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Public Health and Public Order Outcomes Associated with Supervised Drug Consumption Facilities: a Systematic Review

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Purpose of Review: Supervised drug consumption facilities (SCFs) have increasingly been implemented in response to public health and public order concerns associated with illicit drug use. We systematically reviewed the literature investigating the health and community impacts of SCFs. Recent Findings: Consistent evidence demonstrates that SCFs mitigate overdose-related harms and unsafe drug use behaviours, as well as facilitate uptake of addiction treatment and other health services among people who use drugs (PWUD). Further, SCFs have been associated with improvements in public order without increasing drug-related crime. SCFs have also been shown to be cost-effective. Summary: This systematic review suggests that SCFs are effectively meeting their primary public health and order objectives and therefore supports their role within a continuum of services for PWUD. Additional studies are needed to better understand the potential long-term health impacts of SCFs and how innovations in SCF programming may help to optimize the effectiveness of this intervention.
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THE SCIENCE OF PREVENTION (JD STEKLER AND J BAETEN, SECTION EDITORS)
Public Health and Public Order Outcomes Associated
with Supervised Drug Consumption Facilities: a Systematic
Review
Mary Clare Kennedy
1,2
&Mohammad Karamouzian
1,3
&Thomas Kerr
1,4
#Springer Science+Business Media, LLC 2017
Abstract
Purpose of Review Supervised drug consumption facilities
(SCFs) have increasingly been implemented in response to
public health and public order concerns associated with illicit
drug use. We systematically reviewed the literature investigat-
ing the health and community impacts of SCFs.
Recent Findings Consistent evidence demonstrates that SCFs
mitigate overdose-related harms and unsafe drug use behav-
iours, as well as facilitate uptake of addiction treatment and
other health services among people who use drugs (PWUD).
Further, SCFs have been associated with improvements in
public order without increasing drug-related crime. SCFs have
also been shown to be cost-effective.
Summary This systematic review suggests that SCFs are ef-
fectively meeting their primary public health and order
objectives and therefore supports their role within a continu-
um of services for PWUD. Additional studies are needed to
better understand the potential long-term health impacts of
SCFs and how innovations in SCF programming may help
to optimize the effectiveness of this intervention.
Keywords Supervised drug consumption facilities .
Supervised injection facilities .Illicit drug use .Harm
reduction .Systematic review
Introduction
Illicit drug use remains a major global public health con-
cern and, in particular, is a key driver of HIV/AIDS and
overdose epidemics [14]. Public drug use and public dis-
posal of syringes are also community concerns in various
settings, particularly in inner-city neighbourhoods [5]. In
an effort to mitigate these challenges, supervised drug con-
sumption facilities (SCFs) have been established in a num-
ber of cities worldwide [6,7]. SCFs are healthcare facil-
ities that provide sterile equipment and a safe and hygienic
space for people who use drugs (PWUD) to consume pre-
obtained illicit drugs under the supervision of nurses or
other trained staff [7]. SCFs are also referred to as drug
consumption rooms and include supervised injection facil-
ities (SIFs), which accommodate people who inject drugs
(PWID), and supervised inhalation rooms (SIRs), which
accommodate people who inhale drugs.
Although SCFs vary in design and operational proce-
dures, the aims of SCFs are similar across sites [8,9].
Specifically, the primary objectives of SCFs are to attract
higher-risk PWUD and to offer the following public
health and public order benefits: (1) reduce the harms
associated with illicit drug use, including fatal overdose
This article is part of the Topical Collection on The Science of Prevention
Electronic supplementary material The online version of this article
(doi:10.1007/s11904-017-0363-y) contains supplementary material,
which is available to authorized users.
*Thomas Kerr
uhri-tk@cfenet.ubc.ca
1
British Columbia Centre on Substance Use, University of British
Columbia, St. Pauls Hospital, 608-1081 Burrard Street,
Vancouver, BC V6Z 1Y6, Canada
2
School of Population and Public Health, University of British
Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada
3
HIV/STI Surveillance Research Center and WHO Collaborating
Center for HIV Surveillance, Institute for Futures Studies in Health,
Kerman University of Medical Sciences, Kerman, Iran
4
Department of Medicine, University of British Columbia, St. Pauls
Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6,
Canada
Curr HIV/AIDS Rep
DOI 10.1007/s11904-017-0363-y
and infectious disease transmission; (2) connect PWUD
with addiction treatment and other health and social ser-
vices; and (3) reduce public order and safety problems
associated with illicit drug use (e.g. public drug use, pub-
licly-discarded syringes) [8,9]. Since the first legally-
sanctioned SCF opened in Berne, Switzerland in 1986
[7], these facilities have increasingly been implemented
and there are now more than 90 SCFs operating interna-
tionally [7]. Nonetheless, concerns regarding the poten-
tial negative consequences of SCFs, including that these
may promote drug use and crime, have made these facil-
ities difficult to implement [8,10,11].
In recent years, the evidence specific to SCFs has grown
considerably. However, previous reviews of this evidence
have suffered from some notable methodological short-
comings, including employment of search strategies that
were narrow in scope, application of broad study eligibility
criteria that resulted in the inclusion of low-quality evi-
dence, and/or lack of assessment of the quality of included
evidence [6,8,12]. Guided by the primary health and
public order objectives of SCFs noted above, the purpose
of the present study was to systematically review existing
quantitative research on the health and community out-
comes associated with SCFs. In addition, we sought to
identify underexplored opportunities to inform future re-
search specific to SCFs.
Methods
Search Strategy
Following the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) guidelines for sys-
tematic reviews (see Supplement 1)[13], we searched for
SCF studies published in the following databases from incep-
tion to May 01, 2017: MEDLINE,EMBASE,Web of Science,
PsychINFO,Google Scholar and CINAHL. Search terms were
combined using appropriate Boolean operators and included
the subject heading terms or key words related to SCFs (see
Supplement 2for a detailed search strategy). In addition to
electronic databases, we searched the reference lists of re-
trieved studies, relevant conference proceedings and key
journals in the area of addiction. We also conducted a com-
prehensive grey literature search (i.e. dissertations, reports).
We did not restrict our search to a specific language.
Inclusion and Exclusion Criteria
The population, interventions, comparisons, outcomes and
study designs considered in the review are listed in Table 1.
Study Screening, Data Extraction and Analysis
Title and abstract screening were conducted to identify studies
that potentially met our inclusion criteria. Full texts of all
potentially eligible studies were retrieved (MCK) and inde-
pendently assessed for eligibility by two authors (MCK and
MK). Disagreements between the authors were resolved
through discussion. Extracted data on study-specific informa-
tion were summarized narratively and in a structured table.
Quality Assessment
Quality assessment of cohort, cross-sectional and pre-post
studies was conducted using the 14-item National Heart,
Blood and Lung Institute (NHBLI) Quality Assessment Tool
for Observational Cohort and Cross-Sectional Studies [14]or
the 12-item NHBLI Quality Assessment Tool for Before-After
(Pre-Post) Studies [15], as appropriate. Quality assessment for
cost-effectiveness studies was completed using the Joanna
Briggs Institutes Critical Appraisal Checklist for Economic
Evaluations [16].
Results
As shown in Fig. 1, database searching yielded 1476 records,
and hand searching yielded an additional 85 records to ac-
count for a total of 1469 potentially eligible studies after dupli-
cate removal. Of these, 1128 records were excluded through
title and abstract screenings. Assessment of the full text of the
remaining341recordsresultedintheexclusionofanadditional
294 studies. In total, 47 studies published between 2003 and
2017 met the eligibility criteria and were included in the review.
Summary of Included Studies
Of the 47 included studies, the majority (n= 28) were con-
ducted in Vancouver, Canada; ten were conducted in Sydney,
Australia; and the remaining studies were conducted in the
following European countries: Germany (n= 4), Denmark
(n=2),Spain(n= 2) and the Netherlands (n=1).
Seventeen studies employed prospective cohort designs,
while the remaining studies employed times series or pre-
post ecological (n=10),cross-sectional(n= 9), mathematical
simulation (n=8)orseriescross-sectional(n=3)designs.
Study quality scores are presented in Table S13. Overall,
most studies had good methodological quality. Additional
study-specific information (including study location, design,
participant characteristics, exposure(s), outcome(s), and main
findings) is presented in Table 2.
