Supervised Injection Facility Research Articles

Supervised injecting facilities: a case study of contrasting narratives in a contested health policy arena

In 2006, 2010, and 2011 attempts were made by health policy advocates to ignite policy debate about the introduction of supervised injecting facilities (SIFs) in Melbourne, Australia. Although there have been a number of attempts to introduce SIFs in Australia, only one facility has been introduced in Sydney, and it has only recently achieved full operating status beyond an extended nine-year trial period. This article retraces the policy narratives in documentary materials (parliamentary debates, policy documents, public advocacy and empirical research) to reflect on the causes for policy impermeability in this contested arena. Interest in supervised injecting rooms, whilst always an exemplar of harm reduction, actually emerged in New South Wales in the mid-1990s from government concern over endemic police corruption. Subsequent policy narratives in Victorian SIF advocacy tended to focus heavily on the health and welfare of drug users, with a notable absence of concern about SIFs as a response to police corruption. It is suggested that future policy initiatives in this arena be mindful of the role and influence of policy narratives that focus on policing, if future SIF advocacy is to be successful.

Lessons from INSITE, Vancouver's supervised injection facility: 2003–2012

This paper focuses on the evolution of INSITE, North America's first supervised injection site, first opened in 2003, and subjected to continuous empirical and political scrutiny from that date to the present. This analysis considers the relevant global history of supervised injection sites, and key events in the Canadian timeline. The article canvasses the origins of INSITE and its support by the Liberal government of Canada from 2003 to 2006, the change of federal government in 2006 and the decision of the Harper Conservatives to refuse to grant a continuing exemption to INSITE. The paper considers three court decisions, one by the B.C. Supreme Court in 2008, followed by a B.C. Court of Appeal decision in 2010, and, ultimately, the Supreme Court of Canada's decision in the fall 0f 2011, a decision that ordered the federal government to grant an operating exemption to INSITE. The paper examines how empirical evidence was presented to governments and to the courts, and how both governments and the judiciary interpreted the relevance of empirical evidence in the formulation of law and policy. The paper concludes by comparing the parallel experiences of Vancouver's INSITE with the MSIC in Sydney, Australia.

Prospects for scaling‐up supervised injection facilities in Canada: the role of evidence in legal and political decision‐making

North America's first supervised injection facility-Insite-opened in Vancouver in 2003 under a special federal legal exemption. Insite has faced significant political and legal opposition, which culminated in a recent Supreme Court of Canada ruling that ordered the federal Minister of Health to extend the facility's exemption and cited evidence that the facility is life-preserving and does not increase public disorder. Officials in several other cities have initiated or accelerated preparations for new facilities due to speculation that the ruling provides sufficient legal basis to expand supervised injection in Canada. However, a comprehensive assessment of the barriers and facilitators to supervised injection facility scale-up is lacking. This policy case study reviews a corpus of jurisprudence, legislation, scientific research and media texts to: describe the role of evidence in legal and political decision-making around Insite; analyze the implications of the Insite decision for new facilities; and discuss alternative avenues for supervised injection facility expansion. The Insite decision does not simplify the path towards new supervised injection facilities, but nor does it does pose an insurmountable hurdle. Whether new facilities will be established depends largely upon how the Minister of Health interprets the ruling, the proponents' ability to demonstrate need and support from municipal and provincial governments and community members. Formally defining supervised injection as within nurses' scope of practice could further efforts to establish new facilities. Additional court action may be required to establish a stable legal and policy basis for supervised injection facilities in Canada.

Should North America’s first and only supervised injection facility (InSite) be expanded in British Columbia, Canada?

BackgroundThis article reports qualitative findings from a sample of 31 purposively chosen injection drug users (IDUs) from Vancouver, Surrey and Victoria, British Columbia interviewed to examine the context of safe injection site in transforming their lives. Further, the purpose is to determine whether the first and only Supervised injection facility (SIF) in North America, InSite, needs to be expanded to other cities.MethodsSemi-structured qualitative interviews were conducted in a classical anthropological strategy of conversational format as drug users were actively involved in their routine activities. Purposive sampling combined with snowball sampling techniques was employed to recruit the participants. Audio recorded interviews were transcribed verbatim and analyzed thematically using NVivo 9 software.ResultsAttending InSite has numerous positive effects on the lives of IDUs including: saving lives, reducing HIV and HCV risk behavior, decreasing injection in public, reducing public syringe disposal, reducing use of various medical resources and increasing access to nursing and other primary health services.ConclusionsThere is an urgent need to expand the current facility to cities where injection drug use is prevalent to reduce overdose deaths, reduce needle sharing, reduce hospital emergency care, and increase safety. In addition, InSite’s positive changes have contributed to a cultural transformation in drug use within the Downtown Eastside and neighboring communities.

