Supervised Consumption Facilities & Safe Injection Facilities

"Supervised injecting centres in general may be defined as '... legally sanctioned and supervised facilities designed to reduce the health and public order problems associated with illegal injection drug use'. Further, these centres '... enable the consumption of pre-obtained drugs in an anxiety and stress-free atmosphere, under hygienic and low risk conditions.'[1]."

"Rooms set aside for the consumption of illicit drugs have been referred to as drug consumption facilities, or rooms, health rooms or injecting rooms in Europe. Terms used in the Australian context include medically supervised injecting centres (in NSW), supervised injecting place (in the ACT) and off-street injecting facilities (in Victoria), among others."

"Generally speaking, it is reasonable to conclude, on the basis of the available knowledge, that to a large extent DCFs [Drug Consumption Facilities] achieve the objectives set for them, and that the criticisms made of them are rarely justified. In fact, DCFs help to:

"• reduce risk behaviour likely to lead to the transmission of infectious diseases, particularly HIV/AIDS, among the population of the worst affected drug users;

"• reduce the incidence of fatal overdoses and, therefore, the mortality rate in this population;

"• establish and maintain contact between this population and the social-service and health-care network, within which low-threshold facilities (LTFs) are often the First point of access because of the care and social assistance they offer;

"• reduce public order problems, particularly by doing away with open drug scenes, reducing drug use in public places, recovering used syringes, and reducing the impact of drug problems on residential areas (apartment buildings).

"At the same time, the available data do not indicate any specific detrimental effect on:

"• the number of drug users and the frequency with which they use drugs; the figures are falling in both cases;

"• entry and retention in treatment, because the majority of DCF users are undergoing treatment, the proportion of those in treatment is growing, this subject is tackled within the facilities, and the users themselves state that DCFs do not have any major influence on their treatment.

"All of these observations relate to the overall level of public health and do not mean that DCFs may not have negative effects in some individual cases. However, on the basis of existing knowledge, it would appear that the overall effect of DCFs on drug-related problems is positive."

"Evidence indicates SIFs [Safe Injection Facilities] are uniquely effective in sustaining contact with the most marginalised and chaotic users who inject drugs in public places. These users are at the greatest risk for disease and death, and are also the least likely to engage directly in a traditional abstinence-based health services. Evidence indicates that SIFs can reduce drug overdose deaths; minimize risks for abscesses, bacterial infections and endocarditis; minimise the risk of HIV, hepatitis C and hepatitis B transmission; and increase referral to drug treatment and other health services, while improving public order."

"Nuns who run one of Australia's best known hospitals are to operate the country's first legal and medically supervised heroin injecting room after a radical overhaul of the drug laws in New South Wales. The 18 month trial will be administered by the Sisters of Charity, who also run Sydney's inner city St Vincent's Hospital.

"An estimated 50 000 visits a year by drug users are expected at the centre, which will be staffed by a medical supervisor, a registered nurse, and security staff. The controversial plan will include the provision of clean needles and syringes; users must supply their own drugs."

"Our review suggests that SIFs target several public health problems that municipalities in North America may wish to consider, problems largely unaddressed by needle exchange, street-outreach, education campaigns, HIV counseling, and other conventional services. SIFs target injectors' use of public spaces to inject drugs in order to reduce the many risks associated with the practice. Compared to conventional services, SIFs provide greater opportunities for health workers to connect with injectors, and to move them into primary care, drug treatment, and other rehabilitation services. Finally, SIFs target the 'nuisance factor' of drug scenes -- the hazardous litter and intimidating presence of injectors congregating in city parks, public playgrounds and on street corners -- by offering them an alternative, supervised 'public' space. Our review also suggests that, for municipalities considering SIFs in order to address these problems, their implementation would not necessarily require any significant or fundamental changes in public policy or law: SIFs require the same working agreements with social service providers and the police that needle exchange, street-outreach, drug treatment and similar health programs for injectors already receive."

"Governmentally sanctioned 'safer injection facilities' (SIFs) are a health service that several countries around the world have been adding to the array of public health programs they offer. These countries include:

"· Canada where the federal government, in collaboration with the Federal, Territorial and Provincial Advisory Committee on Population Health, has created a task force to examine the feasibility of a national research-based trial of SIFs (Kerr & Palepu, 2001); Vancouver, B.C. where SIFs are included in the Mayor’s “Four Pillar Drug Strategy,” and a formal proposal to implement SIFs has been put forward (Kerr, 2000; MacPherson, 2001)

"· Germany with 13 SIFs operating in 4 cities

"· The Netherlands with 16 SIFs operating in 9 cities

"· Switzerland with 17 SIFs operating in 12 cities

"· Spain with 1 SIF operating in Madrid

"· Australia where an SIF began operations in May, 2001 in Sydney, and legislation has been approved to operate an SIF in Canberra and is pending in Melbourne (New York Times, 2001; Dolan, 2000)."

