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Do Supervised Injecting Facilities Attract Higher-Risk Injection Drug Users?
Abstract
In Western Europe and elsewhere, medically supervised safer injection facilities (SIFs) are increasingly being implemented for the prevention of health- and community-related harms among injection drug users (IDUs), although few evaluations have been conducted, and there have been questions regarding SIFs' ability to attract high-risk IDUs. We examined whether North America's first SIF was attracting IDUs who were at greatest risk of overdose and blood-borne disease infection.
We examined data from a community-recruited cohort study of IDUs. The prevalence of SIF use was determined based on questionnaire data obtained after the SIF's opening, and we determined predictors of initiating future SIF use based on behavioral information obtained from questionnaire data obtained before the SIF's opening. Pearson's chi-square test was used to compare characteristics of IDUs who did and did not subsequently initiate SIF use.
Overall, 400 active injection drug users returned for follow-up between December 1, 2003 and May 1, 2004, among whom 178 (45%) reported ever using the SIF. When we examined behavioral data collected before the SIF's opening, those who initiated SIF use were more likely to be aged <30 years (odds ratio [OR]=1.6, 95% confidence interval [CI]=1.0-2.7], p=0.04); public injection drug users (OR=2.6, 95% CI=1.7-3.9, p<0.001); homeless or residing in unstable housing (OR=1.7, 95% CI=1.2-2.7, p=0.008); daily heroin users (OR=2.1, 95% CI=1.3-3.2, p=0.001); daily cocaine users (OR=1.6, 95% CI=1.1-2.5, p=0.025); and those who had recently had a nonfatal overdose (OR=2.7, 95% CI=1.2-6.1, p=0.016).
This study indicated that the SIF attracted IDUs who have been shown to be at elevated risk of blood-borne disease infection and overdose, and IDUs who were contributing to the public drug use problem and unsafe syringe disposal problems stemming from public injection drug use.
... 16 The SIFs are designed to attract high-risk, socially vulnerable PWID. SIFs attract PWID who are likely to be unemployed, 11 are homeless or residing in unstable housing, 11,17,18 have low levels of education, 19 or have been incarcerated. 11 Previous research has shown that PWID who use SIFs differ from those who do not. ...
... 11 Previous research has shown that PWID who use SIFs differ from those who do not. PWID who use SIFs are more likely to be male 19 ; to be older 11,18 ; to report risk behaviors such as a recent overdose, 18 injecting in the public, 11,18 or injecting daily or more frequently 11,17−21 ; and to have been exposed to hepatitis C virus (HCV) 19 than PWID who do not use SIFs. PWID using SIFs are also more likely to have a history of drug treatment 11 and less likely to have injected with borrowed syringes/needles. ...
... 11 Previous research has shown that PWID who use SIFs differ from those who do not. PWID who use SIFs are more likely to be male 19 ; to be older 11,18 ; to report risk behaviors such as a recent overdose, 18 injecting in the public, 11,18 or injecting daily or more frequently 11,17−21 ; and to have been exposed to hepatitis C virus (HCV) 19 than PWID who do not use SIFs. PWID using SIFs are also more likely to have a history of drug treatment 11 and less likely to have injected with borrowed syringes/needles. ...
Introduction
In 2018, the first Medically Supervised Injecting Room in Melbourne, Australia was officially opened. This study assessed whether this facility attracted people who inject drugs, who were socially vulnerable, and who engaged in drug-related behaviors associated with increased morbidity and mortality risk.
Methods
This was a cross-sectional analysis of the frequency of Medically Supervised Injecting Room use during the first 18 months after opening (July 2018–December 2019) among 658 people who inject drugs participating in the Melbourne Injecting Drug User Cohort Study (SuperMIX). To examine the differences between no Medically Supervised Injecting Room use, infrequent use (<50% injections within the facility), and frequent use (≥50% of injections within the facility), RRRs were estimated using bivariate multinomial logistic regression analyses and postestimation Wald tests. Analyses were conducted in 2020.
Results
A total of 451 participants (68%) reported no Medically Supervised Injecting Room use, 142 (22%) reported infrequent use, and 65 (10%) reported frequent use. Participants who reported either infrequent or frequent use of the facility were more socially vulnerable (e.g., more often homeless) and more likely to report risky drug-related behaviors and poor health outcomes than those who reported no use. Participants who reported frequent use of the facility were also more likely to live close to the facility than those reporting infrequent use.
Conclusions
The Melbourne Medically Supervised Injecting Room attracted socially marginalized people who inject drugs who are most at risk of harms related to injecting drug use and therefore who are most in need of the service. To determine the long-term impact use of this facility on key health outcomes such as overdose, future studies should consider the differences in vulnerability and risk behavior of people who inject drugs who use the Medically Supervised Injecting Room when examining the outcomes associated with the use of the facility.
... Evaluations of SIFs in Canada and international settings have provided extensive evidence of the effectiveness of this form of health intervention [11,19,20]. For instance, past studies have consistently shown that SIFs effectively attract and retain their target client population, including PWID who contend with structural vulnerabilities (e.g., homelessness) and engage in drug use practices associated with heightened risk of morbidity and mortality (e.g., public injection, binge injection, frequent injection) [6,[21][22][23][24][25][26][27][28][29][30][31]. Additionally, studies have identified associations between SIF use and various positive changes in health-related outcomes among PWID, including reduced likelihood of engaging in injection practices associated with infectious disease transmission (e.g., syringe sharing), as well as increased uptake of addiction treatment and other health and social services [21,[32][33][34][35][36][37][38][39][40][41][42][43]. ...
... As previously mentioned, SIF use has been associated with a number of notable health benefits for PWID [11,19,20]. However, existing literature also indicates that PWID who engage with this health service tend to be more likely than non-users to possess various markers of structural vulnerability and drug-related risk and therefore may have an inherently greater risk of death [6,[21][22][23][24][25][26][27][28][29][30][31]. We expected that such selection effects would preclude individuals who had never used SIFs from being an appropriate comparison population when examining the association between frequent SIF use and mortality, as has been described in studies of frequent needle exchange use [52]. ...
... To examine the independent association between frequent SIF use and all-cause mortality, we assessed the following as potential confounding variables on the basis of previous literature concerning mortality and SIF use among PWID [1,6,8,[21][22][23][24][25][26]29]: age (per year older), sex (male versus female), ancestry (white versus non-white), HIV status (positive versus negative serological test); hepatitis C virus status (positive versus negative serological test), and heavy alcohol use (average of >3 alcoholic drinks per occasion at least once per week or >7 drinks in total per week in the previous 6 months for women, and average of >4 alcoholic drinks per occasion at least once per week or >14 drinks in total per week in the previous 6 months for men [57]). Other potential confounders examined included Downtown Eastside residence, unstable housing, binge injection drug use, public injection drug use, non-fatal overdose, enrolment in addiction treatment, exposure to violence, incarceration, involvement in sex work, and benzodiazepine use (all yes versus no). ...
Background
People who inject drugs (PWID) experience elevated rates of premature mortality. Although previous studies have demonstrated the role of supervised injection facilities (SIFs) in reducing various harms associated with injection drug use, including accidental overdose death, the possible impact of SIF use on all-cause mortality is unknown. Therefore, we examined the relationship between frequent SIF use and all-cause mortality among PWID in Vancouver, Canada.
Methods and findings
Data were derived from 2 prospective cohort studies of PWID in Vancouver, Canada, between December 2006 and June 2017. Every 6 months, participants completed questionnaires that elicited information regarding sociodemographic characteristics, substance use patterns, social-structural exposures, and use of health services including SIFs. These data were confidentially linked to the provincial vital statistics database to ascertain mortality rates and causes of death. We used multivariable extended Cox regression analyses to estimate the independent association between frequent (i.e., at least weekly) SIF use and all-cause mortality. Of 811 participants, 278 (34.3%) were women, and the median age was 39 years (IQR 33–46) at baseline. In total, 432 (53.3%) participants reported frequent SIF use at baseline, and 379 (46.7%) did not. At baseline, frequent SIF users were on average younger than nonfrequent users, and a higher proportion of frequent SIF users than nonfrequent users were unstably housed, resided in the Downtown Eastside neighbourhood, injected in public, had a recent non-fatal overdose, used prescription opioids at least daily, injected heroin at least daily, injected cocaine at least daily, and injected crystal methamphetamine at least daily. A lower proportion of frequent SIF users than nonfrequent users were HIV positive and enrolled in addiction treatment at baseline. The median duration of follow-up among study participants was 72 months (IQR 24–123). In total, 112 participants (13.8%) died during the study period, yielding a crude mortality rate of 22.7 (95% CI 18.7–27.4) deaths per 1,000 person-years. The median years of potential life lost per death was 34 (IQR 27–42) years. In a time-updated multivariable model, frequent SIF use was inversely associated with risk of all-cause mortality after adjusting for potential confounders, including age, sex, HIV seropositivity, unstable housing, at least daily cocaine injection, public injection, incarceration, enrolment in addiction treatment, and calendar year of interview (adjusted hazard ratio 0.46, 95% CI 0.26–0.80, p = 0.006). The main study limitations are the limited generalizability of findings due to non-random sampling, the potential for reporting biases due to reliance on some self-reported information, and the possibility that residual confounding influenced findings.
Conclusions
We observed a high burden of premature mortality among a community-recruited cohort of PWID. Frequent SIF use was associated with a lower risk of death, independent of relevant confounders. These findings support efforts to enhance access to SIFs as a strategy to reduce mortality among PWID. Further analyses of individual-level data are needed to determine estimates of, and potential causal pathways underlying, associations between SIF use and specific causes of death.
... DCRs attract the most socially marginalized [23] and atrisk users in terms of health [12,17,23], and therefore represent harm reduction mechanisms with a great potential for impact. Users of DCRs are more likely to be in unstable housing situations [21], have recently overdosed [21], and be at elevated risk of bloodborne diseases from unsafe injection or syringe-sharing practices [21]. ...
... DCRs attract the most socially marginalized [23] and atrisk users in terms of health [12,17,23], and therefore represent harm reduction mechanisms with a great potential for impact. Users of DCRs are more likely to be in unstable housing situations [21], have recently overdosed [21], and be at elevated risk of bloodborne diseases from unsafe injection or syringe-sharing practices [21]. ...
... DCRs attract the most socially marginalized [23] and atrisk users in terms of health [12,17,23], and therefore represent harm reduction mechanisms with a great potential for impact. Users of DCRs are more likely to be in unstable housing situations [21], have recently overdosed [21], and be at elevated risk of bloodborne diseases from unsafe injection or syringe-sharing practices [21]. ...
Background:
Ahead of opening Portugal's first mobile drug consumption room (MDCR) in Lisbon, information from People Who Use Drugs (PWUD) and local community members was necessary to determine current needs and shape the intervention. A participatory and peer-led process was ensured at all stages of data gathering and planning of the intervention.
Methods:
Prospective clients were surveyed to determine their willingness to use the service and preferences for use and to gain sociodemographic information. Persons over the age of 18 who reported injection drug use (PWID) were recruited using convenience sampling in the main open drug use scenes in Lisbon. In-person interviews were conducted by trained peer workers between November and December of 2017. The results (n = 72) of the questionnaires were analyzed, providing descriptive statistics.
Results:
There is a high level of willingness to use the MDCR, primarily for reasons of hygiene, privacy, and security. Most participants expressed a desire to use the MDCR daily. Potential clients are socially marginalized, and many suffer from unstable housing. Most are daily users and engage in unsafe injecting practices, such as public injecting and material sharing. High levels of hepatitis C, HIV, and hepatitis B were observed among the target population with low levels of healthcare access and utilization. Preferences were gauged regarding the scheduling of the MDCR's hours and amount of time willing to travel to reach the MDCR and will be taken into account for implementation. The combination of high levels of willingness to utilize the service and high levels of need among the target population support the implementation of Lisbon's first MDCR.
Conclusions:
Continual participation of PWUD and other community members will be necessary to maximize the public health and social impacts of this intervention, relative to this baseline. The plan to continue the participatory and peer-led development of the MDCR includes integrating peer workers, clients, and local community members within the operation, management, and evaluation of the service. This research adds to a growing literature about drug consumption rooms (DCRs) in Europe, which is especially limited concerning MDCRs.
... 3,4 Since established, Insite has been found to have attained all of the aforementioned objectives of SIFs without producing unintended adverse impacts. 2 Specifically, studies have demonstrated that Insite effectively attracts PWID at elevated risk of drug-related harms, including structurally vulnerable subpopulations who might otherwise inject drugs in public settings. 5,6 The establishment of Insite was also associated with reductions in overdose deaths and improvements in public order in the surrounding neighborhood of the facility without increasing crime. 7−9 Further, regular use of the SIF has been associated with declines in injection-related infectious disease risk behaviors, 10 as well as increased enrollment in addiction treatment and subsequent injection cessation. ...
... Although previous studies have identified correlates of short-term SIF use, 5,6,[27][28][29]38,39 this study addresses gaps in current evidence concerning long-term SIF utilization patterns in that it is the first study, to the authors' knowledge, to longitudinally characterize discontinuation of SIF use among a community-recruited cohort of PWID. The study shows that most (77%) PWID discontinued using the Insite SIF over a median follow-up duration of 50 months, and that injection drug use cessation co-occurred with the majority (58%) of SIF use cessation events. ...
... Alternatively, it could be that sustained SIF users are simply more likely to contend with exposures (e.g., involvement in prohibited income-generation activities) that increase their vulnerability to criminalization. 5,6,38,55 However, these interpretations were not investigated in the present study and therefore further examination of potential explanations for this association is warranted. ...
Introduction:
Although the health and community benefits of supervised injection facilities are well documented, little is known about long-term patterns of utilization of this form of health service. The present study seeks to longitudinally characterize discontinuation of use of a supervised injection facility in Vancouver, Canada.
Methods:
Data were drawn from 2 community-recruited prospective cohorts of people who inject drugs between December 2005 and December 2016. In 2018, extended Cox regression for recurrent events was used to examine factors associated with time to cessation of supervised injection facility use during periods of active injection.
Results:
Of 1,336 people who inject drugs that were followed for a median of 50 months, 847 (63.4%) participants reported 1,663 6-month periods of supervised injection facility use cessation while actively injecting drugs (incidence density of 26.6 events per 100 person-years). An additional 2,282 (57.8%) of the total 3,945 6-month periods of supervised injection facility use cessation occurred during periods of injection cessation. In multivariable analyses, enrollment in methadone maintenance therapy (adjusted hazard ratio=1.41) and HIV seropositivity (adjusted hazard ratio=1.23) were positively associated with supervised injection facility use cessation during periods of active injection, whereas homelessness (adjusted hazard ratio=0.59), at least daily heroin injection (adjusted hazard ratio=0.70), binge injection (adjusted hazard ratio=0.68), public injection (adjusted hazard ratio=0.67), nonfatal overdose (adjusted hazard ratio=0.73), difficulty accessing addiction treatment (adjusted hazard ratio=0.69), and incarceration (adjusted hazard ratio=0.70) were inversely associated with this outcome (all p<0.05). The most commonly reported reasons for supervised injection facility use cessation were injection drug use cessation (42.3%) and a preference for injecting at home (30.7%).
