Research

POTENTIAL USE OF SAFER INJECTING FACILITIES AMONG INJECTION DRUG USERS IN
VANCOUVER'S DOWNTOWN EASTSIDE

Thomas Kerr, Evan Wood, Dan Small, Anita Palepu and Mark W. Tyndall

From the Canadian HIV/AIDS Legal Network, Montreal, Que. (Kerr); the
British Columbia Centre for Excellence in HIV/AIDS (Kerr, Wood, Tyndall)
and the Centre for Health Evaluation and Outcome Sciences (Palepu), St.
Paul's Hospital, Vancouver, BC; the Department of Healthcare and
Epidemiology (Wood) and the Department of Medicine (Palepu, Tyndall),
University of British Columbia, Vancouver, BC; and the Portland Hotel
Society, Vancouver, BC (Small)

Correspondence to: Dr. Thomas Kerr, Canadian HIV/AIDS Legal Network, 417,
rue Saint Pierre, Suite 408, Montreal QC H2Y 2M4; fax 514 397-8570;
tkerr@aidslaw.ca

Abstract

Background: The Vancouver Coastal Health Authority will initiate North
America's first sanctioned safer injecting facility, as a pilot project, on
Sept. 15, 2003. The analyses presented here were conducted to estimate the
potential use of safer injecting facilities by local illicit injection drug
users (IDUs) and to evaluate the potential impact of newly established
Health Canada restrictions and current police activities on the use of the
proposed facility.

Methods: During April and May 2003, we recruited active IDUs in Vancouver's
Downtown Eastside to participate in a feasibility study. We used
descriptive and univariate statistics to determine potential use of a safer
injecting facility and to explore factors associated with willingness to
use such a facility with and without federal restrictions and police presence.

Results: Overall, 458 street-recruited IDUs completed an
interviewer-administered survey, of whom 422 (92%) reported a willingness
to use a safer injecting facility. Those expressing willingness were more
likely to inject in public (odds ratio [OR] 3.9, 95% confidence interval
[CI] 1.9=AD8.0). When the restrictions in the Health Canada guidelines were
considered, only 144 (31%) participants were willing to use a safer
injecting facility. IDUs who inject alone were more likely (OR 1.8, 95% CI
1.0=AD3.1) and women were less likely (OR 0.6, 95% CI 0.4=AD0.9) to be
willing to use a safer injecting facility operating under these
restrictions. Only 103 (22%) of the participants said they would be willing
to use a safer injecting facility if police were stationed near the entrance.

Interpretation: Most IDUs participating in this study expressed a
willingness to use a safer injecting facility. However, willingness
declined substantially when the IDUs were asked about using a facility
operating under selected Health Canada restrictions and in the event that
police were stationed near the entrance.

Many Canadian cities are experiencing an array of health and social harms
as a result of illicit injection drug use, including epidemics of HIV,
hepatitis C and overdose deaths.1,2,3 Health care costs due to
injection-related bacterial infections also take a substantial toll on
health care budgets.4,5 In other settings, where similar health crises have
emerged, medically supervised safer injecting facilities, where injection
drug users (IDUs) can inject previously obtained illicit drugs under the
supervision of medical staff, have been implemented to reduce the
community, public health and fiscal impacts of illicit drug use.6 Although
safer injecting facilities vary considerably in design and function,
evaluations conducted in Germany, Switzerland, Australia and the
Netherlands indicate that such facilities have improved the health and
social functioning of their clients,7 while reducing overdose deaths,8 HIV
risk behaviours,7 improper disposal of syringes8 and use of drugs in
public.9 In addition, improved access to medical care and drug treatment
has been attributed to attendance at safer injecting facilities.6

