Supervised injection site

Supervised injection sites (SIS)^[1] (also known as supervised injection facilities,^[2] safe injection site^[1] safer injection facility (SIF), drug consumption facility (DCF)^[3] or medically supervised injection center (MSIC)^[4]) are legally sanctioned and medically supervised facilities designed to reduce nuisance from public drug use and provide a hygienic and stress-free environment for illicit drug users when consuming drugs, mostly injecting drug use.^[3]

They are part of a harm reduction approach towards drug problems. The facilities provide sterile injection equipment, information about drugs and basic health care, treatment referrals, and access to medical staff. Some offer counseling, hygienic and other services of use to itinerant and impoverished individuals. Most programs prohibit the sale or purchase of recreational drugs. Many require identification cards. Some restrict access to local residents and apply other admission criteria, such as only allowing injection drug users, but generally in Europe they do not exclude addicts who consume by other means.

Operating facilities

What disparagingly is called "shooting galleries" have existed for a long time; there were illicit for-profit facilities in New York during the 1980s and in Sydney during the 1990s. What differs these from the legally sanctioned is the care they provide. While the operators of the facilities in New York and Sydney had little regard for the health of their clients, modern supervised injection facilities are a professionally staffed health and welfare service.^[5]

The first professionally staffed service where drug injection was accepted emerged in the Netherlands during the early 1970s as part of the "alternative youth service" provided by the St. Paul's church in Rotterdam. At its peak it had two centers that combined an informal meeting place with a drop-in center providing basic health care, food and a laundering service. One of the centers was also a pioneer in providing needle-exchange. Its purpose was to improve the psychosocial function and health of its clients. The centers received some support from law enforcement and local government officials, although they were not officially sanctioned until 1996.^[5]

In 1986 a café was set up in Berne for injecting drug users who were unwanted at other cafés. Part of a project combatting HIV, the general concept of the café was a place where simple meals and beverages would be served, and information on safe sex, safe drug use, condoms and clean needles provided. Social workers providing counselling and referrals were also present. An injection room was not originally conceived, however, drug users began to use the facility for this purpose, and this soon became the most attractive aspect of the café. After discussions with the police and legislature, the café was turned into the first legally sanctioned drug consumption facility provided that no one under the age of 18 was admitted.^[6]

During the 1990s additional legal facilities emerged in other cities in Switzerland, Germany and the Netherlands.^[3][5] In the first decade of 2000, facilities opened in Spain, Luxembourg, Norway, Canada and Australia.^[3]

Police corruption and street crime in the Kings Cross district of Sydney, prompted the Wood Royal Commission to recommend the opening of an injection facility in the area,^[7] with the Sydney Medically Supervised Injecting Centre (MSIC) opening in May, 2001.^[8] In Canada: problems with drug use, discarded needles and crime made Downtown Eastside of Vancouver the location for the first facility, when Insite commenced operation in 2003.^[8]

Whereas injection facilities in Europe often evolved from something else, such as different social and medical out-reaches or perhaps a homeless shelter, the degree and quality of actual supervision varies. As many European centers also allow clients to consume drugs by other means then by injecting it on its premises, EMCDDA prefers call them "drug consumption facilities" instead of anything alluding to "injection". The history of the European centers also mean that there have been no or little systematic collection of data needed to do a proper evaluation of effectiveness of the scheme.^[3]

However, some of the very rationale for the projects in Sydney and Vancouver are specifically to gather data, as they are created as scientific pilot projects. The approach at the centers is also more clinical in nature, as they provide true supervision with a staff that is equipped and trained to administer Oxygen or Naloxone in the case of a heroin or other opioid overdose.^[8]

At the beginning of 2009 there were 92 facilities operating in 61 cities, including 30 cities in the Netherlands, 16 cities in Germany and 8 cities in Switzerland.^[3]