According to the final report of the evaluation of the Sydney, Australia, Medically Supervised Injecting Centre (MSIC) by the MSIC Evaluation Committee (established by the New South Wales Dept. of Health):

"In summary, the evidence available from this Evaluation indicates that:

"• operation of the MSIC in the King Cross area is feasible;

"• the MSIC made service contact with its target population, including many who had no prior treatment for drug dependence;

"• there was no detectable change in heroin overdoses at the community level;

"• a small number of opioid overdoses managed at the MSIC may have been fatal had they occurred elsewhere;

"• the MSIC made referrals for drug treatment, especially among frequent attenders; "- there was no increase in risk of blod borne virus transmission;

"• there was no overall loss of public amenity;

"• there was no increase of crime;

"• the majority of the community accepted the MSIC initiative;

"• the MSIC has afforded an opportunity to improve knowledge that can guide public health responses to drug injecting and its harms."

"States have clear legal authority to authorize SIFs, just as they can legalize the cultivation, distribution, and possession of marijuana for medical purposes.76 State authorization could make a SIF legal under state law and prevent state law enforcement officials from taking action against it. It is equally clear, however, that state authorization cannot nullify federal drug laws, and so does not protect a SIF against being shut down by federal law enforcement agencies through raids, arrests, or other legal proceedings.

"There are at least 2 sections of the federal Controlled Substances Act that could be interpreted to bar a SIF. Section 844 prohibits drug possession and so is violated by every client who appears at the clinic with drugs.77 Although federal law enforcement officials rarely if ever target simple possession by individuals, 78 the law would allow them to do so if they wished to interfere with the operation of a SIF.

"A SIF authorized at the state or local level could also be deemed to violate Section 856, known as the Crack House Statute. This law makes it illegal to 'knowingly open or maintain . . . [or] manage or control any place . . . for the purpose of unlawfully . . . using a controlled substance.'"

(heroin maintenance) "These pilot study findings showed that opiate-dependent injecting drug users with long injecting careers (most started between 1970 and 1982) and for whom opiate treatment had failed multiple times previously were attracted into and retained by therapy with injectable opiates."

In an evaluation of the Vancouver supervised injection facility, researchers concluded that: "Our study indicates that the opening of North America's first supervised injection facility was not associated with measurable negative changes in the use of injected drugs. Indeed, we found a substantial reduction in the starting of binge drug use after the opening of the facility, suggesting that it had not prompted 'risk compensation' among local injecting drug users, whereby the benefits of a safer environment are overcome by more risky behaviours such as higher intensity drug use."

"Evaluation of the Vancouver facility has shown that its opening has been associated with reductions in public drug use and publicly discarded syringes and reductions in syringe sharing among local injecting drug users. Our study suggests that these benefits have not been offset by negative changes in community drug use."

In an evaluation of the Vancouver supervised injection facility, researchers concluded that: "Although there was a substantial increase in the number of participants who started smoking crack cocaine, it is unlikely that the facility, which does not allow smoking in the facility, prompted this change. These findings are relevant to a recent review of supervised injection facilities by the European Monitoring Centre on Drugs and Drug Addiction, which highlighted concerns that these facilities could potentially 'encourage increased levels of drug use' and 'make drug use more acceptable and comfortable, thus delaying initiation into treatment.'"

Researchers for the European Monitoring Centre on Drugs and Drug Addiction (EMCDDA) looking into safer injection facilities and drug consumption rooms found that, "Service users' sociodemographic data and drug use profile are similar across countries. Data show that the rooms reach the intended target groups of long-term addicts, street injectors, homeless drug users and drug-using sex workers and are thus facilitating contact with the most problematic and marginalised drug users. Demographic information also shows that these services can be successful in reaching long-term drug users with no previous contact with treatment services."

"Consumption rooms can reduce significantly the level of drug use in public. The extent to which this is achieved depends on their accessibility, opening hours and capacity to accommodate drug consumptions that would otherwise occur in public.

