Evaluating Vancouver's supervised injection facility: data and dollars, symbols and ethics

Drug consumption rooms: A systematic review of evaluation methodologies

ISSUES

Drug consumptions rooms (DCR) and supervised injecting facilities (SIF) are expanding internationally. Previous reviews have not systematically addressed evaluation methodologies.

APPROACH

Results from systematic searches of scientific databases in English until June 2017 were coded for paper type, country and year of publication. For evaluation papers, study outcome, methodology/study design and main indicators of DCR/SIF 'exposure' were recorded.

KEY FINDINGS

Two hundred and nineteen eligible peer-reviewed papers were published since 1999: the majority from Canada (n = 117 papers), Europe (n = 36) and Australia (n = 32). Fifty-six papers reported evaluation outcomes. Ecological study designs (n = 10) were used to assess the impact on overdose, public nuisance and crime; modelling techniques (n = 6) estimated impact on blood-borne diseases, overdose deaths and costs. Papers using individual-level data included four prospective cohorts (n = 28), cross-sectional surveys (n = 7) and service records (n = 5). Individual-level data were used to assess safer injecting practice, uptake into health and social services and all the other above outcomes except for impact on crime and costs. Four different indicators of DCR/SIF attendance were used to measure service 'exposure'.

IMPLICATIONS

Research around DCRs/SIFs has used ecological, modelling, cross-sectional and cohort study designs. Further research could involve systematic inclusion of a control group of people who are eligible but do not access SIFs, validation of self-reported proportion of injections at SIFs or a stepped-wedge or a cluster trial comparing localities.

CONCLUSIONS

Methodologies appropriate for DCR/SIF evaluation have been established and can be readily replicated from the existing literature. Research on operational aspects, implementation and transferability is also warranted.

The value of harm reduction for injection drug use: A clinical and public health ethics analysis

The US is facing dual public health crises related to opioid overdose deaths and HIV. Injection drug use is fueling both of these epidemics. The War on Drugs has failed to stem injection drug use and has contributed to mass incarceration, poverty, and racial disparities. Harm reduction is an alternative approach that seeks to decrease direct and indirect harms associated with drug use without necessarily decreasing drug consumption. Although overwhelming evidence demonstrates that harm reduction is effective in mitigating harms associated with drug use and is cost-effective in providing these benefits, harm reduction remains controversial and the ethical implications of harm reduction modalities have not been well explored. This paper analyzes harm reduction for injection drug use using the core principles of autonomy, nonmaleficence, beneficence, and justice from both clinical ethics and public health ethics perspectives. This framework is applied to harm reduction modalities currently in use in the US, including opioid maintenance therapy, needle and syringe exchange programs, and opioid overdose education and naloxone distribution. Harm reduction interventions employed outside of the US, including safer injection facilities, heroin-assisted treatment, and decriminalization/legalization are then discussed. This analysis concludes that harm reduction is ethically sound and should be an integral aspect of our nation's healthcare system for combating the opioid crisis. From a clinical ethics perspective, harm reduction promotes the autonomy of, prevents harms to, advances the well-being of, and upholds justice for persons who use drugs. From a public health ethics perspective, harm reduction advances health equity, addresses racial disparities, and serves vulnerable, disadvantaged populations in a cost-effective manner.

Experiences with skin and soft tissue infections among people who inject drugs in Philadelphia: A qualitative study

OBJECTIVES

To understand how people who inject drugs (PWID) experience skin and soft tissue infections (SSTI) and make decisions to seek or delay medical treatment.

METHODS

We conducted semi-structured, in-depth interviews in 2015 with 19 PWID at a syringe exchange program in Philadelphia. We analyzed the data using standard qualitative techniques.

RESULTS

PWID described adequate knowledge about SSTI, although they could not always implement knowledge about SSTI prevention due to environmental constraints. Participants reported different experiences with incident SSTI. Some sought immediate medical care at initial presentation. Most, however, waited to seek care. Previous positive and negative healthcare experiences, both in general -including stigma and withdrawal- and specific to SSTI, influenced this decision. Among those who delayed medical care, some reported self-treatment, including increased drug use for pain control, and lancing and draining their own wounds.

CONCLUSION

Reducing the incidence of SSTI and promoting earlier treatment are important public health priorities. Both require ongoing attention and improvements to the environments in which PWID inject and receive care.

