Refined Research Question: Do supervised injection sites/Supervised Consumption Facilities (SCF) impact the number of overdose deaths?

Databases searched: PsychInfo, MEDLINE, PsycARTICLES, Social Work Abstracts

Search terms used:

Supervised injection facilities + overdose

Supervised injection sites + harm reduction

References:
Kerr, T., Small, W., Moore, D., & Wood, E. (2007). A micro-environmental intervention to reduce the harms associated with drug-related overdose: Evidence from the evaluation of Vancouver’s safer injection facility. International Journal of Drug Policy, 18(1), 37–45. https://doi-org.avoserv2.library.fordham.edu/10.1016/j.drugpo.2006.12.008

Background
Conventional drug overdose prevention strategies have been criticised for failing to address the macro- and micro-environmental factors that shape drug injecting practices and compromise individual ability to reduce the risks associated with drug-related overdose. This in turn has led to calls for interventions that address overdose risks by modifying the drug-using environment, including the social dynamics within them. Safer injection facilities (SIFs) constitute one such intervention, although little is known about the impact of such facilities on factors that mediate risk for overdose.

Methods
Semi-structured qualitative interviews were conducted with fifty individuals recruited from a cohort of SIF users in Vancouver, the Scientific Evaluation Of Supervised Injecting (SEOSI). Audio recorded interviews elicited injection drug users’ (IDU) accounts of overdoses as well as perspectives regarding the impact of SIF use on overdose risk and experiences of overdose. Interviews were transcribed verbatim and a thematic analysis was conducted. Results: Fifty IDU, including 21 women, participated in this study. The perspectives of participants suggest that the Vancouver SIF plays an important role in mediating various risks associated with overdose. In particular, the SIF addresses many of the unique contextual risks associated with injection in public spaces, including the need to rush injections due to fear of arrest. Further, SIF use appears to enable overdose prevention by simultaneously offsetting potential social risks associated with injecting alone and injecting in the presence of strangers. The immediate emergency response offered by nurses at the SIF was also valued highly, especially when injecting adulterated drugs and drugs of unknown purity and composition.

Conclusion
The perspectives of IDU participating in this study suggest that SIFs can address many of the micro-environmental factors that drive overdose risk and limit individual ability to employ overdose prevention practices. Although challenges related to coverage remain in many settings, SIFs may play a unique role in managing overdoses, particularly those occurring within street-based drug scenes. 

Milloy, M.-J. S., Kerr, T., Tyndall, M., Montaner, J., & Wood, E. (2008). Estimated Drug Overdose Deaths Averted by North America’s First Medically-Supervised Safer Injection Facility. PLoS ONE, 3(10), 1–6. https://doi-org.avoserv2.library.fordham.edu/10.1371/journal.pone.0003351

Background
Illicit drug overdose remains a leading cause of premature mortality in urban settings worldwide. We sought to estimate the number of deaths potentially averted by the implementation of a medically supervised safer injection facility (SIF) in Vancouver, Canada.

Methods
The number of potentially averted deaths was calculated using an estimate of the local ratio of non-fatal to fatal overdoses. Inputs were derived from counts of overdose deaths by the British Columbia Vital Statistics Agency and non-fatal overdose rates from published estimates. Potentially-fatal overdoses were defined as events within the SIF that required the provision of naloxone, a 911 call or an ambulance. Point estimates and 95% Confidence Intervals (95% CI) were calculated using a Monte Carlo simulation. Between March 1, 2004 and July 1, 2008 there were 1004 overdose events in the SIF of which 453 events matched our definition of potentially fatal. In 2004, 2005 and 2006 there were 32, 37 and 38 drug-induced deaths in the SIF’s neighbourhood. Owing to the wide range of non-fatal overdose rates reported in the literature (between 5% and 30% per year) we performed sensitivity analyses using non-fatal overdose rates of 50, 200 and 300 per 1,000 person years. Using these model inputs, the number of averted deaths were, respectively: 50.9 (95% CI: 23.6–78.1); 12.6 (95% CI: 9.6–15.7); 8.4 (95% CI: 6.5–10.4) during the study period, equal to 1.9 to 11.7 averted deaths per annum.

Conclusions
Based on a conservative estimate of the local ratio of non-fatal to fatal overdoses, the potentially fatal overdoses in the SIF during the study period could have resulted in between 8 and 51 deaths had they occurred outside the facility, or from 6% to 37% of the total overdose mortality burden in the neighborhood during the study period. These data should inform the ongoing debates over the future of the pilot project.

