Overdose Prevention Centers / Safe Consumption Spaces / Supervised Inhalation Rooms / Supervised Injection Facilities

"Our review found at the individual-level that SCFs were efficacious in reducing drug use related infection and disease transmission, enhancing access to addiction and other health services, and reducing the risk of non-fatal overdoses, and were not associated with a significant increase in drug use. These findings challenge the notion that SCFs may perpetuate substance use and lead to increased use among PWID. With regard to non-fatal overdose, the evidence over the past ten years have been largely been qualitative and would benefit from the use of quantitative methods that help to approximate causality. For example, the use of a propensity score modeling may help to determine the effectiveness of SCFs for individual-level outcomes based on observational or cross-sectional data (Hullsiek and Louis, 2002). Future studies may also want to consider the use of comparison groups or cities to examine the different factors influencing the effectiveness of SCFs. Additionally, we found emerging evidence that SCFs provide PWID with a sense of community that may support their overall wellbeing, thereby increasing their chances of accessing addiction treatment services. However, this evidence came qualitative studies (Rance and Fraser, 2011; Jozaghi and Andresen, 2013; Davidson et al., 2018; Kerman et al., 2020), and provides a future direction for research examining the impact of SCFs."

"Future quantitative studies may want to include a validated measure of wellbeing and sense of belonging. In particular, longitudinal studies should examine the degree to which a sense of belonging and having a supportive community may play a role in injection cessation and help-seeking behaviors for SCF attenders. At the community level, the evidence shows that SCFs were not associated with an increased rate of drug-related crime, and were linked to a decrease use of other costly public services (e.g. ambulance transport to hospital following an overdose). However, this evidence is still growing and requires additional research that accounts for other cofounding relationships using a longitudinal, inferential research design. Furthermore, we found that SCFs were associated with a reduction in public disorder, including less public disposal of syringes and use in public spaces. Future research should consider the gathering information from multiple sources (e.g. community members, service providers, police services) to examine the impact of SCFs on the public. Finally, there appear to be significant cost-benefits associated with SCFs, yet all of these studies have focused on the benefits related to the reduction of infectious disease transmission and injection-related death. Future studies should consider additional benefits related to the families of SCF attenders and reduction in community costs associated with decrease in public disorder."

"We observed that the increase in crack pipe distribution services coincided with a corresponding increase in the uptake of crack pipes obtained through health service points only. Further, rates of reporting health problems associated with crack smoking declined significantly after the crack pipe distribution program was implemented. In the multivariable analysis, compared to obtaining crack pipes through other non-health service sources only, obtaining pipes through health service points only was significantly and negatively associated with reporting health problems from smoking crack. These findings suggest that the recent expansion of crack pipe distributions in this setting has likely served to reduce health problems experienced by crack smokers, achieving the desired outcome of the program.

"While crack users are obtaining their safe crack smoking equipment from health service points, they may also be exposed to education around safer smoking techniques and practices, by being in direct contact with service providers in the community. This may also have the benefit of exposing drug users with no connections to health care to available providers in their area [27]. A previous study of an outreach-based crack smoking kit distribution service indicated that unsafe smoking practices such as using Brillo pads and sharing crack paraphernalia remained prevalent, even after the implementation of the service [10], suggesting the importance of placing such service in a continuum of broader health service system and ensuring the availability of smoking kits to reduce risky smoking behaviours."

"Our findings of a reduction of health problems, are consistent with harm reduction programs for people who inject drugs [19], including needle exchange programs and supervised injection sites, where they are effective in reducing overall negative health consequences. By providing users with high-quality smoking equipment and reducing the dependence on unsafe equipment, the unintended negative consequences, including exploding pipes, burns, and inhaling brillo fragments, are further reduced."

"Increasingly, SCS are incorporating services to address the risks associated with consuming adulterated drugs from the toxic drug supply. These services include incorporating drug checking services [60, 61] and the provision of pharmaceutical grade alternatives to street drugs (e.g., safe supply) [62, 63]; although these services are largely targeted to people who use opioids and often do not address the needs of people who use stimulants [64]. As these services are relatively recent developments, they were not discussed in the included articles and therefore the extent to which they are incorporated within SCS that allow non-injection routes of consumption remains unclear. However, the current emphasis on innovative solutions to the overdose crisis [65] highlights the need for SCS to be responsive to the needs of their participants. Furthermore, the current COVID-19 pandemic has also demonstrated the importance of flexibility in response to the evolving needs of SCS participants [66]. People who smoke illegal drugs may be particularly at risk for complications associated with respiratory illness [67]. Many people who use drugs have been impacted by sudden closures of their SCS due to their inability to meet public health directives [68, 69], while other SCS had to reduce their capacity to meet physical distancing requirements [70]. The operational characteristics of both injection and non-injection SCS should be flexible and continuously adapted to address local needs and context."

