Drug-related overdoses within a medically supervised safer injection facility

BackgroundIn September 2003, North America's first supervised injection facility (SIF) opened in Vancouver, Canada. We sought to examine the incidence and characteristics of overdose events at the SIF.MethodsThe Vancouver SIF evaluation involves a comprehensive database within the SIF and the Scientific Evaluation of Supervised Injection (SEOSI) cohort consisting of 1046 SIF users. We examined the incidence and features of overdoses at the SIF and the responses made by SIF staff. Cox regression was used to examine factors associated with time to overdose among SEOSI participants.ResultsBetween 1 March 2004 and 30 August 2005, there were 336 overdose events at the SIF, yielding a rate of 1.33 (95% CI: 0.0–3.6) overdoses per 1000 injections. The most common indicator of overdose was depressed respiration (60%), and the most common intervention involved the administration of oxygen (87%). In total, 90 SEOSI participants had an overdose at the SIF during the study period. Factors independently associated with time to overdose included fewer years injecting (RH = 0.98, 95% CI: 0.96–1.00 per year), daily heroin use (RH = 1.82, 95% CI: 1.16–2.85), and having a history of overdose (RH = 1.92, 95% CI: 1.21–3.06).ConclusionsThere have been a large number of overdoses within the SIF, and it is noteworthy that none of these overdoses resulted in a fatality. These findings suggest that SIF can play a role in managing overdoses among IDU and indicate the need for further evaluation of the impact of SIF on morbidity and mortality associated with overdose.     

Injection drug users' perceptions regarding use of a medically supervised safer injecting facility

BACKGROUND: In recent years, there has been increased interest in supervised safer injecting facilities (SIF) as a strategy to reduce the harms of illicit drug use; however, little work has been done to assess drug users' satisfaction with this service. This study was undertaken to explore injection drug users' experiences and opinions regarding North America's first SIF in Vancouver, Canada. METHODS: Injection drug users (IDU) were randomly recruited from within the Vancouver SIF and invited to enroll in the Scientific Evaluation of Supervised Injecting (SEOSI) cohort. For the present study, participants were then surveyed regarding their experiences and beliefs regarding the SIF. RESULTS: Of 1082 IDU surveyed, 809 (75%) reported that their injecting behavior had changed as a result of using the SIF. Among these individuals, 80% indicated that the SIF had resulted in less rushed injecting, 71% indicated that the SIF had led to less outdoor injecting and 56% reported less unsafe syringe disposal. The three most common features always or usually limiting IDU's use of the SIF were: travel to the SIF (12%), limited operating hours (7%), and waiting times to access the SIF (5%). When asked in what ways the SIF might be improved, the three most common suggestions were: longer hours of operation (53%), addition of a washroom (51%), and reduced waiting times (46%). CONCLUSIONS: Many IDU reported changes in their injecting behaviors that have important implications for community and public health. Addressing a number of programmatic issues related to operating hours and waiting times, and the provision of additional amenities within SIF, may help to further improve their impact.     

Injection drug use cessation and use of North America's first medically supervised safer injecting facility

BackgroundVancouver, Canada has a pilot supervised injecting facility (SIF), where individuals can inject pre-obtained drugs under the supervision of medical staff. There has been concern that the program may facilitate ongoing drug use and delay entry into addiction treatment.MethodsWe used Cox regression to examine factors associated with the time to the cessation of injecting, for a minimum of 6 months, among a random sample of individuals recruited from within the Vancouver SIF. In further analyses, we evaluated the time to enrolment in addiction treatment.ResultsBetween December 2003 and June 2006, 1090 participants were recruited. In Cox regression, factors independently associated with drug use cessation included use of methadone maintenance therapy (Adjusted Hazard Ratio [AHR] = 1.57 [95% Confidence Interval [CI]: 1.02–2.40]) and other addiction treatment (AHR = 1.85 [95% CI: 1.06–3.24]). In subsequent analyses, factors independently associated with the initiation of addiction treatment included: regular SIF use at baseline (AHR = 1.33 [95% CI: 1.04–1.72]); having contact with the addiction counselor within the SIF (AHR = 1.54 [95% CI: 1.13–2.08]); and Aboriginal ancestry (AHR = 0.66 [95% CI: 0.47–0.92]).ConclusionsWhile the role of addiction treatment in promoting injection cessation has been well described, these data indicate a potential role of SIF in promoting increased uptake of addiction treatment and subsequent injection cessation. The finding that Aboriginal persons were less likely to enroll in addiction treatment is consistent with prior reports and demonstrates the need for novel and culturally appropriate drug treatment approaches for this population.     