Evaluations

In the late 1990s there were a number of studies available on consumption rooms in Germany, Switzerland and the Netherlands. “The reviews concluded that the rooms contributed to improved public and client health and reductions in public nuisance but stressed the limitations of the evidence and called for further and more comprehensive evaluation studies into the impact of such services.”^[9] To that end, the two non-European injecting facilities, Australia’s Sydney Medically Supervised Injecting Centre (MSIC) and Canada’s Vancouver Insite Supervised Injection Site have had more rigorous research designs as a part of their mandate to operate.^[10]

The NSW Government has provided extensive funding for ongoing evaluations of the Sydney MSIC, with a formal comprehensive evaluation produced in 2003, 18 months after the centre was opened. Other later evaluations studied various aspects of the operation - service provision (2005), community attitudes (2006), referral and client health (2007) and a fourth (2007) service operation and overdose related events.^[11] Other evaluations of drug-related crime in the area were completed in 2006, 2008 and 2010, the SAHA International cost-effectiveness evaluation in 2008 and a final independent KPMG evaluation in 2010.

In 2003, 2006 and 2010 a drug prevention advocacy group, Drug Free Australia, completed analyses of evaluations up to these dates.^[12][13] The reports of these analyses, distributed to the media and to politicians were informed by teams of published experts, researchers and professionals which in the 2010 analysis included Dr Robert DuPont, first President of the United States National Institute of Drug Abuse (NIDA). These analyses have led to a robust debate about the effectiveness of the Sydney MSIC in Australia. In the NSW parliament, some politicians from the Labor Party which installed the injecting room referred to Drug Free Australia as "peddling misinformation", claiming that MSIC staff members of the facility had refuted their analysis, referring other members back to the official evaluations.^[14][15] In turn, Drug Free Australia has documented its allegation that the Sydney injecting room's evaluations were demonstrably the production of partisan sympathizers and colleagues of injecting room staff, responsible for "often providing misleading or totally erroneous conclusions or otherwise failing to make the necessary conclusions from negative data." Drug Free Australia has likened the extant criticisms of climate science, where science is alleged to have been manipulated to fit ideological and political ends, to that of its criticisms of the injecting room's scientific evaluations.^[16][17]

The Vancouver Insite facility was evaluated during the first three years of its operation by researchers from the BC Center for Excellence in HIV/AIDS with published and some unpublished reports available. In March 2008 a Final Report of the Expert Advisory Committee appointed by the Canadian Ministry of Health was released, evaluating the performance of the Vancouver Insite against its stated objectives.

Client characteristics and utilization

The 2010 KPMG evaluation of the Sydney MSIC found that it had made service contact with its target population,^[18] with 12,050 visitors to the Centre for a total of 604,022 injections between May 2001 and April 2010, where clients averaged 14 years of illicit drug use and where 39% - 51% across the various years were heroin injectors^[19] and 35% in 2007 had experienced an overdose previously.^[20]

The Drug Free Australia 2010 analysis found that the 7% of clients who attended the centre more than 98 times in a year were still injecting 80% of the time outside the centre, while the 26% who visited 10-98 times per year injected 95% of the time on the street, in a car, a toilet, at home or someone else’s home.^[21] With injector safety the most prominent rationale for the establishment of injecting rooms, the analysis questioned such low utilization rates in light of the room’s capacity for 330 injections per day,^[22] but where between 2001 and 2010 it had averaged just 185 injections per day.^[21]

The Expert Advisory Committee for Insite^[23] cited 8,000 people who had visited INSITE, with 18% accounting for 80% of all visits to INSITE, less than 10% using the site for all injections, a median number of 8 visits across all clientele, and 600 visits per day, of which 80% were to inject, showing that the facility was near capacity. Drug Free Australia has noted that for the 1,506 injectors who most regularly use the centre, who would cumulatively inject somewhere between 6,000 and 9,000 times daily, the less than 500 injections in Insite daily represents at best one injection in every 12 by its highest utilizers inside the facility.

