Supervised Consumption Facilities & Safe Injection Facilities
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"Governmentally sanctioned 'safer injection facilities'
(SIFs) are a health service that several countries around the
world have been adding to the array of public health programs
they offer. These countries include:
"Canada where the federal government, in collaboration with the Federal, Territorial and Provincial Advisory Committee on Population Health, has created a task force to examine the feasibility of a national research-based trial of SIFs (Kerr & Palepu, 2001); Vancouver, BC where SIFs are included in the Mayor's 'Four Pillar Drug Strategy,' and a formal proposal to implement 2 SIFs has been put forward (Kerr, 2000; MacPherson, 2001)
"Germany with 13 SIFs operating in 4 cities
"The Netherlands with 16 SIFs operating in 9 cities
"Switzerland with 17 SIFs operating in 12 cities
"Spain with 1 SIF operating in Madrid
"Australia where an SIF began operations in May, 2001 in Sydney, and legislation has been approved to operate an SIF in Canberra and is pending in Melbourne (New York Times, 2001; Dolan, 2000)."Source: Broadhead, Robert S., Thomas Kerr, Jean-Paul C. Grund, and Frederick L. Altice, "Safer Injection Facilities in North America: Their Place in Public Policy and Health Initiatives," Journal of Drug Issues (Tallahassee, FL: Florida State University, Winter 2002), Vol. 32, No. 1, p. 331, citing Kerr, T and Palepu, A, "Safe Injection Facilities: Is It Time?" Canadian Medical Association journal, 165(4), 436-437; Kerr, T., "Safe Injection Facilities: A Proposal for a Vancouver Pilot Project," Harm Reduction Action Society, retrieved on November 13, 2001 from http://www.cfdp.ca/safei.pdf; MacPherson, D., "A Framework for Action: A Four-Pillar Approach to Drug Problems in Vancouver," Vancouver, BC: City of Vancouver; "Australia Allows Addicts' Center to be Opened in Sydney," New York Times, May 10, 2001, p. 3; Dolan, K., et al., "Drug Consumption Facilities in Europe and the Establishment of Supervised Injection Centres in Australia," Drug and Alcohol Review, 19, 337-46.
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"Our review suggests that SIFs target several public health
problems that municipalities in North America may wish to
consider, problems largely unaddressed by needle exchange,
street-outreach, education campaigns, HIV counseling, and other
conventional services. SIFs target injectors' use of public
spaces to inject drugs in order to reduce the many risks
associated with the practice. Compared to conventional services,
SIFs provide greater opportunities for health workers to connect
with injectors, and to move them into primary care, drug
treatment, and other rehabilitation services. Finally, SIFs
target the 'nuisance factor' of drug scenes -- the hazardous
litter and intimidating presence of injectors congregating in
city parks, public playgrounds and on street corners -- by
offering them an alternative, supervised 'public' space. Our
review also suggests that, for municipalities considering SIFs
in order to address these problems, their implementation would
not necessarily require any significant or fundamental changes
in public policy or law: SIFs require the same working agreements
with social service providers and the police that needle exchange,
street-outreach, drug treatment and similar health programs for
injectors already receive."
Source: Broadhead, Robert S., Thomas Kerr, Jean-Paul C. Grund, and Frederick L. Altice, "Safer Injection Facilities in North America: Their Place in Public Policy and Health Initiatives," Journal of Drug Issues (Tallahassee, FL: Florida State University, Winter 2002), Vol. 32, No. 1, p. 347-8.
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"The present study demonstrates that the opening of the
Vancouver SIF was associated with a greater than 30%
increase in the rate of detoxification service use among
SIF users in comparison to the year prior to the SIF’s
opening. Subsequent analyses demonstrated that detoxification
service use was associated with increased use of
methadone and other forms of addiction treatment, as
well as reduced injecting at the SIF."
Source: Wood, Evan, Tyndall, Mark W., Zhang, Ruth, Montaner, Julio S.G., and Kerr, Thomas, "Rate of Detoxification Service Use and its Impact among a Cohort of Supervised Injecting Facility Users," Addiction, Vol. 102, p. 918.
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"In summary, the present study demonstrates that the
SIF was associated with increased use of detoxification
service use and that residential detoxification was associated
with increased rates of methadone use and other
forms of addiction treatment. Given the known role of
methadone and other forms of addiction treatment in
reducing levels of injection drug use, and given
that detoxification programme use was associated with
reduced injecting at the SIF, our findings imply that the
SIF has probably helped to reduce rates of injection drug
use among users of the facility."