Curr HIV/AIDS Rep
Objective 1: to Reduce the Harms Associated with Illicit
Drug Use
1a. Overdose-Related Morbidity and Mortality
Of eight studies examining overdose-related outcomes [18,
20,21,29,36,37,49,52], six suggested a protective effect of
SCFs [18,20,29,37,49,52]. For example, the establishment
of Insite, Vancouvers largest SIF, was associated with a 35%
reduction in overdose deaths in the immediate vicinity of the
SIF after the facility opened, compared to a 9% reduction in
the rest of the city [52]. An earlier simulation study found that
Insite averts an estimated 1.9 to 11.7 overdose deaths per year
[37].Similarfindingshavebeenobservedinecologicaland
simulation studies conducted in Germany [18,20]. Likewise,
the establishment of the SIF in Sydney, Australia, was associ-
ated with declines in opioid poisoning emergency department
presentations [29] and ambulance attendances at opioid-
related overdoses near the SIF [49]. However, there were no
statistically significant changes in the number of opioid-
related deaths in the neighbourhood of the SIF compared to
the rest of the state after the SIF opened [29]. Another Sydney
Tabl e 1 Population, interventions, comparisons, outcomes and study design (PICOS) criteria for study inclusion
Criteria Definition
Population People who use or inject drugs and the broader communities in which supervised drug consumption
facilities (SCFs) are located
Interventions
a
Use, establishment or operation of SCFs
Comparisons No exposure to SCFs
Outcomes
a
All individual- or population-level health or social outcomes
Study design
b
Original quantitative studies that assessed associations between SCFs and outcome(s) of interest for statistical
and/or apriori-defined clinical significance
a
Original quantitative research studies were included if they examined the relationship between any aspect of use, establishment or operation of SCFs
(including any service provided within SCFs) and any individual- or population-level health or social outcome (with significance assessed through an
appropriate statistical test; the estimation of a measure of association (such as an odds ratio or rate ratio) and 95% confidence intervals; or an a priori-
defined effect size considered to be of clinical significance). Feasibility studies that considered potential outcomes associated with the hypothetical
establishment of SCFs were excluded. Studies that examined SCF use as an outcome were excluded, as examining characteristics of SCF users was
beyond the scope of the present study. We also excluded studies that examined outcomes associated with exposure to larger facilities with integrated
SCFs (unless use or operation of the SCF specifically was examined)
b
Review articles, case reports, case series, commentaries, editorials, qualitative studies and descriptive studies (that did not assess statistical or a priori-
defined clinical significance) were excluded. If separate records presented overlapping results, the publication with the most complete information was
included
Records identified through
database searching
(n = 1476)
Screening
Included Eligibility Identification
Additional records identified
through other sources
(n = 85)
Records after duplicates removed
(n = 1469)
Records screened
(n = 1469)
Records excluded
(n = 1128)
Full-text articles assessed
for eligibility
(n = 341)
294 full-text articles
excluded:
SCF not exposure or SCF
definition not met (n =
94)
Outcome(s) not eligible
(n = 19)
Study design not eligible
(n = 170)
Overlapping/duplicate
data (n = 11)
Studies included in
systematic review
(n = 47)
Fig. 1 Flowchart of record
screening and selection process.
From [17]
Curr HIV/AIDS Rep
Tab l e 2 Summary of included studies examining health and community outcomes associated with supervised drug consumption facilities (SCFs), arranged chronologically (n= 47)
Authors Location Study design Participants Exposure(s) Outcome(s) Main findings
Poschadel et al.
2003 [18]
Saarbrüken, Hannover,
Hamburg and Frankfurt,
Germany
Time series N/A Establishment of SCFs Monthly police records of
drug-related deaths
After the establishment of SCFs,
there were significant reductions
in drug-related deaths in the four
respective cities (all p<0.05].
Zurhold et al.
2003 [19]
Hamburg, Germany Cross-sectional 616 people who use illicit
drugs (PWUD) who
used the SCF; mean age
32.6 years; 20% female
Frequent (daily) SCF use;
occasional (< daily to
weekly) SCF use; rare
(< weekly) SCF use
Self-reported utilization of
other services since
began visiting SCFs (yes
vs. no)
Frequent SCF users were more likely
to use syringe exchange services
compared to occasional or rare
visitors (59 vs. 54 and 44%,
respectively; p< 0.05). The same
was true of counselling services
(corresponding percentages = 46
vs. 35 and 25%; p< 0.01),
medical services (37 vs. 29 and
17%; p<0.01)andeducationon
safer use (9 vs. 3 and 3%;
p< 0.05).
Hedrich 2004
b
[20] Germany Mathematical
simulation
N/A Operation of SCFs Estimated annual overdose
fatalities prevented
An estimated > 10 deaths are
preventedbySCFsinGermany
each year.
vanBeeketal.
2004 [21]
Sydney, Australia Cross-sectional
(derived from
prospective
cohort)
3747 people who inject
drugs (PWID) and used
supervised injection
facility (SIF)
Frequent SIF use (top
quartile of the visits
frequency distribution
during the study period
(i.e. 11+ visits during
17-month study period,
measured through SIF
database))
Non-fatal overdose at SIF
during the study period
(yesvs.no),measured
through SIF database
In multivariable logistic regression
analyses, frequent SIF use was
positively associated with
experiencing a non-fatal overdose
within the SIF (AOR = 6.1; 95%
CI 4.38.6).
Wood et al. 2004 [5] Vancouver, Canada Pre-post
ecological
N/A Establishment of SIF
(6 weeks before vs.
12 weeks after SIF
opened)
Number of people injecting
in public,
publicly-discarded
syringes and
injection-related litter in
the 10 blocks
surrounding the SIF
(measured by researcher
counts)
The SIF opening was associated with
reductions in the number of
people injecting in public (mean
daily # 2.4 (95% confidence
interval [CI] 1.93.0) after vs. 4.3
(95% CI 3.55.4) before SIF
opening), publicly discarded
syringes (mean daily # 5.4 (95%
CI 4.76.3) after vs. 11.5 (95% CI
10.013.2) before SIF opening),
and injection-related litter (mean
daily # 310 (95% CI 305317)
after vs. 601 (95% CI 590613)
before SIF opening) (all p<0.05)
Freeman et al.
2005 [22]
Sydney, Australia Time series N/A Establishment of SIF Police-recorded trends in
theft and robbery
incidents; drug use and
drug dealing (measured
by proxy of drug-related
and total loiterers,
The SIF opening did not contribute
to significant changes in trends
(increases/decreases) in theft
incidents, robbery incidents or
drug-related loitering at the front
of SIF after it opened (all
Curr HIV/AIDS Rep
Tab l e 2 (continued)
Authors Location Study design Participants Exposure(s) Outcome(s) Main findings
counted by hired
personnel)
p> 0.05). There were slight
increases in drug-related loitering
at the back of the SIF and total
loitering at both the back and front
of the SIF after opening (all
p< 0.05).
Kerr et al. 2005 [23] Vancouver, Canada Cross-sectional
and
retrospective
analyses
(derived from
prospective
cohort)
431 PWID Self-reported SIF use (all,
most or some vs. few or
no injections at SIF) in
the previous 6 months
Self-reported syringe
sharing(borrowingor
lending) in the previous
6 months (yes vs. no)
In multivariable logistic regression
analyses, SIF use was associated
with reduced syringe sharing
(AOR = 0.30; 95% CI
0.110.82). The odds of syringe
sharing between SIF users and
non-users were similar prior to the
SIF opening (p=0.50),
suggesting that the observed
reduction in syringe sharing
among SIF users was not due to
the SIF selecting PWID at
inherently lower risk of syringe
sharing.
Thein et al.
2005 [24]
Sydney, Australia Series cross-
sectional
515 and 540 residents;
209 and 207 business
owners in the 2
respective study years
(i.e. 2000 and 2002)
Establishment and
operation of SIF
(17 months after vs.
7 months before)
Support for SIFs; whether
or not SIF reduces risk of
HIV/HCV; reduces
publicly discarded
syringes; show dangers
of injecting; reduces
public injection;
encourages drug
injection; attracts
PWUD; encourages
belief that heroin
injection is legal; makes
law enforcement difficult
(all yes vs. no)
The level of support for the SIF
significantly increased in the
neighbourhood of established SIF
(68 to 78%, p< 0.001) among
residents. There was no significant
change in support for the SIF
among business owners
(p> 0.20). There was an increase
in the proportion of residents who
agreed that SIFs reduce risk of
HIV/ HCV (87 to 92%,
p= 0.0004) and reduce discarded
syringes (80 to 82%, p= 0.01).
There was an increase in the
proportion of residents who
disagreed that SIFS encourage
illicit drug injection (62 to 73%,
p< 0.001), or encourage belief
that heroin injection is legal (44 to
52%, p=0.006).Among
business owners, there was an
increase in the proportion who
agreed that SIFs reduce public
injection (67 to 72%, p= 0.01)
and show dangers of injecting
drug use (47 to 51%, p< 0.001),
and there was a decrease in the
Curr HIV/AIDS Rep
Tab l e 2 (continued)
Authors Location Study design Participants Exposure(s) Outcome(s) Main findings
proportion who agreed that SIFs
encourage people to think that
heroin injection is legal (55 to
43%, p=0.001).
Woo d et al .
2005 [25]
Vancouver, Canada Cross-sectional
(derived from
prospective
cohort)
582 PWID who used SIF
(479 HIV-negative and
103 HIV-positive at
baseline); 30% female
Self-reported exclusive SIF
use for injection drug use
in the previous month
(yes vs. no)
Self-reportedborrowinga
used syringe in the
previous 6 months
among HIV-negative
participants; Lending a
used syringe in the
previous 6 months
among HIV-positive
participants (both yes vs.
no)
In bivariable logistic regression
analyses, exclusive SIF use was
associated with decreased odds of
syringe borrowing among
HIV-negative participants
(OR = 0.14; 95% CI 0.000.78)
but was not significantly
associated with syringe lending
among HIV-positive participants
(OR = 0.94; 95% CI 0.007.90).