"Between November 30, 2021, and January 31, 2022, 613 individuals used OPC services 5975 times across 2 sites. Most individuals identified as male (78.0%), and 55.3% identified as Hispanic, Latino, or Latina. The mean (range) age was 42.5 (18-71) years. A plurality of individuals (36.9%) reported being street homeless. Fewer than one-fifth of individuals (17.8%) were living in their own rooms or apartments (Table).

"In self-reported data, the drug most commonly used across 2 sites was heroin or fentanyl (73.7%) and the most frequent route of drug administration at the OPC was injection (65.0%). Among all participants, 75.9% reported that they would have used their drugs in a public or semipublic location if OPC services had not been available (Figure).

"During the first 2 months of OPC operation, trained staff responded 125 times to mitigate overdose risk. In response to opioid-involved symptoms of overdose, naloxone was administered 19 times and oxygen 35 times, while respiration or blood oxygen levels were monitored 26 times. In response to stimulant-involved symptoms of overdose (also known as overamping), staff intervened 45 times to provide hydration, cooling, and de-escalation as needed. Emergency medical services responded 5 times, and participants were transported to emergency departments 3 times. No fatal overdoses occurred in OPCs or among individuals transported to hospitals.

"More than half of individuals using OPC services (52.5%) received additional support during their visit. This included, but was not limited to naloxone distribution, counseling, hepatitis C testing, medical care, and holistic services (eg, auricular acupuncture)."

"We found a range of rules and criteria across the different SCS. Many SCS enacted eligibility criteria that risk excluding the populations most in need of the service. For example, women who use drugs are more likely to experience violence and are at a higher risk of bloodborne virus infections [71], yet some SCS policies (e.g., excluding people who are pregnant or who have children with them), disproportionately impact women attempting to access SCS. Many SCS did not permit people who are younger than 18 years of age to consume drugs on site. This is problematic because youth who consume illegal drugs are at heightened risk of hazardous consumption patterns or other activities (e.g., sex work) that increase risk of exposure to blood-borne viruses [72, 73]. Excluding people who wish to access these services on the basis of age does not take into account their needs [74, 75], and eliminates an opportunity to improve health outcomes amongst an especially vulnerable subpopulation of people who use drugs. Furthermore, SCS typically have limited operating hours, commonly operating only during the day. Recent research indicates that program participants and consumption patterns vary according to the time of day, with an increase in vulnerable populations (e.g., women and those experiencing homelessness) and stimulant use during night hours [76]. Restricting operating hours may also increase harms to vulnerable subpopulations of people who use drugs (e.g., violence, overdose). In contrast, several SCS sought to address these service gaps by specifically targeting populations of women, including those who engage in sex work [32, 33, 44], permitting people under 18 to access the SCS [33], operating 23–24 h per day [36, 77, 78], or extending hours past midnight [32, 33, 79]."

"Supervised inhalation rooms (SIR) have the potential to minimise the aforementioned barriers to care and harms associated with crack cocaine smoking [12,21]. Modelled after supervised injection facilities, SIRs are regulated environments in which people can smoke pre-obtained drugs with sterile equipment under the supervision of nurses or other trained staff [22]. These facilities aim to reduce high-risk drug use practices and blood-borne infections, increase contact between PWUD and health and social services, and improve public order through reductions in public drug use [23]. To date, SIRs have been implemented in seven countries: Canada, Germany, Luxembourg, Netherlands, Switzerland, Spain and France [24–26]. In contrast with the significant evidence of the health and community benefits of supervised injection sites, rigorous evaluation of the specific outcomes of SIRs is lacking [24,27]. However, it is plausible that many of the demonstrated health benefits associated with supervised injection sites could extend to SIRs, with available evidence suggesting that SIRs have potential to improve public order, connect PWUD with health and social services, and reduce drug-related harms [11,25]."

"A 2014 meta-analysis of 75 studies concluded that OPCs have largely fulfilled their initial objectives;³⁹ the implementation of new OPCs in places with high rates of IDU and its associated harms appears to be supported by the existing evidence.³⁹ Methodological caveats notwithstanding, drug use supervision and overdose management have the potential to provide health benefits to at-risk PWID as well as economic advantages to the larger community. The preponderance of the evidence suggests these sites are able to provide sterile equipment, overdose reversal, and linkage to medical care for addiction, in the virtual absence of significant direct risks like increases in drug use, drug sales, or crime. OPCs may represent a novel way of addressing some of the many challenges presented by the overdose crisis, and they could contribute to reduced morbidity and mortality, and improved public health.

