Overdose Prevention Sites, also known as Supervised Consumption Sites or Safe Injection Facilities

1. Rhode Island Becomes First State in US to Approve Legal Establishment of Overdose Prevention Sites

"Gov. Dan McKee has signed legislation introduced by Majority Floor Manager John G. Edwards (D-Dist. 70, Tiverton, Portsmouth) and Sen. Joshua Miller (D-Dist. 28, Cranston, Providence) that authorizes a two-year pilot program to prevent drug overdoses through the establishment of harm reduction centers, which are a community-based resource for health screening, disease prevention and recovery assistance where persons may safely consume pre-obtained substances.

"The law (2021-H 5245A, 2021-S 0016B) authorizes facilities where people may safely consume those substances under the supervision of health care professionals. It requires the approval of the city or town council of any municipality where the center would operate."

State of Rhode Island General Assembly. Harm reduction center pilot program to combat overdose deaths becomes law. News Release, July 7, 2021.

2. Successful Operation of an Unsanctioned Supervised Consumption Site in the US

"In total, there were 10,514 injections and 33 opioid-involved overdoses over 5 years, all of which were reversed by naloxone administered by trained staff (Table 1). No person who overdosed was transferred to an outside medical institution, and there were no deaths. The number of overdoses increased over the years of operation, due partially to the number of injections increasing over the same period of time (Fig. S1 in the Supplementary Appendix). The types of drugs used at the site changed over the 5 years of operation, with a steady increase in the proportion of injections involving the combination of opioids and stimulants, from 5% in 2014 to 60% in 2019 (Fig. S2).

"Although this evaluation was limited to one city and one site that is unsanctioned, and therefore the findings cannot be generalized, our results suggest that implementing sanctioned safe consumption sites in the United States could reduce mortality from opioid-involved overdose. Sanctioning sites could allow persons to link to other medical and social services, including treatment for substance use, and facilitate rigorous evaluation of their implementation and effect on reducing problems such as public injection of drugs and improperly discarded syringes."

Kral, Alex H., Lambdin, Barrot H., Wenger, Lynn D., Davidson, Pete J. Evaluation of an Unsanctioned Safe Consumption Site in the United States. New England Journal of Medicine. July 8, 2020. 10.1056/NEJMc2015435.

3. Supervised Injection Facilities (SIFs), Sanitary Consumption Facilities (SCFs), and Drug Consumption Rooms (DCRs)

"Drug consumption rooms are professionally supervised healthcare facilities where drug users can consume drugs in safer conditions. They seek to attract hard-to-reach populations of users, especially marginalised groups and those who use on the streets or in other risky and unhygienic conditions. One of their primary goals is to reduce morbidity and mortality by providing a safe environment for more hygienic use and by training clients in safer use. At the same time, they seek to reduce drug use in public and improve public amenity in areas surrounding urban drug markets. A further aim is to promote access to social, health and drug treatment facilities (see ‘Service model’).

"Drug consumption rooms initially evolved as a response to health and public order problems linked to open drug scenes and drug markets in cities where a network of drug services already existed, but where difficulties were encountered in responding to these problems. As such they represent a ‘local’ response, closely linked to policy choices made by local stakeholders, based on an evaluation of local need and determined by municipal or regional options to proceed. Facilities for supervised drug consumption tend to be located in settings that are experiencing problems of public use and targeted at sub-populations of users with limited opportunities for hygienic injection (e.g. people who are homeless or living in insecure accommodation or shelters). In some cases clients who are more socially stable also use drug consumption rooms for a variety of reasons, for example because they live with non-using partners or families (Hedrich and Hartnoll, 2015)."

"Perspectives On Drugs: Drug consumption rooms: an overview of provision and evidence," European Monitoring Centre for Drugs and Drug Addiction, June 2017.

4. Supervised Consumption Facilities Reduce Overdose Morbidity and Improve Access to Treatment

"This systematic review of 22 effectiveness studies relayed evidence of the public health benefits of SIFs for SIF clients as well as to surrounding communities. The strongest evidence suggests that SIFs may help reduce overdose morbidity and mortality and improve access to addiction treatment. An increase in crime, an often-cited concern of SIF opponents, was not observed to be associated with SIFs in most included studies, and crime was actually found to decrease in 2 studies (1 greatest and 1 least suitability of design)."