Characteristics of young illicit drug injectors who use North America's first medically supervised safer injecting facility

The study examined whether North America's first medically supervised safer injection facility (SIF) attracts young injection drug users (IDUs) who are at high risk of health-related harm. Prevalence of SIF use was determined based on data obtained after the SIF's opening. Predictors of initiating future SIF use were determined based on behavioral information obtained from the participant's study visit immediately preceding the SIF's opening. The median duration between the acquisition of pre-SIF opening behavioral data and the more recent interview, where SIF use was measured, was 16 months. Characteristics of IDUs who did and did not subsequently initiate SIF use were statistically compared (N?=?135). Data from the 6-month period prior to the SIF's opening showed that youth initiating SIF use were significantly more likely to have been in jail, to use heroin daily, to have overdosed, to have binged on drugs, to have loaned needles, and to have been homeless. The study suggests that among IDUs 29 years of age or younger, those who used the SIF were at higher risk than those who were not.     

Accessing care for injection-related infections through a medically supervised injecting facility: a qualitative study

Injection drug users (IDU) experience complex barriers to accessing primary medical care which may result in over reliance on emergency health services. Supervised injecting facilities (SIF) aim to address HIV and overdose risks, as well as improve access to primary medical care among IDU. This study sought to investigate IDU perspectives regarding the impact of SIF on access to care and treatment of injection-related infections. Semi-structured qualitative interviews were conducted with 50 individuals recruited from a cohort of SIF users known as the Scientific Evaluation of Supervised Injecting (SEOSI). Audio-recorded interviews were transcribed verbatim and a thematic analysis was conducted. IDU narratives indicate the availability of on-site nursing attention at the SIF facilitated uptake of health services. IDU reported that the facility provided assessment and care of injection-related infections, as well as enhanced access to off-site medical services. The presence of professional nursing personnel within a sanctioned drug consumption setting serves to address social and structural barriers that often impede IDU access to health care. This study emphasizes that the facility enables contact with the healthcare system and thereby helps to facilitate the management of injection-related infections.     

Integrating smoking cessation care into routine service delivery in a medically supervised injecting facility: An acceptability study

BackgroundAmong people who inject drugs (PWIDs) the prevalence of tobacco smoking exceeds 80%; making smoking cessation intervention a priority for this population. This study aims to examine staff and client perspectives from a supervised injecting facility regarding: i) whether an organizational change intervention increased rates of smoking cessation care delivery (pre- to post-intervention); and ii) acceptability of the intervention.MethodsA pre-and-post intervention pilot study in a supervised injecting facility was conducted in Sydney, Australia between July 2014–December 2015. The intervention employed an organizational change approach and included six components. Cross-sectional samples of staff (pre n = 27, post n = 22) and clients (pre n = 202, post n = 202) completed online surveys pre and post intervention.ResultsFrom pre to post-intervention staff reported smoking cessation practices significantly increased for the provision of verbal advice (30% to 82%; p < 0.001), offer of free or subsidized nicotine replacement therapy (30% to 91%; p < 0.001), referral to a general practitioner (19% to 64%; p = 0.001), and follow-up to check on quit smoking progress (18.5% to 64%; p = 0.001). Significantly more clients reported receiving all smoking cessation strategies post-intervention. Over 85% of staff agreed that it was acceptable to address client smoking as part of usual care and 95% of clients agreed that it was acceptable to be asked by staff about their tobacco smoking.ConclusionsIncreasing the provision of smoking cessation care using an organizational change approach is both feasible for staff and acceptable to staff and clients of supervised injecting facilities.     

Access to health and social services for IDU: The impact of a medically supervised injection facility

Introduction and Aims. Injection drug users (IDU) often experience barriers to conventional health‐care services, and consequently might rely on acute and emergency services. This study sought to investigate IDU perspectives regarding the impact of supervised injection facility (SIF) use on access to health‐care services. Design and Methods. Semi‐structured qualitative interviews were conducted with 50 Vancouver‐based IDU participating in the Scientific Evaluation of Supervised Injecting cohort. Audio‐recorded interviews elicited IDU perspectives regarding the impact of SIF use on access to health and social services. Interviews were transcribed verbatim and a thematic analysis was conducted. Results. Fifty IDU, including 21 women, participated in this study. IDU narratives indicate that the SIF serves to facilitate access to health care by providing much‐needed care on‐site and connects IDU to external services through referrals. Participants’ perspectives suggest that the SIF has facilitated increased uptake of health and social services among IDU. Discussion and Conclusions. Although challenges related to access to care remain in many settings, SIF have potential to promote health by facilitating enhanced access to health‐care and social services through a model of care that is accessible to high‐risk IDU.[Small W, Van Borek N, Fairbairn N, Wood E, Kerr T. Access to health and social services for IDU: The impact of a medically supervised injection facility. Drug Alcohol Rev 2009;28:341–346]     