"Based on the above considerations, there is a clear need for more rigorous research and evaluation of OPCs. Given the amount and quality of the existing data, it may be prudent to consider the American Medical Association’s recommendation of developing and implementing OPC pilot programs in the United States designed, monitored, and evaluated to generate locality-relevant data to inform policymakers on the feasibility and effectiveness of OPCs in reducing harms and health care costs related to IDU.⁹⁴

On November 30, 2021, the Office of the Mayor of the City of New York announced that "the first publicly recognized Overdose Prevention Center (OPC) services in the nation have commenced in New York City. OPCs are an extension of existing harm reduction services and will be co-located with previously established syringe service providers."

According to the release:
"OPCs, also referred to as supervised consumption sites or facilities, are safe places where people who use drugs can receive medical care and be connected to treatment and social services. OPC services are proven to prevent overdose deaths, and are in use in jurisdictions around the world. There has never been an overdose death in any OPC. A Health Department feasibility study found that OPCs in New York City would save up to 130 lives a year.

"Additionally, OPCs are a benefit to their surrounding communities, reducing public drug use and syringe litter. Other places with OPCs have not seen an increase in crime, even over many years.

"OPCs will be in communities based on health need and depth of program experience. A host of City agencies will run joint operations focused on addressing street conditions across the City, and we will include an increased focus on the areas surrounding the OPCs as they open."

"Gov. Dan McKee has signed legislation introduced by Majority Floor Manager John G. Edwards (D-Dist. 70, Tiverton, Portsmouth) and Sen. Joshua Miller (D-Dist. 28, Cranston, Providence) that authorizes a two-year pilot program to prevent drug overdoses through the establishment of harm reduction centers, which are a community-based resource for health screening, disease prevention and recovery assistance where persons may safely consume pre-obtained substances.

"The law (2021-H 5245A, 2021-S 0016B) authorizes facilities where people may safely consume those substances under the supervision of health care professionals. It requires the approval of the city or town council of any municipality where the center would operate."

"We estimated nearly 3.7 million people, or 1.5% of the US adult population, injected drugs in 2018. This estimate is more than 5 times the most recent US estimate of ∼774,000 from 2011 [25]. Much of this increase is likely attributable to increases in IDU, but it is important to consider methodological differences in the creation of this 2018 estimate vs the 2011 estimate. The 2011 estimate was based on self-reported IDU among respondents to household surveys [26], but the present estimate combines available data on substance-specific overdose deaths and treatment admissions with cohort and cross-sectional data collected from known PWID. Applying the same data sources and analytic methods used for the 2018 estimate to 2011 yields an estimated 1.3 million PWID in 2011, which suggest the 2018 estimate is closer to 3 times higher than in 2011. By any measure, these estimates suggest the number of PWID has increased substantially in the U.S. during the past decade.

"One of the primary contributions of this estimate is the transparent, replicable nature of the methods described. Overdose data specifically among PWID in the United States continue to be relatively sparse, both in research and surveillance data. We used the best data currently available for each input, which are subject to limitations in some cases given data sparsity. For example, we used the meta-analyzed ratio of fatal to nonfatal overdose among PWID in OECD countries rather than a ratio specific to the United States, which was unattainable given currently available data. The uncertainty associated with this meta-analyzed ratio is reflected in confidence intervals around estimates presented here. Our intention is that, as surveillance systems implemented in the United States in recent years mature [39], resulting data can be used to refine and update this PWID population size estimate.

"Notwithstanding data input limitations, this updated estimate provides a data point for monitoring the US PWID population size over time and can inform strategies to reduce transmission of infectious diseases. In recent years, political will has been building to eliminate HCV and HIV infections in the United States [27, 28]. Both bloodborne infections disproportionately affect PWID but are highly preventable using evidence-based interventions, such as provision of sterile syringes through syringe services programs and substance use treatment [40–43], as well as treatment of prevalent infections with antiretroviral therapy [44] and direct-acting antivirals [45]. Increases in IDU prevalence will threaten the success of elimination strategies for HCV and HIV infections in the absence of concomitant increases in availability of harm reduction services and treatment for both infectious diseases and substance use. These services will need to be substantially scaled up nationally to meet the needs of nearly 4 million people [46].

"In addition to the high burden of infectious diseases, PWID experience preventable mortality and morbidity due to drug overdose. Overall, the rate of overdose deaths increased from approximately 6 per 100,000 persons to 22 per 100,000 persons during 1999–2019 [21], and provisional data indicate the number of overdose deaths increased by another 31% during just 1 year of the pandemic era from March 2020 to March 2021 [24]. During the pandemic era in particular, many questions remain about the extent to which increased overdose mortality rates are attributable to injection initiation vs changes in injection behaviors or the drug supply as well as to disruptions in access to treatment and recovery support services and harm reduction services. These estimates provide a prepandemic baseline and can improve our understanding of potential increases vs changes in pandemic-era injection behavior."

