Review

SUMMARY OF FINDINGS FROM THE EVALUATION OF A PILOT MEDICALLY
SUPERVISED SAFER INJECTING FACILITY

Correspondence to: Dr. Evan Wood, Division of Epidemiology and
Population Health, BC Centre for Excellence in HIV/AIDS, 608-1081
Burrard St., Vancouver BC V6Z 1Y6; fax 604 806-9044; ewood@cfenet.ubc.ca

ABSTRACT

In many cities, infectious disease and overdose epidemics are
occurring among illicit injection drug users (IDUs). To reduce these
concerns, Vancouver opened a supervised safer injecting facility in
September 2003. Within the facility, people inject pre-obtained
illicit drugs under the supervision of medical staff. The program was
granted a legal exemption by the Canadian government on the condition
that a 3-year scientific evaluation of its impacts be conducted. In
this review, we summarize the findings from evaluations in those 3
years, including characteristics of IDUs at the facility, public
injection drug use and publicly discarded syringes, HIV risk
behaviour, use of addiction treatment services and other community
resources, and drug-related crime rates. Vancouver's safer injecting
facility has been associated with an array of community and public
health benefits without evidence of adverse impacts. These findings
should be useful to other cities considering supervised injecting
facilities and to governments considering regulating their use.

Many cities are experiencing infectious disease and overdose
epidemics as a result of illicit injection drug use,1-4 an activity
that is also associated with a number of negative community impacts,
including public drug use.5,6 Despite these harms, innovative public
health programs for reducing health and community concerns remain
highly controversial in North America and other settings where HIV
infection is spreading rapidly among injection drug users (IDUs).7-9
In Canada, Vancouver has been an epicentre of drug-related harm
during the last decade.10 In response, the affected community began
advocating a medically supervised safer injecting facility where IDUs
could inject pre-obtained drugs under the supervision of medical
staff.11 Within the facility, IDUs are typically provided with
sterile syringes and emergency care in the event of overdose, as well
as primary care services and referral to addiction treatment.12 Such
facilities exist in more than 2 dozen European cities and, more
recently, in Sydney, Australia.12,13

Vancouver's safer injecting facility (Fig. 1) was opened in September
2003 as a pilot study.13 The legal exemption by the federal
government that allowed operation of the facility was limited to 3
years and was granted on the condition that an external 3-year
scientific evaluation of its impacts be conducted. Given the
controversial nature of the program,14 stakeholders agreed that all
findings from the evaluation, including this report, should be
externally peer-reviewed and published in the medical literature
before dissemination. In this review we report on the 3 years' findings.

Program and Evaluation Methods

As described previously,13 the Vancouver safer injecting facility has
12 injection stalls where IDUs inject pre-obtained illicit drugs
under the supervision of nurses. Nurses respond to overdoses and
address other health needs (e.g., treating injection-site abscesses),
and the facility has an addiction counsellor and support staff who
seek to meet the needs of IDUs or refer them to appropriate community
resources (e.g., housing services, addiction treatment).13

Although the best strategy for evaluating the safer injecting
facility would be to randomly assign IDUs to either full access or no
access to the program, interventional study designs for the
evaluation of such facilities have been deemed unethical;15 thus, the
evaluation of the Vancouver facility was structured primarily around
prospective cohort studies involving IDUs who used the facility and
those who did not. In accordance with the Transparent Reporting of
Evaluations with Nonrandomized Designs (TREND) criteria for
observational research,16 a detailed description of the evaluation
methods has been published.17 The evaluators were entirely external
to facility operations, which are overseen by Vancouver Coastal
Health, and the evaluation was supervised by a provincial steering
committee and funded by Health Canada.

SUMMARY OF FINDINGS

Characteristics of People Using the Safer Injecting Facility

Before the safer injecting facility opened, a key concern was its
ability to attract its target population.18 The facility's public
health and community benefit would clearly be limited if it did not
attract the IDUs who were at highest risk of health-related harms and
those responsible for public order problems (e.g., public injection
drug use). Identification of the characteristics of IDUs initiating
use of the facility was helped by the existence of an ongoing
prospective cohort study of IDUs operating in the community before
the facility opened. This cohort has been described in detail.17,19
Thus, it was possible to examine drug use patterns in the community
during the year before the opening of the facility and identify
patterns that predicted subsequent initiation of use of the facility
during the year after it opened.