"A Little Heaven in Hell": The Role of a Supervised Injection Facility in Transforming Place

While numerous studies on InSite (North America's first supervised injection facility) have been published in leading international journals, little attention has been given to the facility's role in the local culture of drug use and its transformation of place in Vancouver's Downtown Eastside. This study analyzes the transformative role of InSite in the lives of injection drug users (IDUs). Semi-structured qualitative interviews were conducted with a small, purposively chosen sample of IDUs attending InSite. Interviews were transcribed verbatim and analyzed thematically using NVivo 8 software. Participants' narratives indicate that attending InSite has had numerous positive effects in their lives, including changes in sharing behavior, improving health, establishing social support and saving their lives. Furthermore, attending InSite has been particularly effective in creating a unique microenvironment where IDUs are increasingly identifying the facility as their community center.

Responding to vulnerability: The case of injection drug use

This article examines the case of Insite, North America’s only supervised injection facility, to consider the relationship between dependence, relational autonomy, and vulnerability. At state-funded Insite, users inject illicit drugs under medical supervision. By conceiving of Insite as a health-care facility and addiction as disease, advocates evoke a shared sense of vulnerability among the nonusing public and users, garnering considerable support for the site. Through Insite, the state responds to vulnerability by reshaping the meaning of dependence and conferring recognition upon users, in turn fostering users’ autonomy. However, the medicalized discourse surrounding Insite may obscure drug users’ vulnerabilities emerging not from “disease,” but from stigma and criminalization. Vulnerability analysis must emphasize not merely a naturalized conception of vulnerability, but the socially constructed nature of human beings’ experiences of vulnerability.

Science versus politics: The need for supervised injection facilities in Montreal, Canada

Science versus politics: The need for supervised injection facilities in Montreal, Canada

The Point of Diminishing Returns: An Examination of Expanding Vancouver’s Insite

North America’s only government-sanctioned supervised injection facility, Insite, has been subjected to substantial research. This research has found evidence for numerous public health benefits: decreased risky injection behaviour, decreased fatal overdoses, increased probability of initiating and maintaining addiction treatment, and cost-effectiveness. To date, a small number of costing studies have emerged with none of them investigating Insite expansions. Such an analysis is reported in this paper and it is found that, based on benefit–cost ratios, Insite should be expanded. However, this expansion is dependent on altering injection drug user behaviour outside Insite.

Expanding into New Territory

Discussions about harm reduction have been in the news on and off for the past few years — largely because of Insite, North America's first safe injection site located in Vancouver, BC, and the legal cases surrounding it.1 When the Supreme Court of Canada ruled last September in favour of the continued operation of Insite (and against the federal Conservative government ministers who wanted to halt its operation as part of their removal of harm reduction elements from their anti-drug strategies), many of those cheering were health professionals who support the harm reduction model as an important component of public health.2 For those unsure of what harm reduction is (and isn't), it is a public health concept with the primary goal of decreasing the negative consequences, i.e., harms, from the use of drugs (or alcohol, tobacco and even high-risk sexual practices) to both the individual involved and society at large.3 Harm reduction is not the promotion or encouragement of illicit drug use or other addictive behaviours. It is usually accomplished using a step-wise approach, aiming to implement the easiest, most realistic goals first.4 Advocates of the method realize that abstinence may not be a realistic or even desirable goal for some users, particularly in the short term, although many clients of harm reduction programs ultimately do enter abstinence or detoxification programs. The benefits of such programs have been well documented in published research and include improvements to the health of individuals and their communities, as well as savings to the health care system.5,6 In this issue of CPJ, you will find 2 interesting articles addressing the role of pharmacists in harm reduction programs (see pages 123 and 124). In many instances, pharmacists are already participants in harm reduction efforts such as needle exchange programs and opioid substitution therapy without fully recognizing the public health benefits of their work. As pharmacist Andrea Fernandes found, it is possible to overcome any initial concerns to find practice in an addiction clinic fulfilling and rewarding.7 With a recent report recommending the implementation of supervised injection facilities in Toronto and Ottawa8 and demands for similar services in other parts of the country, it's a great time for pharmacists to become more familiar with the opportunities in this expanding practice area. As our authors conclude, future research efforts should be directed at evaluating the effectiveness of pharmacists and pharmacies in delivering harm reduction interventions.9 Let us know what you think of this or any issue — your feedback is always welcome! Contact ac.stsicamrahp@neellikr.

The Injection Support Team: A Peer-Driven Program to Address Unsafe Injecting in a Canadian Setting

In 2005, members of the Vancouver Area Network of Drug Users (VANDU) formed the Injection Support Team (IST). A community-based research project examined this drug-user-led intervention through observation of team activities, over 30 interviews with team members, and 9 interviews with people reached by the team. The IST is composed of recognized “hit doctors,” who perform outreach in the open drug scene to provide safer injecting education and instruction regarding safer assisted-injection. The IST represents a unique drug-user-led response to the gaps in local harm reduction efforts including programmatic barriers to attending the local supervised injection facility.