Kerr et al. 2006 [26] Vancouver, Canada Prospective
cohort
871 PWID; median age
(IQR) 35.3 (28.641.3)
years; 39% female
Establishment of SIF (year
after the SIFs opening
vs. the year before)
Self-reported relapse into
injection among former
users; stopping injecting;
introduction
/discontinuation of
methadone
There were no substantial changes in
rates of relapse into injection drug
use (17 to 20%), stopping injected
drug use (17 vs. 15%), starting
methadone use (11 vs. 7%), or
stopping methadone use (13 vs.
11%).
Woo d et al .
2006 [11]
Vancouver, Canada Pre-post
ecological
N/A Establishment of SIF (year
before vs. year after SIF
opened)
Police-recorded drug
trafficking and
drug-related crime in
neighbourhood of SIF
There were no increases in the
number of drug trafficking
offences (124 vs. 116, p=0.803)
or assaults/robbery offences (174
vs. 180, p= 0.565). A decline was
observed in vehicle
break-ins/vehicle theft offences
(302 vs. 227, p=0.001).
Woo d et al .
2006 [27]
Vancouver, Canada Prospective
cohort
1031 PWID who used the
SIF
a
Regular SIF use (weekly
vs. < weekly) in the
previous 6 months; any
contact with an
addictions counsellor at
the SIF in the previous
6 months (both
measured through the
SIF database)
Use of detoxification
service (measured
through database
linkage)
In multivariable Cox regression
analyses, regular SIF use
(AHR = 1.72; 95% CI 1.252.38)
and contact with the SIF
addictions counsellor
(AHR = 1.98; 95% CI 1.263.10)
were associated with more rapid
time to entry into a detoxification
programme.
Kerr et al. 2007 [28] Vancouver, Canada Prospective
cohort
1065 PWID who used the
SIF
a
N/A Rate of initiation into
injection drug use at the
SIF (measured through
self-report and
subtracting age at first
injection from current
age)
Among the entire population of SIF
users (n= ~ 5000), the estimated
number who may have initiated
injection drug use inside the SIF
since the SIF opened was 5 (95%
CI 212), which is comparatively
lower than the expected rate of
initiation into injection drug use
among local street-involved youth
Curr HIV/AIDS Rep
Tab l e 2 (continued)
Authors Location Study design Participants Exposure(s) Outcome(s) Main findings
during a similar follow-up period
(100 initiations; 95% CI 81122).
NCHECR 2007
b
[29]
Sydney, Australia Pre-post
ecological
1652 opioid-related deaths;
1558 opioid poisoning
presentations at
emergency departments
(EDs)
Establishment of SIF
(60 months after vs. 36
prior to opening)
Opioid-related deaths
(measuredbythestate
health department);
opioid poisoning
presentations at two EDs
(measuredbyED
records)
There was a significant decrease
from an average of 4 to 1 deaths
per month in the immediate
vicinity of the SIF after the SIF
was established (p< 0.001),
compared to a decrease from 27 to
8 deaths in the rest of the state
(p< 0.001). This difference in
rate changes was not statistically
significant (p=0.877).Therewas
a significant decrease from an
average of 11 to 7 opioid
poisoning ED presentations (35%
reduction) after the SIF
establishment (p< 0.001).
Salmon et al.
2007 [30]
Sydney, Australia Series
cross-sectional
515, 540 and 316 residents
and 269, 207 and 210
business operators in the
3 respective study years
(i.e. 2000, 2002 and
2005)
Establishment and
operation of SIF
Witnessed public injection
in last month; publicly
discarded syringes in last
month; drugs offered for
purchase in the last
month (all yes vs. no)
The proportions of residents who had
witnessed public injecting in the
last month were 33, 28 and 19% in
2000, 2002 and 2005, respectively
(p< 0.001), while the
corresponding proportions for
business operators were 38, 32,
and 28% (p= 0.03). The
proportion of residents who had
seen publicly discarded syringes
in the last month was 67, 58 and
40% in 2000, 2002 and 2005,
respectively (p< 0.001) while the
corresponding proportions for
business owners were 72, 64 and
57% (p= 0.01). The proportion of
residents who had been offered
drugs for purchase in the last
month was 28, 29 and 26% in
2000, 2002 and 2005 (p=0.80).
The corresponding proportions for
business owners were 33, 34 and
28% (p=0.26).
Stoltz et al.
2007 [31]
Vancouver, Canada Cross-sectional
(derived from
prospective
cohort)
760 PWID who used SIF
a
Consistent SIF use (25%
of injections vs. < 25%)
in the previous 6 months
Self-reported changes since
SIF opening in: syringe
reuse; rushed injecting;
injecting outdoors; use
of sterile water; cooking
or filtering drugs; tying
off; safer syringe
In multivariable logistic regression
analyses, consistent SIF use was
positively associated with a
change in each injection
behaviour: reuse syringes less
often (AOR = 2.04; 95% CI
1.383.01), less rushed during
Curr HIV/AIDS Rep
Tab l e 2 (continued)
Authors Location Study design Participants Exposure(s) Outcome(s) Main findings
disposal; easier finding
vein; injecting in clean
place (all yes vs. no)
injection (AOR = 2.79; 95% CI
2.033.85), less injecting outdoors
(AOR = 2.70; 95% CI
1.933.87), using clean water for
injecting (AOR = 2.99; 95% CI
2.134.18), cooking or filtering
drugs prior to injecting
(AOR = 2.76; 95% CI
1.844.15), tying off prior to
injection (AOR = 2.63; 95% CI
1.584.37), safer disposal of
syringes (AOR = 2.13; 95%
CI1.473.09), easier finding of a
vein (AOR = 2.66; 95% CI
1.833.86) and injecting in a clean
place (AOR = 2.85; 95% CI
2.093.87).
Woo d et al .
2007 [32]
Vancouver, Canada Prospective
cohort
1031 PWID who used SIF
a
Establishment of SIF (year
before vs. year after SIF
opened)
Enrolment in detoxification
service; number of visits
to the SIF in the month
after detoxification
enrolment (both
measured through
database linkage)
In multivariable generalized
estimated equations (GEE) with
logit link analyses, there was a
significant increase in uptake of
detoxification services in the year
after vs. the year before the SIF
opened (AOR = 1.32; 95% CI
1.111.58). In multivariable Cox
regression analyses, detoxification
service use was associated with
more rapid entry into MMT
(AHR = 1.56; 95% CI 1.042.34)
and other forms of addiction
treatment (AHR = 3.73; 95% CI
2.575.39). Among those who
enrolled in detoxification, the rate
of SIF use declined in the month
after enrollment compared to the
rate of SIF use in the month prior
to enrolment (19 vs. 24 visits,
p= 0.002).
Bayoumi and Zaric
2008 [33]
Vancouver, Canada Mathematical
simulation
Estimated 3000 to 20,000
PWID infected with HIV
and/or HCV
SIF operation (simulation
over 10 years)
Cost-effectiveness of the
SIF based on the
prevention of incident
HIV and HCV infections
(with the SIF vs. without
the SIF)
An estimated 1191 incident HIV and
54 incident HCV cases were
averted over 10 years, resulting in
an estimated minimum savings of
$CAD 14 million and 920 years
of life gained over 10 years.
Kimber et al.
2008 [34]
Sydney, Australia Prospective
cohort
3715 PWID who used SIF;
47% > 30 years; < 40%
female
Frequent SIF use (top
quartile of the visits
frequency distribution
Addiction treatment referral
(received at least one
written referral during
In multivariable Cox regression
analyses, frequent SIF use was
positively associated with drug
Curr HIV/AIDS Rep
Tab l e 2 (continued)
Authors Location Study design Participants Exposure(s) Outcome(s) Main findings
during the 17 month
studyperiod(i.e.12+
visits, measured through
SIF database))
the study period);
Addiction treatment
uptake (use of referral
card, yes vs. no).
treatment referral (AHR = 1.6;
95% CI 1.22.2) but was not
significantly associated with drug
treatment referral uptake
(AOR = 0.8; 95% CI 0.42.0).
Lloyd-Smith et al.
2008 [35]
Vancouver, Canada Prospective
cohort
1065 PWID who used SIF
a
Self-reported exclusive SIF
use for injection drug use
in the previous 6 months
(yes vs. no)
Current cutaneous
injection-related
infection (CIRI),
measured visually by
study nurse (yes vs. no)
In multivariable generalized linear
mixed-effects analyses, exclusive
SIF use was not significantly
associated with development of a
CIRI (AOR = 0.58; 95% CI
0.291.19).
Milloy et al.
2008 [36]
Vancouver, Canada Prospective
cohort
1090 PWID who used SIF
a
Self-reported frequent SIF
use in the previous
6months(75 vs.
< 75% of injections);
self-reporting that SIF
use had resulted in a
change in injection
practices in the previous
6 months (yes vs. no).
Self-reported non-fatal
overdose in the previous
6 months (yes vs. no)
In multivariable GEE analyses,
frequent SIF use was not
associated with recent non-fatal
overdose (AOR 1.01; 95% CI
0.771.32). In bivariable GEE
analyses, reporting that SIF use
had changed injection practices
was not associated with recent
non-fatal overdose (AOR = 0.77;
95% CI 0.531.11).