Two surveys of approximately 1,000 users established some key user characteristics – clients averaged 15 years of drug use, 51% injected heroin and 32% cocaine, 87% were infected with Hepatitis C virus and 17% with HIV, 20% were homeless with numerous others living in single resident rooms, 80% had been incarcerated, 21% were using methadone and 59% reported a non-fatal overdose during their lifetime.

European consumption rooms cater more so to users older than 30 years, mainly with problematic heroin and cocaine habits. Various studies have documented an ageing population of clients over time. Whereas in 1990, in one study, 50% of clients were 25 years or younger, by 2001 the percentage was 15%. Clients across European consumption rooms are characterized by heavy injecting drug use, a continuous use of illicit drugs and deriving from a poorer demographic. German studies found that between 19% and 27% of clients were from unstable accommodation. In the injecting rooms near Madrid 42% of the marginalized target group were homeless, while the number was 60% for the Can Tunis area of Barcelona. In a German study 15% of clients had never accessed addiction treatment of any kind.^[24]

Client utilization in the European situation is more difficult to analyze. Studies on sites in Frankfurt and Zurich found that clients used facilities 5 times a week^[25] and in Rotterdam 6 times a week and twice in the previous 24 hours.^[26] A study of clients in Frankfurt in 1997 found that 63% claimed to be daily visitors, while in another surveyed non-random sample from 18 German consumption rooms, 84% claimed use of the facility at least once weekly, with 51% claiming at least once per day utilization.^[27]

Client referral

Evaluators of the Sydney MSIC found that over an 8-year period staff provided 47,396 other occasions of service (94.6 per 1,000 visits) including advice on drug and alcohol treatment on 7,856 occasions, 22,531 occasions where staff had provided vein care and safer injecting advice, with a total of 8,508 referrals to other services where 3,871of referrals were to treatment.^[28] Of the 3,871 referrals to treatment 1,292 were to detox and 434 to abstinence-based rehabilitation or therapy.^[29] The evaluators asserted that the MSIC was thereby evidenced as a gateway for treatment.^[30]

Drug Free Australia has heavily criticized the MSIC referral rates to treatment as abnormally and unjustifiably low. They note that the 2010 MSIC evaluation does not give the percentage of clients referred to drug treatment, but that the 2007 evaluation records just 11% of clients over 6 years referred to treatment. They further cite the 2010 evaluation’s appeal to smoking cessation surveys which demonstrate that 20% of all tobacco smokers, using the most addictive of all commonly used drugs, are currently ready to quit at any point in time. Alternatively, the MSIC has had opportunity to continuously assist their clients over a period of many years and not just at a single point of time.^[31]

The Expert Advisory Committee found that Insite had referred clients such that it had contributed to an increased use of detoxification services and increased engagement in treatment. Insite had encouraged users to seek counseling. Funding has been supplied by the Canadian government for detoxification rooms above Insite.^[32]

Impact on public nuisance

“The Sydney MSIC client survey conducted in 2005, found that public injecting (defined as injecting in a street, park, public toilet or car), which is a high risk practice with both health and public amenity impacts, was reported as the main alternative to injecting at the MSIC by 78% of clients. 49% of clients indicated resort to public injection if the MSIC was not available on the day of registration with the MSIC. From this, the evaluators calculated a total 191,673 public injections averted by the centre.^[33]

Public amenity can be further improved by reduced numbers of publicly disposed needles and syringes. Data from the Sydney MSIC’s 2003 report indicated reductions in needles and syringe counts and resident and business-operator sightings of injections in public places decreased marginally but could not be certain that there was any effect by the MSIC beyond the heroin drought which had commenced some months prior to the opening of the MSIC.^[34] The Drug Free Australia analysis pointed to the needle, syringe and public sighting decreases being almost exactly equivalent to the 20% decreases in the number of needles distributed from local pharmacies, needle exchanges and the MSIC, thereby indicating no clear impact by the MSIC.^[35]