DETERMINANTS OF CUTANEOUS INJECTION-RELATED INFECTIONS AMONG INJECTION DRUG USERS AT AN EMERGENCY DEPARTMENT.

Cutaneous injection-related infections (CIRI) are a primary reason injection drug users (IDU) access the emergency department (ED). Using Cox proportional hazard regression, we examined predictors of ED use for CIRI, stratified by sex, among 1083 supervised injection facility (SIF) users. Over a four-year period, 289 (27%) visited the ED for CIRI, yielding an incidence density for females of 23.8 (95% confidence interval (CI): 19.3 - 29.0) and males of 19.2 per 100 person-years (95% CI: 16.7 - 22.1). Factors associated with ED use for CIRI among females included residing in the Downtown Eastside (DTES) (adjusted hazard ratio [AHR] = 2.06 [1.13 - 3.78]) and being referred to hospital by SIF nurses (AHR = 4.48 [2.76 - 7.30]). Among males, requiring assistance with injection (AHR = 1.38 [1.01 - 1.90]), being HIV-positive (AHR = 1.85 [1.34 - 2.55]), and being referred to hospital by SIF nurses (AHR = 2.97 [1.93 - 4.57]) were associated with an increased likelihood of an ED visit for CIRI. These results suggest SIF nurses have facilitated referral of hospital treatment for CIRI, highlighting the need for continued development of efficient and collaborative efforts to reduce the burden of CIRI.

Reducing the Adverse Impact of Injection Drug Use in Canada

Reducing the Adverse Impact of Injection Drug Use in Canada

Overdose deaths and Vancouver's supervised injection facility – Authors' reply

Overdose deaths and Vancouver's supervised injection facility – Authors' reply

Overdose deaths and Vancouver's supervised injection facility

1in which it is claimed that the opening of a supervised injection facility on Sept 21, 2003, in Van couver, BC, Canada, was associated with a 35% decrease in overdose deaths in its immediate surrounding, contains serious errors. The claim that all overdose deaths in Vancouver declined between 2001 and 2005 is strongly aff ected by the highly questionable inclusion of the year 2001—a year of much higher heroin availability and overdose fatalities than all subsequent years. A study period starting from 2002 in fact shows an increasing trend of overdose deaths both for Vancouver and for the Downtown Eastside area in which the facility, Insite, is situated (fi gure), 2

Canada’s highest court unchains injection drug users; implications for harm reduction as standard of healthcare

North America’s only supervised injection facility, Insite, opened its doors in September of 2003 with a federal exemption as a three-year scientific study. The results of the study, evaluated by an independent research team, showed it to be successful in engaging the target group in healthcare, preventing overdose death and HIV infections while increasing uptake and retention in detox and treatment. The research, published in peer-reviewed medical and scientific journals, also showed that the program did not increase public disorder, crime or drug use. Despite the substantial evidence showing the effectiveness of the program, the future of Insite came under threat with the election of a conservative federal government in 2006. As a result, the PHS Community Services Society (PHS), the non-profit organization that operates Insite, launched a legal case to protect the program. On 30 September 2011, Supreme Court of Canada ruled in favour of Insite and underscored the rights of people with addictions to the security of their person under section 7 of the Charter of Rights and Freedoms (Charter of Rights). The decision clears the ground for other jurisdictions in Canada, and perhaps North America, to implement supervised injection and harm reduction where it is epidemiologically indicated. The legal case validates the personhood of people with addictions while metaphorically unchaining them from the criminal justice system.

Use of North America's First Medically Supervised Safer Injecting Facility Among HIV-Positive Injection Drug Users

The objective of this study was to examine supervised injecting facility (SIF) use among a cohort of 395 HIV-positive injection drug users (IDUs) in Vancouver, Canada. The correlates of SIF use were identified using generalized estimating equation analyses. In multivariate analyses, frequent SIF use was associated with homelessness (adjusted odds ratio [AOR] = 1.90), daily heroin injection (AOR = 1.56), and daily cocaine injection (AOR = 1.59). The reasons given for not using the SIF included a preference for injecting at home and already having a safe place to inject. The SIF services most commonly used were needle exchange and nursing services. The SIF appears to have attracted a high-risk subpopulation of HIV-positive IDUs; this coverage perhaps could be extended with the addition of HIV-specific services such as disease monitoring and the provision of antiretroviral therapy.