In December 2002, following a federal task force's recommendation that
safer injecting facility pilot projects proceed, Health Canada released
guidelines for applying for a legal exemption to conduct such research
studies.10 The Vancouver Coastal Health Authority recently received an
exemption from Health Canada to conduct a sanctioned pilot study and
intends to open a safer injecting facility on Sept. 15, 2003.11 The pilot
facility will be open 18 hours a day, 7 days a week. It will have 12
private cubicles where IDUs can self-inject previously obtained drugs under
the supervision of a registered nurse. Included in the Health Canada
guidelines are a number of restrictions on the design and operation of
safer injecting facility pilot sites, including prohibition of the sharing
of drugs and prohibition of assisted injection. The guidelines also require
that individuals register when using a safer injecting facility. These
restrictions have been implemented primarily to limit the scope of the
federal exemption to issues associated with the possession of illicit drugs
in the facility and to reduce the risks associated with civil and criminal
liability.

Previous studies have indicated that the use of safer injecting facilities
may be limited when the service design includes many rules and
restrictions.12,13 In addition, although the adverse effects of a police
presence on access to health care services among IDUs has been well
documented,14,15 the Vancouver Police Department is currently undertaking a
controversial operation whereby police cruisers are at times parked outside
local health services.16,17 Although willingness among Vancouver IDUs to
use a safer injecting facility has been examined previously,18 the impacts
of the newly established federal restrictions and current police activities
have not been characterized. Therefore, we undertook a survey to estimate
the potential use of a safer injecting facility by IDUs in Vancouver's
Downtown Eastside and to evaluate how new federal restrictions and police
activities might affect this potential use.

Methods

During April and May 2003, active IDUs were recruited for participation in
a feasibility study of safer injecting facilities. The IDUs were informed
of the study through street-based recruitment and "snowballing" methods and
were eligible for inclusion if they reported being active IDUs (currently
injecting illicit drugs), provided evidence of track marks and provided
written informed consent. Participants completed an
interviewer-administered survey in 1 of 3 Downtown Eastside locations: a
rented storefront, a newly established Life Skills Centre and a large space
that operates as a needle exchange site. A published definition of a
medically supervised safer injecting facility18 was read to each
participant, who was then shown 2 pictures of a facility similar to the
model planned for Vancouver. Each study participant received $15 upon
completion of the survey. The University of British Columbia/Providence
Health Care Research Ethics Board approved the study.

Sociodemographic variables considered in these analyses included sex, age
and housing status. In addition, because of the recent observation that
Aboriginal IDUs in Vancouver are at heightened risk for HIV infection,1
ethnicity (Aboriginal or non-Aboriginal) was also examined. Unstable
housing was defined as living in a single room occupancy hotel or shelters
or having no fixed address. Drug use and behavioural variables were
sex-trade work, number of previous overdoses, injecting in public spaces,
requiring help injecting, injecting alone, and frequency of cocaine and
heroin injection per day. Variables specific to safer injecting facilities
included willingness to use such a facility and willingness to use a
facility under 3 of the conditions stipulated by Health Canada's guidelines
for a scientific pilot study: no sharing of drugs, no assisted injection
and mandatory registration. More specifically, participants were told that
a number of restrictions were being considered for safer injecting
facilities and were then asked to indicate whether they would use a
facility operating under each condition (e.g., "... if you were required to
register to use the facility"). The survey further evaluated willingness to
attend a safer injecting facility if police were stationed near the
facility entrance.

We used descriptive and univariate statistics to determine potential use of
safer injecting facilities and to explore factors associated with
willingness to use a facility with and without the Health Canada
restrictions. Categorical and explanatory variables were analyzed by means
of Pearson 2, normally distributed continuous variables were analyzed by
means of t-tests for independent samples, and skewed continuous variables
were analyzed with Mann=ADWhitney U-tests.

Results

In total, 458 active IDUs were recruited and completed questionnaires
during April and May 2003. There were no refusals to participate in the
study, although one IDU was unable to participate because of intoxication.
The participants consisted of 197 women (43%) and 261 men (57%). Almost a
third (149 or 32%) of the participants were of Aboriginal ancestry, the
median age was 40 years, and 307 (67%) participants reported that they
regularly injected in public places.