The Canadian government's treatment of scientific process and evidence: inside the evaluation of North America's first supervised injecting facility

Although the recommendations of scientific review bodies have traditionally been free of political interference in Canada, there have recently been growing concerns raised about Canada's new federal government's treatment of scientific processes and evidence. This concern is relevant to the scientific evaluation of Canada's first medically supervised safer injecting facility (SIF), which opened in Vancouver in 2003, where illicit injection drug users can inject pre-obtained illicit drugs under the supervision of nurses. This commentary describes what may be a serious breach of international scientific standards relating to the Canadian government's handling of the SIF's scientific evaluation, and the circumstances which eventually led to a moratorium on SIF trials in other Canadian cities. Although the primary focus of this discussion should remain on the health of the people using the SIF, it is hoped that the publication of the information contained in this report will lead to greater public scrutiny of the Canadian government's handling of addiction research and drug policy, and provide lessons for researchers, drug policy-makers, and affected communities in other settings.     

Assisted injection within supervised injection services: Uptake and client characteristics among people who require help injecting in a Canadian setting

BackgroundPeople who require help injecting illicit drugs experience elevated rates of a range of health-related harms, including overdose and acquisition of blood-borne pathogens. In response, some supervised injection services (SIS) in Canada have begun to permit clients to be physically injected by fellow clients or staff members. However, little is known about uptake and characteristics of clients who engage in this practice. We therefore sought to examine factors associated with receiving injection assistance at SIS among people who require help injecting drugs in Vancouver, Canada.MethodsData were drawn from two community-recruited prospective cohort studies of people who inject drugs (PWID). We used multivariable generalized estimating equation (GEE) analyses with time-updated covariates to identify factors associated with self-reported receipt of injection assistance at SIS.ResultsBetween June 2017 and December 2018, 319 individuals who reported having recently required help injecting were included in the study. Of these, 160 (51.0%) were women and the median age was 42 years at baseline. In total, 54 (16.9%) participants reported receiving injection assistance at a SIS at least once over an average of 3.3 months of follow-up. In multivariable GEE analyses, recent homelessness (Adjusted Odds Ratio [AOR] = 2.04; 95% confidence interval [CI]: 1.13 – 3.66), fentanyl injection (AOR = 3.45; 95% CI: 1.42 – 8.41), non-fatal overdose (AOR = 1.86; 95% CI: 1.02 – 3.38) and enrolment in methadone maintenance therapy (AOR = 1.89; 95% CI: 1.03 – 3.47) were associated with increased odds of receiving injection assistance at SIS.ConclusionAlthough uptake of assisted injection at SIS was relatively low among this sample of people who require help injecting, this practice was associated with several indicators of structural vulnerability and drug-related risk. These findings suggest that accommodating assisted injection within SIS may be providing opportunities to engage and reduce harms among higher-risk subpopulations of PWID in this setting.     

Towards a public health response for preventing the spread of HIV amongst injecting drug users within Nepal and the development of a treatment,rehabilitation and prevention programme in Pokhara

Within Nepal there remains an urgent need to develop strategies and policies aimed at reducing the spread of HIV infection amongst injecting drug users. Programmes currently operating within the country need to be evaluated and these programmes need to be expanded and strengthened and encouraged to work together in a more cohesive way. A programme for drug users in Pokhara, Nepal which was initiated in 1994 is attempting to provide an integrated and co-ordinated approach, and to give a comprehensive range of services to Nepali people which includes education, prevention, treatment, support, care and rehabilitation in a way which is both culturally appropriate and sensitive to the local scene.     

HIV/AIDS and injecting drug use: Information,education and communication

Information, education and communication (IEC) has an important role to play in HIV/AIDS prevention and harm reduction among injecting drug users and their sexual partners. This paper reviews what is known about the effects of IEC within this context. It distinguishes between six types of individual level intervention in which IEC has a role to play (mass reach interventions, outreach work, harm minimisation, drug cessation/treatment programmes, voluntary and confidential counselling and testing, and risk reduction counselling) and two different styles of structural intervention (structural and environmental outreach work to tackle the structured vulnerabilities associated with HIV/AIDS). Though the evidence base is weak, evidence relating to IEC's contribution and effects in each of these fields is reviewed. Overall, and by itself, IEC can do little more than raise levels of knowledge, awareness and understanding; however, when combined with other measures, including service provision and a supportive social environment, more positive and sustainable effects can be achieved.     

