ReviewSupervised injection services: What has been demonstrated? A systematic literature review☆
Introduction
Injection drug use represents a source of numerous harmful effects on both the health conditions of people who inject drugs (PWID) and their social environment. Drug injection is one of the main factors in the dissemination of blood-transmissible viral infections such as human immunodeficiency virus or the hepatitis B and C viruses (EMCDDA, 2008, Joint United Nations Programme on HIV/AIDS, 2002, WHO, 1997). In addition, numerous other physical problems can result from drug injection, including other viral and bacterial infections, cutaneous lesions, locomotive disorders, and hepato-gastroenterological pathologies (INSERM, 2010, Klee and Morris, 1995, Palepu et al., 2001). Psychiatric disorders are also more frequent in PWID (EMCDDA, 2008), who are subject to reduced access to medical services (Kerr et al., 2005b). Moreover, PWID exhibit enhanced marginalization from society, which increases their exposure to social precariousness, unemployment, homelessness, crime, and prostitution (DeBeck et al., 2007, EMCDDA, 2008). Thus, injection drug use induces considerably higher mortality. Partly because of its illegal nature, injection drug use is also responsible for numerous societal consequences, e.g., violence, traffic, crime, and public space degradation (Kerr et al., 2005a, Renn and Lange, 1996, Singer et al., 2001). For these reasons, injection drug use places a heavy burden on society.
During the early 1980s, PWID had to face the HIV epidemic. Preventing viral infection became crucial, and, therefore, care professionals had to consider the damage caused by drug use rather than focusing on drug use itself. Moreover, in face of the failure of public policies that aimed to eradicate drug use and drug trafficking (Drucker, 1999) and in consideration of the number of PWID who were not ready to enter into classical abstinence care, new prevention and care paradigms emerged, constituting the ‘harm reduction’ approach (MacPherson, 2001, Wodak and Owens, 1996). The first aim of these new care systems was to reduce the social and medical consequences of injection drug use and to stop the marginalization spiral to which PWID were exposed (Berridge, 1999, MacPherson, 2001). In this context, the first syringe exchange programs and the development of opiate maintenance therapies were implemented (WHO, 1998).
Similarly, new facilities emerged at the end of the 1980s, and the first objective was to allow PWID to inject self-provided drugs within a supervised framework in enhanced aseptic conditions with medical monitoring and no risk of police control (EMCDDA, 2008, Jozaghi, 2012, Semaan et al., 2011). These facilities have had different appellations, including ‘safer injection facilities,’ ‘supervised injecting centers/sites/rooms/facilities,’ ‘drug consumption rooms,’ and ‘supervised injection services’ (SISs) (Hedrich, 2004, Noël et al., 2009). Throughout the present article, we will indistinctly use the term ‘SISs’ to designate these facilities. The concept of SISs rapidly spread in Western countries, and in 2010, there were more than 90 identified SISs in Canada, Australia, Norway, Germany, Switzerland, Spain, the Netherlands and Luxembourg (Semaan et al., 2011).
SISs were implemented complementarily to other harm reduction measures for the following purposes (EMCDDA, 2009, INSERM, 2010, Noël et al., 2009): (1) to reach the most marginalized populations of PWID, who are least likely to obtain access to medical and social support, and connect them with health and social services; (2) to reduce overdose-induced morbidity and mortality; (3) to educate PWID to enhance their health behaviors; (4) to reduce injection-related risks by promoting the prevention and education of safe self-injecting practices; (5) to improve the global health conditions of PWID by promoting the prevention, screening and medical orientation of viral infections; (6) to foster the initiation of dependence care programs among PWID; and (7) to reduce the nuisances triggered by injection drug use in public spaces, e.g., urban violence and crime, drug trafficking and drug-use waste.
