Supervised Consumption Facilities & Safe Injection Facilities (SCFs and SIFs)
Needle and Syringe Exchange Programs
(SIFs worldwide) "As of 2009, there were 65 safe injection facilities operating in 27 cities in eight countries."Source:Dooling, Kathleen and Rachlis, Michael, "Vancouver’s supervised injection facility challenges Canada’s drug laws," Canadian Medical Association Journal (Ottawa, Ontario: September 21, 2010), Vol. 182, Issue 13, p. 1443.
(Benefits of SIFs) "Focusing on the base assumption of decreased needle sharing as the only effect of the supervised injection facility, we found that the facility was associated with an incremental net savings of almost $14 million and 920 life-years gained over 10 years. When we also considered the health effect of increased use of safe injection practices, the incremental net savings increased to more than $20 million and the number of life-years gained to 1070. Further increases were estimated when we considered all 3 health benefits: the incremental net savings was more than $18 million and the number of life-years gained 1175."Source:Bayoumi, Ahmed M. and Zaric, Gregory, "The cost-effectiveness of Vancouver’s supervised injection facility," Canadian Medical Association Journal (Ottawa, Ontario: November 18, 2008), Vol. 179, Issue 11, p. 1143.
(Definition of SIF) "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. In this article the term — supervised injecting centre ̃ or — Centre ̃ will be used to denote the facility as a whole and — injecting or smoking room ̃will be used to refer to the actual space in which drug consumption occurs.
"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' ̃."Source:Kate Dolan, Jo Kimber, Craig Fry, John Fitzgerald, David McDonald, Franz Trautmann, "Drug consumption facilities in Europe and the establishment of supervised injecting centres in Australia," Drug and Alcohol Review (2000), pp. 337-338.
(Benefits of SIFs) "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."Source:Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 47.
(Effects of SIFs) "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."Source:Zobel, Frank & Françoise Dubois-Arber, "Short appraisal of the role and usefulness of Drug consumption facilities (DCF) in the reduction of drug-related problems in Switzerland: appraisal produced at the request of the Swiss Federal Office of Public Health (Lausanne: University Institute of Social and Preventive Medicine, 2004), p. 27.
(SIF Target Populations) 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."Source:Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 41.
(SIF Target Populations) "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."Source:Broadhead, Robert S., Thomas Kerr, Jean-Paul C. Grund, and Frederick L. Altice, "Safer Injection Facilities in North America: Their Place in Public Policy and Health Initiatives," Journal of Drug Issues (Tallahassee, FL: Florida State University, Winter 2002), Vol. 32, No. 1, p. 347-8.
(SIF overdose rates) "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: 0.03.6) 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."Source:Thomas Kerr, Mark W. Tyndall, Calvin Lai, Julio S.G. Montaner, Evan Wood, "Drug-related overdoses within a medically supervised safer injection facility," International Journal of Drug Policy 17 (2006) p. 440.
(Drug Consumption Rooms) "Drug consumption rooms (DCRs) represent one of the most controversial responses to drug problems, providing a space for drug users to use illicitly obtained drugs in a supervised, hygienic environment. This distinguishes them from informal spaces for drug use, such as ‘crack houses’ and ‘shooting galleries’, where drugs may be purchased and used in an unsupervised and often unhygienic environment.
"While it is difficult to be precise, there are around 65 DCRs operating worldwide. DCRs have been set up in Australia, Canada, Germany, Holland, Luxembourg, Norway, Spain and Switzerland. However, there are no DCRs operating in the UK."Source:Lloyd, Charlie and McKeganey, Neil, "Drugs Research: An overview of evidence and questions for policy," Joseph Rowntree Foundation (London, United Kingdom: June 2010), p. 50.
(SIF Overdose Rates) "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."Source:Thomas Kerr, Mark W. Tyndall, Calvin Lai, Julio S.G. Montaner, Evan Wood, "Drug-related overdoses within a medically supervised safer injection facility," International Journal of Drug Policy 17 (2006) p.440.