Injecting drug user attitudes towards rules for supervised injecting rooms: implications for uptake

Supervised injecting rooms (SIRs) have been implemented in Europe to assist in reducing the health and public order problems from street-based injecting drug use. Since 1997, extensive debate around the feasibility of SIR trials has occurred in the Australian jurisdictions of Victoria, New South Wales and the Australian Capital Territory. A trial is currently underway in Sydney, NSW. An important issue for SIR feasibility and trial design is injecting drug user (IDU) attitudes about SIR rules and regulations. In this study, 215 IDU were surveyed about SIR knowledge, willingness to use SIRs and attitudes towards SIR rules. Participants were knowledgeable about SIR issues, were willing to use SIRs (89%) and undeterred from uptake by: mandatory hand-washing (96%); close supervision (82%); bans on pill injecting (87%) or client-to-client injecting (71%) and deal splitting (55%). Significant minorities said they would not use SIRs if prevented from splitting drug deals (34%) or assisting others to inject (18%) on-site. The high level of SIR rule acceptance suggests that SIRs will play an important role in reducing the public impact of street injecting and various injecting related health harms. However, that some IDU would avoid SIRs due to certain rules implies that additional strategies will be needed if the health and other concerns of this group (and that of the surrounding community) are to be adequately addressed. The design and implementation of SIRs must be informed by extensive IDU consultation to be target group appropriate.     

Minimal uptake of sterile drug preparation equipment in a predominantly cocaine injecting population: implications for HIV and hepatitis C prevention

ObjectiveTo identify factors associated with using sterile drug injection equipment by injection drug users (IDUs).Methods275 IDUs were recruited from syringe exchange programs in Montreal, Canada in 2004–2005. A structured, interviewer-administered questionnaire collected information about demographics, drug injection practices, self-reported HIV and hepatitis C virus (HCV) status, and harm reduction behaviours. Logistic regression was used to model variables in relation to the use of sterile syringes, containers, filters, and drug preparation water.ResultsSterile syringes, containers, filters, and water were used for at least half of injecting episodes by 95%, 23%, 23%, and 75% of subjects, respectively. In multivariate analysis, users of sterile syringes had higher odds of being older and injecting alone, and were less likely to report problems obtaining sterile syringes and requiring or providing help with injecting. Using sterile filters was associated with having at least high school education, injecting heroin, and injecting alone. In addition to the factors associated with filters, users of sterile containers were more likely to be HCV-negative and older. Using sterile water was associated with daily injecting and being HCV-negative.ConclusionsImproving the uptake of sterile drug preparation equipment among IDUs could be aided by considering drug-specific risks, such as drug of choice and injecting context, while reinforcing existing messages on safer injecting. The association between sterile equipment use and HCV-negative status may be representative of an established subgroup of safer injectors who have remained free of infection because of consistent safe injecting practices.     

The impact of an HIV prevention intervention for injecting drug users in Svetlogorsk,Belarus: model predictions

Background: From the mid-1990s there has been a rapid spread of HIV infection amongst injecting drug users (IDUs) in Svetlogorsk, Belarus. In 1997, when the IDU HIV prevalence had reached 74%, two needle and syringe exchange points (NEPs) were established in the town. These interventions have been operating since then, with some interruptions due to a lack of funding 1998. Methods: This article presents a deterministic epidemiological model ‘IDU 2.4’ that simulates the transmission of HIV among IDUs sharing injecting equipment, and between IDUs and their sexual partners. The model incorporates the impact of the interrupted distribution of clean syringes and condoms, is validated against data from Svetlogorsk, and is used to estimate the impact of the intervention on HIV transmission. Results: The model predicts that between 1997 and 2000 the intervention averted 414 HIV infections in Svetlogorsk (95% CI, 180–690) and caused a 6.5% decrease in IDU HIV prevalence compared to if there had been no intervention. The analysis also suggests that the gap in funding between 1998 and 1999 resulted in a 35% reduction in the number of HIV infections averted among IDUs during that period, and that the IDU HIV prevalence is 3% higher in 2000 (95% CI, 1.9–4.6%) than if there had been no gap in funding. Conclusions: Even though the HIV prevalence and incidence amongst the IDUs remained high, the findings suggest that the intervention had an important affect on HIV transmission in Svetlogorsk, Belarus. The findings reinforce the importance of strengthening existing projects and replicating similar projects in the region, and highlight the detrimental impact of gaps in intervention funding.