Safer injection facilities for injection drug users: the debate continues
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* Evan Wood
* Mark W. Tyndall
* Thomas Kerr
* Patricia M. Spittal
* Michael V. O'Shaughnessy
* Martin T. Schechter

The answers to the questions raised by Gordon Brock and Vydas Gurekas are quite straightforward. We would hope that safer injecting rooms could operate on a 24-hour basis every day. After all, these are precisely the operating hours of the alleyways and shooting galleries where the public health crisis has emerged. Clients would bring their own drugs and would have access to sterile injecting equipment, which would be disposed of safely on site rather than in parks and schoolyards. Overdoses would be addressed sooner on site by staff, rather than later in ambulances and emergency departments. It is noteworthy that although British Columbia has had an average of 300 overdose deaths per year, there has never been a fatal overdose in any of the 42 safer injecting sites operating across Europe.1

If a safer injecting room only provided sterile injecting equipment and a place to inject where staff could respond to overdoses, it would represent a substantial improvement over the present situation. However, we further propose that referrals to detox, addiction treatment, counselling and primary health care be available for these difficult-to-reach populations. The legal issues have been fully considered by experts in the field and are not insurmountable.2

William Campbell and Nady el-Guebaly rightly point out that the provision of addiction treatment is woefully inadequate in Canada. Access to methadone must be improved, but it will ultimately not reach a significant proportion of opiate users3 or cocaine addicts.4 For these reasons, we concur that novel treatments such as heroin prescription must be explored.5 For those not ready for treatment, programs such as safe injection sites should be implemented to prevent irreversible harms to these people and the health care system while they continue to inject.

Such sites should obviously be located close to where injection drug users presently congregate, such as Vancouver's Downtown Eastside. Brock and Gurekas wonder about the open-mindedness of neighbours, whose reaction may present the largest barrier to implementation of safer injection rooms. Although community concerns will have to be addressed, experience has shown that groups initially opposed to safer injection rooms often later become their strongest supporters, because they find the presence of a safer injecting room more acceptable than the intense open-drug scenes that preceded them.1,6 Why would a neighbour oppose a safer injection room in their backyard, when they currently have unsafe injection scenes in their back alley?

We do indeed live in an era of intense pressures on constrained health care resources. For example, the lifetime direct medical costs associated with each case of HIV infection are in the range of $150 000.7 The costs of hepatitis C infection are also extremely high, and the burden of in-patient care for patients with endocarditis, abscesses, nonfatal overdoses and other drug-related harms is crippling our inner-city hospitals.8 Approximately $300 000 is spent annually on ambulance services to respond to overdoses in Vancouver alone.9

“How can we afford to pay for safe injection sites?” A better question might be, How can we afford not to? 

## References

1.  1. Dolan K, Kimber J, Fry C, Fitzgerald J, McDonald D, Frautmann F. Drug consumption facilities in Europe and the establishment of supervised injecting centres in Australia. Drug Alcohol Rev 2000;19:337-46.
    
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2.  2. Malkin I, Gold J, Elliott R. *Safe injection sites: issues, obstacles and obligations*. Montreal: Canadian HIV/AIDS Legal Network, 2002.
    
    

3.  3. Mino A, Page D, Dumont P, Broers B. Treatment failure and methadone dose in a public methadone maintenance treatment programme in Geneva. Drug Alcohol Depend 1998;50(3):233-9.
    
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4.  4. Tyndall MW, Spittal PM, Laliberte N, Li K, O'Shaughnessy MV, Schechter MT. Intensive injection cocaine use as a primary risk factor of HIV seroconversion among polydrug users in Vancouver. Can J Infect Dis 2001;12(Suppl B):70B.
    
    

5.  5. Rehm J, Gschwend P, Steffen T, Gutzwiller F, Dobler-Mikola A, Uchtenhagen A. Feasibility, safety, and efficacy of injectable heroin prescription for refractory opioid addicts: a follow-up study. Lancet 2001;358(9291):1417-23.
    
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6.  6. Kent H. Australia's safe “shooting gallery” proving popular. CMAJ 2001;165(10):1375.
    
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7.  7. Albert T, Williams G, Remis R, Legowski B. Canadian Policy Research Networks. *The economic burden of HIV/AIDS in Canada*. Ottawa: Renouf Publishing Co. Ltd; 1998.
    
    

8.  8. Palepu A, Tyndall MW, Leon H, Muller J, O'Shaughnessy MV, Schechter MT, et al. Hospital utilization and costs in a cohort of injection drug users. CMAJ 2001;165(4):415-20. 
    
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9.  9. Kerr, T. *Safe injection facilities: a proposal for a Vancouver pilot project.* Vancouver: Harm Reduction Action Society; 2000. Available: [www.cfdp.ca/safei.pdf](http://www.cfdp.ca/safei.pdf) (accessed 2002 Jan 18).