SIS access is usually restricted and regulated (Hedrich, 2004, INSERM, 2010). Most SISs are forbidden to subjects under 18 years of age, pregnant women, irregular or unidentified PWID, and individuals who wish to experience their first drug injection. Internal rules also forbid violence and drug selling. Moreover, many SISs prohibit drug sharing or helping other users with drug injection. However, SISs have endured criticism. Some official organizations have argued that “any national, state or local authority that permits the establishment and operation of drug injection rooms or any outlet to facilitate the abuse of drugs (by injection or any other route of administration) also facilitates illicit drug trafficking” (INCB, 1999). The detractors of SISs often argue that SIS implementation is equivalent to the tacit acceptance of injection drug use by public authorities, which will foster drug use, attract drug traffickers and increase drug-related consequences in the surrounding area (Boyd, 2013, Elliott et al., 2002, Gandey, 2003, Parliament of New South Wales, 1998). This perception has often been shared by groups of local residents and politicians in cities where new SISs were implemented (Elliott et al., 2002) and has sometimes led to long court procedures (Health Canada, 2006, Small, 2010, Wodak et al., 2003, Wood et al., 2007).
Twenty-eight years after the first legal opening of an SIS (Zobel and Dubois-Arber, 2004), we have performed a systematic review of the literature to collect the published data currently available on SISs and to synthesize these data to determine whether SISs have achieved their objectives and whether the fears raised against them are justified.
Section snippets
Materials and methods
A systematic search for relevant articles was conducted and is presented herein according to the PRISMA statement (Liberati et al., 2009). The research was performed using the PubMed, Web of Science, and ScienceDirect databases. To avoid selection bias, an inventory of the different English appellations for SIS was conducted, which led to our use of the following keyword algorithm: (“SUPERVISED” OR “SAFER”) AND (“INJECTION” OR “INJECTING” OR “SHOOTING” OR “CONSUMPTION”) AND (“FACILITY” OR
Overall results
We initially found 618 articles using the aforementioned keyword algorithm, among which 75 articles were finally included in the review (cf. Fig. 1).
Table 1 lists the final selection of articles, which were clustered according to the specific subject they addressed: (1) the description of SIS users; (2) the impact of SISs on overdose-induced mortality and morbidity; (3) the impact of SISs on injection behaviors and their consequences; (4) the impact of SISs on the adherence to care of PWID; (5)
Discussion
The aim of this review was to depict the currently available evidence regarding the positive and negative consequences of SISs. Several literature reviews have evaluated the multiple impacts of SISs on PWID or on their local environment (Hyshka et al., 2013, Kelly and Conigrave, 2002, Kerr et al., 2007a, Semaan et al., 2011, Tyndall, 2003, Wood et al., 2006b). However, the present review is the first to systematically embrace the full scope of SIS-related issues using a reproducible keyword
Role of the funding source
Nothing declared.
Contributors
B. Rolland and C. Potier designed the study. C. Potier, B. Rolland and V. Laprevote conducted the literature searches and summaries of previous related work. C. Potier and B. Rolland wrote the first draft of the manuscript. F. Dubois-Arber, V. Laprevote and O. Cottencin corrected the first draft of the manuscript. All authors contributed to and have approved the final manuscript.
Conflict of interest
No conflict declared.
References (126)
- et al.
A cost-benefit and cost-effectiveness analysis of Vancouver's supervised injection facility
Int. J. Drug Policy
(2010) - et al.
Public opinion towards supervised injection facilities and heroin-assisted treatment in Ontario, Canada
Int. J. Drug Policy
(2007) - et al.
Income generating activities of people who inject drugs
Drug Alcohol Depend.
(2007) - et al.
Injection drug use cessation and use of North America's first medically supervised safer injecting facility
Drug Alcohol Depend.
(2011) - et al.
Seeking refuge from violence in street-based drug scenes: women's experiences in North America's first supervised injection facility
Soc. Sci. Med.
(2008) Injecting drug user attitudes towards rules for supervised injecting rooms: implications for uptake
Int. J. Drug Policy
(2002)- et al.
Use of a medically supervised injection facility among drug-injecting street youth
J. Adolesc. Health
(2014) - et al.
Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement
Value Health J. Int. Soc. Pharmacoecon. Outcomes Res.
(2013) Science versus politics: the need for supervised injection facilities in Montreal, Canada
Int. J. Drug Policy
(2012)- et al.
