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.

11. Supervised Injection Facilities and Reductions in Overdose Mortality

"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 in 88%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."

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.

12. Supervised Injection Facilities and 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."

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.

13. Drug Consumption Facilities Bring Underserved Populations Into Contact With Healthcare and Treatment Services

"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."

Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 41.

14. SIFs and Referrals to Treatment

"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."

"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.

15. SIFs, 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."

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
Abstract: http://www.ncbi.nlm.nih.gov/pu...

16. Benefits of SIFs - Improvements in Public Order and Reductions in Crime

"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."

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.

17. Public Order, Overdose Mortality, and 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."

Nat M.J. Wright, Charlotte N.E. Tompkins, "Supervised Injecting Centres," British Medical Journal, Vol. 328, Jan. 10, 2004, p. 101.

18. Cost 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."

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.

19. Cost-Effectiveness of Proposed Supervised Injection Facility in Montreal, Canada

"The model used here [18], 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) [40].
"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)."

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

20. Estimated Number of Safe Injection Facilities (SIFs) worldwide, 2009

"As of 2009, there were 65 safe injection facilities operating in 27 cities in eight countries."

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.