Observations before and after the opening of Insite indicated a reduction in public injecting.^[18]

Impact on blood-borne viruses

The 2003 evaluators of the Sydney MSIC found that it “had not increased blood-borne virus transmission”^[18] with the data more specifically showing no improvement re HIV infection incidence, no improvement in Hep B infections,^[36] either worse or no improvement (depending on the suburb studied) in new Hep C notifications,^[37] no improvement in reuse of others' syringes and injecting equipment, no improvement in tests taken for HIV and Hep C and initial improvement in tests taken for Hep B but worsening again in 2002.^[38] The 2010 evaluation found no measurable impact on blood-borne diseases.^[39]

The Expert Advisory Committee for Vancouver’s Insite found that journal studies with mathematical modeling by researchers from self-reports of users generated a wide range of estimates for HIV cases averted, but they were not convinced that the assumptions were valid.

Impact on community levels of overdose

Over a nine-year period the Sydney MSIC managed 3,426 overdose-related events with not one fatality^[40] while Vancouver’s Insite had managed 336 overdose events in 2007 with not a single fatality.

The 2010 MSIC evaluators found that over 9 years of operation it had made no discernable impact on heroin overdoses at the community level with no improvement in overdose presentations at hospital emergency wards.^[41]

Research by injecting room evaluators in 2007 presented statistical evidence that there had been later reductions in ambulance callouts during injecting room hours,^[42][43][44] but failed to make any mention of the introduction of sniffer dog policing, introduced to the drug hot-spots around the injecting room a year after it opened.^[45]

Site experience of overdose

While overdoses are managed on-site at Vancouver, Sydney and the facility near Madrid, German consumption rooms are forced to call an ambulance due to naloxone being administered only by doctors. A study of German consumption rooms indicated that an ambulance was called in 71% of emergencies and naloxone administered in 59% of cases. The facilities in Sydney and Frankfurt indicate 2.2-8.4% of emergencies resulting in hospitalization.^[46]

Vancouver’s Insite yielded 13 overdoses per 10,000 injections shortly after commencement,^[47] but in 2009 had more than doubled to 27 per 10,000.^[48] The Sydney MSIC recorded 96 overdoses per 10,000 injections for those using heroin.^[49] Commenting on the high overdose rates in the Sydney MSIC, the evaluators suggested that,

“In this study of the Sydney injecting room there were 9.2 (sic) heroin overdoses per 1000 heroin injections in the centre. This rate of overdose is higher than amongst heroin injectors generally. The injecting room clients seem to have been a high-risk group with a higher rate of heroin injections than others not using the injection room facilities. They were more often injecting on the streets and they appear to have taken greater risks and used more heroin whilst in the injecting room.^[50]

The Drug Free Australia 2010 analysis of the Sydney MSIC evaluations found overdose levels in the MSIC 32 times higher than clients’ own recorded histories of overdose prior to registering to use the facility.^[51] The Drug Free Australia calculations compared the registration data for overdose histories published in the MSIC’s 2003 evaluation document, which allowed comparison rates of overdose from a period before a heroin drought reduced overdoses Australia-wide, with rates of overdose drawn from data in the 2010 evaluation. Drug Free Australia has expressed concern that the evaluators, in using injecting room overdose data to calculate quite incorrect 'lives saved' estimates, failed to examine the extent to which overdoses were over-represented in the injecting room against data they had available to them on clients’ prior histories of overdose.