A total of 422 (92%) of the participants reported a willingness to use a
safer injecting facility in the absence of Health Canada restrictions, and
those expressing willingness were more likely to inject in public (odds
ratio [OR] 3.9, 95% confidence interval [CI] 1.9=AD8.0) (Table 1). There
were no differences in willingness to use a safer injecting facility with
regard to any of the other characteristics examined (Table 1).

Among the 422 participants (92%) who initially expressed willingness to use
a safer injecting facility, 296 (64% of the total sample) were willing to
use such a facility under a restriction prohibiting the sharing of drugs
(Fig. 1). In bivariate analyses, injecting alone was associated with
willingness under this restriction (OR 2.0, 95% CI 1.2=AD3.6), whereas
female sex was associated with nonwillingness (OR 0.6, 95% CI 0.4=AD0.9).

Fig. 1: Flow diagram illustrating initial willingness to use a safer
injecting facility (SIF) and reductions in willingness related to Health
Canada restrictions and police presence. All percentages are calculated on
the basis of the complete sample of 458 survey participants.

Similarly, 282 participants (62% of the total sample) were willing to use a
safer injecting facility under the restriction prohibiting assisted
injection (Fig. 1). Injecting alone was also associated with willingness
under this restriction (OR 1.8, 95% CI 1.1=AD2.9), whereas female sex (OR
0.4, 95% CI 0.3=AD0.7) and requiring help injecting (OR 0.4, 95% CI
0.2=AD0.6) were associated with nonwillingness.

Two hundred and forty-six participants (54% of the total sample) were
willing to use a safer injecting facility under the restriction requiring
client registration (Fig. 1). Aboriginal ethnicity (OR 1.6, 95% CI
1.0=AD2.4) and injecting in public (OR 1.6, 95% CI 1.0=AD2.3) were
associated with willingness under this restriction.

Finally, only 144 participants (31% of the total) were willing to use a
safer injecting facility when the 3 Health Canada restrictions (no sharing
of drugs, no assisted injection and mandatory registration) were considered
together, on the basis of overlap for the 3 restrictions separately (Fig.
1, Table 2). Injecting alone was associated with willingness to use a
facility under these restrictions (OR 1.8, 95% CI 1.0=AD3.1), whereas
injecting in public was marginally associated with willingness (Table 2).
Conversely, women were less likely to be willing to use a facility
operating under these restrictions (OR 0.6, 95% CI 0.4=AD0.9) (Table 2).

Table 2.

Only 103 (22%) of the participants said they would be willing to use a
safer injecting facility if police were stationed near the entrance. About
half of these (59 or 13% of the total) would be willing to use a safer
injecting facility when all 3 Health Canada restrictions and police
presence were considered together (on the basis of overlap). None of the
variables under study were associated with willingness to use a safer
injecting facility under the latter 2 scenarios.

Interpretation

In this study 92% of IDUs expressed willingness to use a medically
supervised safer injecting facility, and injection of drugs in public was
associated with willingness. However, willingness declined substantially
when participants were asked if they would use a facility operating under 3
of the Health Canada restrictions. Study participants who inject alone were
more likely and women were less likely to be willing to use a safer
injecting facility operating under these restrictions. Only 22% of
participants said they would use a safer injecting facility if police were
stationed near the entrance.