(Safe Consumption Rooms in the EU) "A more controversial approach has been adopted in some cities in Europe, where the concept of safe consumption rooms, usually targeting drug injection, has been extended to drug inhalation. Rooms for supervised inhalation have been opened in several Dutch, German and Swiss cities (EMCDDA, 2004c). Although the supervision of consumption hygiene is a main objective of such services, there is some evidence that they could also act as a conduit to other care options; for example, monitoring of one service in Frankfurt, Germany, reported that, during a six-month evaluation period in 2004, more than 1,400 consumptions were supervised, while 332 contact talks, 40 counselling sessions and 99 referrals to other drugs services were documented."Source:"Annual Report 2006: The State of the Drugs Problem in Europe," European Monitoring Centre for Drugs and Drug Addiction (Luxembourg: Office for Official Publications of the European Communities, 2006), p. 64.
(Heroin Injection Room Run by Nuns) "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."
(Cost-Effectiveness of Proposed Supervised Injection Facility in Montreal, Canada) "The model used here , predicted the number of new HIV and HCV cases prevented based on the needle sharing rate. This included the impact of behavioral changes in injection activities outside of the SIF. The behavioral change, according to Table 2 and Table 3, was only considered twice (once for the first SIF and later for the second SIF)—this modeling decision is apparent in the marginal number of new HIV cases averted in Tables 3, 4 and 5. This calculation of behavioral impact is based on a conservative odds-ratio that falls within the limit specified by Kerr et al. (2005) .
"As expected, the results presented in Table 2 and Table 3 show that increasing the scope of SIFs through site expansion would result in a decrease of HIV infection cases. The model predicts: 14–53 fewer HIV cases and 84–327 fewer HCV cases annually, with the marginal range being much smaller: 5–14 fewer HIV cases and 33–84 fewer HCV cases annually.
"This range disparity, as outlined in Table 2 and Table 3, translates into substantial differences between the economic evaluation of SIFs with respect to the cumulative versus marginal estimates: the total effect of establishing SIFs and the effect of establishing each subsequent SIF, respectively.
"For example, according to Table 3, the cumulative annual estimates of new HIV cases averted, translates into a cost savings for society ranging from $0.764 million (benefit) for the first SIF to -$4.1 million (loss) for the seventh SIF. Benefit-cost ratios range from 1.35 to 0.73, and cost-effectiveness values range from $155,914 to $288,294 (cost per lifetime treatment). The cumulative annual estimates of new HCV cases averted translate into a cumulative cost savings that range from $0.769 million (benefit) for the first SIF to -$3.7 million (loss) for the seventh SIF. Benefit-cost ratios range from 1.35 to 0.73, and incremental cost-effectiveness values range from $25,986 to $46,727 (cost per lifetime treatment).
"In contrast, the marginal estimates of Montreal’s SIF expansion translate into a much smaller return. This is particularly true with respect to its benefit-cost and cost-effectiveness ratios. For instance, the marginal benefit-cost ratio varies from 1.35 to 0.77 for HIV and 1.35 to 0.76 for HCV. The marginal cost-effectiveness value for HIV ranges from $155,914 to $436,560 (cost per life- time treatment). The HCV marginal cost-effectiveness value ranges from $25,986 to $66,145 (cost per lifetime treatment)."Source:Jozaghi et al., "A cost-benefit/cost-effectiveness analysis of proposed supervised injection facilities in Montreal, Canada." Substance Abuse Treatment, Prevention, and Policy 2013 8:25. doi:10.1186/1747-597X-8-25
(Countries with SIFs, 2001) "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)."Source:Broadhead, Robert S., Thomas Kerr, Jean-Paul C. Grund, and Frederick L. Altice, "Safer Injection Facilities in North America: Their Place in Public Policy and Health Initiatives," Journal of Drug Issues (Tallahassee, FL: Florida State University, Winter 2002), Vol. 32, No. 1, p. 331.
Law & Policies
(United States Law) "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.'"Source:Leo Beletsky, Corey S. Davis, Evan Anderson, and Scott Burris, "The Law (and Politics) of Safe Injection Facilities in the United States," American Journal of Public Health, (Vol. 98, No. 2) February 2008, p. 234.
