what parts of drug use could be managed.
Factors associated with injury and blood-borne infection risk when providing assisted injection among people who inject drugs
2021, International Journal of Drug Policy
Prior research has associated assisted injection with risk behaviors, but other risks such as injury, missed veins, and incidental exposures to blood-borne infections during an injection episode have not been assessed. In the following, we present the frequency of these other risks and determine factors associated with missing a vein and incidental blood exposure among people who inject drugs (PWID).
We conducted a cross-sectional analysis of data from PWID who were recruited using targeted sampling in Los Angeles and San Francisco, California, during 2016 and 2017. The analytic sample consist of 336 participants who reported providing injection assistance in the last 6 months. Multivariate logistic regression models were developed for reporting the following risks: missing a vein; getting the recipient's blood on the injection provider; and getting blood on clothes or surfaces.
In the last 6 months, the most common negative consequences were getting blood on clothes or surfaces (40%), getting the recipient's blood on the injection provider (23%), and missing a vein (17%). In multivariate logistic regression analysis, missing the vein was significantly associated with higher odds of assisting a leg injection while getting the injection recipient's blood on the provider or getting blood on clothes or nearby surfaces was associated with higher odds of assisting a groin injection injecting in the groin.
Providing injection assistance can result in incidental blood exposures and injury, particularly when injecting in sensitive locations on the body. Harm reduction interventions to reduce risks associated with this practice are essential to improving the well-being of PWID.
The prevalence of non-fatal overdose among people who inject drugs: A multi-stage systematic review and meta-analysis
2019, International Journal of Drug Policy
People who inject drugs (PWID) are at an elevated risk of fatal overdose in the first year after experiencing a non-fatal event. Such non-fatal events may also result in overdose-related sequelae, ranging from physical injury to paralysis. Given variation in drug markets and treatment availability across countries and regions, we may see similar variations in non-fatal overdose prevalence. Monitoring non-fatal overdose prevalence among PWID is essential for informing treatment intervention efforts, and thus our review aims to estimate the global, regional, and national prevalence of non-fatal overdose, and determine characteristics associated with experiencing such an event.
We conducted a systematic review and meta-analyses to estimate country, regional, and global estimates of recent and lifetime non-fatal overdose prevalence among PWID. Using meta-regression analyses we also determined associations between sample characteristics and non-fatal overdose prevalence.
An estimated 3.2 (1.8–5.2) million PWID have experienced at least one overdose in the previous year. Among PWID, 20.5% (15.0–26.1%) and 41.5% (34.6–48.4%) had experienced a non-fatal event in the previous 12 months and lifetime respectively. Frequent injecting was strongly associated with PWID reporting recent and lifetime non-fatal overdose. Estimates of recent non-fatal overdose were particularly high in Asia and North America.
Around one in five PWID are at an elevated risk of fatally overdosing every year, however there is substantial geographical variation. In countries with higher rates of non-fatal overdose there is need to introduce or mainstream overdose prevention strategies such as opioid agonist treatment and naloxone administration training programs.
Perceptions about supervised injection facilities among people who inject drugs in Philadelphia
2018, International Journal of Drug Policy
People who inject drugs (PWID) are at high risk for infectious diseases, skin and soft tissue infections, and overdose. However, these harms are all avoidable when sterile injection equipment, hygienic places to inject, and medical care are accessible. Unfortunately, many PWID in the U.S lack these resources. The most vulnerable are forced to inject in public spaces, where individual risks are high and communal harms are sometimes many. Supervised Injection Facilities (SIFs) are an established intervention for reducing these harms. Despite positive experiences in other countries, little research explores how PWID in the U.S. perceive the value of such facilities.
We conducted a freelisting exercise with PWID (n = 42) and healthcare providers (n = 20) at a syringe exchange program (SEP) that provides comprehensive clinical and social services in Philadelphia to inform in-depth semi-structured interviews with PWID (n = 19) at the same location.
Participants expressed support for a potential SIF as a valuable public health intervention. They suggested that an SIF would improve PWID health while reducing the public disorder associated with injecting drugs in public. The latter was especially important to participants without stable housing, whose decision to inject furtively in secluded places was often motivated by desire not to upset community members, and particularly children. These participants acknowledged that such seclusion elevated the risk of fatal overdose. Despite similarly positive perceptions about an SIF, participants with stable housing reported that they would prefer to continue injecting at home.
Results both confirm and extend prior research about PWID and SIFs. Participants expressed support for SIFs as in prior survey research in the U.S. and in other countries. Facility location and housing status were identified as important determinants of facility use. Results extend prior research by illuminating PWID perceptions in the U.S. including motivations grounded in concern for public order.
Use of on-site detoxification services co-located with a supervised injection facility
2017, Journal of Substance Abuse Treatment
Supervised injection facilities (SIFs) are increasingly being implemented worldwide in response to the harms associated with injection drug use. Although SIFs have been shown to promote engagement of people who use injection drugs (PWID) with external health services, little is known about the potential of co-locating on-site detoxification services with SIFs. The aim of this study was to characterize use of detoxification services co-located at Insite, North America's first SIF, among PWID in Vancouver, Canada.
Data were derived from two prospective cohorts of PWID in Vancouver, Canada between November 2010 and December 2012. Using multivariable generalized estimating equation logistic regression, we identified factors independently associated with reporting use of detoxification services at the SIF.
Among 1316 PWID, 147 (11.2%) reported enrolling in detoxification services co-located with the SIF at least once during the two year study period. In multivariable analyses, after adjustment for other potential cofounders, factors independently and positively associated with use of this service included residence < 5 blocks from the SIF (Adjusted Odds Ratio [AOR] = 1.70), enrollment in methadone maintenance therapy (AOR = 1.90), public injection (AOR = 1.53), binge injection (AOR = 1.93), recent overdose (AOR = 1.90) and frequent SIF use (AOR = 8.15) (all p < 0.05).
Use of on-site detoxification services offered at the SIF was common among PWID and associated with frequent SIF use and various markers of vulnerability and drug-related risk. These findings highlight the potential role of SIFs as a point of access to detoxification services for high-risk PWID. Future studies should examine if co-location leads to higher uptake of addiction services in comparison to services that create geographic or other obstacles.
Social determinants of HIV/HCV co-infection: A case study from people who inject drugs in rural Puerto Rico
2017, Addictive Behaviors Reports