Against other measures the Sydney MSIC’s overdose rate is highly disproportionate. Estimates of the number of dependent heroin users in Australia completed for the year 1997,^[52] compared with estimates of the number of total non-fatal and fatal overdoses in Australia for 1997/98^[53] yields a rate of 2 overdoses for every 10,000 injections against the MSIC’s rate of 96 overdoses for every 10,000 injections in the 2003 evaluation and rates as high as 146 overdoses per 10,000 injections in the year 2009/10.^[54]

A review of the MSIC registration surveys recording each client’s previous overdose histories^[55] reveals that MSIC clients’ previous overdose history were less prone to overdose than various other previously studied heroin injector cohorts in Australia.^[56]

People living with HIV/AIDS

The results of a research project undertaken at the Dr. Peter Centre (DPC), a 24-bed residential HIV/AIDS care facility located in Vancouver, were published in the Journal of the International AIDS Society in March 2014, stating that the provision of supervised injection services at the facility improved health outcomes for DPC residents. The DPC considers the incorporation of such services as central to a "comprehensive harm reduction strategy" and the research team concluded, through interviews with 13 residents, that "the harm reduction policy altered the structural-environmental context of healthcare services and thus mediated access to palliative and supportive care services", in addition to creating a setting in which drug use could be discussed honestly. Highly active antiretroviral therapy (HAART) medication adherence and survival are cited as two improved health outcomes.^[57]

Calculations of lives saved

The European Monitoring Centre (EMCDDA) 2004 Review of Drug Consumption Rooms^[3] calculated the number of lives saved for all 25 drug consumption rooms across Germany. It calculated from known overdose mortality rates per 100 dependent heroin users (2%) and the number of injections per 100 person years per dependent heroin user (1,000 injections per year per user). Their calculation indicated that 100 dependent heroin users, cumulatively injecting 100,000 times a year, would statistically have 2 overdose fatalities annually. Thus 500,000 injections results in 10 expected fatalities averted by the entirety of injecting facilities across Germany.

Drug Free Australia has noted that the EMCDDA review’s 2% overdose fatality rate appears excessive in light of mortality studies done by the EMCDDA for 5 European countries, (Germany was not included, but Spain, with the highest heroin overdose mortality, was still well below 2%). The percentages by country were Barcelona, Spain 1.4%; Rome, Italy 0.2%; Sweden 0.7%; Amsterdam, Netherlands unknown; Vienna, Austria 0.2%.^[58]

The Canadian Expert Advisory Committee 2008 review of Insite did not declare the method by which it concluded that 1.08 lives are saved by the facility each year,^[59] but Drug Free Australia claims that the EMCDDA method, used with Canadian data and assumptions, yields the same result.^[60] Canadian heroin mortality in 2002/3 was roughly the same as Australia’s at 1% (958 deaths from more than 80,000 dependent heroin users)^[61] and mortality percentages for 2006 or 2007, Drug Free Australia claims, might well be expected to be little changed. Further, the Expert Advisory Committee clearly state their assumption that a typical Canadian heroin user injects 4 times daily.^[62]

Consequently 100 Canadian heroin users would cumulatively inject 146,000 times annually, and the 144,000 opiate injections in Vancouver’s Insite would avert the death of the one injection in 146,000 which would likely have been fatal.

The conclusion of the 2003 Sydney MSIC evaluators was that “a small number of opioid overdoses managed at the MSIC might have been fatal had they occurred elsewhere”, calculating that the centre had saved 4 lives per annum during the evaluation period.^[63] Estimates were directly calculated from the 329 heroin overdose interventions in the centre. A later SAHA International evaluation of the MSIC calculated 25 lives saved by the facility in a single year.^[64]

Drug Free Australia cites two statistics together which demonstrate that the Sydney MSIC cannot statistically claim to save even one life per year. The first is that 1% of dependent heroin users die from fatal overdose each year in Australia. The second is that a dependent heroin user averages ‘at least’ three injections per day according to the MSIC 2003 evaluation’s researchers. Taking these two statistics together, it is clear that the injecting room would need to host 300 injections per day (ie enough heroin injections for 100 heroin addicts injecting 3 times daily) before they could claim they had saved the life of the one (1%) of those 100 who would have died annually. But the injecting room averages just half that number with less than 150 opiate injections per day. Drug Free Australia has shown that the 2003 and 2008 MSIC evaluators indefensibly failed to factor the vastly elevated number of overdoses in the centre into their calculations of lives saved.^[65]