"In conclusion, we found that areas where SCS were implemented in Toronto subsequently had significant reductions in overdose mortality incidence, although other areas in the city did not. Furthermore, we found an inverse spatial association between SCS and overdose mortality incident locations, and this association increased in magnitude over time. This finding suggests that the implementation of SCS could contribute to reductions in overdose mortality in proximal areas. Criticisms of SCS have focused on the lack of evidence of their capacity to meaningfully affect population-level overdose mortality.8 Our finding of potential positive community spillover effects of SCS suggests that, beyond their immediate capacity to reverse onsite overdoses among onsite clients, they might also contribute to population-level overdose prevention efforts. As such, the inclusion of population-level metrics to evaluate the effectiveness of SCS is not only warranted but can also inform policy planning regarding SCS service design, implementation, and operation."

"Another major gap globally is the lack of diverse harm reduction services to match the diversity of drugs being used around the world. In Latin America and the Caribbean, for instance, stimulant drugs are more frequently used than opioids. Yet the availability of harm reduction interventions for these substances is insufficient.^114,115,116  Some civil society organisations run peer-led drug-checking initiatives designed for stimulants in Argentina, Brazil, Chile, Uruguay, Peru, Colombia and Mexico,h but these interventions are typically unsanctioned and lack official government support.¹¹⁷ 

"These services have traditionally been aimed at people who use stimulants in the nightlife scene.¹¹⁸  In Western Europe, where drug checking services are available in 12 countries, these services have also produced data and information on the substances available and emerging trends across the region.^119,120,121  In Eurasia, where nine countries have introduced drug checking services to some extent, they all appear to be operating in a legally grey area. An exception is Slovenia, where drug checking services are part of a National Early Warning System on psychoactive substances. In Hungary, Estonia, Czechia, Croatia, Lithuania, Georgia, Ukraine and Poland, drug checking services distribute reagent test kits (mostly in nightlife settings), people perform tests themselves and are invited to come back to discuss the results.¹²² 

"These initiatives could be part of a beneficial package of harm reduction strategies for people who inject drugs, offering alternatives to injecting.¹²⁴ We can report that safer smoking equipment is distributed in at least 25 countries, up from 19 in 2022, with new smoking equipment distribution initiatives reported in Bulgaria, Greece, Ireland, Mexico, Puerto Rico and South Africa. This is an important though limited development. People who smoke drugs are a seriously underserved subpopulation of people who use drugs. For example, in Africa, we can identify only one country that makes safer smoking equipment available (South Africa). Similarly in Asia, we can report availability in only one country (Indonesia).¹²"

"In conclusion, we found that areas where SCS were implemented in Toronto subsequently had significant reductions in overdose mortality incidence, although other areas in the city did not. Furthermore, we found an inverse spatial association between SCS and overdose mortality incident locations, and this association increased in magnitude over time. This finding suggests that the implementation of SCS could contribute to reductions in overdose mortality in proximal areas. Criticisms of SCS have focused on the lack of evidence of their capacity to meaningfully affect population-level overdose mortality.8 Our finding of potential positive community spillover effects of SCS suggests that, beyond their immediate capacity to reverse onsite overdoses among onsite clients, they might also contribute to population-level overdose prevention efforts. As such, the inclusion of population-level metrics to evaluate the effectiveness of SCS is not only warranted but can also inform policy planning regarding SCS service design, implementation, and operation."

"Drug consumption rooms have been defined as professionally supervised healthcare facilities where people who use drugs can do so in safer and more hygienic conditions (Hedrich et al., 2010). Importantly, they aim to offer hygienic conditions, often supervision by medically trained staff, and a safe environment where people can use drugs without fear of arrest or legal repercussions. DCRs are intended to complement existing prevention, harm reduction and treatment interventions, and are known by various names (see Box 1). DCRs may differ significantly across, and even within, jurisdictions as they are adapted to local needs and regulatory frameworks. This is also an intervention area that is rapidly changing both in terms of approach and models of service delivery. It is important to note that both the diversity in programme design and the dynamic nature of service development in this area means that generalisations need to be made with caution.

"To date there are more than 140 legally-sanctioned DCRs operating in a number of cities in 11 European countries, as well as in Australia, Canada, Mexico and the USA."

"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)."

"DCRs are generally established with the aim of addressing a mix of individual health, public health and public order objectives. These services typically aim to reach out to and maintain contact with the most marginalised populations of people who use drugs — those experiencing high barriers to accessing medical and social support — and to provide a gateway through which these groups can connect with a broader range of health and social support services. DCRs further seek to reduce overdose-related morbidity and mortality, and prevent the spread of infectious diseases by offering access to sterile equipment, safer use advice and emergency interventions. By giving people who use drugs the opportunity to consume in a calm, hygienic and supervised environment DCRs also aim to reduce harms resulting from the broader ‘risk environment’ that socially marginalised or excluded groups may be exposed to as a consequence of multiple interacting physical, social, economic and policy factors (Rhodes, 2002).

