SAFE INJECTION FACILITIES IN CANADA: IS IT TIME?

About 100 000 Canadians are injection drug users (IDUs), and almost
onethird live in Toronto, Montreal or Vancouver. [1] Illicit drug injection
is associated with significant health and social consequences for drug
users, their families and communities. The consequences include
injectionrelated infections, overdose, bloodborne disease transmission,
exposure to discarded needles, violence, property crime and sex trade.

Two articles in this issue of CMAJ highlight the continuing unsafe
injection practices [2] and the health related consequences [3] that are
occurring in a cohort of IDUs in Vancouver despite the availability of a
large needleexchange program. [4,5] In the first report (page 405), 214
(27.6%) of 776 participants from the Vancouver Injection Drug User Study
(VIDUS) stated that they had recently shared needles. [2] Factors
associated with this highrisk behaviour included difficulty getting sterile
needles, requiring help injecting, needle reuse, and frequent cocaine and
heroin injection.

In the second report (page 415), the downstream health effects of such
behaviour are reflected in high rates of emergency department use and
hospital admission: during a 39 month period 440 VIDUS participants made
2763 emergency department visits, and 210 participants were admitted to
hospital 495 times. [3] The most common reasons for emergency department
visits were softtissue infections and other problems related to illicit
drug use, such as overdose, intoxication and withdrawal. Most of the
hospital admissions were the result of bacterial infections related to drug
injection; these cases might have been prevented if safe injection
techniques had been used.

In Canada, British Columbia has the highest number of fatal overdoses,
about 4.7 per 100 000 population annually, and in recent years illicit drug
use has been the leading cause of death among adults 30 to 49 years of age.
[6] In the VIDUS cohort, overdose is the leading cause of death, regardless
of HIV status. [7] In terms of bloodborne infections, IDUs have recently
accounted for 26% of all new cases of HIV infection in Canada, [1] and HIV
positive IDUs typically incur substantial medical costs. [3,8] In addition,
35% of IDUs among Montreal street youth and 88% of VIDUS participants have
hepatitis C. [4,9] IDUs who congregate in public areas to inject drugs are
at increased risk of injection related complications and blood borne
infections because of the lack of clean water or sterile injection
equipment, and the presence of discarded needles. [10] In addition, the
concentration of IDUs in public areas affects nearby small businesses and
discourages people from using public amenities. [10,11,12,13]

In light of these circumstances, safe injection facilities must be
considered. They have been part of a pragmatic harm reduction strategy in
the Netherlands, [13] Switzerland [14] and Germany, [15,16] and a facility
has recently been established in Australia on a trial basis. [16,17] A
number of Canadian reports have called for the need to establish and
evaluate such facilities. [1,18,19] Recently, Health Canada, in partnership
with the Federal, Provincial and Territorial Task Group on Population
Health, has created a task force that is examining the feasibility of a
trial of safe injection facilities in Canada. [1] Experience in Europe and
Australia indicates that there has been considerable acceptance of the
facilities by health care professionals and IDUs. [12,15] Since offering a
range of programs to address problems associated with illicit drug use,
Switzerland and Germany have observed declines in HIV infection rates,
drugrelated overdoses and crime in the last decade. [20,21] During the same
period, drug related harm has increased in Canada. [21]

Programs for the management of people who inject illicit drugs can be
categorized as high, medium and low threshold. "Threshold" refers to the
eligibility criteria for program entrance and the state of readiness to
participate and meet program demands.

For example, abstinence based programs are high threshold, standard
methadone maintenance programs are considered medium threshold, and needle
exchange and street based outreach programs are low threshold programs.

The inclusion of a range of low threshold harm reduction services such as
safe injection facilities has been crucial to the success of comprehensive
drug strategies in Europe. Unlike illegal "shooting galleries" run by drug
dealers, safe injection facilities are controlled health care settings
where people can inject preobtained drugs under staff supervision and
receive sterile injecting equipment, primary health care, counselling, and
referral to health and social services.

The goals associated with the establishment of safe injection facilities
are to reduce the incidence of blood borne disease transmission, overdoses
and public nuisance associated with injection drug use; to improve the
general health of IDUs; and to increase their use of appropriate primary
health care and social services.

Typically, safe injection facilities achieve these goals by supervising
injections in a controlled setting to ensure safety and quick response to
overdoses; providing sterile injecting equipment and condoms, and
collecting used needles and syringes; providing information on safer sex
and injecting practices; providing counselling, primary health care and, in
some cases, food; and maintaining and improving contact with marginalized
IDUs and facilitating their reintegration into society through referral to
various drug treatment services.

Safe injection facilities serve a unique and important function,
particularly in terms of providing immediate response to overdoses, [17,22]
increasing use of health and social services, and reducing the problems
described earlier that are associated with injecting drugs in public.
[10,11,12,13] Although outreach services and needle exchange programs are
able to provide sterile injecting equipment, and in some cases referrals,
there are no indications that these services reduce the amount of injection
drug use occurring in public spaces. [10] As well, safe injection
facilities offer more direct and sustained contact with IDUs. Within these
sites, staff are better able to encourage people to seek help, to discuss
health concerns with them and to provide them with immediate medical care,
counselling or referrals. [10] IDUs are allowed to return to the facilities
throughout the day, which is beneficial to those who inject cocaine
frequently. Before a range of low threshold harm reduction services were
introduced in Switzerland, data indicated that medium and high threshold
services reached only 20% of IDUs. [21] Safe injection facilities were
established as a way of increasing contact with the most marginalized IDUs.
[13,23]

Given the ongoing harm associated with injection drug use and the lack of
controlled outcome studies of safe injection facilities, there is a great
need for rigorous evaluation to assess whether they will serve a useful
role in Canada. The ethical imperative to provide more comprehensive care
for IDUs is also evident. [24] Increased integration of low and
mediumthreshold harm reduction strategies with primary care and expanded
drug treatment options are the next steps Canada must take to curb the
morbidity and mortality associated with illicit drug use.

Competing interests: None declared.

Contributors: Anita Palepu drafted the commentary and revised it with the
input of her coauthor.

Thomas Kerr critically reviewed and contributed substantial revisions to
the commentary.

Mr. Kerr is with the University of Victoria, Victoria, BC, and Dr. Palepu
is with the Centre for Health Evaluation and Outcome Sciences, St. Paul's
Hospital, Vancouver, BC, and is an Associate Editor of CMAJ.

Correspondence to: Dr. Anita Palepu, Rm. 620B, St. Paul's Hospital, 1081
Burrard St., Vancouver BC V6Z 1Y6; fax 604 806 8005; anita@hivnet.ubc.ca

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