Levengood, T. W., Yoon, G. H., Davoust, M. J., Ogden, S. N., Marshall, B., Cahill, S. R., & Bazzi, A. R. (2021). Supervised Injection Facilities as Harm Reduction: A Systematic Review. American journal of preventive medicine, 61(5), 738–749. doi.org/10.1016/j.amepre.2021.04.017

5. Success of Overdose Prevention Sites In Response to a Public Health Emergency

"The rapid implementation of OPSs [Overdose Prevention Sites] in the province of British Columbia, Canada during a public health emergency provides an international example of an alternative to drawn-out, cumbersome sanctioning processes for SCSs [Supervised Consumption Services]. Unsanctioned SCSs provide alternative evidence to inform the implementation of SCSs that are more inclusive and responsive to PWUD [People Who Use Drugs]. Our research adds to this evidence. In particular, we found evidence that shifts in the outer context facilitated rapid implementation of a more user focused and driven intervention. We found innovation and inclusionary practices that typically define unsanctioned sites were possible within state-sanctioned OPSs. Community-driven processes of implementation involve centering PWUD in service design, implementation and delivery. Overdose prevention sites provide an example of a novel service design and nimble implementation process that combines the benefits of state-sanctioned service and community-driven implementation. As described by those individuals implementing the services, OPSs effectively provide supervised injection services and overdose responses while addressing many of the documented limitations of existing sanctioned SCSs implementation processes and resultant service designs. However, OPSs lack permanency and ongoing funding due to enactment under a Ministerial Order that is limited to the duration of the public health emergency. Specific attention needs to be paid to the development maintenance of OPSs as primary points of contact and entry into the health system and as part of an ongoing system of substance use services."

Bruce Wallace, Flora Pagan, Bernadette (Bernie) Pauly, The implementation of overdose prevention sites as a novel and nimble response during an illegal drug overdose public health emergency, International Journal of Drug Policy, Volume 66, 2019, Pages 64-72, ISSN 0955-3959. doi.org/10.1016/j.drugpo.2019.01.017.

6. Drug Consumption Rooms in Operation in the EU

"Breaking this down further, as of February 2017 there are: 31 facilities in 25 cities in the Netherlands; 24 in 15 cities in Germany; five in four cities in Denmark 13 in seven cities in Spain; two in two cities in Norway; two in two cities in France; and one in Luxembourg (Luxembourg is preparing to open a second facility in 2018); and 12 in eight cities in Switzerland. In Slovenia following a change in the penal code that created an enabling environment for the opening of supervised consumption facilities, a planned pilot project is pending. Following HIV outbreaks among people who inject drugs, discussions about the introduction of supervised drug consumption facilities are ongoing in Glasgow (Scotland) and Dublin (Ireland). A study to explore the feasibility of drug consumption facilities in five major cities in Belgium (Ghent, Antwerp, Brussels, Liège and Charleroi) was launched in 2016. Outside Europe there are two facilities in Vancouver (Canada) and one medically supervised injecting centre in Sydney (Australia)."

"Perspectives On Drugs: Drug consumption rooms: an overview of provision and evidence," European Monitoring Centre for Drugs and Drug Addiction, June 2017.

7. Effectiveness and Impact of Drug Consumption Rooms and Supervised Injection Facilities

"The effectiveness of drug consumption facilities to reach and stay in contact with highly marginalised target populations has been widely documented (Hedrich et al., 2010; Potier et al., 2014). This contact has resulted in immediate improvements in hygiene and safer use for clients (e.g. Small et al., 2008, 2009; Lloyd-Smith et al., 2009), as well as wider health and public order benefits.

"Research has also shown that the use of supervised drug consumption facilities is associated with self-reported reductions in injecting risk behaviour such as syringe sharing. This reduces behaviours that increase the risk of HIV transmission and overdose death (e.g. Stoltz et al., 2007; Milloy and Wood, 2009). Nevertheless, the impact of drug consumption rooms on the reduction of HIV or hepatitis C virus incidence among the wider population of injecting drug users remains unclear and hard to estimate (Hedrich et al., 2010; Kimber et al., 2010), due in part to the facilities’ limited coverage of the target population and also to methodological problems with isolating their effect from other interventions.