"In addition, DCRs aim to play a role in combating stigma by treating people who use drugs with dignity and supporting them in multiple aspects of social integration, such as finding employment and housing.

"DCRs are usually set up in areas near urban drug markets that are characterised by high rates of public drug use. By providing a space for safe consumption that is sheltered from public view they may also have the objective of reducing drug use in public and to improve public amenities (e.g., through fewer improperly discarded syringes and less drug-userelated waste in general). In this respect DCRs can be characterised as a response to public order and safety concerns regarding drug scenes while creating an improved environment for local residents (see, e.g., Hedrich et al., 2010; Potier et al., 2014; Schäffer et al., 2014; EMCDDA, 2018).

"The specific goals and objectives of DCRs can vary between cities and may change over time. The first DCRs, established in the 1980s and early 1990s in Swiss, Dutch and German cities, emerged as a local component of HIV prevention and focused on bringing populations of street-based heroin injectors closer to care. Three decades later, the most prominent argument for supporting the scaling up of DCRs in North America relates to their role as part of a comprehensive response to the opioid/fentanyl overdose crisis and the need to curb extremely high levels of opioid-related morbidity and mortality in this region."

"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."

"Results  No significant changes were detected in violent crimes or property crimes recorded by police, 911 calls for crime or medical incidents, or 311 calls regarding drug use or unsanitary conditions observed in the vicinity of the OPCs. There was a significant decline in low-level drug enforcement, as reflected by a reduction in arrests for drug possession near the OPCs of 82.7% (95% CI, −89.9% to −70.4%) and a reduction in their broader neighborhoods of 74.5% (95% CI, −87.0% to −50.0%). Significant declines in criminal court summonses issued in the immediate vicinity by 87.9% (95% CI, −91.9% to −81.9%) and in the neighborhoods around the OPCs by 59.7% (95% CI, −73.8% to −38.0%) were observed. Reductions in enforcement were consistent with the city government’s support for the 2 OPCs, which may have resulted in a desire not to deter clients from using the sites by fear of arrest for drug possession.

"Conclusions and Relevance  In this difference-in-differences cohort study, the first 2 government-sanctioned OPCs in the US were not associated with significant changes in measures of crime or disorder. These observations suggest the expansion of OPCs can be managed without negative crime or disorder outcomes."

"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."

"This systematic review of 22 effectiveness studies relayed evidence of the public health benefits of SIFs for SIF clients as well as to surrounding communities. The strongest evidence suggests that SIFs may help reduce overdose morbidity and mortality and improve access to addiction treatment. An increase in crime, an often-cited concern of SIF opponents, was not observed to be associated with SIFs in most included studies, and crime was actually found to decrease in 2 studies (1 greatest and 1 least suitability of design)."

"SCS are a core part of a public health response to an unprecedented poisoning epidemic that has resulted in 36,442 opioid toxicity deaths between January 2016 and December 2022, driven largely by the production and trafficking of novel illegally manufactured opioids (Public Health Agency of Canada, 2021). SCS provide monitored spaces where people can consume drugs without risk of criminal sanction, receive emergency health care if needed, and access sterile harm reduction supplies and health and social supports (Health Canada, 2020). The number of federally sanctioned SCS in Canada increased from two in 2016 to a peak of 42 in 2020 (Health Canada, 2020). Additionally, more than 40 overdose prevention sites—a low-threshold form of SCS meeting an immediate community need and requiring less pre-implementation consultation—have opened in Canada since 2016. Collectively, these services have prevented and managed thousands of drug poisoning events and saved thousands of lives (Irvine et al., 2019).

"SCS are designed to reduce health and social risks, including risks associated with using drugs alone amid a toxic drug supply crisis. They also provide social support for structurally vulnerable populations who experience barriers to accessing health care (Kennedy et al., 2017). A substantial body of peer-reviewed research demonstrates the positive impacts of SCS. A systematic review by Kennedy et al. (with findings later corroborated by Levengood et al.) synthesized 47 studies from Vancouver, Australia, Germany, Denmark, Spain, and the Netherlands (Kennedy et al., 2017; Levengood et al., 2021). Studies adopted a mix of prospective cohort, time series or pre/post ecological, cross-sectional, mathematical simulation, or series cross-sectional designs and the majority were assessed to have good methodological quality. The review found that SCS mitigate drug poisoning–related harm and unsafe drug use practices, facilitate uptake of substance use treatment and other health services, are associated with improvements in public order (e.g., reductions in publicly discarded syringes), do not increase drug-related crime, and are cost-effective. A subsequent modelling study estimated that British Columbia’s overdose prevention sites averted 230 deaths in a 20-month period (Irvine et al., 2019). A study from Calgary, Alberta, found significant health system cost-savings arising from decreases in opioid-related ambulance responses and emergency department visits following the implementation of an SCS (Khair et al., 2022)."