Source: Wood, Evan, Tyndall, Mark W., Zhang, Ruth, Montaner, Julio S.G., and Kerr, Thomas, "Rate of Detoxification Service Use and its Impact among a Cohort of Supervised Injecting Facility Users," Addiction, Vol. 102, p. 918.
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In an evaluation of the Vancouver supervised injection
facility, researchers concluded that:
"Our study indicates that the opening of North America’s
first supervised injection facility was not
associated with measurable negative changes in the
use of injected drugs. Indeed, we found a substantial
reduction in the starting of binge drug use after the
opening of the facility, suggesting that it had not
prompted 'risk compensation' among local injecting
drug users, whereby the benefits of a safer
environment are overcome by more risky behaviours
such as higher intensity drug use."
Source: Kerr, Thomas, Jo-Anne Stoltz, Mark Tyndall, Kathy Li, Ruth Zhang, Julio Montaner, Evan Wood, "Impact of a medically supervised safer injection facility on community drug use patterns: a before and after study," British Medical Journal, Vol. 332, Jan. 28, 2006, pp. 221-222.
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In an evaluation of the Vancouver supervised injection
facility, researchers concluded that:
"Although there
was a substantial increase in the number of
participants who started smoking crack cocaine, it is
unlikely that the facility, which does not allow smoking
in the facility, prompted this change. These findings
are relevant to a recent review of supervised injection
facilities by the European Monitoring Centre on
Drugs and Drug Addiction, which highlighted
concerns that these facilities could potentially
'encourage increased levels of drug use' and 'make
drug use more acceptable and comfortable, thus
delaying initiation into treatment.'"
Source: Kerr, Thomas, Jo-Anne Stoltz, Mark Tyndall, Kathy Li, Ruth Zhang, Julio Montaner, Evan Wood, "Impact of a medically supervised safer injection facility on community drug use patterns: a before and after study," British Medical Journal, Vol. 332, Jan. 28, 2006, p. 222.
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"Evaluation of the Vancouver
facility has shown that its opening has been associated
with reductions in public drug use and publicly
discarded syringes and reductions in syringe sharing
among local injecting drug users. Our study suggests
that these benefits have not been offset by negative
changes in community drug use."
Source: Kerr, Thomas, Jo-Anne Stoltz, Mark Tyndall, Kathy Li, Ruth Zhang, Julio Montaner, Evan Wood, "Impact of a medically supervised safer injection facility on community drug use patterns: a before and after study," British Medical Journal, Vol. 332, Jan. 28, 2006, p. 222.
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"In the present analysis we found that overdose events were
not uncommon at the Vancouver safer injection facility. During
an 18-month period, 285 individuals accounted for 336
overdose events, yielding an overdose rate of 1.33 (95% CI:
0.0–3.6) overdoses per 1000 injections. Heroin was involved
in approximately 70% of all overdoses, and opiates considered
together were involved in88%of overdoses. It is notable,
however, that approximately one-third of overdoses involved
stimulants. The most common indicators of overdose were
depressed respiration, limp body, face turning blue, and a failure
to respond to pain stimulus. The majority of overdoses
were successfully managed in the SIF, with the most common
overdose interventions undertaken by SIF staff involving the
administration of oxygen, a call for ambulance support, and
the administration of naloxone hydrochloride via injection.
Among a randomly selected sample of SIF users, factors associated
with time to overdose at the SIF included fewer years
injecting, daily heroin use, and having a history of overdose.
None of the overdose events occurring at the SIF resulted in
a fatality."
Source: Thomas Kerr, Mark W. Tyndall, Calvin Lai, Julio S.G. Montaner, Evan Wood, "Drug-related overdoses within a medically supervised safer injection facility," International Journal of Drug Policy, 2006.
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"The rate of overdose observed at the Vancouver SIF is
within the range of rates observed in an international review
of SIF which estimated the rates of overdose typically to
be between 0.01 and 3.6 per 1000 injections (Kimber et al.,
2005). However, the rate observed in Vancouver is lower
than rates observed recently in M¨unster, Germany (6.4 per
1000 injections) and Sydney, Australia (7.2 per 1000 injections)
(Kimber et al., 2003). This may reflect differences in
threshold for coding and intervention by staff, and differences
in drug consumption patterns across cities, especially
as it pertains to the use of opioids and other central nervous
system depressants."
Source: Thomas Kerr, Mark W. Tyndall, Calvin Lai, Julio S.G. Montaner, Evan Wood, "Drug-related overdoses within a medically supervised safer injection facility," International Journal of Drug Policy, 2006.