Characteristics and behaviours were defined based on questionnaire
data obtained immediately before the safer injecting facility opened,
whereas the prevalence of use of the facility was ascertained based
on the first questionnaire after the facility opened. In a
community-recruited cohort of IDUs, 45% reported using the facility
and, as shown in Fig. 2, the characteristics and drug-use behaviours
that predicted initiation of use of the facility included lower age,
public injection drug use, homelessness or unstable housing, daily
heroin injection, daily cocaine injection and a recent nonfatal overdose.20

Subsequent analysis of IDUs using the facility between Mar. 10, 2004,
and Apr. 30, 2005, revealed that about 5000 unique IDUs used the
facility during the first year of operation. Heroin was used in about
40% of injections, cocaine in 30% of injections, and other illicit
drugs, drug combinations or diverted pharmaceuticals in the remaining
injections.21 In a survey of perceptions regarding their use of the
facility, about 95% of IDUs using the facility reported high levels
of satisfaction with the site and the staff.22

Examination of a random sample of 670 IDUs recruited from within the
safer injecting facility between Dec. 1, 2003, and July 30, 2004,
demonstrated that the following factors were independently associated
with daily use of the facility: daily heroin injection (odds ratio
[OR] 3.44, 95% confidence interval [CI] 2.50-4.73), homelessness (OR
2.4, 95% CI 1.6- 3.6), not receiving methadone maintenance treatment
(OR 2.1, 95% CI 1.44-3.1) and daily cocaine injection (OR 2.0, 95% CI
1.4-2.8).23

Requiring help with injections was negatively associated with daily
use of the facility (OR 0.61, 95% CI 0.43-0.86), a finding of
concern, because this factor has been identified as an independent
predictor of HIV incidence in the community.24 This finding implies
that the rule prohibiting assisted injecting within the facility
should be examined. It is noteworthy that local IDUs have begun
outreach efforts to help teach safer injecting methods to those who
need help with injections.

The above series of analyses demonstrated wide acceptance of the
safer injecting facility within the local IDU community and showed
that the facility attracted a particularly high-risk population.20,21,23

Public Order

In anticipation of the facility's opening, a field survey protocol
was developed to measure specified public order indicators within the
10 city blocks that surround the facility.25 These indicators
included number of publicly discarded syringes, public injection drug
use, injection-related litter and the presence of suspected drug
dealers. Because law enforcement activities have an impact on the
location of injection drug use, the total number of police patrols
encountered during the hours of data collection was recorded to
control for the potentially confounding effect of enforcement
activities. The indicators were measured during the 6 weeks before
and 12 weeks after the facility opened. This 18-week study period was
selected to obtain sufficient follow-up evidence to provide
statistical power while attempting to minimize the potential effect
of seasonal changes in drug-use patterns, although rainfall patterns
were also adjusted for in the Poisson log-linear regression models
that were used on the daily counts of the public-order indicators.

All measures of public disorder showed decreases in the wake of the
facility's opening (Fig. 3). Regression models using parameter
estimates showed a decline in the predicted mean number of public
injections and publicly discarded syringes that coincided with the
opening of the facility (Table 1). As an external measure of the
impact of the facility on public drug use, an examination of data
from the city of Vancouver on the number of syringes discarded in the
neighbourhood's outdoor safe disposal boxes revealed that the mean
number of syringes safely discarded in each of the boxes also
declined in the 12-week period after the facility opened (p (
0.001).25 Subsequent to this, police have continued to report a
qualitative decline in public drug use.26

Use of Education Services About Safer Injecting

One of the greatest risk factors for HIV infection among IDUs in
Vancouver has been the need for assistance with injections.24 Because
lack of knowledge regarding safer injecting practices is a major
factor contributing to the risk,27 education in this area was an
important objective of the facility. To evaluate progress, 874
facility users were recruited between May 31, 2003, and Oct. 22,
2004. More than 30% of them reported receiving safer injecting
education from nurses within the facility (e.g., how to inject
oneself safely to avoid infection). Requiring help with injections at
least once in the 6 months before the evaluation was one of the
strongest independent predictors of receiving safer injecting
education (OR 2.20, 95% CI 1.62-2.98).28 Another study showed that
IDUs who previously required help with injections no longer needed
assistance as a result of education from nurses within the facility.29

HIV Risk Behaviour and Safer Injecting Practices

Evaluation of the impact of the safer injecting facility on syringe
sharing was undertaken by examining factors associated with this
practice among community-recruited IDUs and by comparing rates of
syringe sharing among regular versus irregular users of the
facility.30 A potential conservative bias in these analyses stems
from the fact that, as indicated in Fig. 2, users of the facility had
a number of drug-use behaviours, such as daily cocaine injection,
that have been associated with increased levels of syringe sharing.31
Nevertheless, as shown in Table 2, among IDUs followed between Dec.
1, 2003, and June 1, 2004, use of the facility was independently
associated with reduced syringe sharing (OR 0.3, 95% CI 0.1-0.8) in
multivariable analyses.

