Overdose Prevention Sites, also known as Supervised Consumption Sites or Safe Injection Facilities

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Page last updated July 8, 2020 by Doug McVay, Editor/Senior Policy Analyst.

1. Successful Operation of an Unsanctioned Supervised Consumption Site in the US

"In total, there were 10,514 injections and 33 opioid-involved overdoses over 5 years, all of which were reversed by naloxone administered by trained staff (Table 1). No person who overdosed was transferred to an outside medical institution, and there were no deaths. The number of overdoses increased over the years of operation, due partially to the number of injections increasing over the same period of time (Fig. S1 in the Supplementary Appendix). The types of drugs used at the site changed over the 5 years of operation, with a steady increase in the proportion of injections involving the combination of opioids and stimulants, from 5% in 2014 to 60% in 2019 (Fig. S2).

"Although this evaluation was limited to one city and one site that is unsanctioned, and therefore the findings cannot be generalized, our results suggest that implementing sanctioned safe consumption sites in the United States could reduce mortality from opioid-involved overdose. Sanctioning sites could allow persons to link to other medical and social services, including treatment for substance use, and facilitate rigorous evaluation of their implementation and effect on reducing problems such as public injection of drugs and improperly discarded syringes."

Kral, Alex H., Lambdin, Barrot H., Wenger, Lynn D., Davidson, Pete J. Evaluation of an Unsanctioned Safe Consumption Site in the United States. New England Journal of Medicine. July 8, 2020. 10.1056/NEJMc2015435

2. Supervised Injection Facilities (SIFs), Sanitary Consumption Facilities (SCFs), and Drug Consumption Rooms (DCRs)

"Drug consumption rooms are professionally supervised healthcare facilities where drug users can consume drugs in safer conditions. They seek to attract hard-to-reach populations of users, especially marginalised groups and those who use on the streets or in other risky and unhygienic conditions. One of their primary goals is to reduce morbidity and mortality by providing a safe environment for more hygienic use and by training clients in safer use. At the same time, they seek to reduce drug use in public and improve
public amenity in areas surrounding urban drug markets. A further aim is to promote access to social, health and drug treatment facilities (see ‘Service model’).

"Drug consumption rooms initially evolved as a response to health and public order problems linked to open drug scenes and drug markets in cities where a network of drug services already existed, but where difficulties were encountered in responding to these problems. As such they represent a ‘local’ response, closely linked to policy choices made by local stakeholders, based on an evaluation of local need and determined by municipal or regional options to proceed. Facilities for supervised drug consumption tend to be located in settings that are experiencing problems of public use and targeted at sub-populations of users with limited opportunities for hygienic injection (e.g. people who are homeless or living in insecure accommodation or shelters). In some cases clients who are more socially stable also use drug consumption rooms for a variety of reasons, for example because they live with non-using partners or families (Hedrich and Hartnoll, 2015)."

"Perspectives On Drugs: Drug consumption rooms: an overview of provision and evidence," European Monitoring Centre for Drugs and Drug Addiction, June 2017, p. 2, last accessed Nov. 8, 2017.

3. Ninety Officially Sanctioned Drug Consumption Rooms in Operation in the EU and Switzerland

"In terms of the historical development of this intervention, the first supervised drug consumption room was opened in Berne, Switzerland in June 1986. Further facilities of this type were established in subsequent years in Germany, the Netherlands, Spain, Norway, Luxembourg, Denmark, Greece and France. A total of 78 official drug consumption facilities currently operate in seven EMCDDA reporting countries, following the opening of the first two drug consumption facilities in the framework of a 6-year trial in France in 2016. There are also 12 facilities in Switzerland (see ‘Facts and figures’)."

"Perspectives On Drugs: Drug consumption rooms: an overview of provision and evidence," European Monitoring Centre for Drugs and Drug Addiction, June 2017, p. 2, last accessed Nov. 8, 2017.

4. Success of Overdose Prevention Sites In Response to a Public Health Emergency

"The rapid implementation of OPSs [Overdose Prevention Sites] in the province of British Columbia, Canada during a public health emergency provides an international example of an alternative to drawn-out, cumbersome sanctioning processes for SCSs [Supervised Consumption Services]. Unsanctioned SCSs provide alternative evidence to inform the implementation of SCSs that are more inclusive and responsive to PWUD [People Who Use Drugs]. Our research adds to this evidence. In particular, we found evidence that shifts in the outer context facilitated rapid implementation of a more user focused and driven intervention. We found innovation and inclusionary practices that typically define unsanctioned sites were possible within state-sanctioned OPSs. Community-driven processes of implementation involve centering PWUD in service design, implementation and delivery. Overdose prevention sites provide an example of a novel service design and nimble implementation process that combines the benefits of state-sanctioned service and community-driven implementation. As described by those individuals implementing the services, OPSs effectively provide supervised injection services and overdose responses while addressing many of the documented limitations of existing sanctioned SCSs implementation processes and resultant service designs. However, OPSs lack permanency and ongoing funding due to enactment under a Ministerial Order that is limited to the duration of the public health emergency. Specific attention needs to be paid to the development maintenance of OPSs as primary points of contact and entry into the health system and as part of an ongoing system of substance use services."