(International Treaties) "23. It might be claimed that this approach [drug injection rooms] is incompatible with the obligations to prevent the abuse of drugs, derived from article 38 of the 1961 Convention and article 20 of the 1971 Convention. It should not be forgotten, however, that the same provisions create an obligation to treat, rehabilitate and reintegrate drug addicts, whose implementation depends largely on the interpretation by the Parties of the terms in question. If, for example, the purpose of treatment is not only to cure a pathology, but also to reduce the suffering associated with it (like in severe-pain management), then reducing IV drug abusers exposure to pathogen agents often associated with their abuse patterns (like those causing HIV-AIDS, or hepatitis B) should perhaps be considered as treatment. In this light, even supplying a drug addict with the drug he depends on could be seen as a sort of rehabilitation and social reintegration, assuming that once his drug requirements are taken care of, he will not need to involve himself in criminal activities to finance his dependence."Source:"Flexibility of Treaty Provisions as Regards Harm Reduction Approaches," Legal Affairs Section UNDCP (Vienna, Austria: International Narcotics Control Board, September 30, 2002), p. 5.
(SIFs in the US) "A ruling by the Supreme Court of Canada will not only have ramifications across Canada but will also likely have an impact in the United States, which has taken an active role in debating Canadian drug issues.40 A review of the legal framework in the United States concluded that states and municipalities have some authority to regulate safe injection facilities, but federal agencies could supervene under the Controlled Substances Act.41 Local public health activists have investigated the establishment of safe injection facilities in San Francisco and New York City.42 There are no official facilities in the United States, but anecdotally, some agencies do informally provide safer environments for drug injection."Source:Dooling, Kathleen and Rachlis, Michael, "Vancouver’s supervised injection facility challenges Canada’s drug laws," Canadian Medical Association Journal (Ottawa, Ontario: September 21, 2010), Vol. 182, Issue 13, p. 1443.
Sociopolitical and Clinical Research
(Australian SIF Evaluation) 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."Source:MISC Evaluation Committee, "Final Report on the Sydney Medically Supervised Injecting Centre" (New South Wales, Australia: MISC Evaluation Committee, 2003), p. xiv.
(SIFs in Germany) "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."Source:Nat M.J. Wright, Charlotte N.E. Tompkins, "Supervised Injecting Centres," British Medical Journal, Vol. 328, Jan. 10, 2004, p. 101.
(Australia - Evaluation) "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."Source:Wright, Nat M.J., Charlotte N.E. Tompkins, "Supervised Injecting Centres," British Medical Journal, Vol. 328, Jan. 10, 2004, p. 100.
(Crime Near SIFs) "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."Source:Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 82.
(SIFs and Public Consumption) "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."Source:Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 82.
(SIFs Don't Encourage Use) "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."Source:Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 83.
(SIF User Population) "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."Source:Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 41.
(Effectiveness) "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."Source:Barbara Tempalski and Hilary McQuie, "Drugscapes and the role of place and space in injection drug use-related HIV risk environments," International Journal of Drug Policy, (2009), p. 9.
(Effectiveness and Perceptions)
"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."Source:Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 81.
(Public Order) "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."Source:Wood, Evan, Thomas Kerr, Will Small, Kathy Li, David C. Marsh, Julio S.G. Montaner & Mark W. Tyndall, "Changes in Public Order After the Opening of a Medically Supervised Safer Injecting Facility for Illicit Injection Drug Users," Canadian Medical Association Journal, Vol. 171, No. 7, Sept. 28, 2004, p. 733.
(Reduction in Public Use) "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."Source:Wood, Evan, Thomas Kerr, Will Small, Kathy Li, David C. Marsh, Julio S.G. Montaner & Mark W. Tyndall, "Changes in Public Order After the Opening of a Medically Supervised Safer Injecting Facility for Illicit Injection Drug Users," Canadian Medical Association Journal, Vol. 171, No. 7, Sept. 28, 2004, p. 734.