Conclusions:
These findings suggest that this supervised injection facility successfully retains people who inject drugs at elevated risk of drug-related harms and indicate that many supervised injection facility clients neither use this service nor inject drugs perpetually.
... Two papers that used this indicator reported on cross-sectional studies from Europe [219,223], and seven on cohort studies-six were from Canada and one from Europe. Of the seven cohort study papers, three pertained to cohorts recruited both in and outside of DCR/SIF [208,210,211], two to those recruited at DCR/SIF [198,201] and another two pertained to having received a referral at the DCR/SIF among those recruited there [197,199]. ...
... The prospective/follow-up cohort design was used to assess the DCR/SIF impact across all outcome categories specified in Table 1 except for 'not increasing crime' (see Table 3 for details). That is, it was used to assess whether DCRs/SIFs were attracting high-risk drug users [207][208][209][210][211], managing overdose [187,205], enhancing safe injecting practice [188][189][190][191][192][193]204,211,212], decreasing public use [188,189,194] Evaluation methods for drug consumption rooms [ 188,189], d [190][191][192][193] [ 188,189], d [194] [195] f , [196][197][198][199], [200] e [201] X [195] f , [202][203][204][205][206] From both within and outside of DCR/SIF [207] [196] b ; referral covariates not included in the analysis [50] and other healthcare [195][196][197][198]200], addressing BBV transmission and yield cost savings [201,213] and the impact on drug use and related risks [195,[202][203][204][205][206]214]. Individual-level service records were used to assess SIF effectiveness in terms of attracting high-risk drug users [46,217], managing non-fatal overdoses [215][216][217] and increasing treatment and health service uptake via referrals [50,218]. ...
... Future research utilising cohort designs would benefit from systematically including high-risk PWUD eligible to use DCR/SIF, who both do and do not engage with DCRs/SIFs at baseline (with the limitation that more 'at risk' PWUD will likely engage). Several papers have done this [207][208][209][210][211][212][213][214], but they do not incorporate all of the key outcome measures. Accordingly, at this time, large cohort studies capable of extensive covariate adjustment offer the best option for dealing with potential unmeasured confounding. ...
Issues
Drug consumptions rooms (DCR) and supervised injecting facilities (SIF) are expanding internationally. Previous reviews have not systematically addressed evaluation methodologies.
Approach
Results from systematic searches of scientific databases in English until June 2017 were coded for paper type, country and year of publication. For evaluation papers, study outcome, methodology/study design and main indicators of DCR/SIF ‘exposure’ were recorded.
Key Findings
Two hundred and nineteen eligible peer‐reviewed papers were published since 1999: the majority from Canada (n = 117 papers), Europe (n = 36) and Australia (n = 32). Fifty‐six papers reported evaluation outcomes. Ecological study designs (n = 10) were used to assess the impact on overdose, public nuisance and crime; modelling techniques (n = 6) estimated impact on blood‐borne diseases, overdose deaths and costs. Papers using individual‐level data included four prospective cohorts (n = 28), cross‐sectional surveys (n = 7) and service records (n = 5). Individual‐level data were used to assess safer injecting practice, uptake into health and social services and all the other above outcomes except for impact on crime and costs. Four different indicators of DCR/SIF attendance were used to measure service ‘exposure’.
Implications
Research around DCRs/SIFs has used ecological, modelling, cross‐sectional and cohort study designs. Further research could involve systematic inclusion of a control group of people who are eligible but do not access SIFs, validation of self‐reported proportion of injections at SIFs or a stepped‐wedge or a cluster trial comparing localities.
Conclusions
Methodologies appropriate for DCR/SIF evaluation have been established and can be readily replicated from the existing literature. Research on operational aspects, implementation and transferability is also warranted.
... Linking SIFs/DCRs clients to support services is crucial as SIFs/DCRs have been shown to attract drug users who experience high health and social risks, such as high rates of HCV infection, imprisonment and homelessness (Wood et al., 2005); with homelessness levels ranging from 49 per cent in Spain (Bravo et al., 2009) to 70 per cent in Vancouver, Canada (Wood et al., 2005). Not surprisingly, those clients who attend SIFs/DCRs frequently are more likely to receive referrals into health and social services (Kimber et al., 2008;Wood et al., 2006). ...
... Linking SIFs/DCRs clients to support services is crucial as SIFs/DCRs have been shown to attract drug users who experience high health and social risks, such as high rates of HCV infection, imprisonment and homelessness (Wood et al., 2005); with homelessness levels ranging from 49 per cent in Spain (Bravo et al., 2009) to 70 per cent in Vancouver, Canada (Wood et al., 2005). Not surprisingly, those clients who attend SIFs/DCRs frequently are more likely to receive referrals into health and social services (Kimber et al., 2008;Wood et al., 2006). ...
... This is less than the level of unstable accommodation among clients of the Canadian SIF (i.e. 70 per cent at Insite) (Wood et al., 2005), and is a far higher level than the Australian general population (0.5 per cent ); other Australian studies that have shown that approximately 1 in 5 PWID are living in unstable accommodation (Topp et al., 2013;Whittaker et al., 2015). ...
PURPOSE: The Uniting Medically Supervised Injecting Centre (MSIC) in Sydney is currently the only Supervised Injecting Facility (SIF) in Australia. Homelessness among people who inject drugs (PWID) in Australia has been increasing; establishing how SIFs might best support clients into housing is an important goal. This study aimed to update knowledge regarding the accommodation status of MSIC clients and thereby to support a better understanding the complex needs of these clients.
DESIGN: Client accommodation status at MSIC registration (first visit) and in a Brief Survey conducted in May 2016 were compared; unstable accommodation was defined as rough sleeping, couch surfing, hostel, boarding house or crisis accommodation. Analysis involved bivariate logistic regression exploring the association between socio-demographics and accommodation status at both time points plus a comparison of the visit records for those who reported stable and unstable accommodation in May 2016, assessed with paired t-test.
FINDINGS: Of 232 clients who presented at MSIC during the week, the Brief Survey was administered to 107 (46%). Most were male (78%) with a mean age of 41.4 years. A total of 64 (60%) identified as having unstable accommodation; having increased from 40% at registration (first visit). There were significant positive associations between unstable accommodation status and unemployment, imprisonment and history of overdose, all measured at registration. In May 2016, unstable accommodation status was significantly associated with age of first injection and with unemployment status (as measured at registration), with lower number of visits, of referrals to health and social services and of overdoses at MSIC than those reported living in a stable accommodation.
CONCLUSIONS: The rates of living in unstable accommodation among MSIC clients have been increasing. These findings highlight the importance of SIFs and drug consumption rooms as a venue to address the essential needs of PWID such as housing. The window of opportunity to support PWID who experience housing instability seems to be narrower than for those who live in stable accommodation.
... Difficulty accessing SCS was associated with several notable markers of structural vulnerability and drug-related risk including unstable housing, non-fatal overdose, active injection drug use, and daily crystal methamphetamine use. This is concerning given that many of these are characteristics of the primary target client population of SCS [32,38]. Further, studies conducted prior to the emergence of COVID-19 have found SCS to effectively engage such higher-risk subpopulations of people who use drugs, raising questions about potential inequitable impacts of COVID-19 response measures [6,31,32,38]. ...
... This is concerning given that many of these are characteristics of the primary target client population of SCS [32,38]. Further, studies conducted prior to the emergence of COVID-19 have found SCS to effectively engage such higher-risk subpopulations of people who use drugs, raising questions about potential inequitable impacts of COVID-19 response measures [6,31,32,38]. In the context of the current overdose crisis, it is particularly concerning that people who use drugs who reported recently experiencing a non-fatal overdose were more likely to experience difficulty accessing SCS, especially given that non-fatal overdose is a strong predictor of future fatal overdose [39,40] and that people who have recently overdosed may seek to use SCS as a strategy to reduce risk of overdose-related harm [41]. ...
Background
The overdose crisis in Canada has worsened since the emergence of the COVID-19 pandemic. Although this trend is thought to be driven in part by closures or reduced capacity of supervised consumption services (SCS), little is known about the factors that may impede access to such services during the COVID-19 pandemic among people who use drugs. This study sought to characterize the prevalence and correlates of having difficulty accessing SCS during the COVID-19 pandemic among people who use drugs in Vancouver, Canada.
Methods
Cross-sectional data from two open prospective cohorts of people who use drugs were collected via phone or videoconferencing interviews conducted between July 2020 and November 2020. Multivariable logistic regression analyses were used to examine factors associated with experiencing difficulty accessing SCS.
Results
Among the 428 people who use drugs who participated in the study, 223 (54.7%) self-identified as men and the median age was 51 years (1st to 3rd quartile: 42–58). A total of 58 (13.6%) participants reported experiencing difficulty accessing SCS. In a multivariable analysis, factors positively associated with difficulty accessing SCS included daily crystal methamphetamine use (Adjusted odds ratio [AOR] = 2.60; 95% confidence interval [CI] 1.28–5.30), active injection drug use (AOR = 4.06; 95% CI 1.38–11.90), recent non-fatal overdose (AOR = 2.45; 95% CI 1.24–4.85), and unstable housing (AOR = 2.14; 95% CI 1.08–4.23). Age was inversely associated with the outcome (AOR = 0.96; 95% CI 0.93–0.99) in multivariable analyses. The most commonly reported reasons for experiencing difficulty accessing SCS were: COVID-19-related site closure or shortened hours (42.9%) and having to wait too long to use a site (39.3%).
Conclusions
We found that people who use drugs with markers of structural vulnerability and drug-related risk were more likely to experience difficulty accessing SCS during the COVID-19 pandemic. These findings point to the need for strategies to support access to such services as part of pandemic response efforts.
... The primary explanatory variable of interest was exclusive SIF use, defined in response to the question, "In the last six months, what proportion of injections did you do at Insite?" Consistent with our past work (Lloyd-Smith et al., 2008;Wood, Tyndall, Stoltz et al., 2005), responses were classified as all vs. most, some, a few or none. Given that SIFs have been found to engage PWID who are more likely to inject drugs in public and other potentially unsafe settings (Bravo et al., 2009;Kennedy et al., 2019;Kimber et al., 2003;Wood, Tyndall, Li et al., 2005, Wood, Tyndall, Qui et al., 2006, this measure of SIF use was employed in effort to rule out the possibility that estimates of the association between SIF use and violence may be biased due to SIF users being more likely to experience violence while consuming drugs in such settings. ...
... The underlying explanations for this finding cannot be determined with certainty based on the analyses presented herein. However, our measurement of our primary exposure as exclusive SIF use for injections (as opposed to a lower level of service use) allows us to exclude the possibility that this finding is simply explained by the confounding influence of SIFs tending to engage PWID who are more likely to inject drugs in public or other settings in which they are susceptible to violence (Bravo et al., 2009;Kennedy et al., 2019;Kimber et al., 2003;Wood, Tyndall, Li et al., 2005, Wood, Tyndall, Qui et al., 2006. Instead, this finding is likely largely explained by gender Note: not all cells add up to n = 1251 due to missing values. ...
Background:
Supervised injection facilities (SIFs) have been established in many settings, in part to reduce risks associated with injecting in public, including exposure to violence. However, the relationship between SIF use and experiencing violence has not yet been thoroughly evaluated. We sought to longitudinally examine the gender-specific relationship between SIF use and exposure to violence among people who inject drugs (PWID) in a Canadian setting.
Methods:
Data were drawn from two prospective cohort studies of PWID in Vancouver, Canada, between December 2005 and December 2016. Semi-annually, participants completed questionnaires that elicited data concerning sociodemographic characteristics, behavioural patterns, violent encounters and health service utilization. We used multivariable generalized estimating equations (GEE) to estimate the independent association between exclusively injecting drugs at a SIF and experiencing physical or sexual violence among men and women PWID, respectively.
Results:
Of 1930 PWID followed for a median of four years, 679 (35.2%) were women and the median age was 41 years at baseline. In total, 353 (52.0%) women and 694 (55.5%) men reported experiencing at least one incident of violence during follow-up. In multivariable analyses, exclusive SIF use was associated with decreased odds of experiencing violence among men after adjusting for potential confounders (Adjusted Odds Ratio [AOR] = 0.64; 95% confidence interval [CI]: 0.46–0.89). Exclusive SIF use was not significantly associated with experiencing violence among women in adjusted analyses (AOR = 0.97; 95% CI: 0.57–1.66).
Conclusions:
In light of the recent expansion of SIFs in Canada, our finding of a protective association between exclusive SIF use and exposure to violence among men is encouraging. The fact that we did not observe a significant association between SIF use and experiencing violence among women highlights the need for social-structural interventions that are more responsive to the specific needs of women PWID in relation to violence prevention.
... Given that early, rapid and well-equipped overdose intervention is available 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,[64][65][66], the broader expansion of SCFs in settings contending with overdose epidemics may afford opportunities to mitigate overdoserelated morbidity and mortality. Indeed, compelling ecological and simulation studies included in this review have demonstrated the contributions of SCFs to reductions in overdose-related deaths, emergency department presentations and ambulance attendances [18,20,29,37,49,52]. ...
... In addition, most studies relied on non-random samples of PWUD in resource-rich settings 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,[64][65][66], 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 databases searched for this review. ...
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.
... These facilities provide PWID with sterile injecting equipment and a safe and hygienic space in which to inject pre-obtained illicit drugs under the supervision of nurses or other trained staff. The goals of SIFs are to engage high-risk PWID, reduce injection-related harms and infections, facilitate access to health and social services, reduce morbidity and mortality associated with overdose, and improve public order (Wood et al., 2004;Wood et al., 2005). There are currently over 90 SIFs operating in over 60 cities across the world (EMCDDA, 2016). ...
... We should note that certain variables of interest, such as public injection and overdose, were significantly associated with on-site detoxification use among the full sample of PWID but not once restricted to the sub-sample of recent SIF users. We suspect that these discrepancies in findings are likely due to the fact that SIF users are more likely to be structurally disadvantaged and to experience drug-related risks and harms (Wood et al., 2005;. These differences in characteristics between those in the cohort who do and do not use the SIF further suggests the need to co-locate treatment programming with SIFs that is responsive to the unique needs of the vulnerable populations who use these facilities. ...
... While there is considerable evidence that SIF contribute to lower-risk environments for people who inject drugs (Aspinall et al., 2013(Aspinall et al., -2014Gowing, Farrell, Bornemann, Sullivan, & Ali, 2006;Hurley, Jolley, & Kaldor, 1997;Marshall, Milloy, Wood, Montaner, & Kerr, 2011;McNeil & Small, 2014;Stoltz et al., 2007;Tobin, Sherman, Beilenson, Welsh, & Latkin, 2009;Wood et al., 2005), there remain significant challenges to implementation of these interventions throughout British Columbia (BC), Canada, and elsewhere (Canadian Association of People Who Use Drugs, 2014;Carter & MacPherson, 2013;. While changes to federal legislation have been made since 2015 to reduce the number of requirements involved in exemption applications for implementation of permanent SIF, significant hurdles to gaining approval remain (Kerr, Mitra, Kennedy, & McNeil, 2017). ...