"Some evidence has been provided by ecological studies suggesting that, where coverage is adequate, drug consumption rooms may contribute to reducing drug-related deaths at city level (Poschadel et al., 2003; Marshall et al., 2011). A study in Sydney showed that there were fewer emergency service call-outs related to overdoses at the times the safe injecting site was open (Salmon et al., 2010).

"In addition, the use of consumption facilities is associated with increased uptake both of detoxification and drug dependence treatment, including opioid substitution. For example, the Canadian cohort study documented that attendance at the Vancouver facility was associated with increased rates of referral to addiction care centres and increased rates of uptake of detoxification treatment and methadone maintenance (Wood et al., 2007; DeBeck et al., 2011)."

"Perspectives On Drugs: Drug consumption rooms: an overview of provision and evidence," European Monitoring Centre for Drugs and Drug Addiction, June 2017.

8. Public Safety and Community Response to Supervised Injection Facilities and Drug Consumption Rooms

"Evaluation studies have found an overall positive impact on the communities where these facilities are located. However, as with needle and syringe programmes, consultation with local key actors is essential to minimise community resistance or counter-productive police responses. Drug treatment centres offering supervised consumption facilities have generally been accepted by local communities and businesses (Thein et al., 2005). Their establishment has been associated with a decrease in public injecting (e.g. Salmon et al., 2007) and a reduction in the number of syringes discarded in the vicinity (Wood et al., 2004). For example, in Barcelona, a fourfold reduction was reported in the number of unsafely disposed syringes being collected in the vicinity from a monthly average of over 13 000 in 2004 to around 3 000 in 2012 (Vecino et al., 2013).

"The effect of the Sydney supervised injecting facility on drug-related property crime and violent crime in its local area was examined using time series analysis of police-recorded theft and robbery incidents (Freeman et al., 2005). No evidence was found that the existence of the facility led to either an increase or decrease in thefts or robberies around the facility. Similarly, a study by Wood and colleagues compared the monthly number of charges for drug trafficking, assaults and robbery — crimes that are commonly linked to drug use — in Vancouver’s Downtown Eastside the year before versus the year after the local drug consumption room opened and found that the establishment of the facility was not associated with a marked increase in these crimes (Wood et al., 2006)."

"Perspectives On Drugs: Drug consumption rooms: an overview of provision and evidence," European Monitoring Centre for Drugs and Drug Addiction, June 2017.

9. Ninety Officially Sanctioned Drug Consumption Rooms in Operation in the EU and Switzerland

"In terms of the historical development of this intervention, the first supervised drug consumption room was opened in Berne, Switzerland in June 1986. Further facilities of this type were established in subsequent years in Germany, the Netherlands, Spain, Norway, Luxembourg, Denmark, Greece and France. A total of 78 official drug consumption facilities currently operate in seven EMCDDA reporting countries, following the opening of the first two drug consumption facilities in the framework of a 6-year trial in France in 2016. There are also 12 facilities in Switzerland (see ‘Facts and figures’)."

"Perspectives On Drugs: Drug consumption rooms: an overview of provision and evidence," European Monitoring Centre for Drugs and Drug Addiction, June 2017.

10. Public Health Benefits of Supervised Injection Facilities and Drug Consumption Facilities

"Consumption rooms achieve the immediate objective of providing a safe place for lower risk, more hygienic drug consumption without increasing the levels of drug use or risky patterns of consumption.

"Direct benefits of supervised injecting appear to be a reduction in some of the risk behaviours related to injecting, in particular improvements in injecting practice, use of sterile equipment and lack of opportunity for sharing drugs. Other benefits are that, if medical emergencies should occur, immediate medical intervention is possible, and the consumption equipment used in the rooms is correctly disposed of. Client surveys consistently show that service users appreciate the hygienic conditions, safety and peace that the rooms provide."

Hedrich, Dagmar, "European Report on Drug Consumption Rooms." Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004.

11. Effectiveness and Benefits of Supervised Consumption Facilities

"Generally speaking, it is reasonable to conclude, on the basis of the available knowledge, that to a large extent DCFs [Drug Consumption Facilities] achieve the objectives set for them, and that the criticisms made of them are rarely justified. In fact, DCFs help to:

"• reduce risk behaviour likely to lead to the transmission of infectious diseases, particularly HIV/AIDS, among the population of the worst affected drug users;

"• reduce the incidence of fatal overdoses and, therefore, the mortality rate in this population;

"• establish and maintain contact between this population and the social-service and health-care network, within which low-threshold facilities (LTFs) are often the First point of access because of the care and social assistance they offer;

"• reduce public order problems, particularly by doing away with open drug scenes, reducing drug use in public places, recovering used syringes, and reducing the impact of drug problems on residential areas (apartment buildings).

