Injection drug use cessation and use of North America's first medically supervised safer injecting facility

https://doi.org/10.1016/j.drugalcdep.2010.07.023Get rights and content

Abstract

Background

Vancouver, Canada has a pilot supervised injecting facility (SIF), where individuals can inject pre-obtained drugs under the supervision of medical staff. There has been concern that the program may facilitate ongoing drug use and delay entry into addiction treatment.

Methods

We used Cox regression to examine factors associated with the time to the cessation of injecting, for a minimum of 6 months, among a random sample of individuals recruited from within the Vancouver SIF. In further analyses, we evaluated the time to enrolment in addiction treatment.

Results

Between December 2003 and June 2006, 1090 participants were recruited. In Cox regression, factors independently associated with drug use cessation included use of methadone maintenance therapy (Adjusted Hazard Ratio [AHR] = 1.57 [95% Confidence Interval [CI]: 1.02–2.40]) and other addiction treatment (AHR = 1.85 [95% CI: 1.06–3.24]). In subsequent analyses, factors independently associated with the initiation of addiction treatment included: regular SIF use at baseline (AHR = 1.33 [95% CI: 1.04–1.72]); having contact with the addiction counselor within the SIF (AHR = 1.54 [95% CI: 1.13–2.08]); and Aboriginal ancestry (AHR = 0.66 [95% CI: 0.47–0.92]).

Conclusions

While the role of addiction treatment in promoting injection cessation has been well described, these data indicate a potential role of SIF in promoting increased uptake of addiction treatment and subsequent injection cessation. The finding that Aboriginal persons were less likely to enroll in addiction treatment is consistent with prior reports and demonstrates the need for novel and culturally appropriate drug treatment approaches for this population.

Introduction

Illicit injection drug use continues to fuel infectious disease and fatal overdose epidemics in many settings, and has prompted substantial community concerns due to public drug use and publicly discarded syringes (Doherty et al., 1997, Garfield and Drucker, 2001, Karon et al., 2001). Public health programming aimed at reducing the harms of injection drug use have been limited, in part, due to the difficulties in reaching people who use injection drugs (IDU) for the purposes of providing addiction treatment services, even when such services are available (Grund et al., 1992, Neaigus et al., 1994).

In an effort to address outstanding public health and public disorder concerns stemming from injection drug use, an increasing number of cities have opened medically supervised safer injection facilities (SIF), where people who use injection drugs can inject pre-obtained illicit drugs under the supervision of healthcare professionals (Kimber et al., 2003, MSIC Evaluation Committee, 2003, Wood et al., 2004a). Within SIF, individuals are typically provided with sterile injecting equipment and emergency intervention in the event of an accidental overdose, as well as medical care either on site or through referral (Dolan et al., 2000, Wright and Tompkins, 2004). There are now approximately 65 sanctioned supervised drug consumption facilities in operation internationally (Joseph Rowntree Foundation, 2006).

On September 22, 2003, Vancouver, Canada opened North America's first government sanctioned SIF (Wood et al., 2004a). Although the opening of the SIF has been associated with reduced public drug use (Wood et al., 2004b), and HIV risk behaviour (Kerr et al., 2005), the program is controversial and there remains concern that it enables drug use and reduces the likelihood that IDU will seek to reduce or quit their illicit drug use (Yamey, 2000, Gandey, 2003, Wood et al., 2004a, Wood et al., 2008, Jones, 2006, INCB, 2007).

To examine this question, a number of studies have been conducted to explore the relationship between SIF attendance and engagement with addiction treatment programs. An evaluation of the SIF in Sydney Australia, demonstrated that individuals who frequently used the facility were more likely to be referred to drug treatment than other clients (Kimber et al., 2008). In Vancouver, an earlier analysis found that frequent use of the SIF and contact with addictions counsellors at the facility were both independently associated with increased entry into medical detoxification, and that entry into detoxification spurred entry into other treatments (Wood et al., 2006). Another study subsequently found that the SIF opening was independently associated with a 30% increase in detoxification service use among SIF clients (Wood et al., 2007a). Although these analyses imply a positive impact of SIF use on enrolment in detoxification programs, no studies have examined the direct relationship between the use of Vancouver's SIF and entry into other types of addiction treatment (e.g., residential treatment, methadone maintenance therapy), and more importantly, no studies have evaluated rates of injection cessation among SIF clients. The present study was conducted to examine factors associated with drug use cessation among IDU using Vancouver's SIF, and to examine the potential role of SIF in facilitating injection cessation among this population.

Section snippets

Methods

The Vancouver SIF has been evaluated through the Scientific Evaluation of Supervised Injecting (SEOSI) cohort, which has been described in detail previously (Wood et al., 2004c). Briefly, the cohort was assembled through random recruitment of IDU from within the SIF. Among individuals who were recruited, an interviewer-administered questionnaire was administered at baseline and at semi-annual follow-up visits. Since health service use may be over-reported by IDU (Wood et al., 2004c), the

Results

By June 2006, 6747 unique individuals were registered at the SIF, and between 1 December 2003 and 1 June 2006, 1090 individuals were randomly recruited into SEOSI. Among this group 188 (17%) individuals did not return for a second study visit during our study period and were therefore not included in our statistical analyses. These 188 participants were more likely to be younger in age, to have been injecting for fewer years, to be homeless, and less likely to be enrolled in methadone

Discussion

Among IDU who attended Vancouver's supervised injecting facility, regular use of the SIF and having contact with counselors at the SIF were associated with entry into addiction treatment, and enrolment in addiction treatment programs was positively associated with injection cessation. Although SIF in other settings have been evaluated based on wide range of outcomes (Dolan et al., 2000, Kimber et al., 2003, MSIC Evaluation Committee, 2003), our study is the first to consider the potential role

Role of funding source

The evaluation of the supervised injecting facility was originally made possible through a financial contribution from Health Canada, although the views expressed herein do not represent the official policies of Health Canada. The evaluation is currently supported by the Canadian Institutes of Health Research (CIHR) and Vancouver Coastal Health. Kora DeBeck is supported by a Senior Graduate Trainee Award from the Michael Smith Foundation for Health Research and a CIHR Doctoral Research Award.

Contributors

The specific contributions of each author are as follows: KD, TK and EW were responsible for study design and prepared the first draft of the analysis; RZ conducted the statistical analyses; LB, DM, MT and JM contributed to the main content and provided critical comments on the final draft. All authors approved the final manuscript.

Conflict of interest

Dr Julio Montaner has received grants from, served as an ad hoc advisor to, or spoke at various events sponsored by; Abbott, Argos Therapeutics, Bioject Inc, Boehringer Ingelheim, BMS, Gilead Sciences, GlaxoSmithKline, Hoffmann-La Roche, Janssen-Ortho, Merck Frosst, Pfizer, Schering, Serono Inc, TheraTechnologies, Tibotec, Trimeris. Authors declare no other competing interests.

Acknowledgements

The authors wish to thank the participants in SEOSI, the staff of Insite, Mark Townsend, Dan Small and the staff of the Portland Hotel Society, as well as Heather Hay, Chris Buchner, Sarah Evan, David Marsh and Vancouver Coastal Health. We also thank the current and past SEOSI staff. We would specifically like to thank Deborah Graham, Tricia Collingham, Caitlin Johnston, Steve Kain, and Calvin Lai for their research and administrative assistance. Particular thanks goes to Daniel Kane for his

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