... Implementation of HRS such as SIF in Victoria could likely result in reductions in unsafe injecting practices and other injection-related harms similar to the decreases experienced in Vancouver when its main SIF (Insite) opened in 2003 (Jozaghi et al., 2015;Small, Wood, Lloyd-Smith, Tyndall, & Kerr, 2008;Stoltz et al., 2007;Wood et al., 2005). These findings are particularly salient given that Victoria had one of the highest per capita rates of overdose deaths in 2016. ...
Background: In 2016, BC Canada declared a public health emergency in response to increasing illicit drug overdose deaths. Previous research has shown that adverse social conditions including unstable housing and insufficient harm reduction services can exacerbate public injection and overdoses.
Methods: Cross-sectional interview data from Victoria (2008–2015) and Vancouver (2008–2012), BC (n = 548) were analysed using multivariate logistic regression models to assess differences in risks and harms for people 19+ who inject drugs in street-based settings.
Results: Living in Victoria (OR: 5.55, 95%CI: 3.44–8.95; p < 0.001), having unstable housing (OR: 4.24, 95%CI: 2.75–6.54; p < 0.001), injecting daily (OR: 2.24, 95%CI: 1.40–3.58; p < 0.001), sharing needles (OR: 3.00, 95%CI: 1.22–7.38; p < 0.05), and sexual minority status (OR: 2.14, 95%CI: 1.06–4.34; p < 0.05) were significantly associated with increased risk of public injection. Being older (OR: 0.96, 95%CI: 0.94–0.99; p < 0.01), identifying as Indigenous (OR: 0.58, 95%CI: 0.34–0.98; p < 0.05) and later survey year (OR: 0.83, 95%CI: 0.74–0.93; p < 0.001) were associated with a decreased risk of public injection. Living in Victoria (OR: 2.21, 95%CI: 1.30–3.75; p < 0.01) was significantly associated with higher risk of overdose and being older (OR: 0.96, 95%CI: 0.94–0.99; p < 0.01) was associated with decreased risk.
Conclusions: Mitigating risk environments for public injection and overdose requires attention to micro- and macro-level factors. Overall findings indicate that implementation of a supervised injection facility in Victoria would likely reduce public injection and overdoses.
... To address these gaps, the OiSIS-Toronto cohort has recruited 701 PWID and will follow their health and social outcomes using a combination of self-report and administrative data. As indicated by the baseline data presented herein, and consistent with previous studies of SCS clients, [29] the study population experiences multiple forms of social and structural vulnerability: over 9 in 10 were homeless or unstably housed and over onethird were recently incarcerated. Almost half are of Indigenous ancestry and/or belong to racialized groups that, as a consequence of structural racism, often experience poorer health in Canada [30]. ...
The Ontario Integrated Supervised Injection Services cohort in Toronto, Canada (OiSIS-Toronto) is an open prospective cohort of people who inject drugs (PWID). OiSIS-Toronto was established to evaluate the impacts of supervised consumption services (SCS) integrated within three community health agencies on health status and service use. The cohort includes PWID who do and do not use SCS, recruited via self-referral, snowball sampling, and community/street outreach. From 5 November 2018 to 19 March 2020, we enrolled 701 eligible PWID aged 18+ who lived in Toronto. Participants complete interviewer-administered questionnaires at baseline and semi-annually thereafter and are asked to consent to linkages with provincial healthcare administrative databases (90.2% consented; of whom 82.4% were successfully linked) and SCS client databases. At baseline, 86.5% of participants (64.0% cisgender men, median ([IQR] age= 39 [33–49]) had used SCS in the previous 6 months, of whom most (69.7%) used SCS for <75% of their injections. A majority (56.8%) injected daily, and approximately half (48.0%) reported fentanyl as their most frequently injected drug. As of 23 April 2021, 291 (41.5%) participants had returned for follow-up. Administrative and self-report data are being used to (1) evaluate the impact of integrated SCS on healthcare use, uptake of community health agency services, and health outcomes; (2) identify barriers and facilitators to SCS use; and (3) identify potential enhancements to SCS delivery. Nested sub-studies include evaluation of “safer opioid supply” programs and impacts of COVID-19.
... In the event of an overdose, medical care can be provided immediately and onsite, and it has been estimated that between 2004 and 2008, 453 deaths were averted at Insite, the SIF located in Vancouver's Downtown East Side ( Milloy, Kerr, Tyndall, Montaner, & Wood, 2008 ). Importantly, the bivariate association between multiple NFOOD and injecting at an SIF ( Table 1 ) likely reflects the success of SIFs in attracting those most at risk, including those at high risk of NFOD ( Wood et al., 2005 ). The association between public injection and multiple NFOOD observed in the current study indicates a need to address public injection as a key correlate of multiple NFOOD, which has been shown to be associated with increased risk of fatal opioid overdose ( Caudarella et al., 2016 ;Stoové et al., 2009 ). ...
Background
Non-fatal overdose (NFOD) is a major cause of morbidity among people who inject drugs (PWID) and multiple NFOD is associated with increased risk of fatal overdose. Despite this, few studies have examined the prevalence and correlates of drug-specific multiple NFOD. The current study aimed to determine the prevalence and correlates of recent multiple non-fatal opioid overdose (NFOOD) among PWID who access needle syringe programs (NSPs) in Australia.
Methods
The Australian Needle and Syringe Program Survey is conducted annually and was conducted at 46 sites across Australia in 2019. Participation involves completion of a self-administered questionnaire and a capillary dried blood spot for HIV and hepatitis C virus testing. In 2019, respondents who reported a minimum of one NFOOD in the previous 12 months (recent NFOOD) were asked to complete supplementary questions regarding their last NFOOD. Bivariate and multivariate logistic regression were used to determine factors independently associated with multiple recent NFOOD.
Results
A total of 222 respondents reported recent NFOOD. Respondents were predominantly male (59%), one third (39%) were aged less than 39 years and 73% reported last injecting heroin at their last NFOOD. One in two respondents (48%, n = 107) reported multiple opioid overdoses (median 3, interquartile range 2–5). The odds of reporting multiple NFOOD were higher among respondents who reported injecting in a public location at their last NFOOD (adjusted odds ratio [AOR] 2.10, 95% CI 1.14–3.90, p = 0.018) and benzodiazepine use in the 12 h prior to NFOOD (AOR 2.74, 95% CI 1.50–4.99, p = 0.001).
Conclusions
Multiple NFOOD was prevalent among PWID who utilised NSPs who reported recent NFOOD. Public injecting and benzodiazepine use were associated with increased risk of multiple NFOOD, and there is a need for interventions specifically targeting PWID who report these high risk injecting practices.
... Supervised consumption services (SCS) are one such intervention whereby people can access sterile injecting equipment and use pre-obtained drugs in a legally sanctioned environment under the supervision of staff trained to respond in the event of an overdose [9]. Presently, there are over a hundred SCS internationally [10], including stand-alone sites [11,12] and integrated models within healthcare facilities [13,14]. However, despite the fact that women who use drugs are disproportionately impacted by socio-structural violence compared to men [15,16], few SCS are womenonly [17,18]. ...
Background
Smoking or inhaling illicit drugs can lead to a variety of negative health outcomes, including overdose. However, most overdose prevention interventions, such as supervised consumption services (SCS), prohibit inhalation. In addition, women are underrepresented at SCS and are disproportionately impacted by socio-structural violence. This study examines women’s experiences smoking illicit drugs during an overdose epidemic, including their utilization of a women-only supervised inhalation site.
Methods
Qualitative research methods included on-site ethnographic observation and semi-structured interviews with 32 participants purposively recruited from the women-only site. Data were coded and analyzed using NVivo 12 and thematic analysis was informed by gendered and socio-structural understandings of violence.
Results
Participants had preferences for smoking drugs and these were shaped by their limited income, inability to inject, and perceptions of overdose risk. Participants expressed the need for services that attend to women’s specific experiences of gendered, race-based, and structural violence faced within and outside mixed-gender social service settings. Results indicate a need for sanctioned spaces that recognize polysubstance use and drug smoking, accommodated by the women-only SCS. The smoking environment further fostered a sociability where participants could engage in perceived harm reduction through sharing drugs with other women/those in need and were able to respond in the event of an overdose.
Conclusions
Findings demonstrate the ways in which gendered social and structural environments shape women’s daily experiences using drugs and the need for culturally appropriate interventions that recognize diverse modes of consumption while attending to overdose and violence. Women-only smoking spaces can provide temporary reprieve from some socio-structural harms and build collective capacity to practice harm reduction strategies, including overdose prevention. Women-specific SCS with attention to polysubstance use are needed as well as continued efforts to address the socio-structural harms experienced by women who smoke illicit drugs.
... 6,7 Consider the example of supervised consumption services for illustration: These programs to reduce acute morbidity and mortality outcomes for highrisk drug users (or 'hosts') involve resource-intensive facilities, materials and services, where however-by design-drug consumption continues to involve illicit and hazardous drug products ('agents'). 22,26,27 This concept, using the analogy of an acute food or water-borne E. coli outbreak, would parallel 'safer food consumption facilities', where individuals would bring their (contaminated) food for consumption while under observation, with emergency treatment available in the event of acutely adverse outcomes (e.g. vomiting, diarrhea). ...
North America has been experiencing an acute and unprecedented public health crisis involving excessive and increasing levels of opioid-related overdose mortality. In the present commentary, we examine current interventions (as existent mainly in Canada) to date and compare them against established intervention frameworks and practices in other areas of public health, specifically injury and infectious disease control. We observe that current interventions focusing on opioid drug safety or exposure-specifically those that focus on distinctly potent and toxic opioid products driving major increases in overdose mortality-may be considered the equivalent of 'agent-' or 'vector'-based interventions. Such interventions have been largely neglected in favor of 'host' (e.g., drug user-oriented) or 'environmental' measures among strategies to reduce opioid-related overdose, likely contributing to the limited efficacy of current measures. We explore potential reasons, implications and remedies for these gaps in the overall public health strategy employed towards improved interventions to reduce opioid-related health harms.
... In addition to removing the requirement for the waiver, the Mainstreaming Addiction Treatment Act would authorize a national education campaign to educate providers about the law and encourage them to integrate substance use disorder treatment into their practices. Health professional training programs should supplement this by launching a campaign to prepare the next generation of providers to deliver evidence-based care for OUD [12]. ...
... A variety of SCS models exist internationally. There are fixed stand-alone sites that primarily provide SCS, often in a high-traffic drug use area (Wolf et al., 2003;Wood et al., 2005); integrated models within larger care facilities that offer a variety of health and social services, including those for people who do not use drugs (Krusi et al., 2009); embedded models within environments that traditionally do not allow drug use onsite such as supportive housing Schatz and Nougier, 2012) and hospitals (Fox, 2016;Royal Alex, 2017); mobile outreach models that aim to reach dispersed populations across a large urban area (Dietze et al., 2012); and women-only SCS models that aim to provide a safe space, free of gender-based violence (Atira Women's Resource Society, 2018; Boyd et al., 2018). ...
Supervised consumption services (SCS) have been integrated into community health centres in Toronto. We draw on qualitative interviews and ethnographic observations to examine the implementation contexts of these SCS. Participants' perspectives on the integration of SCS within CHCs were mixed. Some participants identified the benefits of integrated SCS such as convenience and access to other health and social services. However, others identified negative consequences of integration, including building design, lack of privacy and anonymity, and limited hours of operation. These perspectives highlight the ways in which contextual factors affect the experiences of clients in accessing SCS, and suggest that various factors need to be considered in order to improve service uptake.
... The authors claim that 'those with more chaotic lives may both attend SCS less frequently and follow safe practices outside SCS less often' ( [1], p. 2); yet a vast body of high-quality, international quasi-experimental evidence [7][8][9][10][11][12][13] has demonstrated that SCSs are specifically attended by the more high-risk (chaotic) users. It is also surprising that adequate research focused on measuring adverse outcomes of SCSs was not found by the authors, other than crime. ...
... Finally, socially desirable responding can be concern in studies of marginalized populations [24]. Nevertheless, we have previously shown how feasibility questions, such as those used in the present study, can be highly valid and accurately predict subsequent health service utilization [25,26]. ...
Background:
North America is in the midst of an opioid overdose epidemic. Although take-home naloxone and other measures have been an effective strategy to reduce overdoses, many events are unwitnessed and mortality remains high amongst those using drugs alone. While wearable devices that can detect and alert others of an overdose are being developed, willingness of people who use drugs to wear such a device has not been described.
Methods:
Drug using persons enrolled in a community-recruited cohort in Vancouver, Canada, were asked whether or not they would be willing to wear a device against their skin that would alert others in the event of an overdose. Logistic regression was used to identify factors independently associated with willingness to wear such a device.
Results:
Among the 1061 participants surveyed between December 2017 and May 2018, 576 (54.3%) were willing to wear an overdose detection device. Factors independently associated with willingness included ever having overdosed (adjusted odds ratio [AOR] = 1.39, 95% confidence interval [CI] 1.06-1.83), current methadone treatment (AOR = 1.86, 95% CI 1.45-2.40), female gender AOR = 1.41, 95% CI 1.09-1.84) and a history of chronic pain (AOR = 1.53, 95% CI 1.19-1.96). Whereas homelessness (AOR = 0.67, 95% CI 0.50-0.91) was negatively associated with willingness.
Conclusions:
A high level of willingness to wear an overdose detection device was observed in this setting and a range of factors associated with overdose were positively associated with willingness. Since some factors, such as homelessness may be a barrier, further research is needed to investigate explanations for unwillingness and to evaluate real world acceptability of a wearable overdose detection devices as this technology becomes available.
... In 2005, Insite clients were mostly from higher-risk populations: young adults, public injectors, and daily heroin or cocaine users. 17 These higher-risk populations are often homeless or without stable housing, and often with a high burden of hepatitis C infection (87.6% of the surveyed population). 18 Two years later, Insite remained a site used by higher-risk populations including youth under 30 with 57% of under 30 IVDUs surveyed reporting to have used Insite. ...
The debate around supervised injection facilities (SIF) rages on more than a decade after the opening of Insite, Canada’s first supervised injection site in Vancouver. Recently, an article published in the journal Addiction reignited the discussion when it made a financial case for introducing facilities in Ottawa and Toronto. The model predicts that the introduction of two SIFs in Ottawa and three in Toronto would be a cost-savings measure to prevent the spread of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) among intravenous drug users (IVDUs). Over 600 total cases of HIV or HCV are projected to be averted in a 20-year period, saving over $40 million in healthcare costs in Toronto and over $30 million in Ottawa. Opponents deny the benefits of safe injection sites despite research conducted on Insite, which suggest that these facilities have tremendous utility and are economically viable. Insite targets and attracts high-risk IVDUs, fosters safer injection habits and prevents transmission of needle-sharing diseases. Insite’s facilities also offer complementary detoxification and rehabilitation services and encourage users to register for these programs. In contrast to arguments made by opponents, Insite has not been found to increase incidental overdoses, neighbourhood crime rates, or public disposal of needles. Given the outcomes of research conducted on Insite, the viability of similar facilities in Ontario should be further explored.