Milloy et al.
2008 [37]
Vancouver, Canada Mathematical
simulation
453 potentially fatal
overdose events out of
766,486 injections
during the study period
Operation of SIF Overdose deaths averted An estimated 1.9 to 11.7 overdose
deaths are averted per year.
Richardson et al.
2008 [38]
Vancouver, Canada Prospective
cohort
1090 PWID who use SIF
a
Self-reported SIF use (25
vs. < 25% of i njections)
in the previous 6 months
Self-reported employment
(job with regular salary
or temporary work) in
the previous 6 months
(yes vs. no)
In multivariable GEE analyses, SIF
use was not associated with
employment (AOR = 1.05; 95%
CI 0.881.27).
Woo d et al .
2008 [39]
Vancouver, Canada Prospective
cohort
1087 PWID who used SIF
a
Self-reported frequent SIF
use (75 vs. < 75% of
injections) in the
previous 6 months
Self-reported receipt of
safer injection education
at the SIF in the previous
6 months (yes vs. no)
In multivariable GEE with logit link
analyses, frequent SIF use was
associated with an increased
likelihood of receiving safer
injection education at the SIF
(AOR = 1.47; 95% CI
1.221.77).
Bravo et al.
2009 [40]
Barcelona and Madrid,
Spain
Cross-sectional
(derived from
prospective
cohort)
249 people who inject
heroin aged 30 years or
younger (137 in
Barcelona; 112 in
Madrid); 76%
> 25 years; 26% female
Any use of at least one of
five SIFs since last
interview
(mean = 17.3 months
[SD = 5.7 months])
Self-reporting of not
borrowing used
syringes; not sharing
injection equipment
since the last interview
(yes vs. no)
In multivariable logistic regression
analyses, SIF use was associated
with not borrowing used syringes
(AOR = 3.3; 95% CI 1.47.7).
SIF use was not significantly
associated with not sharing
injection equipment (AOR = 1.1;
95% CI 0.52.2).
Marshall et al.
2009 [41]
Vancouver, Canada Prospective
cohort
794 PWID who used the
SIF and reported sexual
Time since recruitment
from the SIF (measured
Consistent condom use
during vaginal and/or
In multivariable GEE with logit link
analyses, use of SIF healthcare
Curr HIV/AIDS Rep
Tab l e 2 (continued)
Authors Location Study design Participants Exposure(s) Outcome(s) Main findings
activity during one or
more interviews
a
in SIF database);
self-reported use of
medical services at Insite
(e.g. nurse consultation,
HIV testing, referral to
health services) in the
previous 6 months (yes
vs. no)
anal intercourse in the
previous 6 months
(always vs. usually,
sometimes, occasionally,
never)
services was marginally
associated with consistent
condom use among those with
regular partners (AOR = 1.27;
95% CI 0.991.64) but not among
those with casual partners
(OR = 0.94; 95% CI 0.711.26).
Time since recruitment from the
SIF was associated with consistent
condom use among those with
regular partners (AOR = 1.29;
95% CI 1.061.55) but not those
with casual partners
(AOR = 1.15; 95% CI
0.901.47).
Milloy et al.
2009 [42]
Vancouver, Canada Prospective
cohort
902 PWID who used the
SIF
a
Self-reported frequent SIF
use (75 vs. < 75% of
injections) in the
previous 6 months
Self-reported incarceration
in the previous 6 months
(yes vs. no)
In multivariable GEE analyses,
frequent SIF use was not
associated with recent
incarceration (AOR 0.99; 95% CI
0.791.23).
Andresen and Boyd
2010 [43]
Vancouver, Canada Mathematical
simulation
Estimated 5000 PWID in
population
SIF operation Benefit cost-ratios for the
SIF based on prevention
of incident HIV
infections and overdose
deaths
Mathematical modelling estimated
that Insite prevents approximately
35 incident cases of HIV infection
and 3 overdose deaths per year,
providing an annual excess of $6
million with an average
cost-benefit ratio of 5.12:1.
Baars et al.
2010 [44]
Rotterdam, Utrecht and
South Limburg,
Netherlands
Cross-sectional 309 PWUD; mean age (SD)
41.5 (7.4) years; 22%
female
Self-reported SCF use at
least once in the last
6 months (yes vs. no)
Hepatitis B vaccination
programme awareness
(yes vs. no) and
self-reported uptake (yes
vs. no)
In multivariable logistic regression
analyses, SCF users were more
likely to be aware of Hepatitis B
vaccination programme than
non-users (AOR = 1.86; 95% CI
1.043.33), but SCF use was not
associated with Hepatitis B
vaccination uptake (p> 0.05; data
not shown).
Fitzgerald et al.
2010 [45]
b
Sydney, Australia Time series N/A Establishment and
operation of SIF
Police recorded trends of
criminal incidents of
robbery, property crime
and illicit drug offences
(use or deal
amphetamines narcotics
and cocaine)
Incidence of robbery and property
offences declined in both the
neighbourhood of SIF and the rest
of Sydney between 1999 and
2010. Illicit drug offence incidents
declined in the neighbourhood of
the SIF between 1999 and 2003
and then remained stable until
2009. A similar pattern was
observed in the rest of Sydney
(drug arrests declined from 1999
Curr HIV/AIDS Rep
Tab l e 2 (continued)
Authors Location Study design Participants Exposure(s) Outcome(s) Main findings
to 2003, but with a slight upward
trendfrom2003to2010).
Lloyd-Smith et al.
2010 [46]
Vancouver, Canada Prospective
cohort
1083 PWID who used SIF
a
Referral to hospital by a SIF
nurse (yes vs. no),
measured by linkage to
SIF database
Hospitalization for CIRI
(yes vs. no); duration of
hospitalization (in days),
both measured by
linkages to local hospital
inpatient database
In multivariable Cox regression
analyses, referral to hospital by
SIF nurses was associated with
increased likelihood of
hospitalization for CIRI
(AHR = 5.38; 95% CI
3.398.55). Referral to hospital by
SIF nurses was significantly and
independently associated with
shorter duration of stay in hospital
(4 days [IQR 27] vs. 12 days
[IQR 533]). Each referral by a
SIF nurse would result in an
estimated savings of $CAD 5696
[IQR $213618,512].
Milloy et al.
2010 [47]
Vancouver, Canada Prospective
cohort
1083 PWID who used SIF
a
Self-reported frequent SIF
use (75 vs. < 75% of
injections) in the
previous 6 months
Self-reported inability to
access addiction
treatment in the previous
6 months (yes vs. no)
In bivariable GEE with logit link
analyses, frequent SIF use was not
significantly associated with
trying but being unable to access
addiction treatment (OR = 1.08;
95% CI 0.841.40).
Pinkerton et al.
2010 [48]
Vancouver, Canada Mathematical
simulation
Estimated 5000 PWID Operation of SIF Annual number of HIV
infections and associated
costs
If the SIF ceased operating, there
would be an estimated increase
from 179.3 to 262.8 annual
incident HIV infections among
local PWID, which would be
associated with $CAD 17.6
million in lifetime HIV-related
healthcare costs. These savings
from future hypothetical
healthcare costs exceed the annual
operating costs of the SIF
(approximately $CAD 3 million).
Salmon et al.
2010 [49]
Sydney, Australia Pre-post
ecological
20,409 ambulance
attendees at
opioid-related overdoses
(1485 in the SIF
neighbourhood) before
and after the opening of
the SIF
Establishment and
operation of SIF
(36 months before vs.
60 months after the SIF
opened)
Average monthly
ambulance attendances
at suspected
opioid-related overdoses
in the vicinity of the SIF
vs. the rest of the state
(measured through
ambulance service
database)
After the opening of the SIF, the
average monthly ambulance
attendances at suspected
opioid-related overdoses declined
significantly in the immediate
vicinity of the SIF (by 68%)
compared to 61% in the rest of the
state during SIF operating hours
(p= 0.002). During the SIF
operating hours, this difference
was more pronounced with an
80% decline in the immediate
Curr HIV/AIDS Rep
Tab l e 2 (continued)
Authors Location Study design Participants Exposure(s) Outcome(s) Main findings
vicinity of the SIF compared to a
60% decline in the rest of the state
(p<0.001).
Scherbaum et al.
2010 [50]
Essen, Germany Prospective
cohort
129 PWID who initiated
use of the SIF or began
attending the SIF again
after 6+ weeks of
non-attendance; mean
age (SD) 31 (6); 25%
female
Changes over time (1, 2,
3 months after first use
of SIF vs. first use of
SIF)
Outdoor drug use; use of
non-sterile equipment;
equipment sharing;
injection-related
abscesses
Compared to baseline, at 1 month
follow-up of first use of the SIF,
the proportion of 71 participants
who reported outdoor drug use,
use of non-sterile equipment and
equipment sharing remained
relatively stable at approximately
50, 50 and 20%, respectively (all
p> 0.30). At 1 month follow-up
compared to baseline, the
proportion who had
injection-related abscesses was
similar (8.5 vs. 4.2%, p>0.30).
At 3 months follow-up of first use
of the SIF, the proportion of 26
participants who used drugs
outdoors, used non-sterile
equipment, shared equipment and
had abscesses were comparable to
baseline (all p> 0.30; data not
shown).