"At the same time, the available data do not indicate any specific detrimental effect on:

"• the number of drug users and the frequency with which they use drugs; the figures are falling in both cases;

"• entry and retention in treatment, because the majority of DCF users are undergoing treatment, the proportion of those in treatment is growing, this subject is tackled within the facilities, and the users themselves state that DCFs do not have any major influence on their treatment.

"All of these observations relate to the overall level of public health and do not mean that DCFs may not have negative effects in some individual cases. However, on the basis of existing knowledge, it would appear that the overall effect of DCFs on drug-related problems is positive."

Zobel, Frank & Françoise Dubois-Arber, "Short appraisal of the role and usefulness of Drug consumption facilities (DCF) in the reduction of drug-related problems in Switzerland: appraisal produced at the request of the Swiss Federal Office of Public Health (Lausanne: University Institute of Social and Preventive Medicine, 2004), p. 27.

12. Evaluation Proves Effectiveness of Australian Supervised Injection Facility

"In summary, the evidence available from this Evaluation indicates that:

"• operation of the MSIC in the King Cross area is feasible;

"• the MSIC made service contact with its target population, including many who had no prior treatment for drug dependence;

"• there was no detectable change in heroin overdoses at the community level;

"• a small number of opioid overdoses managed at the MSIC may have been fatal had they occurred elsewhere;

"• the MSIC made referrals for drug treatment, especially among frequent attenders;

"• there was no increase in risk of blod borne virus transmission;

"• there was no overall loss of public amenity;

"• there was no increase of crime;

"• the majority of the community accepted the MSIC initiative;

"• the MSIC has afforded an opportunity to improve knowledge that can guide public health responses to drug injecting and its harms."

MISC Evaluation Committee, "Final Report on the Sydney Medically Supervised Injecting Centre" (New South Wales, Australia: MISC Evaluation Committee, 2003), p. xiv.

13. Reductions in Overdose Mortality Associated With Supervised Injection Facilities

"In the present analysis we found that overdose events were not uncommon at the Vancouver safer injection facility. During an 18-month period, 285 individuals accounted for 336 overdose events, yielding an overdose rate of 1.33 (95% CI: 0.0–3.6) overdoses per 1000 injections. Heroin was involved in approximately 70% of all overdoses, and opiates considered together were involved in 88%of overdoses. It is notable, however, that approximately one-third of overdoses involved stimulants. The most common indicators of overdose were depressed respiration, limp body, face turning blue, and a failure to respond to pain stimulus. The majority of overdoses were successfully managed in the SIF, with the most common overdose interventions undertaken by SIF staff involving the administration of oxygen, a call for ambulance support, and the administration of naloxone hydrochloride via injection. Among a randomly selected sample of SIF users, factors associated with time to overdose at the SIF included fewer years injecting, daily heroin use, and having a history of overdose. None of the overdose events occurring at the SIF resulted in a fatality."

Thomas Kerr, Mark W. Tyndall, Calvin Lai, Julio S.G. Montaner, Evan Wood, "Drug-related overdoses within a medically supervised safer injection facility," International Journal of Drug Policy 17 (2006) p. 440.

14. Supervised Injection Facilities and Overdose Rates

"The rate of overdose observed at the Vancouver SIF is within the range of rates observed in an international review of SIF which estimated the rates of overdose typically to be between 0.01 and 3.6 per 1000 injections (Kimber et al., 2005). However, the rate observed in Vancouver is lower than rates observed recently in Munster, Germany (6.4 per 1000 injections) and Sydney, Australia (7.2 per 1000 injections) (Kimber et al., 2003). This may reflect differences in threshold for coding and intervention by staff, and differences in drug consumption patterns across cities, especially as it pertains to the use of opioids and other central nervous system depressants."

Thomas Kerr, Mark W. Tyndall, Calvin Lai, Julio S.G. Montaner, Evan Wood, "Drug-related overdoses within a medically supervised safer injection facility," International Journal of Drug Policy 17 (2006) p.440.