Crime

The Sydney MSIC was judged by its evaluators to have caused no increase in crime^[18] and not to have caused a ‘honey-pot effect’ of drawing users and drug dealers to the Kings Cross area.^[66] The Drug Free Australia analysis pointed to data within the report clearly demonstrating that drug-related loitering and drug dealing worsened at the station entrance 25 metres opposite the MSIC^[67] and at the rear door of the centre.^[68] A later 2010 evaluation of crime in Kings Cross claimed that drug-related crime had decreased at the same rate as the rest of Sydney after a heroin shortage intervened 6 months before the MSIC opened, but Drug Free Australia has asserted that the evaluators failed to make any mention or assessment of the impact of police sniffer dogs introduced 12 months after the MSIC opened to deter drug dealers and users from the back lanes of Kings Cross, which might well be expected to have decreased drug-related crime more than areas of Sydney not policed by sniffer dogs.^[69]

Testimony of ex-clients reported to the NSW Legislative Council^[70] alleged that the extremely high overdose rates were due to clients experimenting with poly-drug cocktails and higher doses of heroin in the knowledge that staff were present to ensure their safety. The 2003 evaluation explanation for high overdose rates citing greater amounts of heroin used^[71] has been cited by Drug Free Australia as cause for concern. NSW Member of Parliament, Andrew Fraser, made the same allegation regarding the MSIC as a site for experimentation, citing testimony of another ex-client in a Parliamentary speech in 2010.^[72]

Observations before and after the opening of Insite indicated no increases in drug dealing or petty crime in the area. There was no evidence that the facility influenced drug use in the community, but concerns that Insite ‘sends the wrong message’ to non-users could not be addressed from existing data.^[73] The European experience has been mixed.^[74]

Community support

The Sydney MSIC has enjoyed the support of the surrounding Kings Cross community, with the 2010 evaluation indicating 78% of residents supportive of its presence and 70% of business operators.^[75] Contesting the reliability of these evaluation surveys is a 2010 petition to the NSW Parliament by 63 business owners immediately surrounding the MSIC to move the facility elsewhere because it has adversely affected their businesses.^[76]

The Expert Advisory Committee for Vancouver’s Insite found that health professionals, local police, the local community and the general public have positive or neutral views of the service, with opposition decreasing over time.^[73]

Drug Free Australia has expressed concern that supporters, staff and various NSW politicians continually has represented each overdose intervention in the centre to the Australian media as a life saved, when such an equation was clearly false.^[77]

Cost effectiveness

The cost of running Insite per annum is $3 million Canadian. Mathematical modeling showed cost to benefit ratios of one dollar spent ranging from 1.5 to 4.02 in benefit. However, the Expert Advisory Committee expressed reservation about the certainty of Insite’s cost effectiveness until proper longitudinal studies had been undertaken. Mathematical models for HIV transmissions foregone had not been locally validated and mathematical modeling from lives saved by the facility had not been validated.^[32] The Sydney MSIC cost upwards of $2.7 million Australian per annum in 2007.^[78] Drug Free Australia has asserted that in 2003 the cost of running the Sydney MSIC equated to 400 NSW government-funded rehabilitation places^[79] while the Health Minister for the Canadian Government, Tony Clements, has stated that the money for Insite would be better spent on treatment for clients.^[80]

Media

2013 documentary film Making a Place Called Safe: A Public Health Case for a Safer Injection Facility in San Francisco interviews people on the need for a safer drug injection facility in San Francisco.^[81]

See also

• Drug policy of the Soviet Union
• Insite - Supervised Injection Site in Canada
• Illicit drug use in Australia
• Harm reduction

References

External links

• Official homepage of the Sydney Medically Supervised Injecting Centre
• Official homepage of Insite