(Support for Insite) "Since its inception, Insite has been subject to an independent review by a team of physicians and scientists put in place to provide an 'arm’s length' evaluation of the program. The results of this scientific evaluation have been published in peer-reviewed academic journals and have indicated that Insite has reduced unsafe injection practices, public disorder, overdose deaths and HIV/Hepatitis while increasing uptake of addiction services and detox . To date, there have been over three-dozen peer-reviewed papers evaluating Insite published making it one of the most evaluated healthcare programs in the history of Canada [9-38]. In light of the evidence, the program has garnered widespread support from Canadian physicians, scientists and healthcare professionals."Source:Small, Dan, "An appeal to humanity: legal victory in favour of North America’s only supervised injection facility: Insite," Harm Reduction Journal (London, United Kingdom: October 2010), Vol. 7, p. 3.
(Insite's Goals) "Insite opened on 21 September of 2003 under an exemption granting it status as a scientific pilot study until 12 September 2006. The primary goals of the program are: (1) to reach a marginalized group of IDUs with healthcare and supports who would otherwise be forced to use drugs in less safe settings (2) to reduce dangerous injection practices (syringe sharing) thereby reducing the risk of infectious diseases like HIV and HCV; and (3) to reduce fatal overdoses in the population of people that use the facility. The program also aims to provide referrals to treatment and detoxification, reduce public disorder (public injection) and validate the personhood of a deeply stigmatized target population."Source:Small, Dan, "An appeal to humanity: legal victory in favour of North America’s only supervised injection facility: Insite," Harm Reduction Journal (London, United Kingdom: October 2010), Vol. 7, p. 1.
(Medical Care Cost Savings) "Lifetime HIV-related medical care costs are approximately $210,555 in 2008 Canadian dollars (Pinkerton, 2010). Consequently, by preventing 5–6 HIV infections per year, the Insite SIF averts more than $1,000,000 in future HIV-related medical care costs. Andresen and Boyd (2010) estimate that the SIF generates $660,000 in additional cost savings by preventing 1.08 overdose deaths per year. The total savings due to averted HIV-related medical care costs and prevented overdose deaths (approximately $1.7 to $1.9 million per year), in and of itself, is just slightly greater than the estimated $1.5 million annual operating cost of the Insite SIF."Source:Pinkerton, Steven D., "How many HIV infections are prevented by Vancouver Canada’s supervised injection facility?" International Journal of Drug Policy (London, United Kingdom: International Harm Reduction Association, March 11, 2011), p. 5.
(Insite Evaluations) "The British Columbia Centre for Excellence in HIV/AIDS was commissioned to evaluate Insite. A study published in 2006 showed that there was an increase in uptake of detoxification services and addiction treatment.13 Another study published that year showed that Insite did not result in increased relapse among former drug users, nor was it a negative influence on those seeking to stop drug use.14 Results of studies using mathematical modelling showed that about one death from overdose was averted per year by Insite.1 A subsequent study estimated 2–12 deaths averted per year.15 Although these studies did not have sufficient power to detect any difference in incidence of blood-borne infections, Kerr and colleagues did find that Insite users were 70% less likely to report needle-sharing than those who did not use the facility.16 Before the opening of Insite, those same individuals reported needle-sharing that was on par with cohort averages. As for public order, Wood and colleagues found that there was no increase in crime following the opening of the facility.17 In fact, there had been statistically significant decreases in vehicle break-ins and theft, as well as decreases in injecting in public places and injection-related litter."Source:Dooling, Kathleen and Rachlis, Michael, "Vancouver’s supervised injection facility challenges Canada’s drug laws," Canadian Medical Association Journal (Ottawa, Ontario: September 21, 2010), Vol. 182, Issue 13, p. 1441.
(Detox Service Use) "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."Source:Wood, Evan, Tyndall, Mark W., Zhang, Ruth, Montaner, Julio S.G., and Kerr, Thomas, "Rate of Detoxification Service Use and its Impact among a Cohort of Supervised Injecting Facility Users," Addiction (2007), Vol. 102, p. 918.
(Detox and Treatment Service Use) "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."Source:Wood, Evan; Tyndall, Mark W.; Zhang, Ruth; Montaner, Julio S.G.; and Kerr, Thomas, "Rate of Detoxification Service Use and its Impact among a Cohort of Supervised Injecting Facility Users," Addiction (2007), Vol. 102, p. 918.