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"In summary, there have been many overdose events within
Vancouver’s SIF, although the rate of overdoses is similar
to rates observed in SIF in other settings. The majority of
these overdoses involved the injection of opiates, and most
events were successfully managed within the SIF through
the provision of oxygen. It is noteworthy that none of the
overdose events occurring at the SIF resulted in a fatality.
These findings suggest that SIF can play a role in managing
overdoses among IDU and indicate the potential of SIF to
reduce morbidity and mortality associated with illicit drugrelated
overdoses."
Source: Thomas Kerr, Mark W. Tyndall, Calvin Lai, Julio S.G. Montaner, Evan Wood, "Drug-related overdoses within a medically supervised safer injection facility," International Journal of Drug Policy, 2006.
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"Little evaluative work has been conducted into supervised
injection facilities in other countries. In Hanover, however,
98% of users of the medically supervised injecting centre did not
encounter any negative experience with local residents and 94%
reported no negative police encounters. Research from Frankfurt
showed that a drug user who overdoses on the street is 10 times
more likely to stay in hospital for one night than a drug user
who overdoses in a medically supervised injecting centre. In
addition, no one has died from heroin overdose in any medically
supervised injecting centre. Therefore, establishing such centres
in the United Kingdom is likely to reduce the number of drug
related deaths."
Source: Wright, Nat M.J., Charlotte N.E. Tompkins, "Supervised Injecting Centres," British Medical Journal, Vol. 328, Jan. 10, 2004, p. 101.
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Researchers for the EU's drugs monitoring agency looking
into safer injection facilities and drug consumption rooms found that
"Consumption rooms reach a population of often older, long-term
users some of whom have had no previous treatment contact. Services
appear particularly successful in attracting groups that are
difficult to reach. No evidence was found to suggest that naive users
are initiated into injecting as a result of the presence of
consumption rooms."
Source: Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 42.
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Researchers for the EU's drugs monitoring agency looking
into safer injection facilities and drug consumption rooms found that
"Service users’ sociodemographic data and drug use profile are similar
across countries. Data show that the rooms reach the intended target
groups of long-term addicts, street injectors, homeless drug users
and drug-using sex workers and are thus facilitating contact with the
most problematic and marginalised drug users. Demographic information
also shows that these services can be successful in reaching long-term
drug users with no previous contact with treatment services."
Source: Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 42.
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"Consumption rooms achieve the immediate objective of
providing a safe place for lower risk, more hygienic drug consumption
without increasing the levels of drug use or risky patterns of
consumption. Direct benefits of supervised injecting appear to be a
reduction in some of the risk behaviours related to injecting, in
particular improvements in injecting practice, use of sterile equipment
and lack of opportunity for sharing drugs. Other benefits are that,
if medical emergencies should occur, immediate medical intervention
is possible, and the consumption equipment used in the rooms is
correctly disposed of. Client surveys consistently show that service
users appreciate the hygienic conditions, safety and peace that the
rooms provide."
Source: Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 48.
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"There is no evidence that consumption rooms encourage increased drug
use or initiate new users. There is little evidence that by providing
better conditions for drug consumption they perpetuate drug use in
clients who would otherwise discontinue consuming drugs such as
heroin or cocaine, nor that they undermine treatment goals.
"When managed in consultation with local authorities and police, they do not increase public order problems by increasing local drug scenes or attracting drug users and dealers from other areas. If consultation and cooperation between key actors does not take place, then there can be a risk of a 'pull effect' and consumption rooms run the risk of being blamed for aggravating local problems of public order including drug dealing."Source: Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 84.
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"According to the few studies that have examined the effects of
consumption rooms on acquisitive crime, there is no evidence from
police data of a negative effect on local levels of theft, robbery
and burglary.
"The direct effect of the rooms on the small-scale drug dealing in their vicinity is difficult to determine as one of the criteria for deciding where to locate rooms is the existence of public drug use and drug markets. Services have no interest in drug scenes and drug markets expanding outside their front door and rely on sensible police action to prevent these without deterring drug addicts from the use of the supervised consumption facility. House rules in some rooms require that clients do not loiter outside the facility."Source: Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), pp. 83-4.
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"The location of consumption rooms needs to be compatible with the
needs of drug users but also to take account of the needs and
expectations of local residents. A reduction in the number of public
consumptions can contribute to improvements in the neighbourhood by
helping to reduce public nuisance associated with open drug scenes.
However, facilities near illicit drug markets are not able to solve
wider nuisance problems that result from these markets.