A Cost-Benefit Analysis of a Potential Supervised Injection Facility in San Francisco, California, USA

Supervised injection facilities (SIFs) have been shown to reduce infection, prevent overdose deaths, and increase treatment uptake. The United States is in the midst of an opioid epidemic, yet no sanctioned SIF currently operates in the United States. We estimate the economic costs and benefits of establishing a potential SIF in San Francisco using mathematical models that combine local public health data with previous research on the effects of existing SIFs. We consider potential savings from five outcomes: averted HIV and hepatitis C virus (HCV) infections, reduced skin and soft tissue infection (SSTI), averted overdose deaths, and increased medication-assisted treatment (MAT) uptake. We find that each dollar spent on a SIF would generate US$2.33 in savings, for total annual net savings of US$3.5 million for a single 13-booth SIF. Our analysis suggests that a SIF in San Francisco would not only be a cost-effective intervention but also a significant boost to the public health system.

Exploring the role of an unsanctioned, supervised peer driven injection facility in reducing HIV and hepatitis C infections in people that require assistance during injection

Background

Supervised consumption rooms or supervised injection facilities (SIFs) are venues that have reduced the risk of needle sharing and deaths caused by drug overdose among people who inject drugs (PWID). As a result of such a decline in the mortality rate, numerous studies have been able to illustrate its cost-effectiveness. However, studies have neglected to examine the same phenomena for unsanctioned SIFs that are run by peer drug users and provide assisted injections.

Methods

The current study will determine whether the former unsanctioned SIF, that provided assisted injection and was operated by the grass root organization called Vancouver Area Network of Drug Users (VANDU), cost less than the health care consequences of not having such a program in Vancouver, Canada. By analyzing data gathered in 2013, this paper relies on two mathematical models to estimate the number of new HIV and HCV infections prevented by the former unsanctioned facility in Vancouver’s Downtown Eastside.

Results

A conservative estimate indicates that the SIF location that provided assisted injections has a benefit-cost ratio of 33.1:1 due to its low operational cost. At the baseline sharing rate, the facility, on an average, reduced 81 HCV and 30 HIV cases among PWID each year. Such reductions in blood borne infections among PWID resulted in annual savings worth CAN$4.3 million dollars in health care expenditure. In addition to this, the current paper relies on a sensitivity analysis based on different needle sharing rate scenarios.

Conclusions

The sensitivity analysis and the baseline rates indicate that funding SIF facilities operated by peer drug users that facilitate assisted injection appear to be an efficient and effective use of financial resources in the public health domain since they lead to a significant decline in the rate of mortality within a vulnerable population.

Examining the potential role of a supervised injection facility in Saskatoon, Saskatchewan, to avert HIV among people who inject drugs

BACKGROUND

Research predicting the public health and fiscal impact of Supervised Injection Facilities (SIFs), across different cities in Canada, has reported positive results on the reduction of HIV cases among People Who Inject Drugs (PWID). Most of the existing studies have focused on the outcomes of Insite, located in the Vancouver Downtown Eastside (DTES). Previous attention has not been afforded to other affected areas of Canada. The current study seeks to address this deficiency by assessing the cost-effectiveness of opening a SIF in Saskatoon, Saskatchewan.

METHODS

We used two different mathematical models commonly used in the literature, including sensitivity analyses, to estimate the number of HIV infections averted due to the establishment of a SIF in the city of Saskatoon, Saskatchewan.

RESULTS

Based on cumulative cost-effectiveness results, SIF establishment is cost-effective. The benefit to cost ratio was conservatively estimated to be 1.35 for the first two potential facilities. The study relied on 34% and 14% needle sharing rates for sensitivity analyses. The result for both sensitivity analyses and the base line estimates indicated positive prospects for the establishment of a SIF in Saskatoon.

CONCLUSION

The opening of a SIF in Saskatoon, Saskatchewan is financially prudent in the reduction of tax payers' expenses and averting HIV infection rates among PWID.

Supervised injection services: what has been demonstrated? A systematic literature review

BACKGROUND

Supervised injection services (SISs) have been developed to promote safer drug injection practices, enhance health-related behaviors among people who inject drugs (PWID), and connect PWID with external health and social services. Nevertheless, SISs have also been accused of fostering drug use and drug trafficking.

AIMS

To systematically collect and synthesize the currently available evidence regarding SIS-induced benefits and harm.

METHODS

A systematic review was performed via the PubMed, Web of Science, and ScienceDirect databases using the keyword algorithm [("supervised" or "safer") and ("injection" or "injecting" or "shooting" or "consumption") and ("facility" or "facilities" or "room" or "gallery" or "centre" or "site")].