Examination of data obtained before and after the safer injecting
facility opened revealed that the rate of syringe sharing decreased
after the facility opened and only among facility users.30 A
subsequent analysis, which was restricted to facility users recruited
between Mar. 22 and Oct. 22, 2004, demonstrated that greater exposure
to the facility was associated with reduced syringe lending by
HIV-infected IDUs and reduced syringe borrowing by HIV-negative IDUs.32

With respect to the risk of bloodborne bacterial infections, such as
cellulitis and endocarditis, a study involving 760 facility users
recruited between July 1, 2004, and June 30, 2005, demonstrated that
use of the facility was independently associated with other safe
injection practices, including decreased reuse of syringes, increased
use of sterile water and increased use of alcohol swabbing of
injection sites.29

Referral for Addiction Treatment and Other Care

An evaluation conducted between Mar. 10, 2004, and Apr. 30, 2005,
demonstrated that the safer injecting facility serves as a referral
centre for many community resources. More than 800 referrals were
made per quarter, and about 40% of referrals were for various forms
of addiction treatment.21 Because an addiction counsellor is on site
at the facility and other facility staff refer IDUs to addiction
services, an evaluation was undertaken to examine factors associated
with more rapid entry into a detoxification program among facility
users.33 Definition of this end point was based on linkage to a
database maintained by Vancouver's 3 detoxification facilities, which
offer medically monitored residential withdrawal services with
on-site nursing and medical care. The study period considered each
participant's recruitment date up until Mar. 1, 2005. As shown in
Table 3, at least weekly use of the facility (adjusted relative
hazard [RH] 1.72, 95% CI 1.25-2.38; p = 0.001) and contact with the
facility's addiction counsellor (adjusted RH 1.98, 95% CI 1.26-3.10;
p = 0.003) were independently associated with more rapid entry into a
detoxification program.33 Of note, this study concluded that the
increased uptake of detoxification services was not due to selection
effects, because regular facility users had several baseline
characteristics that have been shown to predispose to lower uptake of
addiction treatment.34 These analyses suggested that amenities within
the facility were responsible for increased uptake of addiction
treatment among IDUs. In addition to addiction treatment, referrals
were also commonly made to community health clinics, hospital
emergency departments and housing services.21

Overdoses

Between Mar. 1, 2004, and Aug. 30, 2005, nurses at the safer
injecting facility responded to about 1.3 overdoses per 1000
injections.35 Heroin accounted for about 70% of the overdoses,
cocaine for 15%, and the injection of drug combinations (e.g., heroin
with cocaine), methamphetamine or diverted pharmaceuticals accounted
for the remainder. Although about 40% of cases required an ambulance
call, 60% of overdoses were successfully managed by facility staff
without the need for external support. Naloxone was administered in
about 30% of cases of overdose. Despite the relatively high number of
overdoses within the facility, there have been no overdose-related deaths.35

Potential Negative Impacts

Before the facility was opened, there were concerns that it would
result in increased crime rates in the neighbourhood as a result of
the migration of drug dealers and drug users toward the facility and
subsequent increases in drug dealing and drug acquisition crime.36
The analysis of public order indicators described above showed that
suspected drug dealing did not increase in the vicinity of the
facility and that public drug use declined.25 In addition, police
statistics during the year before versus the year after the facility
opened showed that crime rates remained stable in the neighbourhood
where the facility is located. Specifically, the facility's opening
has not been associated with increases in charges for drug dealing or
several markers of drug-related crime, including assaults, robbery
and vehicle break-ins.37

Before the facility opened, there were also concerns that providing a
safe and sterile place for injection drug use could reduce the
likelihood that IDUs would seek addiction treatment and would result
in increased rates of injection drug use.36 As indicated in the
section on referral for addiction treatment and other care, use of
the facility has been associated with an increased uptake of
detoxification services, which suggests that the facility has not
resulted in a reduced number of IDUs seeking addiction treatment.33
Similarly, comparing the 1-year periods before and after the facility
opened revealed no evidence that the provision of a safe and sterile
place for injection drug use has resulted in increased rates of
relapse into injection drug use or decreased rates of cessation of
injection drug use in the community.38 Finally, an additional study
involving all participants recruited into the cohort by Oct. 21,
2005, demonstrated that the program has not been associated with
increases in new initiates into injection drug use.39

