Synthetic Opioid key responses
- Mapping evidence-based key responses to synthetic opioids and their implementation strategies
- Field-tested Toolkit with seven implementation guides
Scientific and programmatic implications of safer injection facilities for persons who inject drugs illicitly
Background: Persons who inject drugs (PWID), particularly those who inject in streets, alleys, and parks, use needles and syringes used by others, or use unclean drug-preparation equipment (cotton, cookers, or water) are at risk for HIV, HBV, and HCV infections. To reduce risk for infectious diseases and improve health outcomes, cities in Australia, Canada, Germany, Luxembourg, Netherlands, Norway, Spain, and Switzerland established safer injection facilities (SIFs) following establishment of legal support. SIFs provide clean injection environments, sterile injection equipment, and clean drug-preparation equipment at the time of injection.
Method: We reviewed and summarized the published scientific evidence (PubMed, EMBASE, PsychInfo) and appraised the programmatic implications of SIFs.
Results: At SIFs, persons can more safely inject drugs that they have purchased outside of the facility. SIF management and staff do not assist in
injection. SIFs safely dispose of used equipment and provide on-site counseling, referral to addiction treatment and health services, and overdose emergency assistance. SIFs limit transmission of HIV, viral hepatitis, and bacterial infections, reduce overdose mortality, prevent accidental needlestick injuries to community members, reduce public nuisance and litter, and improve health outcomes and public safety. As cost-saving and costeffective interventions, SIFs offer unique and complementary benefits, as compared to other effective interventions (prevention and treatment of drug abuse, syringe exchange programs, non-prescription pharmacy sale of sterile injection equipment, safe disposal programs for used equipment, community overdose prevention programs, prevention and treatment of infectious diseases) which often are not available to all persons who use drugs. Through collaboration with community members, law enforcement officers, persons who inject drugs, service providers, and public health scientists and practitioners, SIFs can meet needs of users and communities.
Conclusions: SIF services, within a multipronged intervention approach, address complex social and public health consequences of injection drug use and ameliorate the negative effects of injection drug use on users and communities.
Supervised consumption sites: a nuanced assessment of the causal evidence
BACKGROUND AND AIMS: Supervised consumption sites (SCS) operate in more than 10 countries. SCS have mostly emerged as a bottom‐up response to crises, first to HIV/AIDS and now overdose deaths, in ways that make rigorous evaluation difficult. Opinions vary about how much favorable evidence must accumulate before implementation. Our aim was to assess the nature and quality of evidence on the consequences of implementing SCS.
METHODS: We reviewed the higher‐quality SCS literature, focusing on articles evaluating natural experiments and mathematical modeling studies that estimate costs and benefits. We discuss the evidence through the lens of three types of decision‐makers and from three intellectual perspectives.
RESULTS: Millions of drug use episodes have been supervised at SCS with no reported overdose deaths; however, uncertainties remain concerning the magnitude of the population‐level effects. The published literature on SCS is large and almost unanimous in its support, but limited in nature and the number of sites evaluated. It can also overlook four key distinctions: (1) between outcomes that occur within the facility and possible spillover effects on behavior outside the SCS; (2) between effects of supervising consumption and the effects of other services offered, such as syringe or naloxone distribution; (3) between association and causation; and (4) between effectiveness and the cost‐effectiveness of SCS compared to other interventions.
CONCLUSIONS: The causal evidence for favorable outcomes of supervised consumption sites is minimal, but there appears to be little basis for concern about adverse effects. This raises the question of how context and priors can affect how high the bar is set when deciding whether to endorse supervised consumption sites. The literature also understates distinctions and nuances that need to be appreciated to gain a rich understanding of how a range of stakeholders should interpret and apply that evidence to a variety of decisions.
Supervised Injection Facilities and International Law
The ongoing public health crisis associated with injection drug use highlights the failure of prohibitionist policies. In contrast, harm reduction approaches aim to protect and promote the health of drug users. Supervised injection facilities (SIFs) are one important component of this approach. This article considers the international legal implications of establishing SIFs. It argues that implementing trials of SIFs is an appropriate measure that states should take pursuant to their international legal obligations to realize progressively the right of their nationals to the highest attainable standard of health. It argues that international drug control treaties do not prevent such measures, as is commonly claimed. The authors conclude that successful trials in Europe and Australia should be emulated elsewhere, in accordance with states' international obligations.
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.
Supervised Injection Sites - Injection Drug Use: A Bibliography
The Canadian Centre on Substance Use and Addiction (CCSA) produces this document to provide a central reference resource for peer-reviewed and grey literature publications presenting or analyzing research on the operation and impact of supervised consumption sites that provide services for injection drug use. CCSA regularly monitors peer-reviewed and grey literature for relevant new publications on this topic and adds them to this document. References are provided in the language of the original article.
This bibliography was first published in May 2009 and has been updated on an annual basis since then. It is intended as a resource for those interested in gaining an overview of recent literature on the topic. It was generated using variations on the term “injection facilities,” as well as searches related to targeted Canadian and Australian locations (specifically, Vancouver’s InSite and Sydney’s Medically Supervised Injecting Centre). Additional sources were identified through referrals from researchers in the field and reviews of reference lists.
For the current edition of this bibliography, 40 references have been added, identified through searches with date limits from June 1, 2016, to August 31, 2017. Additional web-based scans and searches were conducted in early September 2017. Literature searches were conducted in PubMed, PsycNET, EBSCO (MEDLINE Complete, and Psychology and Behavioral Sciences Collection) and Google Scholar. Grey literature was identified through Google searches and targeted website scanning. Four key phrases were used to conduct the searches: “supervised injection,” “injection facilities,” “safe injection” and “drug consumption rooms.” The Appendix provides additional details about the search strategy.
Survey of drug consumption rooms: service delivery and perceived public health and amenity impact.
Drug consumption rooms (DCRs) have operated in Europe for more than 20 years. At the time of this study three Australian jurisdictions were considering trials of DCRs and little information about these services was available in the English literature. We surveyed 39 DCRs in the Netherlands, Germany, Switzerland and Spain in 1999 – 2000 regarding service delivery and perceived public health and amenity impact and 15 (40%) responded. The DCRs surveyed were professionally staffed, low threshold services which provided a range of health, psych-social, drug treatment and welfare services and referrals. No overdose deaths were reported and the estimated rate of non-fatal overdose ranged from 1 to 36 per 10,000 visits. These DCRs appeared to be achieving their service delivery objectives with few negative consequences.
