Supervised Safer Injection Facility Research Articles

Estimated drug overdose deaths averted by North America's first medically-supervised safer injection facility.

BackgroundIllicit drug overdose remains a leading cause of premature mortality in urban settings worldwide. We sought to estimate the number of deaths potentially averted by the implementation of a medically supervised safer injection facility (SIF) in Vancouver, Canada.Methodology/Principal FindingsThe number of potentially averted deaths was calculated using an estimate of the local ratio of non-fatal to fatal overdoses. Inputs were derived from counts of overdose deaths by the British Columbia Vital Statistics Agency and non-fatal overdose rates from published estimates. Potentially-fatal overdoses were defined as events within the SIF that required the provision of naloxone, a 911 call or an ambulance. Point estimates and 95% Confidence Intervals (95% CI) were calculated using a Monte Carlo simulation. Between March 1, 2004 and July 1, 2008 there were 1004 overdose events in the SIF of which 453 events matched our definition of potentially fatal. In 2004, 2005 and 2006 there were 32, 37 and 38 drug-induced deaths in the SIF's neighbourhood. Owing to the wide range of non-fatal overdose rates reported in the literature (between 5% and 30% per year) we performed sensitivity analyses using non-fatal overdose rates of 50, 200 and 300 per 1,000 person years. Using these model inputs, the number of averted deaths were, respectively: 50.9 (95% CI: 23.6–78.1); 12.6 (95% CI: 9.6–15.7); 8.4 (95% CI: 6.5–10.4) during the study period, equal to 1.9 to 11.7 averted deaths per annum.Conclusions/SignificanceBased on a conservative estimate of the local ratio of non-fatal to fatal overdoses, the potentially fatal overdoses in the SIF during the study period could have resulted in between 8 and 51 deaths had they occurred outside the facility, or from 6% to 37% of the total overdose mortality burden in the neighborhood during the study period. These data should inform the ongoing debates over the future of the pilot project.

The Canadian government's treatment of scientific process and evidence: Inside the evaluation of North America's first supervised injecting facility

Although the recommendations of scientific review bodies have traditionally been free of political interference in Canada, there have recently been growing concerns raised about Canada's new federal government's treatment of scientific processes and evidence. This concern is relevant to the scientific evaluation of Canada's first medically supervised safer injecting facility (SIF), which opened in Vancouver in 2003, where illicit injection drug users can inject pre-obtained illicit drugs under the supervision of nurses. This commentary describes what may be a serious breach of international scientific standards relating to the Canadian government's handling of the SIF's scientific evaluation, and the circumstances which eventually led to a moratorium on SIF trials in other Canadian cities. Although the primary focus of this discussion should remain on the health of the people using the SIF, it is hoped that the publication of the information contained in this report will lead to greater public scrutiny of the Canadian government's handling of addiction research and drug policy, and provide lessons for researchers, drug policy-makers, and affected communities in other settings.

Changes in injecting practices associated with the use of a medically supervised safer injection facility

Injection drug users (IDUs) are vulnerable to serious health complications resulting from unsafe injection practices. We examined whether the use of a supervised safer injection facility (SIF) promoted change in injecting practices among a representative sample of 760 IDUs who use a SIF in Vancouver, Canada. Consistent SIF use was compared with inconsistent use on a number of self-reported changes in injecting practice variables. More consistent SIF use is associated with positive changes in injecting practices, including less reuse of syringes, use of sterile water, swabbing injection sites, cooking/filtering drugs, less rushed injections, safe syringe disposal and less public injecting.

Characteristics of young illicit drug injectors who use North America's first medically supervised safer injecting facility

The study examined whether North America's first medically supervised safer injection facility (SIF) attracts young injection drug users (IDUs) who are at high risk of health-related harm. Prevalence of SIF use was determined based on data obtained after the SIF's opening. Predictors of initiating future SIF use were determined based on behavioral information obtained from the participant's study visit immediately preceding the SIF's opening. The median duration between the acquisition of pre-SIF opening behavioral data and the more recent interview, where SIF use was measured, was 16 months. Characteristics of IDUs who did and did not subsequently initiate SIF use were statistically compared (N = 135). Data from the 6-month period prior to the SIF's opening showed that youth initiating SIF use were significantly more likely to have been in jail, to use heroin daily, to have overdosed, to have binged on drugs, to have loaned needles, and to have been homeless. The study suggests that among IDUs 29 years of age or younger, those who used the SIF were at higher risk than those who were not.