Discussion

Evaluations of the Vancouver safer injecting facility have shown that
the program has been successful in attracting IDUs in the community
who have a number of characteristics associated with an increased
risk of HIV infection and overdose, as well as IDUs who were more
likely to inject drugs in public.20,23 In turn, there have been large
reductions in public drug use, publicly discarded syringes and
syringe sharing after the facility opened.25 Use of the facility has
also been associated with increased uptake of detoxification
services;33 the facility has been a central referral mechanism to a
range of other community and medical resources and a key venue for
education about safer injecting.28 Research has indicated that the
facility has not resulted in increases in drug dealing in the
facility's vicinity,25 in drug acquisition crime37 or in rates of new
IDUs or relapse into injection drug use among former IDUs.38,39

This report comes at a critical time: Canada's new prime minister and
federal health minister both expressed reservations about the
Vancouver safer injecting facility before the most recent Canadian
federal election.40 Subsequently, the application to extend for 3.5
years the exemption that allows for the legal operation of the
facility was rejected by the health minister in favour of a shorter
extension and a freeze on research into safer injecting facilities in
other Canadian settings, despite recommendations from Health Canada
that the 3.5-year extension be granted.41 The minister's decision to
go against Health Canada's recommendation followed declarations of
several national law enforcement bodies who, without providing any
data, suggested that the facility has been unsuccessful.42,43
Although the federal health minister's justification was that
"initial research has raised new questions,"41 federal research
funding of the evaluation was halted. In the wake of recent
statements,41-44 it is important to stress that the benefits
demonstrated in the evaluations of the Vancouver facility are largely
consistent with reports from several European settings12 and Australia.45

The evaluations of the Vancouver safer injecting facility were
limited by their observational nature, and hence all findings must be
interpreted with this in mind. Nevertheless, studies to date have
benefited from a number of unique methodological features that may
have served to limit potential biases. There has also been
consistency among a range of measures used to make inferences about
the facility's clientele and its impact on public drug use and HIV
risk behaviour. A further limitation of the evaluations, which can
potentially be viewed as an indication of the facility's success to
date, is that there have been too few HIV seroconversions and fatal
overdoses among facility users to assess the impact of the facility
on these outcomes.

In summary, the evaluations of the Vancouver safer injecting facility
have documented a large number of health and community benefits, and
there have been no indications of community or health-related harms.
Although the effect of closing the facility is unknown, the above
findings suggest a high potential for negative impacts on health and
the community. This report should be useful to international agencies
concerned about the impacts and legality of safer injecting
facilities14,42,46,47 and to those in a large number of national and
international settings currently debating the merits of such
facilities as a strategy to address the injection drug use problem.48-52

FOOTNOTES

This article has been peer reviewed.

Contributors: Evan Wood wrote the original draft of the manuscript
and addressed the reviewer's comments. All of the authors contributed
to the writing and revising of the manuscript and approved the final version.

Acknowledgements: We thank the participants in the evaluations of the
Vancouver safer injecting facility and the staff of the Insite safer
injecting facility, the Portland Hotel Society and Vancouver Coastal
Health (Chris Buchner, David Marsh, Heather Hay). We also thank Aaron
Eddie, Suzy Coulter, Megan Oleson, Peter Vann, Dave Isham, Steve
Gaspar, Cristy Power, Will Small, Elisa Lloyd-Smith, Jo-Anne Stoltz,
Calvin Lai, Deborah Graham, Caitlin Johnston and Steve Kain for their
research and administrative assistance. The evaluations of the safer
injecting facility were made possible by a financial contribution
from Health Canada, although the views expressed herein do not
represent the official policies of Health Canada.

Competing interests: None declared for Evan Wood, Mark Tyndall and
Thomas Kerr. Julio Montaner has received educational grants from,
served as an ad hoc advisor to or spoken at various events sponsored
by Abbott Laboratories, Agouron Pharmaceuticals Inc., Boehringer
Ingelheim Pharmaceuticals Inc., Borean Pharma AS, Bristol-Myers
Squibb, DuPont Pharma, Gilead Sciences, GlaxoSmithKline, Hoffmann-La
Roche, Immune Response Corporation, Incyte, Janssen-Ortho Inc.,
Kucera Pharmaceutical Company, Merck Frosst Laboratories, Pfizer
Canada Inc., Sanofi Pasteur, Shire Biochem Inc., Tibotec
Pharmaceuticals Ltd. and Trimeris Inc.

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