Synthetic Opioid key responses
- Mapping evidence-based key responses to synthetic opioids and their implementation strategies
- Field-tested Toolkit with seven implementation guides
Evidence and Issues Concerning Drug Consumption Rooms
Problematic and chaotic drug use (particularly by persons who inject drugs) carried on in public places such as streets and parks, creates an environment of high risk to personal and public health (including drug-related deaths and contaminated drug litter). Such use frequently gives rise to wider social problems, but it is also indicative of underlying issues and causes such as homelessness, chronic medical conditions, absence (or loss) of adequate harm-reduction services, and financial hardship. As part of a system of interventions to address these issues, a number of cities in Europe and elsewhere have established supervised drug consumption facilities. None yet exists in the UK. This paper details the evidence and issues concerning Drug Consumption Rooms discussed at a one-day conference hosted by the Criminal Justice Centre, School of Law, Queen Mary University of London (in collaboration with Volteface) on March 27, 2018.
Increased risk of HIV and other drug-related harms associated with injecting in public places: national bio-behavioural survey of people who inject drugs
BACKGROUND: Whilst injecting drugs in public places is considered a proxy for high risk behaviour among people who inject drugs (PWID), studies quantifying its relationship with multiple drug-related harms are lacking and none have examined this in the context of an ongoing HIV outbreak (located in Glasgow, Scotland). We aimed to: 1) estimate the prevalence of public injecting in Scotland and associated risk factors; and 2) estimate the association between public injecting and HIV, current HCV, overdose, and skin and soft tissue infections (SSTI).
METHODS: Cross-sectional, bio-behavioural survey (including dried blood spot testing to determine HIV and HCV infection) of 1469 current PWID (injected in last 6 months) recruited by independent interviewers from 139 harm reduction services across Scotland during 2017–18. Primary outcomes were: injecting in a public place (yes/no); HIV infection; current HCV infection; self-reported overdose in the last year (yes/no) and SSTI the last year (yes/no). Multi-variable logistic regression was used to determine factors associated with public injecting and to estimate the association between public injecting and drug-related harms (HIV, current HCV, overdose and SSTI).
RESULTS: Prevalence of public injecting was 16% overall in Scotland and 47% in Glasgow city centre. Factors associated with increased odds of public injecting were: recruitment in Glasgow city centre (aOR=5.45, 95% CI 3.48–8.54, p<0.001), homelessness (aOR=3.68, 95% CI 2.61–5.19, p<0.001), high alcohol consumption (aOR=2.42, 95% CI 1.69–3.44, p<0.001), high injection frequency (≥4 per day) (aOR=3.16, 95% CI 1.93–5.18, p<0.001) and cocaine injecting (aOR=1.46, 95% CI 1.00 to 2.13, p = 0.046). Odds were lower for those receiving opiate substitution therapy (OST) (aOR=0.37, 95% CI 0.24 to 0.56, p<0.001) and older age (per year increase) (aOR=0.97, 95% CI 0.95 to 0.99, p = 0.013). Public injecting was associated with an increased risk of HIV infection (aOR=2.11, 95% CI 1.13–3.92, p = 0.019), current HCV infection (aOR=1.49, 95% CI 1.01–2.19, p = 0.043), overdose (aOR=1.59, 95% CI 1.27–2.01, p<0.001) and SSTI (aOR=1.42, 95% CI 1.17–1.73, p<0.001).
CONCLUSIONS: These findings highlight the need to address the additional harms observed among people who inject in public places and provide evidence to inform proposals in the UK and elsewhere to introduce facilities that offer safer drug consumption environments.
Room for improvement: How drug consumption rooms save lives
Supervised drug consumption rooms (sometimes referred to as ‘safe injecting rooms’ or ‘overdose prevention centres’) allow people who use illicit drugs to consume substances whilst under the supervision of trained staff.
Drug consumption facilities aim to reduce risks of disease transmission, overdose and public nuisance whilst also providing a location for people who have substance dependence to access treatment, employment, and housing support services.
The UK currently does not have any supervised drug consumption rooms, although proposals for facilities have been made by local agencies in West Midlands, North Wales, Southampton, Glasgow, and Bristol. In 2016, the UK Advisory Council on the Misuse of Drugs recommended that consideration be given to the potential of drug consumption rooms within areas of high injecting drug use in order to reduce drug related deaths. The government response was that no plans existed to introduce drug consumption rooms in the UK.
A 2018 survey of injecting drug users in the UK found that a large majority (89%) expressed willingness to use a drug consumption room and accepted the need for rules within such facilities such as no drug sharing (84.3%), no assistance with injecting (81.8%), compulsory supervision (76.7%) and compulsory hand washing (92.1%).
