Injection drug use cessation and use of North America's first medically supervised safer injecting facility
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
References (32)
- et al.
A comparison of the new Federal Guidelines regulating supervised injection site research in Canada and the Tri-Council Policy Statement on Ethical Conduct for Research Involving Human Subjects
Int. J. Drug Policy
(2004) - et al.
Predictors of injection drug use cessation and relapse in a prospective cohort of young injection drug users in San Francisco, CA (UFO Study)
Drug Alcohol Depend.
(2009) - et al.
Safer injection facility use and syringe sharing in injection drug users
Lancet
(2005) - et al.
The relevance of drug injectors’ social and risk networks for understanding and preventing HIV infection
Soc. Sci. Med.
(1994) - et al.
Longitudinal predictors of injection cessation and subsequent relapse among a cohort of injection drug users in Baltimore, MD, 1988–2000
Drug Alcohol Depend.
(2006) - et al.
Attendance, drug use patterns, and referrals made from North America's first supervised injection facility
Drug Alcohol Depend.
(2006) - et al.
Rationale for evaluating North America's first medically supervised safer-injecting facility
Lancet Infect. Dis.
(2004) - et al.
Do supervised injecting facilities attract higher-risk injection drug users?
Am. J. Prev. Med.
(2005) - et al.
The Canadian government's treatment of scientific process and evidence: inside the evaluation of North America's first supervised injecting facility
Int. J. Drug Policy
(2008) - et al.
Incarceration and drug use patterns among a cohort of injection drug users
Addiction
(2009)
Discarded needles do not increase soon after the opening of a needle exchange program
Am. J. Epidemiol.
Drug consumption facilities in Europe and the establishment of supervised injecting centres in Australia
Drug Alcohol Rev.
Longitudinal patterns of drug injection behavior in the ALIVE Study Cohort, 1988–2000: description and determinants
Am. J. Epidemiol.
US slams Canada over Vancouver's new drug injection site
Can. Med. Assoc. J.
Fatal overdose trends in major US cities: 1990–1997
Addict. Res. Theor.
Reaching the unreached: targeting hidden IDU populations with clean needles via known user groups
J. Psychoactive Drugs
Cited by (97)
Drug Consumption Rooms : Opinion and willingness among people who inject drugs in Marseille, France
2023, Revue d'Epidemiologie et de Sante PubliqueHarm reduction or amplification? The adverse impact of a supervised injection room on housing prices
2023, Regional Science and Urban EconomicsCitation Excerpt :The MSIR provides a safe environment to inject illicit drugs with sterile equipment under the supervision of medically trained staff. Existing medical literature shows that MSIRs may promote injection cessation and reduce overdose death risk among existing users (Van Den Boom et al., 2021; DeBeck et al., 2011). A typically feared consequence of promoting safer drug use is potentially increased and/or riskier usage among active users (Doleac and Mukherjee, 2022; Erfanian et al., 2019).
The estimated costs and benefits of a hypothetical supervised consumption site in Providence, Rhode Island
2022, International Journal of Drug PolicyImpact of safe consumption facilities on individual and community outcomes: A scoping review of the past decade of research
2022, Emerging Trends in Drugs, Addictions, and HealthSupervised Injection Facilities as Harm Reduction: A Systematic Review
2021, American Journal of Preventive MedicineCitation Excerpt :Finally, using a before–after study design (rather than a cross sectional design), Kerr et al.34 identified a null change in community injection drug use and binge drug use in the year before and after the opening of the Vancouver SIF. A total of 7 studies29,31,33,36,39,44,54 reported outcomes relevant to access to addiction treatment programs. Review authors deemed 4 studies to be of greatest suitability of study design, with one of these studies (Wood and colleagues54) rated good quality of execution and the rest (Lloyd-Smith et al.,39 DeBeck and colleagues,29 and Kimber et al.36) rated fair.
Socioeconomic stability is associated with lower injection frequency among people with distinct trajectories of injection drug use
2021, International Journal of Drug Policy