"Findings show that smoking drugs is a popular route of administration among people who use drugs and evidence from this review suggests that expanding access to safer smoking within harm reduction services is crucial to risk mitigation. Within the studies included in this review, most study participants, including people who smoke drugs, peers, and service providers, believed safer smoking services to be a necessary harm reduction intervention, especially when considered in relation to existing safer injection services [39, 40, 42,43,44, 51, 54, 56, 63, 64, 67, 68]. Further, across studies, people who use drugs reported a high willingness to utilize these services, and in places where services were offered, many studies reported high utilization of safer smoking services. Additionally, although efficacy data were limited, across studies, people who use drugs reported decreasing their injection drug use in favor of smoking, reducing the sharing of smoking equipment, and in some cases improved health outcomes (e.g., decreased burns and cuts). Despite the clear benefits of safer smoking practices, some people who use drugs and service providers reported ongoing barriers to accessing and delivering these services, respectively. Findings underscore the need for ongoing research and structural interventions to increase access to safer smoking programs and reduce drug use related morbidity and mortality.

"This is a burgeoning area of research, which we expect to grow and evolve as policies shift, more funding becomes available for the inclusion of safer smoking kits into harm reduction service offerings, and the benefits of these practices become more well known. In fact, since the time that this search was conducted, a new study was published in May 2023 that showed high interest in using safer smoking materials, with participants believing it would reduce their injection use of drugs. As additional studies are published, including those that are based on higher quality evidence, we anticipate a need to update this review in future years [70].

"Despite evidence that smoking has benefits over injecting [39, 40, 42,43,44, 51, 54, 56, 63, 64, 67, 68], across studies, people who use drugs report programs providing safer smoking materials are a minority among harm reduction organizations globally. Ongoing work is needed to incorporate safer smoking materials into the services provided by existing harm reduction organizations. The studies reviewed here provide evidence of the presence of peer workers who are part of these communities as people with lived experience and found peers to be integral in engaging people who use drugs and assisting them with changing their practices. Further outreach to educate people who use drugs about smoking as a harm reduction practice is necessary, including the nuanced benefits and risks associated with it."

"Historically, harm reduction principles are actualized when individuals and groups take sometimes illegal measures to protect their communities. Once systemic structures recognize the value in these practices, they might become decriminalized and widely supported by public health institutions. As an example, supervised consumption sites have been created; these are spaces where individuals can use drugs in a sterile and monitored space with access to supplies and care. Legalized in certain European nations, Canada, and Australia, supervised consumption sites in the U.S. operated quietly and against the law [8]. With increased evaluations published globally, and within the country on unsanctioned supervised consumption sites [9], we see increased receptiveness in academic circles. In the U.S., this illicit practice of providing safe spaces to consume drugs recently gained popular ground with Rhode Island becoming the first state to legalize supervised consumption sites [10], and OnPoint in New York City opening the first SCS in the U.S. [11]. Other recent innovations in public health lifted up by the advocacy of people who use drugs include drug checking and safer smoking initiatives."

"The MDCR [Mobile Drug Consumption Room] is the first DCR in Portugal and has an integrated model of care, meaning that it provides a safer space for injected consumption, and basic healthcare, psychosocial support, peer education, referral to other health services, and assistance for clients to navigate the health and social systems. Among the MDCR's services, rapid testing for HIV, viral hepatitis and syphilis are open to all community members, regardless of whether they use drugs. The MDCR is housed in a van, allowing it to travel between locations, and has two spaces for consumption and an office. The team running the MDCR is multidisciplinary, consisting of peer workers, nurses, psychologists and social workers."

"DCRs have been legally possible in Portugal for almost two decades but have not before been implemented. The overhaul of Portugal’s drug policy is summarized in the 1999 National Drug Strategy, which lays out a shift toward a less repressive drug policy and one centered on humanism, pragmatism, and public health. In 2001, both the decriminalization of low-level possession and use of illicit drugs and the Decree-law 183, regulating harm reduction responses, came into effect. DCRs are among the harm reduction measures detailed. However, the relevant law restricts DCR locations to areas that are not densely populated. The opening of a MDCR, which is part of a larger initiative by the city government and harm reduction NGOs to open 3 DCRs, two fixed and one mobile, allows service of the densely populated urban center. Only injection consumption is possible in the van due to limited space and lack of smoke extraction capacities."