Debeck et al.
2011 [51]
Vancouver, Canada Prospective
cohort
1090 PWID who used SIF
a
Regular (weekly vs. <
weekly) SIF use at
baseline; Contact with
addictions counsellor (at
least once before event
or censor date) at the SIF
(both measured through
SIF database)
Self-reported uptake of
addiction treatment (all
treatment modalities
including residential
treatment and
methadone maintenance
therapy); self-reported
injection cessation for
6 months
In multivariable Cox regression
analyses, regular SIF use
(AHR = 1.33; 95% CI 1.041.72)
and having contact with the
addiction counsellor within the
SIF (AHR = 1.54; 95% CI
1.132.08) were independently
and positively associated with
initiation of addiction treatment.
Enrolment in methadone
maintenance therapy
(AHR = 1.57; 95% CI 1.022.40)
and other addiction treatment
(AHR = 1.85; 95% CI 1.063.24)
were positively associated with
injection drug use cessation.
Marshall et al.
2011 [52]
Vancouver, Canada Pre-post
ecological
290 decedents; median age
(IQR) 40 (3248) years;
21% female
Establishment of SIF
(2 years after vs. 2 years
prior to SIF opening)
Fatal overdose (measured
by coroner records)
Fatal overdose decreased by 35.0%
within 500 m from the SIF from
253.8 to 165.1 deaths per 100,000
person-years (p= 0.048) in the
2 years after the opening of the
SIF vs. the 2 years prior to the SIF
opening, compared to a 9.3%
Curr HIV/AIDS Rep
Tab l e 2 (continued)
Authors Location Study design Participants Exposure(s) Outcome(s) Main findings
reduction in fatal overdose from
7.6 to 6.9 per 100,000
person-years in the rest of the city
(p= 0.490). These rate changes
were significantly different
(p=0.049).
Pinkerton et al.
2011 [53]
Vancouver, Canada Mathematical
simulation
Estimated 5000 PWID in
population
Operation of SIF Annual number of HIV
infections and associated
costs
The SIF prevents an estimated
average of 5.6 infections year
(90% CI 4.07.6), reducing HIV
incidence by an estimated 611%
among local PWID and averting
more than $CAD 1 million in
future HIV-related healthcare
costs, and accounting for an
estimated $200,000$400,000 in
savings per year after considering
the SIFs operating costs.
Andresen and
Jozaghi 2012 [7]
Vancouver, Canada Mathematical
simulation
Estimated 5000 PWID in
population
SIF operation Cost-benefit ratios Mathematical modelling estimated
that the SIF prevents 22 incident
HIV infections per year, providing
an average cost-benefit ratio of
3.09:1.
Lloyd-Smith et al.
2012 [54]
Vancouver, Canada Prospective
cohort
1083 PWID who used SIF
a
Referral to hospital by a SIF
nurse (yes vs. no),
measured by linkage to
SIF database
ED use for CIRI (yes vs.
no), measured by linkage
to local hospital ED
database
In multivariable Cox regression
analyses, referral to hospital by
SIF nurses was independently and
positively associated with ED use
for CIRI among females
(AOR = 4.48; 95% CI 2.767.30)
and males (AOR = 2.97; 95% CI
1.934.57).
Donnelly and
Mahoney 2013
b
[55]
Sydney, Australia Time series N/A Establishment and
operation of SIF
Police-recorded trends in
criminal incidents of
robbery, theft and illicit
drug offences
Incidents of robbery and theft
incidents declined over time in
neighbourhood of SIF since it was
established (consistent with the
rest of Sydney) (all p< 0.001).
Possession of illicit substances
remained stable from May 2001
(when SIF opened) to 2008 but
increased from 2009 onwards in
both the neighbourhood of the SIF
and in the rest of Sydney. A
similar trend was documented
with crime rates per 100,000
population. There were no
changes in trends of drug-related
incidents occurring in the 50 m. of
the SIF during the study period.
Curr HIV/AIDS Rep
Tab l e 2 (continued)
Authors Location Study design Participants Exposure(s) Outcome(s) Main findings
Vecino et al.
2013 [56]
Barcelona, Spain Pre-post
ecological
N/A Establishment of SCFs
(after vs. before)
Monthly-averaged publicly
discarded syringes
(collected by local
services)
After the opening of two SCFs, there
was a significant reduction in the
average monthly number of
publicly discarded syringes (from
13.13 in 2004 to 3.19 in 2012).
Jozaghi and
Vancouver Area
Network of Drug
Users 2014 [57]
Vancouver, Canada Mathematical
simulation
Estimated 4330 people who
smoke crack cocaine
Operation of an
unsanctioned supervised
inhalation room (SIR)
Benefit-cost and
cost-effectiveness ratios
for the SIR based on
prevention of incident
HCV infections
The SIR prevented an estimated 57
incident cases of HCV infection
per year, providing average annual
savings of $CAD 1.8 million per
year with an average benefit-cost
ratio of 12.1:1 and a marginal
cost-effectiveness ratio ranging
from $CAD 1705 to 97,203.
Kinnard et al.
2014 [58]
Copenhagen, Denmark Cross-sectional 41 PWID who used SIF;
median age (IQR) 37
(30; 43) years; 9.8%
female
Opening of the SIF (after
vs. before)
Self-reported perceived
changes in syringe
disposal practices and
injection-related risk
behaviours
In total, 24 participants (58.5%)
reported changing syringe
disposal practices (with 23
reporting change from not always
to always disposing safely) after
the SIF opening (p< 0.001).
75.6% reported reductions in
injection risk behaviours after SIF
opening (63.4% less rushed
injecting; 56.1% fewer outdoor
injections; 53.7% stopped syringe
sharing; 43.9% cleaned injection
sites more often).
Skelton et al.
2016 [59]
Sydney, Australia Series
cross-sectional
SIF staff and clients Smoking cessation care
organizational change
intervention at the SIF
(after vs. before)
Self-reported receipt of
smoking cessation care
at the SIF (among SIF
users); self-reported
smoking cessation care
strategies (among SIF
staff)
In the post intervention period, more
SIF users reported receiving
smoking cessation care
(p<0.05),andmoreSIFstaff
reported providing verbal advice
regarding smoking cessation, offer
of free nicotine replacement
therapy, referral to a physician and
follow up to check on smoking
cessation progress (all p<0.01).
Toth et al. 2016 [60] Copenhagen, Aarhus and
Odense, Denmark
Cross-sectional 154 PWUD who used at
least one of five SCFs;
10% < 30 years; 25%
female
Self-reported receipt of
education in hygienic
injection practices at
SCF;
Self-reported referral to
medicalhelpbySCF
staff
Self-reported use of SCF to
access clean injection
equipment (yes vs. no);
Self-reported receipt of
treatment for condition
(yes vs. no)
Those who had received education
on hygienic injection practices at a
SCF were more likely to access
SCFs for clean injection
equipment vs. those who had not
received such education (68.8 vs.
25.9%, p= 0.024). Those advised
to seek medical help by staff for a
medical condition were more
likely to receive treatment for the
condition than who were not
Curr HIV/AIDS Rep
study found that frequent SIF clients were more likely to ex-
perience an overdose within the SIF, likely due to their greater
exposure time at the facility [21]. Finally, a study conducted in
Vancouver examined the association between frequent SIF
use and recent non-fatal overdose among PWID and produced
null results [36].
1b. Drug-Related Risk Behaviours
Nine studies evaluated the relationship between SCFs and
levels of drug use or drug-related behaviours that may in-
crease risk of infectious disease transmission and other harms
[23,25,26,28,35,40,50,58,62]. Of these, four studies
examined the relationship between SCF use and syringe shar-
ing [23,25,40,50], three of which provided evidence of an
inverse association [23,25,40]. For example, a cross-
sectional study of PWID in Vancouver found that regular
SIF users were 70% less likely to report borrowing or lending
used syringes, despite the fact that SIF users and non-users
reported similar levels of syringe sharing prior to the estab-
lishment of the SIF in retrospective analyses [23]. Two studies
(conducted in Demark and Vancouver) demonstrated an asso-
ciation between SCF use and decreased likelihood of other
types of unsafe injection behaviours, including reusing of sy-
ringes, injecting outdoors, and rushing injections, as well as an
increased likelihood of safe behaviours such as using clean
water for injecting, cooking or filtering drugs, and safely
disposing syringes [31,58]. Only one small German study
with a short follow-up period found no evidence of an
association between SCF use and injection-related risks
(e.g. public drug use; equipment sharing) [50]. This study
also found that SIF use was not significantly associated
with development of cutaneous injection-related infec-
tions, as was found in a prospective study conducted in
Vancouver [35,50]. With regard to drug use patterns, a
study undertaken in Vancouver found no substantial
changes in rates of relapse into injection drug use, ceasing
injection, ceasing binge drug use, or participation in meth-
adone maintenance therapy (MMT) after the SIF opened
among a prospective cohort of PWUD [26]. As well, an-
other prospective Vancouver study found that the rate of
recent initiation into injection drug use among SIF users was
markedly lower than the estimated background community-
level rate of injection initiation [28].