"The location of consumption rooms needs to be compatible with the needs of drug users but also to take account of the needs and expectations of local residents. A reduction in the number of public consumptions can contribute to improvements in the neighbourhood by helping to reduce public nuisance associated with open drug scenes. However, facilities near illicit drug markets are not able to solve wider nuisance problems that result from these markets.

"Police actions against drug markets and drug scenes in other neighbourhoods may sometimes increase public order problems near consumption rooms. This implies that, if rooms are to contribute to reducing public nuisance rather than be blamed for aggravating it, there needs to be consultation not only with local residents but also with police, so that action to discourage open drug scenes does not at the same time deter drug users from making use of the facilities."

Researchers for EMCDDA, concluded, "Consumption rooms reach a population of often older, long-term users some of whom have had no previous treatment contact. Services appear particularly successful in attracting groups that are difficult to reach. No evidence was found to suggest that naive users are initiated into injecting as a result of the presence of consumption rooms."

"Consumption rooms achieve the immediate objective of providing a safe place for lower risk, more hygienic drug consumption without increasing the levels of drug use or risky patterns of consumption.

"Direct benefits of supervised injecting appear to be a reduction in some of the risk behaviours related to injecting, in particular improvements in injecting practice, use of sterile equipment and lack of opportunity for sharing drugs. Other benefits are that, if medical emergencies should occur, immediate medical intervention is possible, and the consumption equipment used in the rooms is correctly disposed of. Client surveys consistently show that service users appreciate the hygienic conditions, safety and peace that the rooms provide."

"Neighbourhood attitudes and perceptions. Surveys of local residents and businesses, as well as registers of complaints made to the police, generally show positive changes following the establishment of consumption rooms, including perceptions of decreased nuisance and increases in acceptance of the rooms. Police, too, often acknowledge that consumptions contribute to minimising or preventing open drug scenes.

"Open drug scenes and police policy. There are instances where consumption rooms have been blamed for increasing public nuisance, including open drug scenes and dealing. These arose where police actions in other areas had the effect of relocating drug markets and open scenes.

"Pull effect. Available evidence is not sufficient to draw conclusions on whether consumption rooms exert a 'pull-effect' by attracting drug users from other areas, thus adding to the situation already created by established drug markets. Attempts to decentralise drug scenes by dispersing consumption rooms have not led to increased nuisance around the rooms. However, they have not attracted large numbers of clients either."

"There is no evidence that consumption rooms encourage increased drug use or initiate new users. There is little evidence that by providing better conditions for drug consumption they perpetuate drug use in clients who would otherwise discontinue consuming drugs such as heroin or cocaine, nor that they undermine treatment goals.

"When managed in consultation with local authorities and police, they do not increase public order problems by increasing local drug scenes or attracting drug users and dealers from other areas. If consultation and cooperation between key actors does not take place, then there can be a risk of a'pull effect' and consumption rooms run the risk of being blamed for aggravating local problems of public order including drug dealing."

"There is no evidence that the operation of consumption rooms leads to more acquisitive crime. There is small-scale drug dealing in the vicinity of many services, which is not surprising given their location."

"In the present analysis we found that overdose events were not uncommon at the Vancouver safer injection facility. During an 18-month period, 285 individuals accounted for 336 overdose events, yielding an overdose rate of 1.33 (95% CI: 0.0–3.6) overdoses per 1000 injections. Heroin was involved in approximately 70% of all overdoses, and opiates considered together were involved in88%of overdoses. It is notable, however, that approximately one-third of overdoses involved stimulants. The most common indicators of overdose were depressed respiration, limp body, face turning blue, and a failure to respond to pain stimulus. The majority of overdoses were successfully managed in the SIF, with the most common overdose interventions undertaken by SIF staff involving the administration of oxygen, a call for ambulance support, and the administration of naloxone hydrochloride via injection. Among a randomly selected sample of SIF users, factors associated with time to overdose at the SIF included fewer years injecting, daily heroin use, and having a history of overdose. None of the overdose events occurring at the SIF resulted in a fatality."

"In summary, there have been many overdose events within Vancouver's SIF, although the rate of overdoses is similar to rates observed in SIF in other settings. The majority of these overdoses involved the injection of opiates, and most events were successfully managed within the SIF through the provision of oxygen. It is noteworthy that none of the overdose events occurring at the SIF resulted in a fatality. These findings suggest that SIF can play a role in managing overdoses among IDU and indicate the potential of SIF to reduce morbidity and mortality associated with illicit drugrelated overdoses."

