Attendance, drug use patterns, and referrals made from North America's first supervised injection facility
Introduction
Reducing the adverse health and social consequences of injection drug use continues to present a major challenge to public health in Canada and elsewhere (Aceijas et al., 2004, Benotsch et al., 2004, Craib et al., 2003, Des Jarlais and Friedman, 1998). Although a number of existing programs have contributed to marked improvements in the health outcomes for many individuals who use injection drugs, success at a population level remains elusive (Cohen et al., 2004, Strathdee et al., 1998). In recent years, much of the focus has been on reducing the transmission of HIV and hepatitis C infections within networks of injection drug users (IDUs) with the provision of clean injection equipment via needle and syringe programs (Gibson et al., 2001, Hagan et al., 2000). This is recognized as an important component of a comprehensive approach to reducing harms among IDUs, but has not been sufficient to stop high risk activities, halt the transmission of HIV and Hepatitis C, or reduce widespread public drug use observed in large Canadian cities (Strathdee et al., 1997, Wood et al., 2002). The Downtown Eastside (DTES) of Vancouver has been the site of particularly explosive HIV and hepatitis C epidemics among IDUs with estimated prevalence rates of 30% and 90% respectively (Tyndall et al., 2003). The community is also notable for high numbers of overdose deaths (Tyndall et al., 2001), excessive use of emergency health care services (Palepu et al., 2001), and a highly publicized open drug scene (Wood et al., 2001).
North America's first government sanctioned supervised injection facility (SIF) was opened in response to the ongoing health and social consequences of injection drug use and demands from community advocates and the Vancouver Area Network of Drug Users (VANDU) that the HIV and overdose epidemics were unacceptable. In fact a peer-driven injection site called the Back Alley was established by VANDU between February and October 1996 and this was followed by another “unsanctioned” injection site, the 327 SIS that was open between April and October 2003 (Kerr et al., 2005a). These initiatives, along with other peer-driven projects (Wood et al., 2003), brought an urgency to the debate and were critical to the eventual opening of the current SIF. In addition, reports of the success of similar facilities in many European cities, and more recently Sydney, Australia, pushed policy makers into considering the role of an SIF in dealing with problem drug use in Vancouver (de Jong and Weber, 1999; Broadhead et al., personal communication). Vancouver's SIF was opened in September 2003 and, as part of the approval process, a comprehensive evaluation plan was proposed to assess a number of health and community impacts (Wood et al., 2004b), including changes in public injecting practices, overdose deaths, uptake of addiction treatment, and HIV infection rates. To date, we have shown that the opening of the SIF has been associated with improvements in community levels of public disorder (Wood et al., 2004c), reductions in syringe sharing among those using the SIF (Kerr et al., 2005b), and that the SIF attracts IDUs with histories of high risk behaviors (Wood et al., 2005).
This SIF trial is important for Canada and will largely dictate whether this approach is adopted as a standard component of a comprehensive harm reduction strategy in other Canadian cities. The aim of this analysis is to describe the initial uptake, client characteristics, drug use patterns, and referrals made from the SIF during the first 18 months of operation.
Section snippets
Methods
The justification and methods for evaluating the SIF have been outlined previously (Wood et al., 2004a, Wood et al., 2004b). Briefly, there are several components to the evaluation including a database that operates at the SIF, the recruitment of a large prospective cohort of SIF participants, a comparison cohort of injection drug users who are not using the SIF, and studies evaluating the impact of the SIF on community residents and businesses.
This analysis uses the information collected from
Results
From 10 March 2004 to 30 April 2005 inclusive, there were 4764 unique individuals who registered at the SIF. The monthly attendance, as well as the number of new participants, is shown in Fig. 1. The number of individuals visiting the SIF was relatively consistent from month-to-month, and included a steady flow of new participants. It should be noted that March 2004 data was based on just 22 days of observation. Visits to the SIF between 10 March 2004 and 30 April 2005 numbered 243,701 for a
Discussion
The present study demonstrates that attendance at the SIF has been consistently high since the opening and the facility is operating near capacity at most times. During 14 months of computerized observations, the SIF has attracted over 4700 injection drug users, has intervened in 273 witnessed overdoses, and made 2171 referrals. The attendance patterns indicate that although most participants are returning, there are still new people using the SIF each month. The overall number of visits is
Acknowledgements
The authors wish to thank the staff of the InSite SIF and Vancouver Coastal Health (Chris Buchner, David Marsh, Heather Hay, Jeff West, Sarah Evans). We also thank Aaron Eddie, Suzy Coulter, Megan Oleson, Peter Vann, Dave Isham, and Steve Gaspar for their research and administrative assistance. The SIF evaluation has been made possible through a financial contribution from Health Canada, though the views expressed herein do not represent the official policies of Health Canada.
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