... 19 In addition, research on existing drug consumption rooms (DCR) showed that they improve access to primary healthcare and improve safer injection conditions. 20 By attracting the most marginalised PWID, 21 they also reduce the level of public injection and so the number of used syringes has dropped in public spaces. 22 Finally, it has also been shown that DCR are effective in reducing fatal overdoses. ...
Introduction
The high prevalence of hepatitis C and the persistence of HIV and hepatitis C virus (HCV) risk practices in people who inject drugs (PWID) in France underlines the need for innovative prevention interventions. The main objective of this article is to describe the design of the COSINUS cohort study and outline the issues it will explore to evaluate the impact of drug consumption rooms (DCR) on PWID outcomes. Secondary objectives are to assess how DCR (a) influence other drug-related practices, such as the transition from intravenous to less risky modes of use, (b) reduce drug use frequency/quantity, (c) increase access to treatment for addiction and comorbidities (infectious, psychiatric and other), (d) improve social conditions and (e) reduce levels of violence experienced and drug-related offences. COSINUS will also give us the opportunity to investigate the impact of other harm reduction tools in France and their combined effect with DCR on reducing HIV-HCV risk practices. Furthermore, we will be better able to identify PWID needs.
Methods and analysis
Enrollment in this prospective multi-site cohort study started in June 2016. Overall, 680 PWID in four different cities (Bordeaux, Marseilles, Paris and Strasbourg) will be enrolled and followed up for 12 months through face-to-face structured interviews administered by trained staff to all eligible participants at baseline (M0), 3 month (M3), 6 month (M6) and 12 month (M12) follow-up visits. These interviews gather data on socio-demographic characteristics, past and current drug and alcohol consumption, drug-use related practices, access to care and social services, experience of violence (as victims), offences, other psychosocial issues and perception and needs about harm reduction interventions and services. Longitudinal data analysis will use a mixed logistic model to assess the impact of individual and structural factors, including DCR attendance and exposure to other harm reduction services, on the main outcome (HIV-HCV risk practices).
Ethics and dissemination
This study was reviewed and approved by the institutional review board of the French Institute of Medical Research and Health (opinion number: 14–166). The findings of this cohort study will help to assess the impact of DCR on HIV-HCV risk practices and other psycho-social outcomes and trajectories. Moreover, they will enable health authorities to shape health and harm reduction policies according to PWID needs. Finally, they will also help to improve current harm reduction and therapeutic interventions and to create novel ones.
... The majority of SIF users are daily heroin or cocaine users, homeless or with unstable housing, unemployed or with unstable employment, and have a history of a nonfatal overdose. [109][110][111][112] SIFs promote more hygienic and controlled injections. SIFs provide sterile materials for injecting; and SIF users, under legal protection, can take the time for infection prevention measures such as skin cleaning and removal of impurities and particulate matter from drugs. ...
The US is facing dual public health crises related to opioid overdose deaths and HIV. Injection drug use is fueling both of these epidemics. The War on Drugs has failed to stem injection drug use and has contributed to mass incarceration, poverty, and racial disparities. Harm reduction is an alternative approach that seeks to decrease direct and indirect harms associated with drug use without necessarily decreasing drug consumption. Although overwhelming evidence demonstrates that harm reduction is effective in mitigating harms associated with drug use and is cost-effective in providing these benefits, harm reduction remains controversial and the ethical implications of harm reduction modalities have not been well explored. This paper analyzes harm reduction for injection drug use using the core principles of autonomy, nonmaleficence, beneficence, and justice from both clinical ethics and public health ethics perspectives. This framework is applied to harm reduction modalities currently in use in the US, including opioid maintenance therapy, needle and syringe exchange programs, and opioid overdose education and naloxone distribution. Harm reduction interventions employed outside of the US, including safer injection facilities, heroin-assisted treatment, and decriminalization/legalization are then discussed. This analysis concludes that harm reduction is ethically sound and should be an integral aspect of our nation's healthcare system for combating the opioid crisis. From a clinical ethics perspective, harm reduction promotes the autonomy of, prevents harms to, advances the well-being of, and upholds justice for persons who use drugs. From a public health ethics perspective, harm reduction advances health equity, addresses racial disparities, and serves vulnerable, disadvantaged populations in a cost-effective manner.
... Further, these findings underscore the need to remove governmental barriers in order to allow for the rapid scaling-up of supervised consumption services, which have been shown to effectively address risks of overdose and related harms among structurally vulnerable PWID, including those who would otherwise inject in public settings (Marshall, Milloy, Wood, Montaner, & Kerr, 2011;Small, Rhodes, Wood, & Kerr, 2007). Prior research has documented how it is those individuals experiencing homelessness in which public injecting is common who often access supervised consumption facilities when established (Wood et al., 2005). ...
Background:
In 2016, in the Canadian province of British Columbia, the Provincial Health Officer declared drug-related overdose deaths a public health emergency.
Objectives:
In this study, we examine factors associated with recent non-fatal overdose during a time of unprecedented rates of overdose and increasing involvement of fentanyl and fentanyl derivatives in overdose deaths.
Methods:
Between June and September 2016, a cross-sectional survey was conducted among people who inject drugs (PWID) in Victoria, British Columbia, Canada. Bivariable and multivariable logistic regression analyses were used to examine factors associated with recent non-fatal overdose.
Results:
A total of 187 PWID were included in the present study, of whom 56 (29.9%) reported having overdosed in the previous 6 months. In multivariable analyses, fentanyl injection (Adjusted Odds Ratio [AOR] = 2.60; 95% confidence interval [CI]: (1.08 - 6.27) and public injection (AOR = 2.20; 95% CI: 1.09 - 4.43) were positively associated with recent non-fatal overdose.
Conclusions:
Fentanyl injection and public injection were associated with an increased likelihood of non-fatal overdose. These findings underscore the need for drug checking, safer sources of opioids and safer injecting interventions as part of overdose prevention strategies.
... DCRs/SIFs are evidence-based harm reduction interventions [2] with demonstrated effectiveness [3][4][5][6][7][8][9][10][11]. DCRs/ SIFs generally target the most marginalised populations of people who use drugs (PWUD), people who inject drugs (PWID), and high-risk drug users (HRDU) [12,13]. Studies among PWID have found that Hepatitis C Virus (HCV) prevalence at baseline is higher among DCR/SIF attendees than non-attendees [14], with daily attendees at greatest risk [15]. ...
Background: Prevalence of Hepatitis C Virus (HCV) among people who inject drugs (PWID) is high. Risky injecting behaviours have been found to decrease in drug consumption rooms (DCRs) and supervised injecting facilities (SIFs), yet HCV prevention and treatment in these settings have not been extensively explored.
Methods: To determine the range and scope of HCV prevention and treatment options in these services, we assessed DCR/SIF operational features, their clients’ characteristics and the HCV-related services they provide. A comprehensive online survey was sent to the managers of the 91 DCRs/SIFs that were operating globally as of September 2016. A descriptive cross-country analysis of the main DCR/SIF characteristics was conducted and bivariate logistic models were used to assess factors associated with enhanced HCV service provision.
Results: Forty-nine valid responses were retrieved from DCRs/SIFs in all countries where they were established at the time of the survey (Australia, Canada, Denmark, France, Germany, Luxembourg, Netherlands, Norway, Spain and Switzerland). Internationally, the operational capacities of DCRs/SIFs varied in terms of funding, location, size and staffing, but their clients all shared common features of vulnerability and marginalisation. Estimated HCV prevalence
rates were around 60%. Among a range of health and social services and referrals to other programs, most DCRs/SIFs provided HCV testing onsite (65%) and/or offered liver monitoring or disease management (54%). HCV treatment onsite was offered or was planned to be offered by 21% of DCRs/SIFs. HCV testing onsite was associated with provision of other services addressing blood-borne diseases and HCV treatment was linked to the provision of OST. HCV disease
management was associated with employing a nurse at a DCR/SIF and HCV treatment was associated with employing a medical doctor.
Conclusions: DCRs/SIFs offer easy-to-access HCV-related services for PWID. The availability of onsite medical professionals and provision of support and education to non-medical staff are key to enhanced provision of HCV-related services in DCRs/SIFs. Funding and support for HCV treatment at the community level, via low-threshold services such as DCRs/SIFs, are worthy of action.
Keywords: Drug consumption rooms, Supervised injecting facilities, Hepatitis C testing, Hepatitis C support services, Hepatitis C treatment, People who inject drugs
... 3 They serve a small geographic area (the distance clients will walk), and even among regular service users, only a proportion of injections are covered (43% of Insite users accessed the site for fewer than onequarter of injections 4 ). Moreover, stand-alone models attract a highly socially vulnerable population, 5 and clients continue to face disparities in health status, homelessness and access to opioid agonist therapy. 6 This suggests a need for greater scale-up of existing models as well as for new models that offer a larger suite of on-site health services. ...
... MSIC clients might also be more embedded in their drug use patterns and as a result more resistant to change. Wood, Tyndall, Li et al. (2005) and McKnight et al. (2007), for example, noted that MSIC clients are more likely than nonclients to be daily heroin injectors, daily cocaine injectors and homeless or living in unstable accommodation. Bravo et al. (2009) also reported that MSIC users were more likely to be socially marginal and have higher-risk, drug-use patterns. ...
Background:
Medically Supervised Injection Centres (MSICs) are legally-sanctioned facilities where users can consume pre-obtained drugs under medical supervision. Although there is a substantial body of research exploring their effectiveness, there have been few attempts to quantify outcomes across studies. In order to determine the impact of the body of research as a whole, outcomes from studies were synthesised using meta-analysis.
Methods:
Literature sources were identified through searches in four bibliographic databases. Inclusion in the final review was dependent on the study meeting certain eligibility criteria, including a minimum of pre-test, post-test, control group designs. Data were extracted and pooled in a meta-analysis using both fixed and random effects methods.
Results:
Eight studies met the inclusion criteria. Overall, MSICs had a significant, but small, positive effect on outcomes based on the fixed effect analysis and no effect based on random effect analysis. The results of the independent outcome analyses showed that MSICs had a significant favourable result in relation to drug-related crime and a significant unfavourable result in relation to problematic heroin use or injection. MSICs were found to have no effect on overdose mortality or syringe/equipment sharing.
Conclusion:
Whilst the effectiveness of the early versions of MSICs remains uncertain, this should not rule out continuing to test and develop MSICs in locations where public injecting and other drug-related harms are a major problem. It is important, however, that evaluation research publishes replicable data to enable future meta-analyses and to expand the body of knowledge in the field.
... Coverage continues to expand throughout the country (176), and sustained advocacy is now required to promote public support and ensure responsiveness to drug trends and user needs (171). Although evidence of HCV prevention is currently lacking (173), supervised injection facilities are known to attract highrisk PWID (177), and they may facilitate linkage to HCV care among these primary targets of TaP. ...
Background
The worldwide economic, health, and social consequences of drug use disorders are devastating. Injection drug use is now a major factor contributing to hepatitis C virus (HCV) transmission globally, and it is an important public health concern.
Methods
This article presents a narrative review of scientific evidence on public health strategies for HCV prevention among people who inject drugs (PWID) in Canada.
Results
A combination of public health strategies including timely HCV detection and harm reduction (mostly needle and syringe programmes and opioid substitution therapy) have helped to reduce HCV transmission among PWID. The rising prevalence of pharmaceutical opioid and methamphetamine use and associated HCV risk in several Canadian settings has prompted further innovation in harm reduction, including supervised injection facilities and low-threshold opioid substitution therapies. Further significant decreases in HCV incidence and prevalence, and in corresponding disease burden, can only be accomplished by reducing transmission among high-risk persons and enhancing access to HCV treatment for those at the greatest risk of disease progression or viral transmission. Highly effective and tolerable direct-acting antiviral therapies have transformed the landscape for HCV-infected patients and are a valuable addition to the prevention toolkit. Curing HCV-infected persons, and thus eliminating new infections, is now a real possibility.
Conclusions
Prevention strategies have not yet ended HCV transmission, and sharing of injecting equipment among PWID continues to challenge the World Health Organization goal of eliminating HCV as a global public health threat by 2030. Future needs for research, intervention implementation, and uptake in Canada are discussed.
... 12 Consistent evidence supports the positive role SIFs have on improving various conditions for PWID. 13,14 Specifically, SIFs have been found to reduce overdose mortality, 15 attract high-risk PWID, 16 decrease syringe sharing, 17 decrease public injecting, 18 and improve engagement in treatment programs, 19,20 with no increase in criminal activity or drug trafficking in the areas surrounding the SIF 14 or risky behavior. 21 Safe injection facilities have also been found to reduce the demand on ambulance services. ...
Background: Although the United States and numerous other countries are amidst an opioid overdose crisis, access to safe injection facilities remains limited.
Methods: We used prospective data from ambulance journals in Oslo, Norway to describe the patterns, severity, and outcomes of opioid overdoses, and compared these characteristics among various overdose locations. We also examined what role a safe injection facility may have had on these overdoses.
Results: Based on 48,825 ambulance calls, 1054 were for opioid overdoses from 465 individuals during 2014 and 2015. The rate of calls for overdoses was 1 out of 48 of the total ambulance calls. Males made up the majority of the sample (n = 368, 79%) and the median age was 35 (range 18-96). Overdoses occurred in public locations (n = 530, 50.3%), the safe injection facility (n = 353, 33.5%), in private homes (n = 83, 7.9%), and other locations (n = 88, 8.3%). Patients from the safe injection facility and private homes had similarly severe initial clinical symptoms (Glasgow Coma Scale median =3 and respiratory frequency median = 4 breaths per minute) when compared to other locations, yet the majority from the safe injection facility did not require further ambulance transport to the hospital (n = 302, 85.6%). Those that overdosed in public locations (OR = 1.66, 95% CI= 1.17-2.35), and when the facility was closed (OR = 1.4, 95% CI= 1.04-1.89), were more likely to receive transport for further treatment.
Conclusions: Our findings suggest that the opening hours at the safe injection facility and the overdose location may impact the likelihood of ambulance transport for further treatment.
... The Sydney evaluation report concluded that the facility continued to reach long-term, high frequency injecting drug users who are highly socially marginalised and likely to inject drugs in public settings (NCHECR, 2007b). Similarly, retention and attendance rates at the Vancouver DCR indicate that the DCR is successful in gaining acceptance by its target group and that regular users of DCRs tend to be more marginalised, with various health and social problems, such as those related to public injecting and unstable housing Wood et al., 2005bWood et al., , 2006c. Regarding the latter, the first Sydney evaluation report (MSIC, 2003) indicated that the most common reason given for not using the DCR was injecting in the privacy of their own home. ...