Street-level policing in the Downtown Eastside of Vancouver, Canada, during the 2010 winter Olympics

BackgroundPolice presence within street-based drug scenes has the potential to disrupt injection drug users’ (IDUs) access to health services and prompt increased injection-related risk behaviour. We examined street-level policing in the Downtown Eastside (DTES) of Vancouver during the Olympic Winter games, to assess the potential impact on access to harm reduction services and injection-related risk behaviour. MethodsWe analysed data from observational activities documenting police and drug user behaviour, unstructured interviews with drug users in street settings (n=15), expert interviews with legal and health professionals (n=6), as well as utilisation statistics from a local supervised injection facility (SIF). ResultsAlthough police presence was elevated within the DTES during the Olympics, there was little evidence to suggest that police activities influenced IDUs’ access to health services or injection-related risk behaviour. SIF attendance during the Olympics was consistent with regular monthly patterns. ConclusionPolice presence during the Olympics did not reduce access to health services amongst local IDUs or prompt increased injection-related risk behaviour. Increased cooperation between local law enforcement and public health bodies likely offset the potential for negative health consequences resulting from police activity.

The Validity of Reporting Willingness to Use a Supervised Injecting Facility on Subsequent Program Use among People Who Use Injection Drugs

Background: Innovative health programs for injection drug users (IDUs), such as supervised injecting facilities (SIFs), are often preceded by evaluations of IDUs’ willingness to use the service. The validity of these surveys has not been fully evaluated. We sought to determine whether measures of willingness collected prior to the opening of a Canadian SIF accurately predicted subsequent use of the program. Methods: Data were derived from a prospective cohort of IDUs. The sample size for this study was 640 IDUs. Using multivariate logistic regression, it was assessed if a history of reporting willingness to use the program, were it available, was associated with subsequent use. In sub-analysis restricted to individuals who had a history of reported willingness, we used multivariate longitudinal analysis to identify factors associated with not attending the SIF. Results: Among 442 IDUs, 72% of those who reported initial willingness to use a SIF later attended the program, and a prior willingness to use a SIF significantly predicted later attendance (adjusted odds ratio = 1.67). In sub-analyses restricted to those who had a history of reporting willingness to use the SIF, not using the program was predicted by not frequenting the neighborhood where the SIF was located. Conclusion: Our findings indicate that reported willingness measures collected from IDUs regarding potential SIF program participation prior to its opening independently predicted later attendance even when variables that were likely determinants of willingness were adjusted for. These data suggest that willingness measures are reasonably valid tools for planning the delivery of health services among IDU populations.

Reduction in overdose mortality after the opening of North America's first medically supervised safer injecting facility: a retrospective population-based study

Overdose from illicit drugs is a leading cause of premature mortality in North America. Internationally, more than 65 supervised injecting facilities (SIFs), where drug users can inject pre-obtained illicit drugs, have been opened as part of various strategies to reduce the harms associated with drug use. We sought to determine whether the opening of an SIF in Vancouver, BC, Canada, was associated with a reduction in overdose mortality. We examined population-based overdose mortality rates for the period before (Jan 1, 2001, to Sept 20, 2003) and after (Sept 21, 2003, to Dec 31, 2005) the opening of the Vancouver SIF. The location of death was determined from provincial coroner records. We compared overdose fatality rates within an a priori specified 500 m radius of the SIF and for the rest of the city. Of 290 decedents, 229 (79·0%) were male, and the median age at death was 40 years (IQR 32-48 years). A third (89, 30·7%) of deaths occurred in city blocks within 500 m of the SIF. The fatal overdose rate in this area decreased by 35·0% after the opening of the SIF, from 253·8 to 165·1 deaths per 100,000 person-years (p=0·048). By contrast, during the same period, the fatal overdose rate in the rest of the city decreased by only 9·3%, from 7·6 to 6·9 deaths per 100,000 person-years (p=0·490). There was a significant interaction of rate differences across strata (p=0·049). SIFs should be considered where injection drug use is prevalent, particularly in areas with high densities of overdose. Vancouver Coastal Health, Canadian Institutes of Health Research, and the Michael Smith Foundation for Health Research.

How many HIV infections are prevented by Vancouver Canada's supervised injection facility?

Mathematical modelling analyses of drug injection-related HIV risk reduction interventions can provide policy makers, researchers, and others with important information that would be difficult to obtain through other means. The validity of the results of mathematical modelling analyses that rely on secondary data sources critically depends on the model(s) employed in the analyses and the parameter values used to populate the models. A recent article in the International Journal of Drug Policy by Andresen and Boyd (2010: 70–76) utilised four different mathematical models of injection-related HIV transmission to estimate the number of HIV infections prevented by Vancouver Canada's Insite supervised injection facility (SIF). The present article reviews and critiques the mathematical models utilised in the Andresen and Boyd article, then describes an alternative—and potentially more accurate—method for estimating the impact of the Insite SIF. This model indicates that the SIF prevents approximately 5–6 infections per year, with a plausible range of 4–8 prevented infections. These estimates are far smaller than suggested by Andresen and Boyd (19–57 prevented infections).