(Benefits vs. Risks) "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."Source:Kerr, Thomas, Jo-Anne Stoltz, Mark Tyndall, Kathy Li, Ruth Zhang, Julio Montaner, Evan Wood, "Impact of a medically supervised safer injection facility on community drug use patterns: a before and after study," British Medical Journal, Vol. 332, Jan. 28, 2006, pp. 221-222.
(Benefits) "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."Source:Kerr, Thomas, Jo-Anne Stoltz, Mark Tyndall, Kathy Li, Ruth Zhang, Julio Montaner, Evan Wood, "Impact of a medically supervised safer injection facility on community drug use patterns: a before and after study," British Medical Journal, Vol. 332, Jan. 28, 2006, p. 222.
(Injection Cessation and Entry to Treatment) "Among IDU who attended Vancouver’s supervised injecting facility, regular use of the SIF and having contact with counselors at the SIF were associated with entry into addiction treatment, and enrolment in addiction treatment programs was positively associated with injection cessation. Although SIF in other settings have been evaluated based on wide range of out-comes (Dolan et al., 2000; Kimber et al., 2003; MSIC Evaluation Committee, 2003), our study is the first to consider the potential role of SIF in supporting injection cessation. While our study is unique, our findings build on previous international analyses demonstrating a link between SIF attendance and entry into detoxification programs (Wood et al., 2006, 2007a; Kimber et al., 2008)."
"A postulated benefit of SIF is that, by providing a sanctioned space for illicit drug use, a hidden population of IDU can be drawn into a healthcare setting so that service delivery can be improved. The present study provides additional evidence that SIF appear to promote utilization of addiction services and builds on past evaluations to demonstrate that, through this mechanism,they may also lead to increased injecting cessation."Source:DeBeck, K., et al., "Injection drug use cessation and use of North America’s first medically supervised safer
injecting facility." Drug and Alcohol Dependence. (2010), doi:10.1016/j.drugalcdep.2010.07.023
(Overdose Mortality) "In this population-based analysis, we showed that overdose mortality was reduced after the opening of a SIF. Reductions in overdose rates were most evident within the close vicinity of the facility—a 35% reduction in mortality was noted within 500 m of the facility after its opening. By contrast, overdose deaths in other areas of the city during the same period declined by only 9%. Consistent with earlier evidence showing that SIFs are not associated with increased drug injecting (panel),38,39 these findings indicate that such facilities are safe and effective public-health interventions, and should therefore be considered in settings with a high burden of overdose related to injection drug use.
"In both the primary and sensitivity analyses, we saw no significant reductions in overdose mortality further than 500 m from the SIF. This finding is not surprising, since over 70% of frequent SIF users reported living within four blocks of the facility. Although the facility operates at capacity with over 500 supervised injections per day on average,23 it is a pilot programme with only 12 injection seats in a neighbourhood with about 5000 injection drug users.40 Therefore, and since previous studies have shown that waiting times and travel distance to the facility are barriers to SIF use,41 larger reductions in community overdose mortality would probably require an expansion of SIF coverage."Source:Marshall, Brandon D L; Milloy, M-J; Wood, Evan; Montaner, Julio S G; Kerr, Thomas, "Reduction in overdose mortality after the opening of North America's first medically supervised safer injecting facility: a retrospective population-based study," The Lancet (London, United Kingdom: April 18, 2011) Volume 377, Issue 9775, pp. 1429-1437.
(Overdoses) "In summary, there have been many overdose events within Vancouver's SIF [safe injection facility], 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 [injection drug users] and indicate the potential of SIF to reduce morbidity and mortality associated with illicit drug related overdoses."Source:Thomas Kerr, Mark W. Tyndall, Calvin Lai, Julio S.G. Montaner, Evan Wood, "Drug-related overdoses within a medically supervised safer injection facility," International Journal of Drug Policy 17 (2006) p. 440.
(Other Drug Use) In an evaluation of the Vancouver supervised injection facility Insite, 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.'"Source:Kerr, Thomas, Jo-Anne Stoltz, Mark Tyndall, Kathy Li, Ruth Zhang, Julio Montaner, Evan Wood, "Impact of a medically supervised safer injection facility on community drug use patterns: a before and after study," British Medical Journal, Vol. 332, Jan. 28, 2006, p. 222.