People who use illicit drugs (PWUD) experience a wide range of drug-related harms. The goal of harm reduction is to reduce these adverse effects of drug use, without necessarily reducing drug use itself. By providing a safe and hygienic environment to consume pre-obtained drugs under the supervision of trained staff, drug consumption rooms (DCRs) aim to reduce both individual-level and public-level harms associated with illicit drug use. A substantial body of evidence has accumulated over the past three decades to support the effectiveness of DCRs in achieving their primary health and public order objectives, and therefore supports their role within a continuum of services for PWUD. Despite the abundance of scientific evidence supporting DCRs, there continues to be social and structural barriers to the implementation of this public health intervention in communities across the globe. Yet, the debate about implementing new DCRs remains high on the political agenda in a number of countries worldwide. To date, Belgium does not offer a DCR to its drug using population. Against this background, the Belgian Science Policy Office (BELSPO) commissioned a first-ever study to assess the feasibility of DCRs in Belgium. The objective of the current feasibility study was to identify (legal) preconditions, design and operational considerations that would allow a DCR to be added within a continuum of policy initiatives for PWUD in five Belgian cities: Ghent, Antwerp, Brussels, Charleroi and Liège. The aims were threefold: (1) provide an up-to-date overview of the effectiveness, models, and barriers of DCRs worldwide, with particular attention to DCRs in Belgium’s four neighbouring countries; (2) conduct an in-depth analysis of the legal framework within a DCR could operate in Belgium; and (3) conduct a feasibility study with local stakeholders and PWUD from each of the five cities. Based on our findings, we formulate 18 recommendations specifically tailored to the Belgian context: essential preconditions (including legal options); main considerations when implementing a DCR; the implementation process; and monitoring and evaluation.
... Targeted therapeutic interventions could focus on needle exchange programs and supervised injection rooms that can reduce health-related risks of injection drug use and drug-related crime ( Vlahov et al., 1997;Watters et al., 1994;Wood, Tyndall, Montaner, & Kerr, 2006). Notably, supervised injection facilities generally attract higher-risk injection drug users, which may significantly reduce the healthcare burden these users face ( Wood et al., 2005). In theory, harm reduction education could focus on changing the route of administration from intravenous to non-parenteral; however, studies have found these interventions have limited efficacy ( Darke & Hall, 2003;Swift, Maher, & Sunjic, 1999). ...
Background:
Chronic use of heroin typically leads to numerous negative life consequences and serious clinical impairment. Increased negative consequences can result in poor treatment outcomes as well as adverse health effects and impaired social functioning. Certain risk factors, including early substance use initiation, concurrent use of other illicit substances, and injection drug use are associated with an increase in negative consequences. This study examined whether there are unique domains of heroin consequences and, if so, whether these domains are related to specific substance use characteristics.
Methods:
Data regarding substance use characteristics were collected from 370 non-treatment seeking, heroin-using, 18 to 55year-old participants from the Detroit metropolitan area. Principal component analysis (PCA) was used to analyze the factor structure of 21 negative heroin consequence items.
Results:
PCA demonstrated that heroin consequences could be divided into 5 unique domains. These unique domains were related to specific substance use characteristics and heroin consequence domains. Injection heroin use was significantly associated with increased Factor 1 consequences (primarily acute medical problems) but not with consequences in other domains. Certain substance use characteristics, such as injection status and earlier onset of marijuana use, were associated with increased consequences in specific domains.
Conclusions:
These findings support the existence of unique domains of negative consequences, and indicate that some risk factors (e.g. injection use) may be specific to these domains. Potential tailored-treatment strategies aimed at improving treatment engagement and reducing harm for heroin use based on person-specific risks and negative consequences are discussed.
... This finding has significant implications, suggesting that those who are especially vulnerable to adverse health outcomes would more frequently use the service, if available. Similar findings have been reported in Vancouver, where SIFs were found to attract those who injected in public, those who were homeless or unstably housed, and those who injected heroin daily [45]. Accordingly, SIS may be effective in attracting and connecting vulnerable groups of PWID to medical care, access to clean injecting equipment, emergency response to drug overdose, and referrals to addiction treatment and other support services. ...
Background
Supervised injection services (SIS) have been shown to reduce the public- and individual-level harms associated with injection drug use. While SIS feasibility research has been conducted in large urban centres, little is known about the acceptability of these services among people who inject drugs (PWID) in mid-sized cities. We assessed the prevalence and correlates of willingness to use SIS as well as design and operational preferences among PWID in London, Canada.
Methods
Between March and April 2016, peer research associates administered a cross-sectional survey to PWID in London. Socio-demographic characteristics, drug-use patterns, and behaviours associated with willingness to use SIS were estimated using bivariable and multivariable logistic regression models. Chi-square tests were used to compare characteristics with expected frequency of SIS use among those willing to use SIS. Design and operational preferences are also described.
Results
Of 197 PWID included in this analysis (median age, 39; interquartile range (IQR), 33–50; 38% female), 170 (86%) reported willingness to use SIS. In multivariable analyses, being female (adjusted odds ratio (AOR) 0.29; 95% confidence interval (CI) 0.11–0.75) was negatively associated with willingness to use, while public injecting in the last 6 months (AOR 2.76; 95% CI 1.00–7.62) was positively associated with willingness to use. Participants living in unstable housing, those injecting in public, and those injecting opioids and crystal methamphetamine daily reported higher expected frequency of SIS use (p < 0.05). A majority preferred private cubicles for injecting spaces and daytime operational hours, while just under half preferred PWID involved in service operations.
Conclusions
High levels of willingness to use SIS were found among PWID in this setting, suggesting that these services may play a role in addressing the harms associated with injection drug use. To maximize the uptake of SIS, programme planners and policy makers should consider the effects of gender and views of PWID regarding SIS design and operational preferences.
... Various studies have reported a high prevalence of willingness to use a SIF among people who inject drugs (PWID), and a number of factors related to willingness have been identified, including injecting in public, daily injection drug use, frequency of heroin use, ever experiencing an overdose, and familiarity with the concept of a SIF [37][38][39][40][41][42][43][44][45][46][47]. Studies have also shown that, once implemented, SIFs do indeed attract people at high risk of overdose, including those who inject in public and others at risk of blood-borne infection transmission [48][49][50]. However, to the best of our knowledge, only one peer-reviewed study has explored willingness to use a SIF among a sample in the USA. ...
Background
Supervised injection facilities (SIFs) are legally sanctioned environments for people to inject drugs under medical supervision. SIFs currently operate in ten countries, but to date, no SIF has been opened in the USA. In light of increasing overdose mortality in the USA, this study evaluated willingness to use a SIF among youth who report non-medical prescription opioid (NMPO) use. Methods
Between January 2015 and February 2016, youth with recent NMPO use were recruited to participate in the Rhode Island Young Adult Prescription Drug Study (RAPiDS). We explored factors associated with willingness to use a SIF among participants who had injected drugs or were at risk of initiating injection drug use (defined as having a sex partner who injects drugs or having a close friend who injects). ResultsAmong 54 eligible participants, the median age was 26 (IQR = 24–28), 70.4% were male, and 74.1% were white. Among all participants, when asked if they would use a SIF, 63.0% answered “Yes”, 31.5% answered “No”, and 5.6% were unsure. Among the 31 participants reporting injection drug use in the last six months, 27 (87.1%) reported willingness to use a SIF; 15 of the 19 (78.9%) who injected less than daily reported willingness, while all 12 (100.0%) of the participants who injected daily reported willingness. Compared to participants who were unwilling or were unsure, participants willing to use a SIF were also more likely to have been homeless in the last six months, have accidentally overdosed, have used heroin, have used fentanyl non-medically, and typically use prescription opioids alone. Conclusions
Among young adults who use prescription opioids non-medically and inject drugs or are at risk of initiating injection drug use, more than six in ten reported willingness to use a SIF. Established risk factors for overdose, including homelessness, history of overdose, daily injection drug use, heroin use, and fentanyl misuse, were associated with higher SIF acceptability, indicating that young people at the highest risk of overdose might ultimately be the same individuals to use the facility. Supervised injection facilities merit consideration to reduce overdose mortality in the USA.
... [21][22][23] SIS have also been found to attract a subset of very high-risk PWID, including those at high risk for HIV and hepatitis C infection and overdose, and those who engage in public injecting. 24,25 SIS have also been found to be highly cost-effective, 14,26 and they offer additional benefits for police and emergency services. SIS can serve as a place to refer PWID who are found injecting in public and who may be disconnected from conventional public health programs, 27 and they can also reduce the need for ambulance call-outs for overdoses. ...
... A number of evaluations of the DCR provision in Vancouver, Canada, also showed positive outcomes, including cleaner injecting practices, reduced injecting in public places, less unsafe syringe disposal and reduced needle sharing ( Petrar et al., 2007;Wood et al., 2004). In addition, the facility attracted higher-risk IDUs including public injectors and users at high risk for HIV and overdose ( Wood et al., 2005). A review of the literature on DCRs reported that DCRs were successful in several respects, for example by attracting the most marginalised IDUs, facilitating access to health care, and reducing overdoses; these were achieved without an increase in intravenous drug use or criminal activity ( Potier, Laprevote, Dubois-Arber, Cottencin, & Rolland, 2014). ...
Aim: The study investigated the attitudes of intravenous drug users (IDUs) towards the provision of drug consumption rooms (DCRs) in the UK and their willingness to use DCRs. Methods: Participants were 90 methadone-maintained outpatients recruited from a London clinic. A questionnaire asked about their willingness to use a DCR, their views on various rules commonly-implemented by DCRs, and how they believed DCRs might impact on the drug-taking behaviours of drug users and their peers. Findings: A large majority (89%) expressed willingness to use a DCR and accepted the need for rules such as no drug sharing (84.3%), no assistance with injecting (81.8%), compulsory supervision (76.7%) and compulsory hand washing (92.1%). However, the IDUs were split over whether injection in the neck or groin should be disallowed and whether certain categories of IDUs (e.g. juveniles, pregnant women) should be excluded from DCRs. Majorities thought it unlikely that DCRs would encourage users to try risker drug preparations (76.6%), or encourage non-injectors to inject for the first time (74.5%). Conclusions: In a country where DCRs are not available, the study highlights the willingness of IDUs to use a DCR and accept its rules, even for a sample most of whom were not homeless.
... Internationally, the effectiveness of DCRs in harm reduction has been supported by several studies. DCRs attract people with chronic use of drugs, who have increased health risk [14], contribute toward reducing the transmission of infectious diseases such as HIV and hepatitis C, and offer the treatment of infectious wounds [13][14][15][16][17][18][19][20]. ...
Background
Drug consumption rooms (DCRs) have been implemented worldwide as a harm-reducing strategy. In 2012, Denmark passed legislation allowing establishment of DCRs. The aim of this study was to identify characteristics and gain knowledge of the way service users use the DCRs including bridge building to specialized health care. Associations between nationality, opioid substitution treatment (OST), drug intake method, and response to staff advice on harm-reducing education was investigated, as well as service user’s reasons for using the DCRs, and their perceptions of safety and trust in the DCRs. MethodsA survey questionnaire sampled 154 participants of DCRs. Convenience sampling was used. Key variables covered demographics, drug intake mode, educational advice received in the DCR, and opinions about and role of the DCRs for the service users. ResultsOnly 10 % of the participants were under the age of 30, 30 % between 30 and 39 years, 36 % between 40 and 49 years, and 24 % age 50 or more. A total of 60 % of the participants had encountered drugs before they were 19 years old. Female participants were 25 %, and 73 % were Danish citizens, 8 % were non-Danish EU citizens, and 18 % were non-EU citizens. As drug intake method, 63 % injected drugs in a vein, 7 % sniffed, and 37 % smoked. Of drugs used in the DCR, 49 % used cocaine, 41 % heroin, 16 % a mix of heroin and cocaine, and 16 % used methadone. Participants who smoked drugs made significantly less use of drug rehabilitation than participants who sniffed or injected drugs. There was a similar rate of advice on OST across nationality. Participants accepted staff education on hygienic measures and safe injection practices and found it useful. Participants felt safe and trusted staff and bridge building to specialized health care took place in the DCR. Conclusions
Staff of Danish DCRs educate service users on health related issues and harm-reducing interventions. A subgroup who smoke and a subgroup of nationality other than Danish are underserved and have less likely been in OST. More research on these groups is needed.
... Consistent evidence supports the positive role SIFs have on improving various conditions for PWID 13,14 . Specifically, SIF have been found to reduce overdose mortality 15 , attract high-risk PWID 16 , decrease syringe sharing 17 , decrease public injecting 18 , improve engagement in treatment programs 19,20 , with no increase in criminal activity or drug trafficking in the areas surrounding the SIF 14 or risky behavior 21 . Safe injection facilities have also been found to reduce the demand on ambulance services 22 . ...
Aims: This study compares the characteristics of those who were or were not attended by the emergency services in the year before death. It describes the reasons for emergency service attendance and the prevalence of such attendance. It reports the number of days between the last emergency service attendance and death and examines contact with other health and social services and the association of this with emergency service attendance. Finally, it examines the association between the frequency of emergency service attendance and the frequency of contact with other services.Methods: A retrospective registry study where all overdose fatalities (n = 231) in Oslo, Norway (2006–2008), was identified through the National Cause of Death Registry and linked with data from other health and social services.
Results: Overall, 61% were emergency service attendees and 18% were frequent attendees. Somatic complaints were the most common reason for attendance. Attendees were more known to a number of other services compared to the non-attendees. Furthermore, there was an association between the frequency of emergency service attendance and the frequency of contact with other services.Conclusions: Screening for drug use among emergency service attendees may be a way to identify those at risk of overdose death and enable the introduction of additional interventions.
... Analyses of the demographic characteristics, social circumstances, and health status of SIF attendees suggest that they are able to reach those most in need 88,89 . For instance, among a community cohort in Vancouver, 45% of people with active injecting drug use had ever used the SIF; those who had were more likely to be homeless, use heroin or cocaine on a daily basis, engage in public injecting and have had a recent non-fatal overdose compared to those who did not 90 . Similar findings have been reported from Australian and European facilities 81 . ...
Health needs assessment, NHS Greater Glasgow and Clyde - published June 2016
... Drug consumption rooms are defined as 'professionally supervised healthcare facilities where drug users can use drugs in safer and more hygienic conditions' [2]. A growing body of scientific evidence shows that DCRs have an impact on both improving health and reducing death by overdose among clients who use these facilities [4][5][6][7][8][9][10][11][12][13]. For people who use drugs, unsafe drug intake often involves unhygienic and incorrect injections which cause both injury and infection [14][15][16][17][18]. ...
Background
Drug use contributes to higher rates of morbidity and mortality among people who use drugs compared to the general population. In 2012, Danish politicians passed a law that allowed drug consumption rooms (DCRs) to operate; among the objectives were to improve the well-being of vulnerable citizens and to reduce the number of overdoses. Five Danish DCRs are currently being operated. This article presents results from a national investigation focused on assessing the impact of Danish drug consumption rooms on the health and well-being of DCR clients and factors facilitating the acceptance of DCR clients in order to improve their health and refer them onward to social and health service providers.
Methods
We conducted 250 h of participant observation in the DCRs, followed by in-depth qualitative interviews with 42 DCR clients and 25 staff members. Field notes and interviews were analysed and coded, and themes have been developed.
Results
DCR clients experienced a sense of social acceptance while inside DCRs. Members of staff conveyed a welcoming, non-judgemental attitude, and DCR clients were predominantly satisfied with the facilities. They prioritized forging relations with drug users so as to foster a sense of social acceptance within DCRs. The primary goal of staff members is to prevent overdoses by informing clients about strong drugs and by intervening in cases of intoxication. DCRs provide security to clients. In cases of health-related problems, DCR clients were referred to local health clinics. Members of the staff build bridges for DCR clients by guiding them towards drug treatment programmes and services in the social and the health sectors.