The results of this study suggest that a safer injecting facility in
Vancouver's Downtown Eastside could be well accepted by local IDUs,
including those who inject in public. The latter finding, which is
consistent with an earlier study involving Vancouver IDUs,18 is
encouraging, given previous studies indicating that public injection is
associated with an array of injection-related harms, including
syringe-sharing, bacterial infection and overdose.19,20,21 However, our
results differ from those of the earlier Vancouver study, in which only 36%
of IDUs expressed willingness to use a safer injecting facility;18 the high
rates of willingness observed here may be explained by the fact that,
unlike IDUs in the earlier study, most participants in the current study
were active street-based injectors and all were recruited from the heart of
Vancouver's open drug scene in the Downtown Eastside. Our findings are
consistent with an Australian study of IDU attitudes, which found that
rules prohibiting the sharing of drugs and prohibiting assisted injection
were associated with a substantial reduction in willingness to use a safer
injecting facility.13 Although the overall decline in willingness is
problematic, of particular concern was the finding that female sex was
associated with unwillingness to use a safer injecting facility operating
under specific restrictions, since the risk of HIV infection among female
IDUs living in Vancouver is elevated.22 This negative impact of the
restrictions on potential use of such facilities by women is not
surprising, given that elevated rates of requiring help injecting have been
associated with female sex.23 It should be noted that legal precedents
indicate that operators of safer injecting facilities may be legally
required to accommodate people with disabilities who are physically unable
to self-inject by allowing them to obtain injection assistance from other
IDUs in this supervised setting.24,25 The reduced willingness to use a
safer injecting facility in the event of a police presence near the
entrance is particularly worrisome. Previous studies in Vancouver have
repeatedly indicated that police presence has had a negative impact on
access to health care services,14,16,26 a finding that has also been
demonstrated in the United States.15,27 For example, a recent Vancouver
police operation was found to substantially reduce access to sterile
syringes.14

Our study had several limitations. First, it offers evidence only of
potential use of a safer injecting facility by IDUs; actual use can only be
assessed once Vancouver's pilot study is under way. For instance, the
adverse impact of Health Canada's restrictions may be overestimated in our
study, as previous studies have indicated that IDUs will modify their
behaviour in an effort to reduce harm to themselves and others.28
Nevertheless, the proposed single safer injecting facility in Vancouver
might have difficulty meeting service needs, even in the event of
restrictive guidelines and police presence.29 Second, this study relied on
a convenience sample of IDUs recruited in Vancouver's Downtown Eastside,
which might not be representative of IDU populations in other settings.
Third, the study examined only a limited set of restrictions that might
affect use of such a facility and may have neglected other restrictions
that could limit use. Fourth, the age range of the active IDUs recruited in
this study precluded an assessment of potential use of the safer injecting
facility by youth. However, we feel that our sample is representative of
the population targeted by the pilot project. Finally, the current study
relies on self-reporting and therefore may be susceptible to socially
desirable reporting.30

In summary, 92% of active IDUs in this study expressed an initial
willingness to use a safer injecting facility. Those who expressed
willingness were likely to be public injectors, suggesting the potential
for immediate public health and public order benefits. However, willingness
to use a safer injecting facility declined substantially when IDUs were
asked if they would use a facility operating under Health Canada
restrictions and in the event that police were stationed near its entrance.
To maximize benefit, it is essential that safer injecting facilities be
designed to address concerns regarding liability while making the service
accessible to those at highest risk. In addition, the success of the safer
injecting facility will probably require substantial modification of the
potentially harmful law enforcement practices now in effect in Vancouver's
Downtown Eastside.14,16,26

=DF See related articles pages 777 and 825

Footnotes

Fast-tracked article. Published at www.cmaj.ca on Sept. 12, 2003.

This article has been peer reviewed.

Contributors: Thomas Kerr was the principal investigator of the study, and
he coordinated the collection of the data, conducted the analyses and
prepared the first draft of the manuscript. Thomas Kerr and Evan Wood
designed the methodology for the paper. Evan Wood, Dan Small, Anita Palepu
and Mark Tyndall provided input to the design of the survey questionnaire
and the methodology and made critical comments and revisions to the content
of the manuscript.

Acknowledgements: Anita Palepu is supported by a Canadian Institutes of
Health Research New Investigator Award. Evan Wood is supported by the
Michael Smith Foundation for Health Research.

We acknowledge the contributions of Tomiye Ishida, Daniel Miles Kane, Dean
Wilson, Calvin Lai and the Vancouver Area Network of Drug Users for their
assistance with the study design and for administrative support.

We also acknowledge the assistance of Richard Elliot and Ruth Carey with
the legal and policy analyses.

This research was funded by a Canadian Institutes of Health Research
operating grant (Mark Tyndall, principal investigator).

Competing interests: None declared.

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