The Sydney medically supervised injecting centre: a controversial public health measure
Aust. N. Z. J. Public Health
(2002)
The public health and social impacts of drug market enforcement: a review of the evidence
Int. J. Drug Policy
Safer injection facility use and syringe sharing in injection drug users
Lancet
Drug-related overdoses within a medically supervised safer injection facility
Int. J. Drug Policy
A micro-environmental intervention to reduce the harms associated with drug-related overdose: evidence from the evaluation of Vancouver's safer injection facility
Int. J. Drug Policy
Acceptability of a safer injection facility among injection drug users in San Francisco
Drug Alcohol Depend.
The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration
J. Clin. Epidemiol.
Determinants of cutaneous injection-related infection care at a supervised injecting facility
Ann. Epidemiol.
Reduction in overdose mortality after the opening of North America's first medically supervised safer injecting facility: a retrospective population-based study
Lancet
Prevalence and factors related to public injecting in Ottawa, Canada: implications for the development of a trial safer injecting facility
Int. J. Drug Policy
Injection drug users’ perceptions regarding use of a medically supervised safer injecting facility
Addict. Behav.
Exploring stakeholder perceptions of acceptability and feasibility of needle exchange programmes, syringe vending machines and safer injection facilities in Tijuana, Mexico
Int. J. Drug Policy
How many HIV infections are prevented by Vancouver Canada's supervised injection facility?
Int. J. Drug Policy
Five years on: what are the community perceptions of drug-related public amenity following the establishment of the Sydney Medically Supervised Injecting Centre?
Int. J. Drug Policy
Injecting-related injury and disease among clients of a supervised injecting facility
Drug Alcohol Depend.
High HIV testing and low HIV prevalence among injecting drug users attending the Sydney Medically Supervised Injecting Centre
Aust. N. Z. J. Public Health
Potential role of safer injection facilities in reducing HIV and hepatitis C infections and overdose mortality in the United States
Drug Alcohol Depend.
Accessing care for injection-related infections through a medically supervised injecting facility: a qualitative study
Drug Alcohol Depend.
Ethical reflections emerging during the activity of a low threshold facility with supervised drug consumption room in Geneva, Switzerland
Int. J. Drug Policy
The cost-effectiveness of Vancouver's supervised injection facility
CMAJ
Reporting guidelines for survey research: an analysis of published guidance and reporting practices
PLoS Med.
Evaluation de Quai 9 espace d’accueil et d’injection à Genève
Histories of harm reduction: illicit drugs, tobacco, and nicotine
Subst. Use Misuse
Lessons from INSITE, Vancouver's supervised injection facility: 2003–2012
Drugs Educ. Prev. Policy
Use of supervised injection facilities and injection risk behaviours among young drug injectors
Addiction
Police and public health partnerships: evidence from the evaluation of Vancouver's supervised injection facility
Subst. Abuse Treat. Prev. Policy
The validity of reporting willingness to use a supervised injecting facility on subsequent program use among people who use injection drugs
Am. J. Drug Alcohol Abuse
Evaluating Vancouver's supervised injection facility: data and dollars, symbols and ethics
CMAJ
Drug prohibition and public health: 25 years of evidence
Public Health Rep.
Typology of injection profiles of clients of a supervised drug consumption facility in Geneva, Switzerland
Eur. Addict. Res.
Créer des lieux sécuritaires pour l’injection au Canada: questions juridiques et éthiques
2008 Annual Report: The State of the Drugs Problem in the European Union and Norway
2009 Annual Report on the State of the Drugs Problem in Europe
The perspectives of injection drug users regarding safer injecting education delivered through a supervised injecting facility
Harm Reduct. J.
Trends in property and illicit drug crime around the Medically Supervised Injecting Centre in Kings Cross: an update
Crime Justice Stat.
The impact of the Sydney medically supervised injecting centre (MSIC) on crime
Drug Alcohol Rev.
US slams Canada over Vancouver's new drug injection site
CMAJ
Vancouver's INSITE Service and Other Supervised Injection Sites: What Has Been Learned from Research? – Final Report of the Expert Advisory Committee on Supervised Injection Site Research
My place, your place, or a safer place: the intention among Montreal injecting drug users to use supervised injecting facilities
Can. J. Public Health
No Injection Site For Addicts Until Questions Answered Says Minister Clement. News Releases
European Report on Drug Consumption Rooms
Cited by (0)
- ☆
Supplementary material can be found by accessing the online version of this paper at http://dx.doi.org/10.1016/j.drugalcdep.2014.10.012.