Conclusions
The study reveals a consistency between DCR clients and staff members with respect to appraisal of the importance of DCRs. Both clients and staff agreed that DCRs provide a safe haven in the environment in which DCR clients often live and that staff members’ approach to clients with the intention of promoting acceptance clears the path for the prevention and treatment of overdoses and providing referrals to healthcare facilities, to drug treatment centres and to social services.
Aims
The primary aim of this study was to evaluate the impact of drug consumption rooms (DCRs) in France on injection equipment‐sharing, while the secondary aims focused upon their impact on access to hepatitis C virus (HCV) testing and opioid agonist treatment (OAT).
Design
The COhort to identify Structural and INdividual factors associated with drug USe (COSINUS cohort) was a 12‐month longitudinal study of 665 people who inject drugs (PWID), conducted in Bordeaux, Marseille, Paris and Strasbourg. We used data from face‐to‐face interviews at enrolment and at 6‐month and 12‐month visits.
Setting and participants
The participants were recruited in harm reduction programmes in Bordeaux and Marseille and in DCRs in Strasbourg and Paris. Participants were aged more than 18 years, French‐speaking and had injected substances the month before enrolment.
Measurements
We measured the impact of DCR exposure on injection equipment sharing, HCV testing and the use of medications for opioid use disorder, after adjustment for significant correlates. We used a two‐step Heckman mixed‐effects probit model, which allowed us to take into account the correlation of repeated measures and to control for potential bias due to non‐randomization between the two groups (DCR‐exposed versus DCR‐unexposed participants).
Findings
The difference of declared injection equipment sharing between PWID exposed to DCRs versus non‐exposed was 10% (1% for those exposed versus 11% for those non‐exposed, marginal effect = −0.10; 95% confidence interval = −0.18, −0.03); there was no impact of DCRs on HCV testing and OAT.
Conclusions
In the French context, drug consumption rooms appear to have a positive impact on at‐risk practices for infectious diseases such as human immunodeficiency virus (HIV) and hepatitis C virus.
Objective:
To evaluate the feasibility of testing and treating people who inject drugs at a supervised injecting facility for hepatitis C virus (HCV) infection.
Design:
Retrospective cohort study.
Setting, participants:
People who inject drugs who attended the Melbourne supervised injecting facility, 30 June 2018 - 30 June 2020.
Main outcome measures:
Proportion of people tested for hepatitis C; proportions of people positive for anti-HCV antibody and HCV RNA, and of eligible people prescribed direct-acting antiviral (DAA) treatment; sustained virological response twelve weeks or more after treatment completion.
Results:
Of 4649 people who attended the supervised injecting facility during 2018-20, 321 were tested for hepatitis C (7%); 279 were anti-HCV antibody-positive (87%), of whom 143 (51%) were also HCV RNA-positive. Sixty-four of 321 had previously been treated for hepatitis C (20%), 21 had clinically identified cirrhosis (7%), eight had hepatitis B infections (2%), and four had human immunodeficiency virus infections (1%). In multivariate analyses, people tested for hepatitis C were more likely than untested clients to report psychiatric illness (adjusted odds ratio [aOR], 9.65; 95% confidence interval [CI], 7.26-12.8), not have a fixed address (aOR, 1.59; 95% CI, 1.18-2.14), and to report significant alcohol use (aOR, 1.57; 95% CI, 1.06-2.32). The median number of injecting facility visits was larger for those tested for hepatitis C (101; interquartile range [IQR], 31-236) than for those not tested (20; IQR, 3-90). DAA treatment was prescribed for 126 of 143 HCV RNA-positive clients (88%); 41 of 54 with complete follow-up data were cured (76%).
Conclusions:
People who attend supervised injecting facilities can be tested and treated for hepatitis C on site. Models that provide streamlined, convenient hepatitis C care promote engagement with treatment in a group in which the prevalence of hepatitis C is high.
Background:
There are now more than 100 supervised injection facilities (SIFs) operating in numerous jurisdictions, including Australia, Canada and Western Europe. However, despite the increasing prevalence of people who use or abuse illegal drugs, including those who inject drugs, there are currently no operating SIFs in Africa, Asia, Central and South America and Eastern Europe. With the exception of Canada in North America, no sanctioned facility currently operates in the United Mexican States or the United States of America. This is the first study to systematically synthetizes the overall benefits and cost-effective ratios associated with operating SIFs, hypothetical SIFs, or drug consumption sites in different jurisdictions.
Methods and Analysis:
In this systematic review, through relying on five electronic scientific data bases, the peer-reviewed studies, reports, and theses that have evaluated the cost and benefits of supervised injection or consumption facilities will be identified. Based on the inclusion criteria, all initial articles will be identified and screened via title and abstract. All the articles collected through the initial search will be additionally screened to extract further information and data related to costs, benefits, programs, or services. The final data analysis will include the average cumulative benefits, costs, and ratios associated with operating SIFs.
Discussion:
This review has the potential to provide evidence-based knowledge related to the cost-savings of public health interventions implemented via harm reduction approaches for marginalized populations. However, it is important to emphasize that SIFs are an integral part of health care system for the marginalized populations and their establishments should not be based on health care costs, rather based on human rights.
Systematic review registration: PROPSERO CRD42018100324
Background:
There are now more than 100 supervised injection facilities (SIFs) operating in numerous jurisdictions, including Australia, Canada and Western Europe. However, despite the increasing prevalence of people who use or abuse illegal drugs, including those who inject drugs, there are currently no operating SIFs in Africa, Asia, Central and South America and Eastern Europe. With the exception of Canada in North America, no sanctioned facility currently operates in the United Mexican States or the United States of America. This is the first study to systematically synthetizes the overall benefits and cost-effective ratios associated with operating SIFs, hypothetical SIFs, or drug consumption sites in different jurisdictions.
Methods and Analysis:
In this systematic review, through relying on five electronic scientific data bases, the peer-reviewed studies, reports, and theses that have evaluated the cost and benefits of supervised injection or consumption facilities will be identified. Based on the inclusion criteria, all initial articles will be identified and screened via title and abstract. All the articles collected through the initial search will be additionally screened to extract further information and data related to costs, benefits, programs, or services. The final data analysis will include the average cumulative benefits, costs, and ratios associated with operating SIFs.
Discussion:
This review has the potential to provide evidence-based knowledge related to the cost-savings of public health interventions implemented via harm reduction approaches for marginalized populations. However, it is important to emphasize that SIFs are an integral part of health care system for the marginalized populations and their establishments should not be based on health care costs, rather based on human rights.
Systematic review registration: PROPSERO CRD42018100324
Background and Aims
In response to a dramatic rise in overdose deaths due to injection drug use, there was a rapid scale-up of low-threshold supervised injection services (SIS), termed ‘overdose prevention sites’ (OPS), in Vancouver, Canada in December 2016. We measured the potential impact of this intervention on SIS use and related health outcomes among people who inject drugs (PWID).
Design
Segmented regression analyses of interrupted time series data from two community-recruited prospective cohorts of PWID from January 2015 to November 2018 were used to measure the impact of the OPS scale-up on changes in SIS use, public injection, syringe sharing and addiction treatment participation, controlling for pre-existing secular trends.
Setting
Vancouver, Canada.
Participants
Of 745 PWID, 292 (39.7%) were women, 441 (59.6%) self-reported white ancestry and the median age was 47 years (interquartile range = 38, 53) at baseline.
Measurements
Immediate (i.e. step level) and gradual (i.e. slope) changes in the monthly proportion of participants who self-reported past 6-month SIS use, public injection, syringe sharing and participation in any form of addiction treatment.
Findings
Post OPS expansion, the monthly prevalence of SIS use immediately increased by an estimated 6.4% [95% confidence interval (CI) = 1.7, 11.2] and subsequently further increased by an estimated 0.7% (95% CI = 0.3, 1.1) per month. The monthly prevalence of addiction treatment participation immediately increased by an estimated 4.5% (95% CI = 0.5, 8.5) following the OPS expansion, while public injection and syringe sharing were estimated to immediately decrease by 5.5% (95% CI = 0.9, 10.0) and 2.5% (95% CI = 0.5, 4.6), respectively. Findings were inconclusive as to whether or not an association was present between the intervention and subsequent gradual changes in public injection, syringe sharing and addiction treatment participation.
Conclusions
Scaling-up overdose prevention sites in Vancouver, Canada in December 2016 was associated with immediate and continued gradual increases in supervised injection service engagement and immediate increases in related health benefits.
Opioid use, particularly via injection, is associated with an increased risk of infection, injury, and death. Safer consumption sites (SCSs), where people may consume previously obtained drugs under observation, have been shown to reduce these risks among people who use drugs. Most SCSs employ nurses, but there is limited research into their roles. The objective of this article is to describe and synthesize the roles of nurses at SCSs to better understand their importance in a rapidly proliferating public health intervention. We extracted data from 48 qualitative, quantitative, peer-reviewed, and gray literature, as well as primary source narrative articles on SCSs, whether they were explicitly about nursing or not. We coded each mention of nurses or nursing in each article and identified 11 descriptive themes or roles that SCS nurses carry out. From these, we identified the following three analytical themes or hypotheses about the character of these roles: (a) The primary aim of SCS nursing care is to reduce morbidity and mortality; (b) SCS nurses create a therapeutic community; and (c) SCS nurses engage in research, professional activities, and activism to better understand and promote SCSs. More research into the roles of SCS nurses is needed to better serve a vulnerable population.
Background
People who require help injecting illicit drugs experience elevated rates of a range of health-related harms, including overdose and acquisition of blood-borne pathogens. In response, some supervised injection services (SIS) in Canada have begun to permit clients to be physically injected by fellow clients or staff members. However, little is known about uptake and characteristics of clients who engage in this practice. We therefore sought to examine factors associated with receiving injection assistance at SIS among people who require help injecting drugs in Vancouver, Canada.
Methods
Data were drawn from two community-recruited prospective cohort studies of people who inject drugs (PWID). We used multivariable generalized estimating equation (GEE) analyses with time-updated covariates to identify factors associated with self-reported receipt of injection assistance at SIS.
Results
Between June 2017 and December 2018, 319 individuals who reported having recently required help injecting were included in the study. Of these, 160 (51.0%) were women and the median age was 42 years at baseline. In total, 54 (16.9%) participants reported receiving injection assistance at a SIS at least once over an average of 3.3 months of follow-up. In multivariable GEE analyses, recent homelessness (Adjusted Odds Ratio [AOR] = 2.04; 95% confidence interval [CI]: 1.13 – 3.66), fentanyl injection (AOR = 3.45; 95% CI: 1.42 – 8.41), non-fatal overdose (AOR = 1.86; 95% CI: 1.02 – 3.38) and enrolment in methadone maintenance therapy (AOR = 1.89; 95% CI: 1.03 – 3.47) were associated with increased odds of receiving injection assistance at SIS.
Conclusion
Although uptake of assisted injection at SIS was relatively low among this sample of people who require help injecting, this practice was associated with several indicators of structural vulnerability and drug-related risk. These findings suggest that accommodating assisted injection within SIS may be providing opportunities to engage and reduce harms among higher-risk subpopulations of PWID in this setting.
Background
US jurisdictions are considering implementing supervised drug consumption sites (SCSs) to combat the overdose epidemic. No sanctioned SCS exists in the US, but King County, Washington has proposed Community Health Engagement Locations (CHELs), which would include supervised drug consumption. We assessed characteristics of people engaged in syringe services programs (SSPs) who anticipated SCS use.
Methods
We estimated prevalence of anticipated SCS use in a 2017 cross-sectional sample of King County SSP participants (N = 377). We used Poisson regression with robust standard errors to estimate likelihood of anticipated SCS use by overdose history (experienced, witnessed only, neither), public injection frequency (always, some/most times, never), drug use behaviors, and sociodemographic characteristics.
Results
The sample was primarily male (66.8%), white (69.5%), and averaged 37 years old. Almost two-thirds of participants witnessed or experienced an overdose in the past year (43.2% witnessed only; 19.6% experienced overdose). Four in five SSP participants (83.0%) anticipated any SCS use. Anticipated SCS use was higher among participants who experienced an overdose (risk ratio [RR] = 1.14, 95% CI = 1.04, 1.24) than those with no overdose experience. In multivariable analyses, anticipated SCS use was higher among people reporting injecting publicly (e.g., always vs. never: aRR = 1.26, 95% CI = 1.11, 1.43), and lower among people primarily using methamphetamine (aRR = 0.80, 95% CI = 0.67, 0.96) compared to people primarily using opioids.
Conclusions
In King County, SCS services would be used by people at high risk of overdose, including SSP participants reporting injecting in public. SCSs could be an important step to promote health and safety across communities.
Background:
In Catalonia (Spain), people who inject drugs (PWID) face numerous barriers to access to mainstream healthcare services for hepatitis C confirmatory diagnosis and treatment, so simplified testing strategies for viremic infection are urgently needed. Among PWID attending harm-reduction services in Catalonia, we aimed (i) to assess the utility of an in-house HCV-RNA detection assay on dried blood spots (DBS) as a one-step screening and confirmatory diagnosis strategy for hepatitis C, (ii) to estimate the prevalence of viremic HCV infection, and (iii) to identify factors associated with unawareness of viremic infection.
Methods:
A cross-sectional study of current PWID (N = 410) was performed in four harm-reduction services. All participants underwent HCV antibody point-of-care testing and parallel DBS collection for centralized RNA testing. An epidemiological questionnaire was administered. Paired EDTA-plasma samples were additionally collected for HCV viral load testing in 300 participants.
Results:
HCV-RNA testing from DBS was feasible and showed 97.2% sensitivity and 100% specificity for viral loads >3000 IU/mL in real-life conditions. No significant differences in the performance when detecting viremic infections were observed between this one-step testing strategy vs. the conventional two-step algorithm involving venepuncture. Overall HCV seroprevalence was 79.8%, and prevalence of viremic infection was 58.5%. Importantly, 35.8% of viremic HCV participants were unaware of their status, and no specific socio-demographic or bio-behavioral factors independently associated with unawareness of viremic infection were identified. Among participants reporting a past or current HCV infection, 29.0% stated having received HCV antiviral treatment.
Conclusion:
The high viremic HCV infection burden among PWID attending HRS, estimated for the first time in Catalonia, together with the low levels of awareness of viremic status and access to treatment, suggest that scaling up this one-step screening and diagnosis strategy to the network of harm-reduction services would help to achieve HCV elimination targets set by the World Health Organization.