1c. Other Health and Social Outcomes
Two prospective cohort studies from Vancouver exam-
ined health or social outcomes among PWUD other than
overdose-related outcomes or drug-related behaviours [38,
41]. One of these found that SIF use was not significantly
associated with employment in multivariable analyses
[38]. The other study found that both use of SIF services
Tab l e 2 (continued)
Authors Location Study design Participants Exposure(s) Outcome(s) Main findings
advised to seek treatment for a
condition (51.3 vs. 25.7%,
p= 0.003).
Lysyshyn et al.
2017 [61]
Vancouver, Canada Cross-sectional 472 drug checks for
fentanyl at the SIF
Result of drug test for
fentanyl at the SIF
(positive vs. negative),
measured using a test
strip designed for urine
testing
Disposal of drugs; reduced
dose of drugs;
Experienced overdose at
the SIF (all yes vs. no),
all measured by SIF staff
Receiving a positive fentanyl result
was associated with increased
drug dose reductions (37 vs. 8%;
p< 0.05) but not disposals of
drugs (9 vs. 8%, p>0.05).A
positive fentanyl result was also
associated with overdosing at the
SIF (9 vs. 2%; p<0.05).
N/A not applicable; SCF supervised drug consumption facility, SIF supervised injection facility, SIR supervised inhalation room, PWUD people who use illicit drugs, PWID people who inject drugs, HCV
hepatitis C virus, ED emergency department, CIRI cutaneous injection-related infection, SD standard deviation, GEE generalized estimating equations
a
Median age (IQR): 38.4 (32.744.3), 29% female
b
Not peer reviewed
Curr HIV/AIDS Rep
and time since recruitment from the SIF were independent-
ly and positively associated with consistent condom use
among PWID with regular but not casual partners [41].
Objective 2: to Connect PWUD with Addiction Treatment
and Other Health and Social Services
2a. Addiction Treatment
Four studies provided evidence of a positive association
between SCF use and uptake of addiction treatment [27,32,
34,51]. For example, a prospective study of PWID in
Vancouver found that at least weekly SIF use and contact
with a SIF addictions counsellor were associated with more
rapid entry into detoxification programmes [27]. A follow-up
study demonstrated that rates of entry into detoxification
programmes among SIF users increased by more than 30%
in the year after compared to the year before the SIF was
established [32]. Further, this study found that such enrolment
in a detoxification programme was associated with earlier
entry into MMT and other forms of addiction treatment, as
well as subsequent declines in injections at the SIF [32]. An
additional prospective study in Vancouver found that at least
weekly SIF use was positively associated with enrolment in
addiction treatment, which in turn was associated with an
increased likelihood of injection cessation [51]. Similarly, a
prospective study of PWID in Sydney found that frequent SIF
use was positively associated with referral to addiction treat-
ment, although analyses with addiction treatment uptake as
the outcome produced null results [34]. In addition, a sole
study examining barriers to treatment found that frequent
SIF use was not significantly associated with inability to ac-
cess addiction treatment among SIF users in Vancouver [47].
2b. Other Health and Social Services
Six studies examined the association between SCF use
and utilization of health or social services other than ad-
diction treatment [19,39,44,46,54,60]. For instance, a
recent multi-site cross-sectional study of SCF users in
Denmark found that being advised to seek treatment for
a medical condition by SCF staff was associated with an
increased likelihood of receiving treatment [60].
Additionally, two separate prospective cohort studies of
SIF users in Vancouver found that those referred to hos-
pital by SIF nurses were more likely to access the emer-
gency department and receive hospital care, respectively,
for cutaneous injection-related infections [46,54]. Further,
the latter study also found that such referrals were associ-
ated with shorter durations of hospitalization [46]. Three
studies (conducted in Canada, Germany and Denmark)
demonstrated links between SCF use and utilization of edu-
cation on safer drug use practices at SCFs [19,39,60], while
the German study also found an association between frequent
SCF use and greater likelihood of accessing syringe exchange
services, medical services and counselling at the SCF [19].
Another study, conducted in three cities in the Netherlands,
found that SCF users had a higher level of awareness but a
similar prevalence of uptake of a hepatitis B vaccination pro-
gramme compared to non-users [44].
Two additional studies examined health-related outcomes
associated with programmes offered within SCFs [59,61]. A
recent Vancouver study of a pilot drug checking program of-
fered within Insite found that SIF clients who checked their
drugs and received a positive result for fentanyl (a powerful
opioid associated with elevated overdose risk) were more like-
ly to reduce their doses but not to dispose of their drugs com-
pared to those receiving negative results [61]. Another study
found that the implementation of a smoking cessation organi-
zational change intervention in the Sydney SIF was associated
with an increased likelihood of receiving smoking cessation
care among SIF clients [59].
Objective 3: to Reduce the Public Order and Safety
Problems Associated with Injection Drug Use
3a. Public Drug Use and Publicly Discarded Injection
Equipment
Five studies have demonstrated the role of SCFs in address-
ing public disorder associated with illicit drug use [5,24,29,
30,56]. An ecological study employing a prospective data
collection protocol found that the establishment of a SIF in
Vancouver was associated with reductions in the number of
people injecting drugs in public, publicly discarded syringes
and injection-related litter, independent of changes in police
presence and weather patterns [5]. Similarly, there were ob-
served declines in publicly-discarded syringes and public in-
jection in the neighbourhood of the SIF in Sydney after the
facility opened [29,30]. There were also increases in the pro-
portion of residents who agreed with positive statements re-
garding SIFs (including that these reduce public injection and
public disposal of used syringes), although opinions were
mixed among business owners [24]. Another study found that
the opening of SCFs in Barcelona, Spain, was associated with
a significant reduction in the number of publicly-discarded
syringes collected by local services [56].
3b. Crime
Six studies examined the association between SCF op-
eration and drug-related crime [11,22,42,45,30,55]. Of
these, four were conducted in Sydney and found no chang-
es in police-recorded thefts or robbery incidents, drug pos-
session, drug dealing or illicit drug offences in the
neighbourhood of the SIF after the facility was established
Curr HIV/AIDS Rep
[22,45,30,55]. Similar results have been observed in
Vancouver. For example, a before and after study of local
crime statistics found no increases in incidents of drug
trafficking or assaults/robbery in the neighbourhood of
the SIF after the facility opened [11]. In addition, a pro-
spective cohort study of PWID in Vancouver demonstrated
that frequent SIF use was not associated with recent incar-
ceration in multivariable analyses [42].
3c. Cost-Effectiveness
A total of six studies have evaluated the cost-effectivenessof
SCFs, all of which were conducted in Vancouver [33,43,48,
53,57,63]. Five studies examined the economic impacts of
Insite and found it to be cost-effective [33,43,48,53,63].
For example, a simulation study estimated that the SIF provides
an excess of $CAD 6 million per year (due to averted overdose
deaths and incident HIV cases) after considering the facilitys
annual operating costs [43]. Others have provided more con-
servative estimates, including a study estimating that the pre-
vention of incident HIV cases and overdose deaths by the SIF
provides an excess of $CAD 200,000400,000 per year [53].
Additionally, a recent study of the cost-effectiveness of an un-
sanctioned peer-run SIR found that the facility saved an annual
average of $CAD 1.8 million due to the prevention of incident
cases of hepatitis C (HCV) infection [57].
Discussion
In the present systematic review, we identified consistent,
methodologically sound evidence demonstrating the effec-
tiveness of SCFs in achieving their primary health and public
order objectives. Further, the available evidence does not sup-
port concerns regarding the potential negative consequences
of establishing SCFs, including thatthese promote drug use or
attract crime.
The prevention of drug-related overdose fatalities repre-
sents a significant public health challenge in many settings,
particularly in North America, where opioid-related overdose
deaths have reached epidemic levels and become a leading
cause of accidental death in many jurisdictions [4]. Given that
early, rapid and well-equipped overdose intervention is avail-
able within SCFs [8], and that these facilities have been shown
to attract PWUD who possess risk factors for overdose (e.g.
homelessness, high-intensity drug use) [8,19,21,6466], the
broader expansion of SCFs in settings contending with over-
dose epidemics may afford opportunities to mitigate overdose-
related morbidity and mortality. Indeed, compelling ecological
and simulation studies included in this review have demonstrat-
ed the contributions of SCFs to reductions in overdose-related
deaths, emergency department presentations and ambulance
attendances [18,20,29,37,49,52]. It is also noteworthy that
despite the millions of injections that have occurred within
SCFs internationally over the past three decades, not a single
overdose death has been recorded within a SCF [6,8]. In
addition, although preventing non-fatal overdose is not a key
objective of SCFs, frequent SCF use has not been found to
increase non-fatal overdose risk, which challenges the conten-
tion that these facilities promote riskier drug use practices (e.g.
taking higher doses) associated with overdose [36]. Although
one report included in this review observed non-significant
declines in opioid-related deaths in Sydney after the SCF was
established, the authors note that this study was likely under-
powered [29].
As described elsewhere [8,20], methodological challenges
have impeded efforts to examine the impact of SCFs on the
incidence of infectious diseases such as HIV and HCV.
However, the studies assessed herein indicate positive impacts
of SCFs on reducing unsafe injection practices associated with
infectious disease transmission among higher-risk PWUD.