RESULTS

Seventy-five relevant articles were found. All studies converged to find that SISs were efficacious in attracting the most marginalized PWID, promoting safer injection conditions, enhancing access to primary health care, and reducing the overdose frequency. SISs were not found to increase drug injecting, drug trafficking or crime in the surrounding environments. SISs were found to be associated with reduced levels of public drug injections and dropped syringes. Of the articles, 85% originated from Vancouver or Sydney.

CONCLUSION

SISs have largely fulfilled their initial objectives without enhancing drug use or drug trafficking. Almost all of the studies found in this review were performed in Canada or Australia, whereas the majority of SISs are located in Europe. The implementation of new SISs in places with high rates of injection drug use and associated harms appears to be supported by evidence.

Stigmatizing harm reduction through language: a case study into the use of "addict" and opposition to supervised injection sites in Canada

Stigma continues to be the largest barrier for accessing treatment among people experiencing drug addiction. The dominant portrayals that exist about people who use drugs are often damaging and act to dehumanize the group as a whole. When left unchallenged, stereotypes can act as truthful depictions and facilitate the resistance against harm reduction services that are based on a human rights model. The use of labels is one way stigma is perpetuated by eliciting the label's stereotyped narratives onto an individual or group. Within harm reduction discourse, the word "addict" can have detrimental effects on how the public perceives people experiencing addiction and their deservingness of pragmatic services. This article aims to draw attention to the inattention we give "addict" in language and explain how its routine use in society acts to perpetuate addiction stigma. Using the example of supervised injection site opposition in Canada, the use of "addict" is used as a way to understand how stigma through language works to impede the expansion of harm reduction initiatives.

A cost-benefit/cost-effectiveness analysis of proposed supervised injection facilities in Ottawa, Canada

BACKGROUND

Supervised injection facilities (SIFs) are venues where people who inject drugs (PWID) have access to a clean and medically supervised environment in which they can safely inject their own illicit drugs. There is currently only one legal SIF in North America: Insite in Vancouver, British Columbia, Canada. The responses and feedback generated by the evaluations of Insite in Vancouver have been overwhelmingly positive. This study assesses whether the above mentioned facility in the Downtown Eastside of Vancouver needs to be expanded to other locations, more specifically that of Canada's capital city, Ottawa.

METHODS

The current study is aimed at contributing to the existing literature on health policy by conducting cost-benefit and cost-effective analyses for the opening of SIFs in Ottawa, Ontario. In particular, the costs of operating numerous SIFs in Ottawa was compared to the savings incurred; this was done after accounting for the prevention of new HIV and Hepatitis C (HCV) infections. To ensure accuracy, two distinct mathematical models and a sensitivity analysis were employed.

RESULTS

The sensitivity analyses conducted with the models reveals the potential for SIFs in Ottawa to be a fiscally responsible harm reduction strategy for the prevention of HCV cases--when considered independently. With a baseline sharing rate of 19%, the cumulative annual cost model supported the establishment of two SIFs and the marginal annual cost model supported the establishment of a single SIF. More often, the prevention of HIV or HCV alone were not sufficient to justify the establishment cost-effectiveness; rather, only when both HIV and HCV are considered does sufficient economic support became apparent.

CONCLUSIONS

Funded supervised injection facilities in Ottawa appear to be an efficient and effective use of financial resources in the public health domain.

A cost-benefit/cost-effectiveness analysis of proposed supervised injection facilities in Montreal, Canada

Background

This paper will determine whether expanding Insite (North America’s first and only supervised injection facility) to more locations in Canada such as Montreal, cost less than the health care consequences of not having such expanded programs for injection drug users.

Methods

By analyzing secondary data gathered in 2012, this paper relies on mathematical models to estimate the number of new HIV and Hepatitis C (HCV) infections prevented as a result of additional SIF locations in Montreal.

Results

With very conservative estimates, it is predicted that the addition of each supervised injection facility (up-to a maximum of three) in Montreal will on average prevent 11 cases of HIV and 65 cases of HCV each year. As a result, there is a net cost saving of CDN$0.686 million (HIV) and CDN$0.8 million (HCV) for each additional supervised injection site each year. This translates into a net average benefit-cost ratio of 1.21: 1 for both HIV and HCV.

Conclusions

Funding supervised injection facilities in Montreal appears to be an efficient and effective use of financial resources in the public health domain.