Bruce Wallace, Flora Pagan, Bernadette (Bernie) Pauly, The implementation of overdose prevention sites as a novel and nimble response during an illegal drug overdose public health emergency, International Journal of Drug Policy, Volume 66, 2019, Pages 64-72, ISSN 0955-3959.

5. Drug Consumption Rooms in Operation Around the World

"Breaking this down further, as of February 2017 there are: 31 facilities in 25 cities in the Netherlands; 24 in 15 cities in Germany; five in four cities in Denmark 13 in seven cities in Spain; two in two cities in Norway; two in two cities in France; and one in Luxembourg (Luxembourg is preparing to open a second facility in 2018); and 12 in eight cities in Switzerland. In Slovenia following a change in the penal code that created an enabling environment for the opening of supervised consumption facilities, a planned pilot project is pending. Following HIV outbreaks among people who inject drugs, discussions about the introduction of supervised drug consumption facilities are ongoing in Glasgow (Scotland) and Dublin (Ireland). A study to explore the feasibility of drug consumption facilities in five major cities in Belgium (Ghent, Antwerp, Brussels, Liège and Charleroi) was launched in 2016. Outside Europe there are two facilities in Vancouver (Canada) and one medically supervised injecting centre in Sydney (Australia)."

"Perspectives On Drugs: Drug consumption rooms: an overview of provision and evidence," European Monitoring Centre for Drugs and Drug Addiction, June 2017, p. 3, last accessed Nov. 8, 2017.

6. Effectiveness and Impact of Drug Consumption Rooms and Supervised Injection Facilities

"The effectiveness of drug consumption facilities to reach and stay in contact with highly marginalised target populations has been widely documented (Hedrich et al., 2010; Potier et al., 2014). This contact has resulted in immediate improvements in hygiene and safer use for clients (e.g. Small et al., 2008, 2009; Lloyd-Smith et al., 2009), as well as wider health and public order benefits.

"Research has also shown that the use of supervised drug consumption facilities is associated with self-reported reductions in injecting risk behaviour such as syringe sharing. This reduces behaviours that increase the risk of HIV transmission and overdose death (e.g. Stoltz et al., 2007; Milloy and Wood, 2009). Nevertheless, the impact of drug consumption rooms on the reduction of HIV or hepatitis C virus incidence among the wider population of injecting drug users remains unclear and hard to estimate (Hedrich et al., 2010; Kimber et al., 2010), due in part to the facilities’ limited coverage of the target population and also to methodological problems with isolating their effect from other interventions.

"Some evidence has been provided by ecological studies suggesting that, where coverage is adequate, drug consumption rooms may contribute to reducing drug-related deaths at city level (Poschadel et al., 2003; Marshall et al., 2011). A study in Sydney showed that there were fewer emergency service call-outs related to overdoses at the times the safe injecting site was open (Salmon et al., 2010).

"In addition, the use of consumption facilities is associated with increased uptake both of detoxification and drug dependence treatment, including opioid substitution. For example, the Canadian cohort study documented that attendance at the Vancouver facility was associated with increased rates of referral to addiction care centres and increased rates of uptake of detoxification treatment and methadone maintenance (Wood et al., 2007; DeBeck et al., 2011)."

"Perspectives On Drugs: Drug consumption rooms: an overview of provision and evidence," European Monitoring Centre for Drugs and Drug Addiction, June 2017, p. 5, last accessed Feb 22, 2018.

7. Public Safety and Community Response to Supervised Injection Facilities and Drug Consumption Rooms

"Evaluation studies have found an overall positive impact on the communities where these facilities are located. However, as with needle and syringe programmes, consultation with local key actors is essential to minimise community resistance or counter-productive police responses. Drug treatment centres offering supervised consumption facilities have generally been accepted by local communities and businesses (Thein et al., 2005). Their establishment has been associated with a decrease in public injecting (e.g. Salmon et al., 2007) and a reduction in the number of syringes discarded in the vicinity (Wood et al., 2004). For example, in Barcelona, a fourfold reduction was reported in the number of unsafely disposed syringes being collected in the vicinity from a monthly average of over 13 000 in 2004 to around 3 000 in 2012 (Vecino et al., 2013).

"The effect of the Sydney supervised injecting facility on drug-related property crime and violent crime in its local area was examined using time series analysis of police-recorded theft and robbery incidents (Freeman et al., 2005). No evidence was found that the existence of the facility led to either an increase or decrease in thefts or robberies around the facility. Similarly, a study by Wood and colleagues compared the monthly number of charges for drug trafficking, assaults and robbery — crimes that are commonly linked to drug use — in Vancouver’s Downtown Eastside the year before versus the year after the local drug consumption room opened and found that the establishment of the facility was not associated with a marked increase in these crimes (Wood et al., 2006)."

"Perspectives On Drugs: Drug consumption rooms: an overview of provision and evidence," European Monitoring Centre for Drugs and Drug Addiction, June 2017, p. 5, last accessed Feb 22, 2018.

8. Public Health Benefits of Supervised Injection Facilities and Drug Consumption Facilities

"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."

Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 47.

9. Effectiveness and Benefits of Supervised Consumption Facilities

"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."

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.

10. Effectiveness of Australian SIF

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."

MISC Evaluation Committee, "Final Report on the Sydney Medically Supervised Injecting Centre" (New South Wales, Australia: MISC Evaluation Committee, 2003), p. xiv.