For example, several studies have demonstrated associations
between SCF use and reductions in syringe sharing [23,25,
40], with a previous meta-analysis of three studies undertaken
in Canada and Spain providing a pooled estimate of a 70%
decreased likelihood of syringe sharing among SCF users
[67]. Studies also suggest that SCFs contribute to declines in
other unsafe injection practices such as reusing syringes,
injecting outdoors or rushed injecting [31,58], as has been
found in descriptive studies of SCFs that were ineligible for
this review [18,6879]. In addition to the provision of sterile
injection equipment on site, there are several other mecha-
nisms through which SCFs may reduce such behaviours. For
example, SCFs often become a key source of sterile syringes
for external use [80], which is notable given the well-
documented impact of syringe exchange services in reducing
risk of HIVand HCV transmission [81,82]. Moreover, SCFs
have been shown to increase access to safer injection educa-
tion [19,39,60] and to decrease the need to rush injections
due to fear of arrest [80]. Collectively, these findings provide
strong evidence to support the expansion of SCFs as an infec-
tious disease prevention strategy.
While concerns persist that SCFs may increase illicit drug
use and discourage PWUD from seeking addiction treatment,
such concerns are not supported by existing evidence. Indeed,
the establishment of SCFs has not significantly altered com-
munity drug use patterns such as rates of injection initiation,
relapse or cessation [26,28]. Further, several studies demon-
strate the role of SCFs in facilitating entry into addiction treat-
ment programmes [27,32,34,51] and subsequent injection
cessation and/or reduced injecting at SCFs [32,51]. Thus,
these facilities appear to support rather than undermine the
goals of addiction treatment.
In addition to addiction treatment, the research assessed in
this review also suggests that SCFs provide opportunities for
PWUD to access co-located services, including nursing,
Curr HIV/AIDS Rep
counselling and syringe exchange services [19,44,5961], while
also facilitating critical early medical intervention for the treat-
ment of complex conditions such as cutaneous injection-related
infections [19,46,54,60]. Similarly, descriptive studies have
found that SCFs may help to connect PWUD with other on-
site services, including basic supportive services (e.g. food, per-
sonal care facilities), HIV testing, mental health care and nalox-
one training and distribution programmes [9,83]. Further, the
integration of SCFs and other low-threshold services into
existing HIV/AIDS healthcare programmes has been shown to
improve access to and engagement with HIV treatment and care
among PWUD [8486].Recent qualitative work has provided
insights into how SCFs foster a supportive and welcoming envi-
ronment characterized by social acceptance and belonging in
which PWUD feel comfortable engaging with SCF staff regard-
ing health needs [86,87]. Thus, although PWUD are known to
commonly experience barriers in accessing conventional
healthcare services [88,89], the available data suggests that
SCFs may help to mitigate such barriers in mediating access
to a range of internal and external health and social resources
for higher-risk drug-using populations.
Studies assessed in this review also indicate that SCFs are
largely successful in achieving their objective of reducing
public disorder associated with illicit drug use through de-
clines in public injection and discarded drug use-related para-
phernalia [5,29,30,56]. These findings are consistent with
those observed in descriptive studies showing declines in self-
reported public drug use among SCF users [18,29,74,77,
78]. Further, as has been found in descriptive studies under-
taken in the Netherlands and Switzerland [72,9092], the
implementation of SCFs in Vancouver and Sydney did not
appear to contribute to increases in drug dealing or drug-
related crime [11,22,30,45,55]. Additionally, there is some
evidence from Sydney to suggest increasing public acceptance
and support of these facilities over time, although support was
somewhat inconsistent among business owners [24]. This
largely aligns with descriptive work conducted elsewhere sug-
gesting mixed support in terms of public opinion of SCFs [9,
93], but that this tends to increase with time [8,9,20]. Finally,
despite not being an explicit objective, economic evaluations
undertaken in Vancouver indicate that SCFs also offer an ad-
ditional public benefit of reducing the burden of costs on the
public healthcare system [33,43,48,53,57,63].
Overall, high-quality scientific evidence derived from the
observational and simulation studies included in this review
demonstrates the effectiveness of SCFs in meeting their prima-
ry public health and order objectives. Although randomized
controlled trials (RCTs) are typically defined as the gold stan-
dardfor yielding level-one evidence on the effectiveness of a
given intervention, it should be noted that RCTs of SCFs have
been deemed unethical due to a lack of clinical equipoise and
therefore have not been conducted [8,94,95]. However, reli-
ance on hierarchies of evidence to guide public heath decision
making has been contested in recent years [9698]. Indeed,
there has been growing acknowledgment that, like observation-
al studies, RCTs often suffer from notable methodological
weaknesses, including limited external validity, and that while
RCTs may provide evidence that effectively serves the needs of
clinical medicine, this is not necessarily the case in the realm of
public policy [96,98]. This is particularly relevant to decisions
concerning complex public health interventions, as evidence of
effectiveness in real-worldcontexts and attention to consider-
ations such as health equity and human rights may be of equal
or greater relevance to public health goals than controlled study
of intervention efficacy [98]. Further, assigned level of evi-
dence is not necessarily indicative of methodological quality,
and therefore well-designed observational research can argu-
ably provide a level of evidence that meets or exceeds that
derived from RCTs [9698]. Thus, given that it will not be
possible to obtain evidence from RCTs on SCFs, decisions
regarding the implementation of these facilities should instead
be informed by the best available evidence derived from scien-
tifically-viable studies, which clearly demonstrates the positive
impacts of SCFs in improving public order and advancing the
health and human rights of socially marginalized PWUD.
Directions for Future Research
Although the available evidence suggests that SIFs improve
the health of PWUD and reduce community concerns associ-
ated with illicit drug use, several important research opportu-
nities remain unexplored. First, despite evidence of the short-
and medium-term health impacts of SCFs, rigorous research
on the long-term impacts of SCFs on the health of PWUD is
lacking. For example, while previous work has found that
SCF use increases the likelihood of short-term injection ces-
sation [51], it is not known if SCF use has an impact on
sustained injection cessation or cessation ofdrug use altogeth-
er. An additional area of evaluation that has not received ad-
equate attention is the impact of SCFs on hospitalization
among PWUD. Although previous research indicates that re-
ferral to hospital by SCF nurses facilitates hospital treatment
for cutaneous injection-related infections [46], little is known
about how SCF use might affect acute hospital bed use for
other conditions.
There is also a need for research to evaluate SCF program-
ming that aims to improve their responsiveness to the needs of
vulnerable and underserved subpopulations of PWUD. For
example, with the exception of SCFs operating in Geneva
and Barcelona [99], SCFs in most settings are legally
prohibited from accommodating individuals who require
manual assistance with injections, despite the fact that this
subpopulation accounts for an estimated one third of PWID
[100], is comprised largely of women and people with disabil-
ities [100] and is disproportionally vulnerable to an array of
serious harms including overdose, HIV infection and violence
Curr HIV/AIDS Rep
[101103]. A qualitative evaluation of an unsanctioned, peer-
run SCF in Vancouver that offered manual assistance with
injections found that the provision of this service in a regulat-
ed environment helped to reduce risk for the above-mentioned
harms [104]. Nonetheless, further research on the potential
benefits of offering assisted injection within SCFs may help
to strengthen the case for legal reforms to allow for the wider
adoption of this practice. In addition, although SCFs have
previously been shown to provide protection from street-
based drug scene violence for some women PWUD [105],
other women may avoid SCFs due to perceived threats of
violence [106]. In an effort to address such concerns,
women-only SCFs have been implemented in several settings,
including in Hamburg, Germany, and another is planned to
open in Vancouver, Canada [107,108]. While research under-
taken in Hamburg found that the overwhelming majority of
women-only SCF clients felt safer and more comfortable
using drugs and approaching staff at this SCF [108], studies
should further explore the ability of this form of tailored ser-
vice to engage and support the health of structurally vulnera-
ble drug-using women.
An additional research opportunity is to evaluate the health
and social impacts of SIRs, which accommodate people who
inhale drugs. Although SIRs are presently operating in some
European cities [108] and recent qualitative research indicates
that these facilities have potential to promote safer smoking
practices and reduce health-related harms [60,109,110], the
health and community outcomes specific to SIRs have not
been thoroughly evaluated. As SIRs remain underutilized in
many settings [107,108], further inquiry in this area may
provide critical information to inform the broader implemen-
tation of these facilities.
Another notable knowledge gap concerns the role and
impacts of novel SCF models, including those integrated
into existing healthcare and social services. For instance,
although there is evidence to suggest a high level of will-
ingness to use an in-hospital SCF among PWUD [111]
and a SCF recently opened in a hospital in Paris, France
[112], few studies have investigated the effectiveness of
this type of SCF model. However, recent qualitative re-
search suggests that the provision of in-hospital SCFs
could reduce instances of patients leaving hospital against
medical advice, promote culturally safe care and prevent
adverse outcomes associated with in-hospital drug use
among PWUD [113]. Future studies should also investi-
gate if the benefits of stand-alone SCFs will extend to
SCFs integrated into existing shelters, supportive housing
and community organizations that serve PWUD, as re-
search on such integrated SCF services is lacking. A re-
lated recommendation is to further examine the uptake
and potential outcomes associated with services co-
located with SCFs, including on-site addiction treatment
and low-threshold housing [114]. As well, given the
limited geographic coverage of fixed-site SCFs [52,64],
studies should evaluate how the implementation of mobile
SCFs might improve the responsiveness of SCF program-
ming to the needs of PWUD, particularly those who re-
side in settings with geographically dispersed drug scenes
or who experience social-structural barriers to attending
fixed SCFs (e.g. sex workers working in remote locations;
women who avoid SCFs due to previous experiences of
violence) [106,107,115].