"In France, as elsewhere, people who inject drugs (PWID) faced a dramatic HIV epidemic in the 1990s. In response, the French government’s harm reduction policy, which first developed programmes for access to sterile injection material in 1987, extended access in 1994 to include syringe vending machines and the sale of ready-to-use injection kits (Steribox) in community pharmacies,¹ as well as new state-funded needle exchange programmes (NEP).² These public health initiatives were concomitant with opiate maintenance treatment (OMT) programmes with methadone (available since 1994) and buprenorphine (available since 1995)^{3 4} and HAART for HIV-infected individuals.⁵ HIV prevalence in PWID dramatically decreased from 40% to 20% in 14 years from 1988 to 2002,^{2 6} with a prevalence in 2011 of 10%.⁷ An estimated 77% to 85% of opioid-dependent individuals in France are currently treated with OMT."

"Drug consumption rooms (DCR) are in place for more than three decades in Europe and have been proven to be effective as a public health response. However, their implementation remains slow and controversial in many countries. In Portugal, despite being legal since 2001, the first DCR only came into reality in 2019 by the initiative of the City Council of Lisbon."

"In 2021, NY State and the USA elected executive branch leaders who publicly supported harm reduction as a public health approach to reducing overdose deaths. In April 2021, the Biden administration explicitly listed “enhancing evidence-based harm reduction efforts” as a drug policy priority for its first year in office, which NYC interpreted as potentially aligned with the concept of OPCs. Similarly, members of President Biden’s senior leadership team, including Secretary of Health and Human Services Xavier Becerra, voiced harm reduction as a priority, although they did not go so far as to endorse OPCs as a strategy. At the state level, NYS ushered in a new administration in 2021, including newly appointed health leadership who had previously contributed to efforts to explore OPCs in prior roles and was on record as supporting OPCs. Although NYS was not on an immediate path to formally authorize OPCs through executive or legislative action, it appeared that NYS would not interfere if an OPC were to open in NYC."

"NYC engaged in a series of discussions with local, state, and federal stakeholders to gauge the viability of opening OPCs in the absence of clear authorization. Strong political engagement of local stakeholders—including the New York City Police Department (NYPD), district attorneys, and local elected officials—was critical to not only mitigate risks of local enforcement against OPC operations but also to ensure successful service provision. Education and engagement of city agencies and elected officials have been ongoing since the release of the feasibility report in 2018. In the ensuing years, the NYC Health Department facilitated multiple visits to OPCs in Europe and Canada to allow local leaders, including senior NYPD officials and some district attorneys, to witness OPC operations and community health and safety impacts. Following the city’s renewed commitment to OPCs in 2021, the NYC Health Department conducted briefings for local elected officials and NYC District Attorneys to secure support for or, at minimum, neutrality toward OPCs.

"One significant component of the NYC Health Department’s local political engagement strategy was to consistently advocate for OPCs as the evidence-based, structural response to not only prevent overdose deaths but also reduce public drug use and syringe litter—neighborhood quality of life issues that were particularly salient for community members, local businesses, visitors, elected officials, and city agencies during the summer of 2021. For example, NYC framed OPCs as one intervention to address public drug use in the city’s “joint operations” initiativeFootnote4, a collaboration among the NYC Health Department, Department of Homeless Services, Police Department, health + hospitals, and the Department of Sanitation. By consistently citing the strong evidence base for OPCs, the NYC Health Department was able to develop buy-in across agencies in support of OPCs as an actionable strategy to address the overdose epidemic and reduce public drug use.

"In addition to discussions at the local level, extensive engagement with federal and state officials was necessary to assess and mitigate the risk of interference, particularly in the absence of clear endorsements of OPC operations from the federal and state governments. NYC Health Department and the de Blasio administration informed leadership at the NYS Governor’s Office, NYS DOH, and NYS Office of Addiction Services and Supports (OASAS) of NYC’s intention to implement OPCs in NYC as well as federal leaders at Health and Human Services (HHS), Substance Abuse and Mental Health Services (SAMHSA), and the Office of National Drug Control Policy (ONDCP)Footnote5. Ultimately, in response to the unprecedented number of fatal overdoses reported in 2020, Mayor de Blasio made the decision to endorse OPCs in NYC without explicit support or legal authorization from the federal or state government."

"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’).

"Breaking this down further, as of April 2018 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; one in Luxembourg; and 12 in eight cities in Switzerland.

"In Ireland, a law (Misuse of Drugs Act Supervised Injection Facilities 2017) was passed to enable licensing and regulation of such facilities. In the same month, the locations and area of operation of two fixed, and one mobile, supervised drug consumption facilities were announced in Lisbon, Portugal. The services are expected to become operational in the second half of 2018 and early 2019. Based on a feasibility study on drug consumption facilities in five major cities in Belgium (Ghent, Antwerp, Brussels, Liège and Charleroi), recommendations were presented to Belgian policymakers in February 2018 (Vander Laenen et al., 2018).

"Increasing opioid overdose deaths and research on two existing supervised injection sites in Vancouver are among the factors that currently see various municipalities establishing such facilities across Canada (Kerr et al., 2017; www.sallesdeconsommation.com). In Australia, a medically supervised injecting centre is under preparation in Melbourne, following the model of the existing facility in Sydney."