Impact of a medically supervised safer injecting facility on drug dealing and other drug-related crime

North America's first medically supervised safer injecting facility (SIF) recently opened in Vancouver, Canada. One of the concerns prior to the SIF's opening was that the facility might lead to a migration of drug activity and an increase in drug-related crime. Therefore, we examined crime rates in the neighborhood where the SIF is located in the year before versus the year after the SIF opened. No increases were seen with respect to drug trafficking (124 vs. 116) or assaults/robbery (174 vs. 180), although a decline in vehicle break-ins/vehicle theft was observed (302 vs. 227). The SIF was not associated with increased drug trafficking or crimes commonly linked to drug use.

Prevalence and correlates of hepatitis C infection among users of North America's first medically supervised safer injection facility

North America's first medically supervised safer injection facility (SIF) for illicit drug users was opened in Vancouver, Canada on 22 September 2003. We examined the prevalence and correlates of hepatitis C (HCV) infection among a representative cohort of SIF users. Users of the Vancouver SIF were selected at random and asked to enrol in the Scientific Evaluation of Supervised Injecting (SEOSI) cohort. At baseline, venous blood samples were collected and an interviewer-administered questionnaire was performed. Participants who were HCV-positive were compared with HCV-negative subjects using bivariate and logistic regression analyses. Between 1 December 2003 and 30 July 2004, 691 participants were enrolled into the SEOSI cohort, among whom 605 (87.6%) were HCV-positive at baseline. Factors independently associated with HCV infection in logistic regression analyses included: involvement with the sex trade [adjusted odds ratio (AOR) 3.7, 95% confidence interval (CI) 2.1-6.1], history of borrowing syringes (AOR 1.8, 95%CI 1.1-2.9), and history of incarceration (AOR 2.6, 95%CI 1.5-4.4). Daily heroin use was protective against HCV infection (AOR 0.6, 95%CI 0.3-0.9). The SIF has attracted injection drug users with a high burden of HCV infection and a substantial proportion of uninfected individuals. Although cross-sectional, this study provides some insight into historical risks for HCV infection among this population, and prospective follow-up of this cohort will be useful to determine if use of the SIF is associated with reduced risk behaviour and HCV incidence.

Factors Associated with Syringe Sharing Among Users of a Medically Supervised Safer Injecting Facility

Vancouver, Canada recently opened a medically supervised safer injecting facility (SIF) in an effort to reduce HIV and overdose risk and public injection drug use. We sought to examine factors associated with syringe sharing among SIF users. SIF users were randomly recruited into a prospective cohort of SIF users known as the Scientific Evaluation of Supervised Injecting (SEOSI) cohort. We examined the prevalence and correlates of used syringe borrowing among baseline HIV-negative participants and used syringe lending among baseline HIV-infected participants. Between 22 March 2004 and 22 October 2004, 479 baseline HIV-negative subjects (48 [10%] syringe borrowing events) and 103 baseline HIV-infected participants (17 [16.5%] syringe lending events) were recruited into the cohort. For baseline HIV negative participants, syringe borrowing was positively associated with public drug use (p<0.001) and requiring help injecting (p=0.001), whereas exclusive SIF use was inversely associated with syringe sharing (p=0.019). For baseline HIV-infected participants, syringe lending was positively associated with daily cocaine injection (p=0.022) and shooting gallery use (p=0.007). Although ongoing injection-related HIV risk behavior was reported among some SIF users, rates of syringe sharing were substantially lower than the rate observed previously in this community and it is noteworthy that exclusive SIF use was associated with reduced syringe sharing.

Rationale for evaluating North America's first medically supervised safer-injecting facility

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.

Methodology for evaluating Insite: Canada's first medically supervised safer injection facility for injection drug users

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.