"Police actions against drug markets and drug scenes in other neighbourhoods may sometimes increase public order problems near consumption rooms. This implies that, if rooms are to contribute to reducing public nuisance rather than be blamed for aggravating it, there needs to be consultation not only with local residents but also with police, so that action to discourage open drug scenes does not at the same time deter drug users from making use of the facilities."Source: Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 83.
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"There is no evidence that the operation of consumption rooms
leads to more acquisitive crime. There is small-scale drug dealing
in the vicinity of many services, which is not surprising given
their location."
Source: Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 83.
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"Neighbourhood attitudes and perceptions. Surveys of local residents
and businesses, as well as registers of complaints made to the police,
generally show positive changes following the establishment of
consumption rooms, including perceptions of decreased nuisance and
increases in acceptance of the rooms. Police, too, often acknowledge
that consumptions contribute to minimising or preventing open drug
scenes.
"Open drug scenes and police policy. There are instances where consumption rooms have been blamed for increasing public nuisance, including open drug scenes and dealing. These arose where police actions in other areas had the effect of relocating drug markets and open scenes.
"Pull effect. Available evidence is not sufficient to draw conclusions on whether consumption rooms exert a 'pull-effect' by attracting drug users from other areas, thus adding to the situation already created by established drug markets. Attempts to decentralise drug scenes by dispersing consumption rooms have not led to increased nuisance around the rooms. However, they have not attracted large numbers of clients either."Source: Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 82.
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"There is no evidence that consumption rooms increase levels of
drug use or encourage riskier patterns of use, nor that they increase
morbidity and mortality.
"Few clients use the facilities only for drug consumption. Most at some point use other services, especially medical and in some cases drug treatment.
"There is little evidence that consumption rooms undermine treatment by making drug use more 'comfortable'. Whether clients in oral methadone treatment are allowed to use the rooms for injection, is dealt with in different ways."Source: Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), pp. 80-81.
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"Consumption rooms achieve the immediate objective of providing a
safe place for lower risk, more hygienic drug consumption without
increasing the levels of drug use or risky patterns of consumption."
Source: Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 77.
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"We found significant reductions in public injection drug use,
publicly discarded syringes and injection-related litter after the
opening of the medically supervised safer injecting facility in
Vancouver. These reductions were independent of law enforcement
activities and changes in rainfall patterns.
"Our findings are consistent with anecdotal reports of improved public order following the establishment of safer injecting facilities and are not surprising given that a commonly reported reason for public drug use is the lack of an alternative place to inject and that IDUs who go to safer injecting facilities are often homeless or marginally housed. Our findings are also highly plausible since more than 500 IDUs visited the facility daily after it opened, and several feasibility studies have suggested that IDUs who inject in public would be the most likely to use safer injecting facilities. Our observations suggest that the establishment of the safer injecting facility has resulted in measurable improvements in public order, which in turn may improve the liveability of communities and benefit tourism while reducing community concerns stemming from public drug use and discarded syringes. It is also noteworthy that we did not observe an increase in the number of drug dealers in the vicinity of the facility, which indicates that the facility’s opening did not have a negative impact on drug dealing in the area. Although further study of these issues is necessary, the safer injecting facility may also offer public health benefits, since public injection drug use has been associated with an array of health-related harms."Source: Wood, Evan, Thomas Kerr, Will Small, Kathy Li, David C. Marsh, Julio S.G. Montaner & Mark W. Tyndall, "Changes in Public Order After the Opening of a Medically Supervised Safer Injecting Facility for Illicit Injection Drug Users," Canadian Medical Association Journal, Vol. 171, No. 7, Sept. 28, 2004, p. 733.
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"In summary, we documented significant reductions in
the number of IDUs injecting in public, publicly discarded
syringes and injection-related litter after the opening of the
medically supervised safer injecting facility. These reductions
appeared to be independent of several potential confounders,
and our findings were supported by external data
sources. Although the overall health impacts of the facility
will take several years to evaluate, the findings from this
study should be valuable to other cities that are contemplating
similar evaluations and should have substantial relevance
to many urban areas where public injection drug use
has been associated with substantial public health risks
and adverse community impacts."
Source: Wood, Evan, Thomas Kerr, Will Small, Kathy Li, David C. Marsh, Julio S.G. Montaner & Mark W. Tyndall, "Changes in Public Order After the Opening of a Medically Supervised Safer Injecting Facility for Illicit Injection Drug Users," Canadian Medical Association Journal, Vol. 171, No. 7, Sept. 28, 2004, p. 734.