Link: https://authors.elsevier.com/a/1a0iu3PEroOz3H
Context.— In British Columbia, human immunodeficiency virus (HIV)–infected
persons eligible for antiretroviral therapy may receive it free but the extent
to which HIV-infected injection drug users access it is unknown.Objective.— To identify patient and physician characteristics associated with antiretroviral
therapy utilization in HIV-infected injection drug users.Design.— Prospective cohort study with record linkage between survey data and
data from a provincial HIV/AIDS (acquired immunodeficiency syndrome) drug
treatment program.Setting.— British Columbia, where antiretroviral therapies are offered free to
all persons with HIV infection with CD4 cell counts less than 0.50×109/L (500/µL) and/or HIV-1 RNA levels higher than 5000 copies/mL.Subjects.— A total of 177 HIV-infected injection drug users eligible for antiretroviral
therapy, recruited through the prospective cohort study since May 1996.Main Outcome Measures.— Patient use of antiretroviral drugs through the provincial drug treatment
program and physician experience treating HIV infection.Results.— After a median of 11 months after first eligibility, only 71 (40%) of
177 patients had received any antiretroviral drugs, primarily double combinations
(47/71 [66%]). Both patient and physician characteristics were associated
with use of antiretroviral drugs. After adjusting for CD4 cell count and HIV-1
RNA level at eligibility, odds of not receiving antiretrovirals were increased
more than 2-fold for females (odds ratio [OR], 2.53; 95% confidence interval
[CI], 1.08-5.93) and 3-fold for those not currently enrolled in drug or alcohol
treatment programs (OR, 3.49; 95% CI, 1.45-8.40). Younger drug users were
less likely to receive therapy (OR, 0.47/10-y increase; 95% CI, 0.28-0.80).
Those with physicians having the least experience treating persons with HIV
infection were more than 5 times less likely to receive therapy (OR, 5.55;
95% CI, 2.49-12.37).Conclusions.— Despite free antiretroviral therapy, many HIV-infected injection drug
users are not receiving it. Public health efforts should target younger and
female drug users, and physicians with less experience treating HIV infection.
Objectives.
—To describe prevention activities and risk behavior in cities where human immunodeficiency virus (HIV) was introduced into the local population of injecting drug users (IDUs), but where seroprevalence has nevertheless remained low (<5%) during at least 5 years.Design and Setting.
—A literature search identified five such cities: Glasgow, Scotland; Lund, Sweden; Sydney, New South Wales, Australia; Tacoma, Wash; and Toronto, Ontario. Case histories were prepared for each city, including data on prevention activities and current levels of risk behavior among IDUs.Participants.
—Injecting drug users recruited from both drug treatment and non-treatment settings in each city.Interventions.
—A variety of HIV prevention activities for IDUs had been implemented in each of the five cities.Results.
—There were three common prevention components present in all five cities: (1) implementation of prevention activities when HIV seroprevalence was still low, (2) provision of sterile injection equipment, and (3) community outreach to IDUs. Moderate levels of risk behavior continued with one third or more of the IDUs reporting recent unsafe injections.Conclusions.
—In low-seroprevalence areas, it appears possible to severely limit transmission of HIV among populations of IDUs, despite continuing risk behavior among a substantial proportion of the population. Pending further studies, the common prevention components (beginning early, community outreach, and access to sterile injection equipment) should be implemented wherever populations of IDUs are at risk for rapid spread of HIV.(JAMA. 1995;274:1226-1231)
Although there have been repeated calls for the establishment of safe injection facilities (SIFs) in Vancouver since the early 1990s, questions remain concerning the feasibility of SIFs due to the high prevalence of injection cocaine and the concomitant problems cocaine use presents. Therefore, we determined the prevalence of willingness to attend SIFs among cocaine injectors in Vancouver and explored the factors associated with this willingness, using data from the Vancouver Injection Drug Users Study. After considering the results derived from this analysis, additional qualitative methods were employed to explore further willingness to use SIFs, barriers and facilitators of SIF utilization, and methods of maximizing use among selected subpopulations of cocaine injectors. The results suggest that a high proportion of cocaine injectors, including some of those most at risk, would attend an SIF if one were available. However, in order to better accommodate cocaine injectors, several modifications could be made to conventional SIF service design and delivery. The vast majority of these modifications relate to ensuring effective responses to cocaine toxicity. Given the acceptability of SIFs among cocaine injectors, it appears that an SIF pilot could result in significant and immediate benefits in terms of public health and community safety.
Many Canadian cities are experiencing ongoing infectious disease and overdose epidemics among injection drug users (IDUs). In particular, Human Immunodeficiency Virus (HIV) and hepatitis C Virus (HCV) have become endemic in many settings and bacterial and viral infections, such as endocarditis and cellulitis, have become extremely common among this population. In an effort to reduce these public health concerns and the public order problems associated with public injection drug use, in September 2003, Vancouver, Canada opened a pilot medically supervised safer injecting facility (SIF), where IDUs can inject pre-obtained illicit drugs under the supervision of medical staff. The SIF was granted a legal exemption to operate on the condition that its impacts be rigorously evaluated. In order to ensure that the evaluation is appropriately open to scrutiny among the public health community, the present article was prepared to outline the methodology for evaluating the SIF and report on some preliminary observations. The evaluation is primarily structured around a prospective cohort of SIF users, that will examine risk behavior, blood-borne infection transmission, overdose, and health service use. These analyses will be augmented with process data from within the SIF, as well as survey's of local residents and qualitative interviews with users, staff, and key stakeholders, and standardised evaluations of public order changes. Preliminary observations suggest that the site has been successful in attracting IDUs into its programs and in turn helped to reduce public drug use. However, each of the indicators described above is the subject of a rigorous scientific evaluation that is attempting to quantify the overall impacts of the site and identify both benefits and potentially harmful consequences and it will take several years before the SIF's impacts can be appropriately examined.
To describe prevention activities and risk behavior in cities where human immunodeficiency virus (HIV) was introduced into the local population of injecting drug users (IDUs), but where seroprevalence has nevertheless remained low (< 5%) during at least 5 years.
A literature search identified five such cities: Glasgow, Scotland; Lund, Sweden; Sydney, New South Wales, Australia; Tacoma, Wash; and Toronto, Ontario. Case histories were prepared for each city, including data on prevention activities and current levels of risk behavior among IDUs.
Injecting drug users recruited from both drug treatment and non-treatment settings in each city.
A variety of HIV prevention activities for IDUs had been implemented in each of the five cities.
There were three common prevention components present in all five cities: (1) implementation of prevention activities when HIV seroprevalence was still low, (2) provision of sterile injection equipment, and (3) community outreach to IDUs. Moderate levels of risk behavior continued with one third or more of the IDUs reporting recent unsafe injections.
In low-seroprevalence areas, it appears possible to severely limit transmission of HIV among populations of IDUs, despite continuing risk behavior among a substantial proportion of the population. Pending further studies, the common prevention components (beginning early, community outreach, and access to sterile injection equipment) should be implemented wherever populations of IDUs are at risk for rapid spread of HIV.
In British Columbia, human immunodeficiency virus (HIV)-infected persons eligible for antiretroviral therapy may receive it free but the extent to which HIV-infected injection drug users access it is unknown.
To identify patient and physician characteristics associated with antiretroviral therapy utilization in HIV-infected injection drug users.
Prospective cohort study with record linkage between survey data and data from a provincial HIV/AIDS (acquired immunodeficiency syndrome) drug treatment program.
British Columbia, where antiretroviral therapies are offered free to all persons with HIV infection with CD4 cell counts less than 0.50 x 10(9)/L (500/microL) and/or HIV-1 RNA levels higher than 5000 copies/mL.
A total of 177 HIV-infected injection drug users eligible for antiretroviral therapy, recruited through the prospective cohort study since May 1996.
Patient use of antiretroviral drugs through the provincial drug treatment program and physician experience treating HIV infection.
After a median of 11 months after first eligibility, only 71 (40%) of 177 patients had received any antiretroviral drugs, primarily double combinations (47/71 [66%]). Both patient and physician characteristics were associated with use of antiretroviral drugs. After adjusting for CD4 cell count and HIV-1 RNA level at eligibility, odds of not receiving antiretrovirals were increased more than 2-fold for females (odds ratio [OR], 2.53; 95% confidence interval [CI], 1.08-5.93) and 3-fold for those not currently enrolled in drug or alcohol treatment programs (OR, 3.49; 95% CI, 1.45-8.40). Younger drug users were less likely to receive therapy (OR, 0.47/10-y increase; 95% CI, 0.28-0.80). Those with physicians having the least experience treating persons with HIV infection were more than 5 times less likely to receive therapy (OR, 5.55; 95% CI, 2.49-12.37).
Despite free antiretroviral therapy, many HIV-infected injection drug users are not receiving it. Public health efforts should target younger and female drug users, and physicians with less experience treating HIV infection.
Injection drug use directly or indirectly accounts for nearly half the annual human immunodeficiency virus (HIV) infections in the United States. Prospective studies that investigate both sexual and parenteral HIV risks among injection drug users (IDUs) are needed. We studied factors for HIV seroconversion among male and female IDUs in Baltimore, Md.
The HIV-negative IDUs (1447 male and 427 female) were recruited into a prospective study from 1988 to 1989 or in 1994. Participants underwent semiannual HIV tests and surveys through December 1998. Poisson regression was used to identify risk factors for HIV seroconversion, stratified by sex. Behaviors were treated as time-dependent covariates that varied at each semiannual period.
Subjects were primarily African American (91%), and median age at enrollment was 35 years. Incidence of HIV was 3.14 per 100 person years (95% confidence interval, 2.78-3.53) and did not significantly differ by sex. Younger age independently predicted HIV seroconversion for both men and women. Among men, factors that independently predicted HIV seroconversion were the following: less than a high school education, recent needle sharing with multiple partners, daily injection, and shooting-gallery attendance. The incidence of HIV was double for men recently engaging in homosexual activity and cocaine injection. Among women, the incidence of HIV was more than double for those recently reporting sexually transmitted diseases.
The incidence of HIV remained high among IDUs in Baltimore over the past decade. Risk factors for HIV seroconversion differed markedly by sex. Predominant risks among men included needle sharing and homosexual activity; among women, factors consistent with high-risk heterosexual activity were more significant than drug-related risks. Human immunodeficiency virus interventions aimed at IDUs should be sex-specific and incorporate sexual risks.
1 Illicit drug injection is as- sociated with significant health and social consequences for drug users, their families and communities. The conse- quences include injection-related infections, overdose, bloodborne disease transmission, exposure to discarded needles, violence, property crime and sex trade. Two articles in this issue of CMAJ highlight the contin- uing unsafe injection practices 2 and the health-related con- sequences 3 that are occurring in a cohort of IDUs in Van- couver despite the availability of a large needle-exchange program. 4,5 In the first report (page 405), 214 (27.6%) of 776 participants from the Vancouver Injection Drug User Study (VIDUS) stated that they had recently shared nee- dles. 2
In 1997, we found a higher prevalence of HIV among female than among male injection drug users in Vancouver. Factors associated with HIV incidence among women in this setting were unknown. In the present study, we sought to compare HIV incidence rates among male and female injection drug users in Vancouver and to compare factors associated with HIV seroconversion.
This analysis was based on 939 participants recruited between May 1996 and December 2000 who were seronegative at enrolment with at least one follow-up visit completed, and who were studied prospectively until March 2001. Incidence rates were calculated using the Kaplan-Meier method. The Cox proportional hazards regression model was used to identify independent predictors of time to HIV seroconversion.
As of March 2001, seroconversion had occurred in 110 of 939 participants (64 men, 46 women), yielding a cumulative incidence rate of HIV at 48 months of 13.4% (95% confidence interval [CI] 11.0%-15.8%). Incidence was higher among women than among men (16.6% v. 11.7%, p = 0.074). Multivariate analysis of the female participants' practices revealed injecting cocaine once or more per day compared with injecting less than once per day (adjusted relative risk [RR] 2.6, 95% CI 1.4-4.8), requiring help injecting compared with not requiring such assistance (adjusted RR 2.1, 95% CI 1.1-3.8), having unsafe sex with a regular partner compared with not having unsafe sex with a regular partner (adjusted RR 2.9, 95% CI 0.9-9.5) and having an HIV-positive sex partner compared with not having an HIV-positive sex partner (adjusted RR 2.7, 95% CI 1.0-7.7) to be independent predictors of time to HIV seroconversion. Among male participants, injecting cocaine once or more per day compared with injecting less than once per day (adjusted RR 3.3, 95% CI 1.9-5.6), self-reporting identification as an Aboriginal compared with not self-reporting identification as an Aboriginal (adjusted RR 2.5, 95% CI 1.4-4.2) and borrowing needles compared with not borrowing needles (adjusted RR 2.0, 95% CI 1.1-3.4) were independent predictors of HIV infection.
HIV incidence rates among female injection drug users in Vancouver are about 40% higher than those of male injection drug users. Different risk factors for seroconversion for women as opposed to men suggest that sex-specific prevention initiatives are urgently required.
Harm reduction policies and practices (where anything goes, if it actually reduces harm) have fundamentally altered our approach to the drugs problem. Two innovations were recently considered by the Home Affairs Select Committee—supervised injecting centres and supervised injectable maintenance clinics—but with unhelpful confusion between the two.1 They have different target populations, potential benefits, and legal obstacles.
Supervised injecting centres (also known as supervised drug consumption rooms or fixing rooms) are essentially public access facilities, perhaps the injecting drug user's equivalent of a pub or bar, where the injection of unknown drugs by unknown persons should be safer by virtue of supervision and consequent speed of response in the event of overdose.2 The target population is all injecting drug misusers—regardless of whether or not they are dependent or wish to change their drug taking habits. Perhaps providing this safer haven may lead some to seek …
Medically supervised injecting centres are “legally sanctioned and supervised facilities designed to reduce the health and public order problems associated with illegal injection drug use.”1 Their purpose is to enable the consumption of pre-obtained drugs under hygienic, low risk conditions (box).1 They differ from illegal “shooting galleries,” where users pay to inject on site.2 Worldwide, medically supervised injecting centres (also referred to as health rooms, supervised injecting rooms, drug consumption rooms, and safer injecting rooms or facilities) are receiving renewed attention. In 2001, the first medically supervised injecting centre in recent times was opened in Sydney, Australia. By 2002, there were 16 centres in five German cities,3 over 20 in the Netherlands, and some in Switzerland and Spain.4
Many cities throughout the world are experiencing ongoing infectious disease and overdose epidemics among illicit injection drug users (IDUs). In particular, HIV and hepatitis C virus (HCV) have become endemic in many settings and bacterial infections, such as endocarditis, have become extremely common among this population. In an effort to reduce these public health concerns, in September 2003, Vancouver, Canada, opened a pilot medically supervised safer- injecting facility (SIF), where IDUs can inject pre-obtained illicit drugs under the supervision of medical staff. Before and since the facility's opening, there has been a substantial misunderstanding about the rationale for evaluating SIF as a public-health strategy. This article outlines the evidence and rationale in support of the Canadian initiative. This rationale involves limitations in conventionally applied drug-control efforts, and gaps in current public-health policies in controlling the spread of infectious diseases, and the incidence of overdose among IDUs.
North America's first medically supervised safer injecting facility for illicit injection drug users was opened in Vancouver on Sept. 22, 2003. Although similar facilities exist in a number of European cities and in Sydney, Australia, no standardized evaluations of their impact have been presented in the scientific literature.
Using a standardized prospective data collection protocol, we measured injection-related public order problems during the 6 weeks before and the 12 weeks after the opening of the safer injecting facility in Vancouver. We measured changes in the number of drug users injecting in public, publicly discarded syringes and injection-related litter. We used Poisson log-linear regression models to evaluate changes in these public order indicators while considering potential confounding variables such as police presence and rainfall.