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Personal ViewRationale for evaluating North America's first medically supervised safer-injecting facility

Summary

Section snippets

Safer-injecting facilities

Problems with conventional North American drug strategies

Limitations of conventional public-health strategies for injection drug use

Uptake of primary health care and addiction treatment services

The Vancouver SIF evaluation

Conclusion

Search strategy and selection criteria

Int J Drug Policy

Aust N Z J Public Health

Aust N Z J Public Health

Health Place

J Subst Abuse Treat

Sex differences in risk factors for HIV seroconversion amon injection drug users: A ten year perspective

Arch Intern Med

Risk factors for elevated HIV incidence among Aboriginal injection drug users in Vancouver

CMAJ

Hospital utilization and costs in a cohort of injection drug users

CMAJ

Leaving hospital against medical advice among HIV-positive patients

CMAJ

The social determinants of emergency department and hospital use by injection drug users in Canada

J Urban Health

Prevalence and correlates of untreated HIV-1 infection in the era of modern antiretroviral therapy

J Infect Dis

Impact of HIV infection on mortality in a cohort of injection drug users

J Acquir Immune Defic Syndr

Fatal overdose trends in major US cities: 1990–1997

Addict Res and Theory

Drug consumption facilities in Europe and the establishment of supervised injecting centres in Australia

Drug Alcohol Rev

Safer injection facilities in North America: their place in public policy and health initiatives

J Drug Issues

Unsafe injection practices in a cohort of injection drug users in Vancouver: could safer injecting rooms help?

CMAJ

Health Canada approves Vancouver supervised injection site pilot research project. News release June 24, 2003

Review of the a framework for action: A four pillar approach to drug problems in Vancouver

Can HIV AIDS Policy Law Rev

Canada parts with U.S. on drugs

New York Times

Vancouver to take new approach with legal injection site for addicts

Seattle Times

Canada sets sanctioned site to inject drugs

Boston Globe

Needling the neighbours

The Economist

Drug plan waste of resources, city told: More drug users will come here, US official warns

Vancouver Sun

The potential public health and community impacts of safer injecting facilities: evidence from a cohort of injection drug users

J Acquir Immune Defic Syndr

This quick fix won't work

The Globe and Mail

Supervised injection site nothing more than state-sponsored addiction

The Province

‘Sending the wrong signal’: analysis of print media reportage of the ACT heroin prescription trial proposal

Aust N Z J Public Health

Evaluation for alley-rooms I, II, and III in Basel

Soc Prev Med

Final report: The open drug scene and the safe injection room offers in Frankfurt am Main, 1999. A survey conducted on behalf of the City of Frankfurt/municipal department Women and Health drug policy coordination office

Rethinking America's “War on Drugs” as a public-health issue

The Lancet

The war on drugs—a peace proposal

N Engl J Med

‘Collateral casualties’ climb in drug war

JAMA

2001 Report of the Auditor General of Canada Chapter 11—Illicit drugs: The federal government's role. Office of the Auditor General of Canada

Supply-side policies for control of illicit drugs in the face of the AIDS and overdose epidemics: investigation of a massive heroin seizure

CMAJ

Personal View
Rationale for evaluating North America's first medically supervised safer-injecting facility