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"The only comprehensive evaluation of a medically supervised
injecting centre was conducted during the 18 month trial of
the Sydney centre. Staff intervened in 329 overdoses over one
year with an estimate of at least four lives saved a year. There
was no increase in reported hepatitis B or C infections in the area
that the medically supervised injecting centre served despite an
increase elsewhere in Sydney.
"The report described a decreased frequency of injecting related problems among clients. Half the centre’s clients reported that their injecting practices had become less risky since using the centre. Furthermore, clients were more likely than other injectors to report that they had started treatment for their drug use; 11% of clients were referred to treatment for drug dependence. An economic evaluation of deaths averted by intervention of the medically supervised injecting centre showed that costs were comparable to those of other widely accepted public health measures.
"The centre also had benefits for the local community. Residents and business respondents reported fewer sightings of public injection and syringes discarded in public places, and syringe counts in the vicinity of the centre were lower after it opened than before. In addition, there was no evidence of an increased number of theft and robbery incidents in the area. Acceptance of the medically supervised injecting centre increased among both businesses and residents over the study period."Source: Wright, Nat M.J., Charlotte N.E. Tompkins, "Supervised Injecting Centres," British Medical Journal, Vol. 328, Jan. 10, 2004, p. 100.
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According to the final report of the evaluation of the Sydney,
Australia, Medically Supervised Injecting Centre (MSIC) by the
MSIC Evaluation Committee (established by the New South Wales
Dept. of Health):
"In summary, the evidence available from this Evaluation indicates that:
"- operation of the MSIC in the King Cross area is feasible;
"- the MSIC made service contact with its target population, including many who had no prior treatment for drug dependence;
"- there was no detectable change in heroin overdoses at the community level;
"- a small number of opioid overdoses managed at the MSIC may have been fatal had they occurred elsewhere;
"- the MSIC made referrals for drug treatment, especially among frequent attenders;
"- there was no increase in risk of blod borne virus transmission;
"- there was no overall loss of public amenity;
"- there was no increase of crime;
"- the majority of the community accepted the MSIC initiative;
"- the MSIC has afforded an opportunity to improve knowledge that can guide public health responses to drug injecting and its harms."Source: MISC Evaluation Committee, "Final Report on the Sydney Medically Supervised Injecting Centre" (New South Wales, Australia: MISC Evaluation Committee, 2003), p. xiv.
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"Generally speaking, it is reasonable to conclude, on the
basis of the available knowledge, that to a large extent DCFs
[Drug Consumption Facilities] achieve the objectives set for them,
and that the criticisms made of them are rarely justified. In fact,
DCFs help to:
"reduce risk behaviour likely to lead to the transmission of infectious diseases, particularly HIV/AIDS, among the population of the worst affected drug users;
"reduce the incidence of fatal overdoses and, therefore, the mortality rate in this population;
"establish and maintain contact between this population and the social-service and health-care network, within which low-threshold facilities (LTFs) are often the First point of access because of the care and social assistance they offer;
"reduce public order problems, particularly by doing away with open drug scenes, reducing drug use in public places, recovering used syringes, and reducing the impact of drug problems on residential areas (apartment buildings).
"At the same time, the available data do not indicate any specific detrimental effect on:
"the number of drug users and the frequency with which they use drugs; the figures are falling in both cases;
"entry and retention in treatment, because the majority of DCF users are undergoing treatment, the proportion of those in treatment is growing, this subject is tackled within the facilities, and the users themselves state that DCFs do not have any major influence on their treatment.
"All of these observations relate to the overall level of public health and do not mean that DCFs may not have negative effects in some individual cases. However, on the basis of existing knowledge, it would appear that the overall effect of DCFs on drug-related problems is positive.
"In the special case of DCFs with an inhalation room, the above is less convincingly proven. Although such facilities do indeed reach inhaling drug users, it has not yet been possible to ascertain whether or not they can achieve their set objectives (establishing a point of contact between inhaling drug users and the social-service and health-care network, reducing public order problems, encouraging the switch to lower-risk forms of drug use). Further research is therefore required, especially in respect of:
"the capacity of DCFs with an inhalation room to serve as a point of contact between inhaling drug users and the social-service and health-care network;
"the toxicity of the different substances inhaled and the measures that need to be taken in consequence;
"the extent to which users switch to and continue in another form of drug use, and the consequences."Source: Zobel, Frank & Françoise Dubois-Arber, "Short appraisal of the role and usefulness of Drug consumption facilities (DCF) in the reduction of drug-related problems in Switzerland: appraisal produced at the request of the Swiss Federal Office of Public Health (Lausanne: University Institute of Social and Preventive Medicine, 2004), p. 27.