Refined Research Question #2: Do supervised injection facilities /reduce the spread of infectious disease? 

Databases searched: PsychInfo, MEDLINE, PsycARTICLES, Social Work Abstracts

Search terms used:

Supervised injection facilities + overdose

Supervised injection sites + harm reduction

References:
Andresen, M. A., & Boyd, N. (2010). A cost-benefit and cost-effectiveness analysis of Vancouver’s supervised injection facility. International Journal of Drug Policy, 21(1), 70–76. https://doi-org.avoserv2.library.fordham.edu/10.1016/j.drugpo.2009.03.004

Background

  A supervised injection facility (SIF) has been established in North America: Insite, in Vancouver, British Columbia. The purpose of this paper is to conduct a cost-effectiveness and cost-benefit analysis of this SIF using secondary data gathered and analysed in 2008. In using these data we seek to determine whether the facility’s prevention of infections and deaths among injecting drug users (IDUs) is of greater or lesser economic cost than the cost involved in providing this service – Insite – to this community.

Methods

  Mathematical modelling is used to estimate the number of new  HIV infections and deaths prevented each year. We use the number of these new HIV infections and deaths prevented, in conjunction with estimated lifetime public health care costs of a new HIV infection, and the value of a life, in order to calculate an identifiable portion of the societal benefits of Insite. The annual costs of operating the SIF are used to measure the social costs of Insite. In using this information, we calculate cost-effectiveness and benefit-cost ratios for the SIF. 

Results

Through the use of conservative estimates, Vancouver’s SIF, Insite, on average, prevents 35 new cases of HIV and almost 3 deaths each year. This provides a societal benefit in excess of $6 million per year after the programme costs are taken into account, translating into an average benefit-cost ratio of 5.12:1. 

Conclusion

Vancouver’s SIF appears to be an effective and efficient use of public health care resources, based on a modelling study of only two specific and measurable benefits—HIV infection and overdose death.

Irwin, A., Jozaghi, E., Weir, B. W., Allen, S. T., Lindsay, A., & Sherman, S. G. (2017). Mitigating the heroin crisis in Baltimore, MD, USA: a cost-benefit analysis of a hypothetical supervised injection facility. Harm Reduction Journal, 14(1), 29. https://doi-org.avoserv2.library.fordham.edu/10.1186/s12954-017-0153-2

Background:
In Baltimore, MD, as in many cities throughout the USA, overdose rates are on the rise due to both the increase of prescription opioid abuse and that of fentanyl and other synthetic opioids in the drug market. Supervised injection facilities (SIFs) are a widely implemented public health intervention throughout the world, with 97 existing in 11 countries worldwide. Research has documented the public health, social, and economic benefits of SIFs, yet none exist in the USA. The purpose of this study is to model the health and financial costs and benefits of a hypothetical SIF in Baltimore.


Methods

We estimate the benefits by utilizing local health data and data on the impact of existing SIFs in models for six outcomes: prevented human immunodeficiency virus transmission, Hepatitis C virus transmission, skin and soft-tissue infection, overdose mortality, and overdose-related medical care and increased medication-assisted treatment for opioid dependence.


Results

We predict that for an annual cost of $1.8 million, a single SIF would generate $7.8 million in savings, preventing 3.7 HIV infections, 21 Hepatitis C infections, 374 days in the hospital for skin and soft-tissue infection, 5.9 overdose deaths, 108 overdose-related ambulance calls, 78 emergency room visits, and 27 hospitalizations, while bringing 121 additional people into treatment.


Conclusions 

We conclude that a SIF would be both extremely cost-effective and a significant public health and economic benefit to Baltimore City.

Refined Research Question #3: Do supervised injection facilities impact crime rates in surrounding areas?

Databases searched: PsychInfo, MEDLINE, PsycARTICLES, Social Work Abstracts

Search terms used:
Supervised injection facilities + crime

Supervised + injection + crime

Safe + injection + arrests

References:
Potier, C., Laprévote, V., Dubois-Arber, F., Cottencin, O., & Rolland, B. (2014). Supervised injection services: What has been demonstrated? A systematic literature review. Drug and Alcohol Dependence, 145, 48–68. https://doi-org.avoserv2.library.fordham.edu/10.1016/j.drugalcdep.2014.10.012

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.