A final recommendation is the continued assessment of
peer-run SCFs, which are prohibited in many settings despite
evidence of their ability to engage and reduce harms among
PWUD who may encounter social-structural and programmat-
ic barriers in accessing SCFs operated by healthcare profes-
sionals [9,104,107,110]. Specifically, future studies should
seek to better characterize preferences for, engagement with
and outcomes associated with peer-run SCF models, as this
may help to further elucidate the role of these facilities in
complementing or extending the reach of conventional SCF
programmes.
Limitations
A number of limitations common to observational studies ap-
ply to many of the studies included in this review. First, it is
possible that the findings of the studies assessed herein are
explained by residual confounding. In addition, most studies
relied on non-random samples of PWUD in resource-rich set-
tings and therefore findings may not be generalizable to other
contexts. Further, as previous work has indicated that SCFs
attract socially marginalized and higher-risk PWUD [8,19,
21,6466], observed measures of the health benefits of SCF
use may be biased towards the null. Finally, a limitation of this
review is that despite our comprehensive search strategy, it is
possible that we neglected to include some relevant literature,
particularly non-English literature, not indexed in the data-
bases searched for this review.
Conclusions
In summary, while SCFs remain under-utilized in many settings
worldwide, high-quality scientific evidence suggests that these
effectively achieve their primary public health and order objec-
tives with a lack of adverse impacts, and therefore supports
their role as part of a continuum of services for PWUD.
However, further studies are needed to better understand the
potential long-term health impacts of these facilities. In addi-
tion, future research should continue to investigate innovations
in SCF models and programming, including efforts to tailor
SCFs to the needs of vulnerable subpopulations of PWUD, in
order to optimize the effectiveness and extend the reach and
coverage of this form of harm reduction intervention.
Curr HIV/AIDS Rep
Acknowledgements We would like to thank Tricia Collingham and
Deborah Graham for their research and administrative assistance. Mary
Clare Kennedy is supported by a Social Sciences and Humanities
Research Council (SSHRC) Doctoral Fellowship and a Mitacs
Accelerate Award from Mitacs Canada. Mohammad Karamouzian is sup-
ported by a Vanier Canada Graduate Scholarship. Thomas Kerr is sup-
ported by a Canadian Institutes of Health Research (CIHR) Foundation
Grant (20R74326).
Compliance with Ethical Standards
Conflict of Interest The authors have no conflicts of interest to declare.
Humans and Animal Rights All reported studies/experiments with
human or animal subjects performed by the authors have been previously
published and complied with all applicable ethical standards (including
the Helsinki declaration and its amendments, institutional/national re-
search committee standards and international/national/institutional
guidelines).
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Curr HIV/AIDS Rep
... The first facility was legally established in Bern, Switzerland, in 1986. Currently, there are over 100 DCRs globally (Belackova et al., 2019;Kennedy et al., 2017;The International Network of Drug Consumption Rooms, 2021). ...
... One of the functions of DCRs is to decrease overdose drug deaths (Elliott, 2014;Kennedy et al., 2017;Kimber et al., 2005;Small, 2016). Nevertheless, field experts assert that DCRs would not serve as a direct intervention in overdose deaths in Finland since buprenorphine constitutes the leading substance for drug deaths, where overdosing immediately after injection is unlikely. ...
... No fatal overdose has recorded in any DCRs around the world (Potier et al., 2014), instead, there was a reduction in neighbourhood and city. For instance, 35% reduction in overdose deaths in the vicinity of the DCR (Insite) and a 9% reduction in the city of Vancouver (Kennedy et al., 2017). ...
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Drug consumption rooms are one of the harm reduction interventions to handle complex social problems. The Helsinki city initiative puts drug consumption room (DCR) on a government agenda in Finland, which has also triggered a broader discussion. This study presents how stakeholders problematise and what solutions they propose for DCRs. The research is based on in-depth interviews of 23 stakeholders and the theoretical perspective of Bacchi’s approach – ‘What’s the problem represented to be?’ (WPR). The results show that while stakeholders’ solutions resemble each other on the core DCR functions, the variations are found mainly in the introduction of extended services, policy development strategy, types of drug allowance in DCRs, and drug testing options. Stigmatisation of PWUDs still leads the harm reduction services to be considered from a moral framework. Stakeholders tend to take their positions according to strategic considerations related to electoral politics, expedience and the symbolic role of policies.
... Over 100 DCRs currently operate in at least 66 cities in 10 countries, including sites in Europe, North America, and Australia [2][3][4][5]. International evidence suggests that DCRs may reduce the risk of blood-borne virus transmission, and thousands of on-site overdoses have been reversed [6,7]. However, study quality is limited, and research has only been conducted in a small number of sites [8]. ...
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There is widespread support for the introduction of Drug Consumption Rooms (DCRs)in Scotland as part of a policy response to record levels of drug-related harm. However, existing legal barriers are made more complex by the division of relevant powers between the UK and Scottish Governments. This paper reports on a national, qualitative study of key decision-makers in both local and national roles across Scotland. It explores views on the political barriers and enablers to the adoption of Drug Consumption Rooms and the potential role of these facilities in the wider treatment system. It also considers approaches to evidence, especially the types of evidence that are considered valuable in supporting decision-making in this area. The study found that Scottish decision-makers are strongly supportive of DCR adoption; however, they remain unclear as to the legal and political mechanisms that would make this possible. They view DCRs as part of a complex treatment and support system rather than a uniquely transformative intervention. They see the case for introduction as sufficient, on the basis of need and available evidence, thus adopting a pragmatic and iterative approach to evidence, in contrast to an appeal to traditional evidence hierarchies more commonly adopted by the UK Government.
... A hospital-based supervised consumption service, if available [58,59], could further reduce health risks of VAD injecting. Supervised consumption services are well described in the literature [60,61] and aim to provide a safer and cleaner environment where people can consume pre-obtained drugs in hospital under the supervision of trained staff without the need to rush or fear of criminal prosecution [59]. Supports available within these services, such as nursing assistance to locate a vein, may result in fewer patients needing to use their VAD due to inability to find other venous access. ...
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Background Hospital patients who use drugs may require prolonged parenteral antimicrobial therapy administered through a vascular access device (VAD). Clinicians’ concerns that patients may inject drugs into these devices are well documented. However, the perspectives of patients on VAD injecting are not well described, hindering the development of informed clinical guidance. This study was conducted to elicit inpatient perspectives on the practice of injecting drugs into VADs and to propose strategies to reduce associated harms. Methods Researchers conducted a focused ethnography and completed semi-structured interviews with 25 inpatients at a large tertiary hospital in Western Canada that experiences a high rate of drug-related presentations annually. Results A few participants reported injecting into their VAD at least once, and nearly all had heard of the practice. The primary reason for injecting into a VAD was easier venous access since many participants had experienced significant vein damage from injection drug use. Several participants recognized the risks associated with injecting into VADs, and either refrained from the practice or took steps to maintain their devices while using them to inject drugs. Others were uncertain how the devices functioned and were unaware of potential harms. Conclusions VADs are important for facilitating completion of parenteral antimicrobial therapy and for other medically necessary care. Prematurely discharging patients who inject into their VAD from hospital, or discontinuing or modifying therapy, results in inequitable access to health care for a structurally vulnerable patient population. Our findings demonstrate a need for healthcare provider education and non-stigmatizing clinical interventions to reduce potential harms associated with VAD injecting. Those interventions could include providing access to specialized pain and withdrawal management, opioid agonist treatment, and harm reduction services, including safer drug use education to reduce or prevent complications from injecting drugs into VADs.
... As práticas de Redução de Danos (RD) surgem na década de 1980 como alternativa aos mecanismos proibicionistas, promovendo estratégias que compreendem o uso de drogas como multideterminado, objetivando reduzir os danos que a substância pode causar ao usuário, respeitando o direito à saúde e à liberdade individual daquele que não deseja ou não consegue interromper o uso de drogas (Machado & Boarini, 2013). Pesquisas têm mostrado a eficácia de intervenções baseadas na RD, evidenciando a limitação de tratamentos que objetivam unicamente a abstinência: terapias caracterizadas pelo consumo controlado ou moderado de álcool (Irvin et al., 1999;Larimer et al., 1999;Marlatt & Gordon, 1985); programa de redução de danos relacionados ao álcool em escola (McBride et al., 2004); salas de consumo assistido de droga (European Monitoring Centre for Drugs and Drug Addiction [EMCDDA], 2017; Kennedy et al., 2017;Potier et al., 2014); bem como tratamento assistido com heroína (Blanken et al., 2010;Fischer et al., 2002;Haasen et al., 2007;Verthein et al., 2008). ...
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