"As with any service provided to the public, NYC Health Department viewed community engagement and education as critical to the success of OPCs, particularly given the stigma that substance use providers and participants often face. Prior to implementation, the NYC Health Department conducted general educational briefings with local community groups and leaders in neighborhoods across the city, including those where the OPCs would be located. This entailed conducting broad public education and engagement about harm reduction as an effective and life-saving approach to drug use and the overdose crisis while incorporating information about OPCs as an additional proven public health strategy to prevent fatal overdoses. Similar to political engagement strategies, materials used for community engagement further emphasized the strong evidence supporting the impact of OPCs in improving public safety and addressing concerns about syringe litter and public drug use.

"Through our education efforts, including attendance at Community Board and other community group meetings, the city emphasized the value that an OPC could bring to directly address many of these quality-of-life-related concerns, including syringe litter and public drug use. Furthermore, it was beneficial that OPC services were slated to open in existing SSP facilities, which also house wraparound health and social services, avoiding the need to site a new location."

"Once OPCs were operating in NYC, local Community Board members and other local leaders were invited to tour the sites and see the services firsthand. This has been a powerful tool to demystify OPCs and educate observers about harm reduction. It was helpful, in terms of building community support, that OnPoint already had strong community relationships developed over more than 20 years of operating an SSP. As a result of OnPoint NYC’s consistent community engagement, many community leaders and elected officials have grown to appreciate their work and now serve as strong advocates for OPC services. Some have even called for the expansion of OPC services to other boroughs.

"The city also faced opposition from community boards and several advocacy groups in East Harlem and Washington Heights. In East Harlem, in particular, the local community board felt that the opening of an OPC in their community would contribute to an existing “oversaturation” of social and addiction services in the area. Below is an excerpt from a letter to the NYC Health Department, Community Board 11, regarding oversaturation concerns, May 17, 2022:

"Like, so many other low-income communities of color, East Harlem has been burdened with hosting more than its fair share of social service facilities, including an oversaturation of mental health and substance abuse treatment and prevention programs. Individuals from not just the five boroughs but as far as Westchester and Long Island participate in programs in our community. This has created a strain on resources and contributed to a range of quality of life and public safety concerns for years on end.

"It has remained critical that the NYC Health Department continue to highlight the connection to services/care provided at OPCs, including provision of substance use disorder treatment on-site or through referrals. Since the OPCs opened, briefings for community stakeholders have continued and now include information about the benefits and successes of the OPCs while providing a forum to respond to community questions."

"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).

"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)."

"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)."

"A growing body of data supports the need to deliver HIV prevention in low-barrier settings where PWUD already access services [9]. With opioid use disorder (OUD) increasingly recognized as a chronic and relapsing disease, evidence-based treatment (including medications for OUD [MOUD], harm reduction services, and others) should be integrated into primary care, pharmacies, methadone clinics, social services organizations, fire stations, or other settings alongside other chronic conditions. For example, a clinic may designate a clinic room as their OPS, with injection supplies, peer support, and healthcare personnel available to respond in case of an overdose. To patients, this could signal a non-stigmatizing culture, acknowledge that clinicians should support a patient when their substance use disorder is most active, and may facilitate discussions on MOUD during ongoing use. Drawing on successes of syringe exchange and other peer-based approaches to harm reduction, PWUD should be meaningfully included throughout program development and implementation.

"A decentralized model may have additional benefits. A majority of clients may travel only 1 mile or less to use an OPS [10], meaning that any single location may be inaccessible to some. Decentralized services would assist regions without geographically concentrated drug use. Additionally, the current epidemics, driven by illicitly manufactured fentanyl and stimulants, require frequent injection events—suitable to a decentralized model allowing multiple access points throughout the day. Finally, as federal approval or funding for OPS operation is unlikely in the near future, a decentralized model using existing healthcare infrastructure may minimize costs and improve feasibility."

"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’)."

"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."

"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."

"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."

"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."

"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."

"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."

"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."

"Among IDU [Injection Drug Users] 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 enrollment in addiction treatment programs was positively associated with injection cessation. Although SIF in other settings have been evaluated based on wide range of outcomes (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; Wood et al., 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. While these findings are encouraging, it is concerning that Aboriginal participants were less likely to enter addiction treatment. This finding is consistent with prior reports (Wood et al., 2005a; Wood et al., 2007b), and highlights the need for innovative and culturally appropriate addiction treatment services developed with full consultation with Aboriginal people who use 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."

"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."

"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)."

"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.'"

"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."

"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."

"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."

"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."

"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."

"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."

"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."

"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."

"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."

"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."

"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 [8]. 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."

"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."

"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."

"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."

"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."

"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."

"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."

"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."

"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."

"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.'"