Prospects for scaling-up supervised injection facilities in Canada: the role of evidence in legal and political decision-making

BACKGROUND

North America's first supervised injection facility-Insite-opened in Vancouver in 2003 under a special federal legal exemption. Insite has faced significant political and legal opposition, which culminated in a recent Supreme Court of Canada ruling that ordered the federal Minister of Health to extend the facility's exemption and cited evidence that the facility is life-preserving and does not increase public disorder. Officials in several other cities have initiated or accelerated preparations for new facilities due to speculation that the ruling provides sufficient legal basis to expand supervised injection in Canada. However, a comprehensive assessment of the barriers and facilitators to supervised injection facility scale-up is lacking.

METHODS

This policy case study reviews a corpus of jurisprudence, legislation, scientific research and media texts to: describe the role of evidence in legal and political decision-making around Insite; analyze the implications of the Insite decision for new facilities; and discuss alternative avenues for supervised injection facility expansion.

RESULTS

The Insite decision does not simplify the path towards new supervised injection facilities, but nor does it does pose an insurmountable hurdle. Whether new facilities will be established depends largely upon how the Minister of Health interprets the ruling, the proponents' ability to demonstrate need and support from municipal and provincial governments and community members. Formally defining supervised injection as within nurses' scope of practice could further efforts to establish new facilities.

CONCLUSION

Additional court action may be required to establish a stable legal and policy basis for supervised injection facilities in Canada.

Potential role of safer injection facilities in reducing HIV and hepatitis C infections and overdose mortality in the United States

BACKGROUND

Safer injection facilities (SIFs) reduce risks associated with injecting drugs, particularly public injection and overdose mortality. They exist in many countries, but do not exist in the United States. We assessed several ethical, operational, and public health considerations for establishing SIFs in the United States.

METHOD

We used the six-factor Kass framework (goals, effectiveness, concerns, minimization of concerns, fair implementation, and balancing of benefits and concerns), summarized needs of persons who inject drugs in the United States, and reviewed global evidence for SIFs.

RESULTS

SIFs offer a hygienic environment to inject drugs, provide sterile injection equipment at time of injection, and allow for safe disposal of used equipment. Injection of pre-obtained drugs, purchased by persons who inject drugs, happens in a facility where trained personnel provide on-site counseling and referral to addiction treatment and health care and intervene in overdose emergency situations. SIFs provide positive health benefits (reducing transmission of HIV and viral hepatitis, bacterial infections, and overdose mortality) without evidence for negative health or social consequences. SIFs serve most-at-risk persons, including those who inject in public or inject frequently, and those who do not use other public health programs. It is critical to address legal, ethical, and local concerns, develop and implement relevant policies and procedures, and assess individual- and community-level needs and benefits of SIFs given local epidemiologic data.

CONCLUSIONS

SIFs have the potential to reduce viral and bacterial infections and overdose mortality among those who engage in high-risk injection behaviors by offering unique public health services that are complementary to other interventions.

Is Vancouver Canada's supervised injection facility cost-saving?

OBJECTIVE

To determine whether Vancouver's Insite supervised injection facility and syringe exchange programs are cost-saving--that is, are the savings due to averted HIV-related medical care costs sufficient to offset Insite's operating costs?

METHODS

The analyses examined the impact of Insite's programs for a single year. Mathematical models were used to calculate the number of additional HIV infections that would be expected if Insite were closed. The life-time HIV-related medical costs associated with these additional infections were compared to the annual operating costs of the Insite facility.

RESULTS

If Insite were closed, the annual number of incident HIV infections among Vancouver IDU would be expected to increase from 179.3 to 262.8. These 83.5 preventable infections are associated with $17.6 million (Canadian) in life-time HIV-related medical care costs, greatly exceeding Insite's operating costs, which are approximately $3 million per year.

CONCLUSIONS

Insite's safe injection facility and syringe exchange program substantially reduce the incidence of HIV infection within Vancouver's IDU community. The associated savings in averted HIV-related medical care costs are more than sufficient to offset Insite's operating costs.

Negotiating the Relationship Between Addiction, Ethics, and Brain Science

Advances in neuroscience are changing how mental health issues such as addiction are understood and addressed as a brain disease. Although a brain disease model legitimizes addiction as a medical condition, it promotes neuro-essentialist thinking, categorical ideas of responsibility and free choice, and undermines the complexity involved in its emergence. We propose a 'biopsychosocial systems' model where psycho-social factors complement and interact with neurogenetics. A systems approach addresses the complexity of addiction and approaches free choice and moral responsibility within the biological, lived experience and socio-historical context of the individual. We examine heroin-assisted treatment as an applied case example within our framework. We conclude with a discussion of the model and its implications for drug policy, research, addiction health care systems and delivery, and treatment of substance use problems.