In stratified linear regression models, the 12-week period after the facility's opening was independently associated with reductions in the number of drug users injecting in public (p < 0.001), publicly discarded syringes (p < 0.001) and injection-related litter (p < 0.001). The predicted mean daily number of drug users injecting in public was 4.3 (95% confidence interval [CI] 3.5-5.4) during the period before the facility's opening and 2.4 (95% CI 1.9-3.0) after the opening; the corresponding predicted mean daily numbers of publicly discarded syringes were 11.5 (95% CI 10.0-13.2) and 5.4 (95% CI 4.7-6.2). Externally compiled statistics from the city of Vancouver on the number of syringes discarded in outdoor safe disposal boxes were consistent with our findings.
The opening of the safer injecting facility was independently associated with improvements in several measures of public order, including reduced public injection drug use and public syringe disposal.
The purpose of this study was to determine the prevalence and incidence of HIV and hepatitis C virus (HCV) coinfection among young (aged 29 years or younger) injection drug users (IDUs) and to compare sociodemographic and risk characteristics between (HIV/HCV) coinfected, monoinfected, or HIV- and HCV-negative youth. Data were collected through the Vancouver Injection Drug Users Study (VIDUS). To date, more than 1400 IDUs have been enrolled and followed, of whom 479 were aged 29 years or younger. Semiannually, participants have completed an interviewer-administered questionnaire and have undergone serologic testing for HIV and HCV. Univariate and multivariate logistic regression analyses were undertaken to investigate predictors of baseline coinfection. Cox regression models with time-dependent covariates were used to identify predictors of time to secondary infection seroconversion. A Cochran-Armitage trend test was used to determine risk associations across 3 categories: no infection, monoinfection, and coinfection. Of the 479 young injectors, 78 (16%) were coinfected with HIV and HCV at baseline and a further 45 (15%) with follow-up data became coinfected during the study period. Baseline coinfection was independently associated with being female, being aboriginal, older age, greater number of years injecting, and living in the IDU epicenter. Factors independently associated with time to secondary infection seroconversion were borrowing needles and greater than once-daily cocaine injection, and accessing methadone maintenance therapy in the previous 6 months was protective. There were clear trends across the 3 categories for increasing proportions of female subjects, aboriginal subjects, older age, greater number of years injecting, living in the IDU epicenter, and daily cocaine use. There were a shocking number of youth living with coinfection, particularly female and aboriginal youth. The median number of years injecting for youth seroconverting to a secondary infection was 3 years, suggesting that appropriate public health interventions should be implemented immediately.
Objective:: To describe prevalence and incidence of HIV‐1, hepatitis C virus (HCV) and risk behaviours in a prospective cohort of injecting drug users (IDU). Setting:: Vancouver, which introduced a needle exchange programme (NEP) in 1988, and currently exchanges over 2 million needles per year. Design:: IDU who had injected illicit drugs within the previous month were recruited through street outreach. At baseline and semi‐annually, subjects underwent serology for HIV‐1 and HCV, and questionnaires on demographics, behaviours and NEP attendance were completed. Logistic regression analysis was used to identify determinants of HIV prevalence. Results:: Of 1006 IDU, 65% were men, and either white (65%) or Native (27%). Prevalence rates of HIV‐1 and HCV were 23 and 88%, respectively. The majority (92%) had attended Vancouver's NEP, which was the most important syringe source for 78%. Identical proportions of known HIV‐positive and HIV‐negative IDU reported lending used syringes (40%). Of HIV‐negative IDU, 39% borrowed used needles within the previous 6 months. Relative to HIV‐negative IDU, HIV‐positive IDU were more likely to frequently inject cocaine (72 versus 62%; P < 0.001). Independent predictors of HIV‐positive serostatus were low education, unstable housing, commercial sex, borrowing needles, being an established IDU, injecting with others, and frequent NEP attendance. Based on 24 seroconversions among 257 follow‐up visits, estimated HIV incidence was 18.6 per 100 person‐years (95% confidence interval, 11.1‐26.0). Conclusions:: Despite having the largest NEP in North America, Vancouver has been experiencing an ongoing HIV epidemic. Whereas NEP are crucial for sterile syringe provision, they should be considered one component of a comprehensive programme including counselling, support and education.
In the last decade in a number of larger cities in Western Europe facilities have been initiated in which drug users are permitted to consume drugs like heroin and cocaine. In this paper we will look at the experiences with drug consumption rooms in Switzerland, Germany and the Netherlands. Based on an analysis of the factors and measures that promote their success we will discuss the possible significance of drug consumption rooms for drug policy in the longer term.
In this paper we analyze changing patterns in overdose deaths that occurred between 1990 and 1997 in 27 of the largest US cities. Drug induced deaths reported by the CDC have increased by 57% in the United States during these years - from 9463 to 15973 (3.8/100,000 in 1990 to 6.0/100,000 in 1997). This trend has been observed in all regions of the United States, among both men and women, and in all ethnic and age groups. But there are important local differences in these trends that can be seen in the largest US cities: those with the lowest rates in 1990 have increased to levels equal to or greater than some of the cities that had the highest rates in 1990. And, while users > 30 years of age account for the majority of cases (and most of the overall increase), for those cities with the greatest overall increases, the OD rates have increased sharply among younger people (20-24). This coincides with an expansion of drug markets (for heroin) in a group of smaller US cities and increased heroin use by youth in those cities.
An effective program to prevent HIV infection must have both universal and targeted components. The universal component includes reducing HIV-related discrimination, removing commercial restrictions on the materials necessary for safer behavior, and providing information about the risk of HIV. The targeted component involves focusing the limited resources for intensive programs of behavioral change on situations in which the risk of HIV transmission is highest. Such a strategy would follow the dictum "Warn widely and spend wisely."
To describe prevalence and incidence of HIV-1, hepatitis C virus (HCV) and risk behaviours in a prospective cohort of injecting drugs users (IDU).
Vancouver, which introduced a needle exchange programme (NEP) in 1988, and currently exchanges over 2 million needles per year.
IDU who had injected illicit drugs within the previous month were recruited through street outreach. At baseline and semi-annually, subjects underwent serology for HIV-1 and HCV, and questionnaires on demographics, behaviours and NEP attendance were completed. Logistic regression analysis was used to identify determinants of HIV prevalence.
Of 1006 IDU, 65% were men, and either white (65%) or Native (27%). Prevalence rates of HIV-1 and HCV were 23 and 88%, respectively. The majority (92%) had attended Vancouver's NEP, which was the most important syringe source for 78%. Identical proportions of known HIV-positive and HIV-negative IDU reported lending used syringes (40%). Of HIV-negative IDU, 39% borrowed used needles within the previous 6 months. Relative to HIV-negative IDU, HIV-positive IDU were more likely to frequently inject cocaine (72 versus 62%; P < 0.001). Independent predictors of HIV-positive serostatus were low education, unstable housing, commercial sex, borrowing needles, being an established IDU, injecting with others, and frequent NEP attendance. Based on 24 seroconversions among 257 follow-up visits, estimated HIV incidence was 18.6 per 100 person-years (95% confidence interval, 11.1-26.0).
Despite having the largest NEP in North America, Vancouver has been experiencing an ongoing HIV epidemic. Whereas NEP are crucial for sterile syringe provision, they should be considered one component of a comprehensive programme including counselling, support and education.
We aimed to assess audio-computer-assisted self-interviewing (audio-CASI) as a method of reducing under-reporting of HIV risk behaviour among injecting drug users.
Injecting drug users were interviewed at syringe-exchange programmes in four US cities. Potential respondents were randomly selected from participants in the syringe exchanges, with weekly alternate assignment to either traditional face-to-face interviews or audio-CASI. The questionnaire included items on sociodemographic characteristics, drug use, and HIV risk behaviours for 30 days preceding the interview. We calculated odds ratios for the difference in reporting of HIV risk behaviours between interview methods.
757 respondents were interviewed face-to-face, and 724 were interviewed by audio-CASI. More respondents reported HIV risk behaviours and other sensitive behaviours in audio-CASI than in face-to-face interviews (odds ratios for reporting of rented or bought used injection equipment in audio-CASI vs face-to-face interview 2.1 [95% CI 1.4-3.3] p=0.001; for injection with borrowed used injection equipment 1.5 [1.1-2.2] p=0.02; for renting or selling used equipment 2.3 [1.3-4.0] p=0.003).
Although validation of these self-reported behaviours was not possible, we propose that audio-CASI enables substantially more complete reporting of HIV risk behaviour. More complete reporting might increase understanding of the dynamics of HIV transmission and make the assessment of HIV-prevention efforts easier.
In several European countries safer injecting rooms have reduced the public disorder and health-related problems of injection drug use. We explored factors associated with needle-sharing practices that could potentially be alleviated by the availability of safer injecting rooms in Canada.
The Vancouver Injection Drug User Study is a prospective cohort study of injection drug users (IDUs) that began in 1996. The analyses reported here were restricted to the 776 participants who reported actively injecting drugs in the 6 months before the most recent follow-up visit, during the period January 1999 to October 2000. Needle sharing was defined as either borrowing or lending a used needle in the 6-month period before the interview.
Overall, 214 (27.6%) of the participants reported sharing needles during the 6 months before follow-up; 106 (13.7%) injected drugs in public, and 581 (74.9%) reported injecting alone at least once. Variables independently associated with needle sharing in a multivariate analysis included difficulty getting sterile needles (adjusted odds ratio [OR] 2.7, 95% confidence interval [CI] 1.8-4.1), requiring help to inject drugs (adjusted OR 2.0, 95% CI 1.4-2.8), needle reuse (adjusted OR 1.8, 95% CI 1.3-2.6), frequent cocaine injection (adjusted OR 1.6, 95% CI 1.1-2.3) and frequent heroin injection (adjusted OR 1.5, 95% CI 1.04-2.1). Conversely, HIV-positive participants were less likely to share needles (adjusted OR 0.5, 95% CI 0.4-0.8), although 20.2% of the HIV-positive IDUs still reported sharing needles.
Despite the availability of a large needle-exchange program and targeted law enforcement efforts in Vancouver, needle sharing remains an alarmingly common practice in our cohort. We identified a number of risk behaviours--difficulty getting sterile needles, needle sharing and reuse, injection of drugs in public and injecting alone (one of the main contributing causes of overdose)--that may be alleviated by the establishment of supervised safer injecting rooms.
The prevalence of HIV has been rising among injection drug users (IDUs) and AIDS is now an important cause of death among that population. We tracked mortality and recorded detailed causes of death in the Vancouver Injection Drug Users Study (VIDUS). This is an open cohort of over 1,400 active IDUs that began in May 1996. At enrollment and at semiannual follow-up visits, a trained interviewer administers a detailed semistructured questionnaire. Mortality was recorded during follow-up and detailed causes of death were collected from coroner's reports, hospital records, and the provincial (British Columbia) registry. Causes of death were obtained on 125 participants. Overall, the leading cause of death was overdose accounting for 25% of deaths among HIV-positive participants and 42% among HIV-negative participants. Of the 65 deaths among HIV-positive individuals, 22 (34%) were HIV related. Mortality was associated with older age (adjusted hazards ratio [AHR], 1.03 per year), HIV positivity (AHR, 2.67), injection cocaine use (AHR, 2.23) and methadone treatment (AHR, 0.47). The high rate of HIV in this population has added significantly to the burden of illness and death in this marginalized population.
Vancouver has experienced an explosive HIV epidemic despite the presence of a needle exchange programme (NEP). We sought possible explanations for high-risk syringe sharing among Vancouver injection drug users over the period January 1999 to October 2000. Overall, 14% of participants reported high-risk sharing. Although acquiring needles exclusively from the NEP was independently associated with less sharing, we identified several risk factors for persistent sharing, including difficulty accessing sterile needles, bingeing, and frequent cocaine injection.
Although medically supervised safer injecting facilities (SIFs) remain untested in North America, their implementation is currently being debated. Reluctance of health policy makers to initiate a pilot study of SIFs may in part be hindered by outstanding questions regarding the potential community and public health impact of the intervention. Specifically, it is presently unknown if those at greatest risk of overdose and HIV transmission or those responsible for community impact of injection drug use will be willing to attend.
The current study was conducted to evaluate the proportion of injection drug users (IDU) willing to attend medically supervised SIFs, if they were available, among participants enrolled in the Vancouver Injection Drug User Study (VIDUS). The authors also evaluated factors associated with willingness to use a SIF using univariate and logistic regression analyses. Participants who were followed from June 2001 to June 2002 were eligible for the present analyses.
Overall, 587 active IDU responded to a questionnaire during the study period. Among respondents, 215 (36.6%) expressed willingness to attend a SIF. Variables that were independently associated with willingness to attend a SIF in multivariate analyses included having difficulty accessing sterile syringes (adjusted odds ratio [AOR] = 2.07), requiring help injecting (AOR = 1.52), frequently injecting heroin (AOR = 1.81), sex trade work (AOR = 2.02), and injecting in public spaces (AOR = 2.00).
Several variables that have recently been associated with overdose, syringe sharing, HIV and HCV incidence, and community impact of illicit drug use in this setting were associated with willingness to attend medically supervised SIFs. Although the impact of SIFs in North America can only be quantified by scientific evaluation, these data indicate a high potential for immediate community and public health benefits if SIFs were presently available.
The explosive and ongoing injecting drug use-related HIV-1 epidemic in Vancouver continues to receive international attention. This study was conducted to determine how patterns of cocaine use influence the risk of HIV infection.
The Vancouver Injection Drug Users Study is an open prospective cohort of injecting drug users that began in May 1996. At enrollment and at semi-annual follow-up visits an interviewer administers a detailed semi-structured questionnaire. Cox proportional hazards models were used to determine behavioral and drug use patterns reported in the 6 months prior to HIV seroconversion.
One-hundred and nine incident HIV infections have been observed during a mean follow-up of 31 months, from 940 HIV-seronegative participants. During the 6 months prior to seroconversion, predictors of HIV infection were injecting cocaine use [adjusted hazards ratio (AHR), 3.72], incarceration (AHR, 2.74), unstable housing (AHR, 2.36), methadone maintenance treatment (AHR, 1.98), and Aboriginal ethnicity (AHR, 1.78). Injecting cocaine use was predictive of HIV infection in a dose-dependent fashion. Compared with infrequent cocaine users, participants who averaged more than three injections per day were seven times more likely to contract HIV. In addition, the time to HIV infection was accelerated among regular cocaine injectors independent of concurrent heroin use.
Injecting cocaine use was a strong, dose-dependent predictor of HIV seroconversion in this poly-drug using population. Injection cocaine users remain particularly vulnerable to HIV infection and treatment options for cocaine dependency remain woefully inadequate.
Accidental drug overdose contributes substantially to mortality among drug users. Multi-drug use has been documented as a key risk factor in overdose and overdose mortality in several studies. This study investigated the contribution of multiple drug combinations to overdose mortality trends.
We collected data on all overdose deaths in New York City between 1990 and 1998 using records from the Office of the Chief Medical Examiner (OCME). We standardized yearly overdose death rates by age, sex and race to the 1990 census population for NYC to enable comparability between years relevant to this analysis.
Opiates, cocaine and alcohol were the three drugs most c