Wood, E., Tyndall, M. W., Lai, C., Montaner, J. S. G., & Kerr, T. (2006). Impact of a medically supervised safer injecting facility on drug dealing and other drug-related crime. Substance Abuse Treatment, Prevention, and Policy, 1. https://doi-org.avoserv2.library.fordham.edu/10.1186/1747-597X-1-13

Background

North America’s first medically supervised safer injecting facility (SIF) recently opened in Vancouver, Canada. One of the concerns prior to the SIF’s opening was that the facility might lead to a migration of drug activity and an increase in drug-related crime. Therefore, we examined crime rates in the neighborhood where the SIF is located in the year before versus the year after the SIF opened. No increases were seen with respect to drug trafficking (124 vs. 116) or assaults/robbery (174 vs. 180), although a decline in vehicle break-ins/vehicle theft was observed (302 vs. 227). The SIF was not associated with increased drug trafficking or crimes commonly linked to drug use. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Methods 

For the present analyses, we accessed Vancouver Police Department statistics regarding charges for drug trafficking (which is defined to include selling, administering, giving, transferring, transporting, sending, or delivering illicit drugs), assaults and robberies, and vehicle break-ins and vehicle theft in the neighborhoods broadly defined as the Downtown Eastside area (Downtown Eastside proper, Chinatown, Gastown, Victory Square, and Strathcona). These indicators were selected for several reasons. First, although a reduction in public drug use and publicly discarded syringes has been attributed to the opening of the SIF [12], the potential influx of drug dealers to sell drugs to the SIF’s clientele has not been thoroughly investigated. Second, rates of assaults and robberies and vehicle break-ins and vehicle thefts were evaluated to assess the potential of an increase in drug-related crime, since these activities have been attributed to a concentrated illegal drug scene in the neighborhood [12]. The categories of assaults and robberies and vehicle break-ins and theft were combined in the source data file and it was not possible to separate these indicators. We compared the monthly average number of charges for these activities in the Downtown Eastside between October 1, 2003 and September 30, 2004 (pre-SIF year) versus the monthly average during the period October 1, 2004and September 30, 2005 (post-SIF year). Since there were a limited number of data points to compare trends between years, data were plotted on line graphs, and aver-age annual levels for each of the three indicators (drug trafficking, assaults and robbery, and vehicle break-ins/theft) were compared using paired t-tests.

Conclusion

In summary, the present study suggests that the opening of North America’s first medically supervised safer injecting facility was not associated with a marked increase in drug trafficking or acquisitive crimes in the year after the facility opened. These findings suggest that the benefits of the SIF on public drug use and HIV risk behavior have not been offset by an increase in criminal activity in the neighborhood [12,15]. These findings should make a valuable contribution to the ongoing debates regarding the value of SIF, and for the cities in Canada and elsewhere that are considering initiating SIF trials [8-10,16-19].

Miller, P., McKenzie, S., Lintzeris, N., Martin, A., & Strang, J. (2010). The community impact of RIOTT, a medically supervised injectable maintenance clinic in south London. Mental Health and Substance Use: Dual Diagnosis, 3(3), 248–259. https://doi-org.avoserv2.library.fordham.edu/10.1080/17523281.2010.503937

Background

One of the major issues facing treatment services for alcohol and other drug users (current or ex-) around the world is community backlash, which has led to the closure of some much-needed drug treatment services. Aims: This study investigates the impact on the local community of a Medically Supervised Injectable Maintenance Clinic (MSIMC) implemented as part of the Randomised Injectable Opioid Treatment Trial (RIOTT), a trial into the effectiveness and efficacy of the provision of injectable opioids versus conventional oral methadone. The clinic model is based around a small number of the most entrenched and refractory patients (approx. 30) being treated by the service at any one time. 

Methods

The clinic and the trial were conceived primarily over 2002–2005, and the clinic began actual clinical operation in October 2005. The research was conducted between July 2005 and October 2007. Methods involved: pre-trial community key informant interviews; two-year follow-up key informant interviews; and analysis of Metropolitan Police crime statistics. 

Results
The most common concern raised by key informants in the local community was that the RIOTT would have a ‘honey-pot effect’, resulting in increased numbers of drug users coming to the area. At follow-up, key informants reported no such effect on the local community. Metropolitan Police figures show no significant changes in monthly or average annual crime levels in the local area. 
Conclusions
Community fears of negative social effects of the RIOTT clinic appear to have been unfounded, based on subjective and objective criteria, where such a project operates with the highly structured clinical and monitoring framework and with small patient numbers. 

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