"The rate of overdose observed at the Vancouver SIF is within the range of rates observed in an international review of SIF which estimated the rates of overdose typically to be between 0.01 and 3.6 per 1000 injections (Kimber et al., 2005). However, the rate observed in Vancouver is lower than rates observed recently in Munster, Germany (6.4 per 1000 injections) and Sydney, Australia (7.2 per 1000 injections) (Kimber et al., 2003). This may reflect differences in threshold for coding and intervention by staff, and differences in drug consumption patterns across cities, especially as it pertains to the use of opioids and other central nervous system depressants."

"The only comprehensive evaluation of a medically supervised injecting centre was conducted during the 18 month trial of the Sydney centre. Staff intervened in 329 overdoses over one year with an estimate of at least four lives saved a year. There was no increase in reported hepatitis B or C infections in the area that the medically supervised injecting centre served despite an increase elsewhere in Sydney.

"The report described a decreased frequency of injecting related problems among clients. Half the centre's clients reported that their injecting practices had become less risky since using the centre. Furthermore, clients were more likely than other injectors to report that they had started treatment for their drug use; 11% of clients were referred to treatment for drug dependence. An economic evaluation of deaths averted by intervention of the medically supervised injecting centre showed that costs were comparable to those of other widely accepted public health measures.

"The centre also had benefits for the local community. Residents and business respondents reported fewer sightings of public injection and syringes discarded in public places, and syringe counts in the vicinity of the centre were lower after it opened than before. In addition, there was no evidence of an increased number of theft and robbery incidents in the area. Acceptance of the medically supervised injecting centre increased among both businesses and residents over the study period."

"Little evaluative work has been conducted into supervised injection facilities in other countries. In Hanover, however, 98% of users of the medically supervised injecting centre did not encounter any negative experience with local residents and 94% reported no negative police encounters. Research from Frankfurt showed that a drug user who overdoses on the street is 10 times more likely to stay in hospital for one night than a drug user who overdoses in a medically supervised injecting centre. In addition, no one has died from heroin overdose in any medically supervised injecting centre. Therefore, establishing such centres in the United Kingdom is likely to reduce the number of drug related deaths."

"In summary, we documented significant reductions in the number of IDUs injecting in public, publicly discarded syringes and injection-related litter after the opening of the medically supervised safer injecting facility. These reductions appeared to be independent of several potential confounders, and our findings were supported by external data sources. Although the overall health impacts of the facility will take several years to evaluate, the findings from this study should be valuable to other cities that are contemplating similar evaluations and should have substantial relevance to many urban areas where public injection drug use has been associated with substantial public health risks and adverse community impacts."

"We found significant reductions in public injection drug use, publicly discarded syringes and injection-related litter after the opening of the medically supervised safer injecting facility in Vancouver. These reductions were independent of law enforcement activities and changes in rainfall patterns.

"Our findings are consistent with anecdotal reports of improved public order following the establishment of safer injecting facilities and are not surprising given that a commonly reported reason for public drug use is the lack of an alternative place to inject and that IDUs who go to safer injecting facilities are often homeless or marginally housed. Our findings are also highly plausible since more than 500 IDUs visited the facility daily after it opened, and several feasibility studies have suggested that IDUs who inject in public would be the most likely to use safer injecting facilities. Our observations suggest that the establishment of the safer injecting facility has resulted in measurable improvements in public order, which in turn may improve the liveability of communities and benefit tourism while reducing community concerns stemming from public drug use and discarded syringes. It is also noteworthy that we did not observe an increase in the number of drug dealers in the vicinity of the facility, which indicates that the facility's opening did not have a negative impact on drug dealing in the area. Although further study of these issues is necessary, the safer injecting facility may also offer public health benefits, since public injection drug use has been associated with an array of health-related harms."

"The present study demonstrates that the opening of the Vancouver SIF was associated with a greater than 30% increase in the rate of detoxification service use among SIF users in comparison to the year prior to the SIF's opening. Subsequent analyses demonstrated that detoxification service use was associated with increased use of methadone and other forms of addiction treatment, as well as reduced injecting at the SIF."

"In summary, the present study demonstrates that the SIF was associated with increased use of detoxification service use and that residential detoxification was associated with increased rates of methadone use and other forms of addiction treatment. Given the known role of methadone and other forms of addiction treatment in reducing levels of injection drug use, and given that detoxification programme use was associated with reduced injecting at the SIF, our findings imply that the SIF has probably helped to reduce rates of injection drug use among users of the facility."