The following paper will outline the need for drug consumption rooms in the UK, evidence supporting their use and considerations for implementation at a local level
Similar problems, divergent responses: drug consumption room policies in the UK and Germany
Drug consumption rooms (DCRs) enable the consumption of pre-obtained drugs under supervised conditions. While 24 DCRs exist in Germany, there are none in the UK despite similar levels of drug-related harms. The first official, German DCRs were introduced in Hamburg and Frankfurt in the mid-1990s. A key influence was the appearance of “open drug scenes” in such cities over this time, whereby large numbers of users congregated in parks or shopping centers. This led to powerful coalitions of politicians, police, and treatment agencies and DCRs were seen as a professional response to these problems. In the UK, there have been two high-profile recommendations for the piloting of DCRs, which have been rejected by the government for a number of reasons, including lack of evidence, legal problems, and negative media responses. In explaining the different situations in the two countries, key factors are the potential for city-level policies, the stigma attached to drug users in media reporting, and the historical development of open drug scenes. Chance has also played a part, particularly in the UK. Drug policy is rarely a government priority, and drug policy decisions are therefore affected by wider political goals and pressures in unpredictable ways.
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.
Acceptability of a safer injection facility among injection drug users in San Francisco
OBJECTIVE: Research has shown that safer injection facilities (SIFs) are successful at reducing public nuisance and enhancing public health. Since 2007 support for implementation of a SIF in San Francisco has been building. The objective of this study is to assess the acceptability of a SIF among injection drug users (IDUs) in San Francisco.
METHODS: IDUs were recruited in San Francisco using targeted sampling and interviewed using a quantitative survey (N=602). We assessed the prevalence of willingness to use a SIF as well as correlates of willingness among this group.
RESULTATS: Eighty-five percent of IDUs reported that they would use a SIF, three quarters of whom would use it at least three days per week. In multivariate analysis, having injected in public and having injected speedballs were associated with intent to use a SIF. The majority of IDUs reported acceptability of many potential rules and regulations of a pilot SIF, except video surveillance, and being required to show identification.
CONCLUSIONS: Building on the success of SIFs in various international settings, IDUs in San Francisco appear interested in using a SIF should one be implemented.
Addressing the Nation’s Opioid Epidemic: Lessons from an Unsanctioned Supervised Injection Site in the U.S.
Over half a million people have died of overdose in the U.S. since 2000. As of 2014, an estimated 774,434 people inject drugs in the U.S., the majority of whom inject opioids including prescription opioids and heroin. The prevalence of HIV and hepatitis C virus among people who inject drugs in the U.S. is 2% and 43%, respectively. With the U.S. in the midst of an opioid epidemic causing morbidity and mortality at unprecedented levels, policymakers and public health practitioners are in need of innovative solutions.
Another Senseless Death — The Case for Supervised Injection Facilities
Many heroin users abstain from use while taking buprenorphine, but the daily decision to take it is tough. Supervised injection facilities can save lives, improve health, increase neighborhood safety, reduce cost, and ultimately increase engagement in treatment.
Arguments supporting and opposing legalization of safe consumption sites in the U.S.
BACKGROUND: Safe consumption sites are spaces where people can legally use pre-obtained drugs under medical supervision and are currently in operation in Canada, Australia and Western Europe. These sites are effective in reducing opioid overdose mortality and other harms associated with opioid use, such as HIV infection, and increasing drug treatment entry. Various U.S. communities are considering establishing safe consumption sites, however, only 29% of U.S. adults support their legalization. This purpose of this study is to assess what types of arguments resonate with the public in support of and opposition to legalizing safe consumption sites to combat the opioid epidemic.
METHODS: A public opinion survey of U.S. adults in July-August 2017 (N = 1004) used a probability-based sample of respondents from a large, nationally representative online panel. The survey examined the public’s perception of the strength of common arguments offered in support of and opposition to legalizing safe consumption sites. Arguments were identified through a detailed scan of news media coverage, public reports, and advocacy materials.
RESULTS: The national sample of U.S. adults rated all arguments opposing legalization of safe consumption sites as stronger than any of the arguments supporting legalization. The most highly rated opposing arguments were that public funds were better spent on addiction treatment, and that sites were allowing illegal activity and encouraging people to use drugs. The highest rated arguments supporting legalization were that safe consumption sites were a better alternative than arresting people for using drugs, they would reduce HIV and hepatitis C by encouraging safe injection practices, and that they would lower emergency department admission and hospitalization costs.
CONCLUSION: Legalization of this evidence-based harm reduction approach in U.S. communities will be difficult to advance without public education to confront persistent myths that safe consumption sites encourage drug use and do not facilitate treatment access.