15. Drug Consumption Facilities Bring Underserved Populations Into Contact With Healthcare and Treatment Services

"Service users' sociodemographic data and drug use profile are similar across countries. Data show that the rooms reach the intended target groups of long-term addicts, street injectors, homeless drug users and drug-using sex workers and are thus facilitating contact with the most problematic and marginalised drug users. Demographic information also shows that these services can be successful in reaching long-term drug users with no previous contact with treatment services."

Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 41.

16. SIFs Act As A Conduit To Treatment

"A more controversial approach has been adopted in some cities in Europe, where the concept of safe consumption rooms, usually targeting drug injection, has been extended to drug inhalation. Rooms for supervised inhalation have been opened in several Dutch, German and Swiss cities (EMCDDA, 2004c). Although the supervision of consumption hygiene is a main objective of such services, there is some evidence that they could also act as a conduit to other care options; for example, monitoring of one service in Frankfurt, Germany, reported that, during a six-month evaluation period in 2004, more than 1,400 consumptions were supervised, while 332 contact talks, 40 counselling sessions and 99 referrals to other drugs services were documented."

"Annual Report 2006: The State of the Drugs Problem in Europe," European Monitoring Centre for Drugs and Drug Addiction (Luxembourg: Office for Official Publications of the European Communities, 2006), p. 64.

17. Supervised Injection Facilities, Injection Cessation, and Entry to Treatment

"Among IDU [Injection Drug Users] who attended Vancouver’s supervised injecting facility, regular use of the SIF and having contact with counselors at the SIF were associated with entry into addiction treatment, and enrollment in addiction treatment programs was positively associated with injection cessation. Although SIF in other settings have been evaluated based on wide range of outcomes (Dolan et al., 2000; Kimber et al., 2003; MSIC Evaluation Committee, 2003), our study is the first to consider the potential role of SIF in supporting injection cessation. While our study is unique, our findings build on previous international analyses demonstrating a link between SIF attendance and entry into detoxification programs (Wood et al., 2006; Wood et al., 2007a; Kimber et al., 2008).

"A postulated benefit of SIF is that, by providing a sanctioned space for illicit drug use, a hidden population of IDU can be drawn into a healthcare setting so that service delivery can be improved. The present study provides additional evidence that SIF appear to promote utilization of addiction services and builds on past evaluations to demonstrate that, through this mechanism, they may also lead to increased injecting cessation. While these findings are encouraging, it is concerning that Aboriginal participants were less likely to enter addiction treatment. This finding is consistent with prior reports (Wood et al., 2005a; Wood et al., 2007b), and highlights the need for innovative and culturally appropriate addiction treatment services developed with full consultation with Aboriginal people who use drugs."

DeBeck, K., et al., "Injection drug use cessation and use of North America’s first medically supervised safer injecting facility." Drug and Alcohol Dependence. (2010), doi:10.1016/j.drugalcdep.2010.07.023.

18. Supervised Injection Facilities (SIFs) Associated With Improvements in Public Order and Reductions in Crime

"Our review suggests that SIFs target several public health problems that municipalities in North America may wish to consider, problems largely unaddressed by needle exchange, street-outreach, education campaigns, HIV counseling, and other conventional services. SIFs target injectors' use of public spaces to inject drugs in order to reduce the many risks associated with the practice. Compared to conventional services, SIFs provide greater opportunities for health workers to connect with injectors, and to move them into primary care, drug treatment, and other rehabilitation services. Finally, SIFs target the 'nuisance factor' of drug scenes -- the hazardous litter and intimidating presence of injectors congregating in city parks, public playgrounds and on street corners -- by offering them an alternative, supervised 'public' space. Our review also suggests that, for municipalities considering SIFs in order to address these problems, their implementation would not necessarily require any significant or fundamental changes in public policy or law: SIFs require the same working agreements with social service providers and the police that needle exchange, street-outreach, drug treatment and similar health programs for injectors already receive."

Broadhead, Robert S., Thomas Kerr, Jean-Paul C. Grund, and Frederick L. Altice, "Safer Injection Facilities in North America: Their Place in Public Policy and Health Initiatives," Journal of Drug Issues (Tallahassee, FL: Florida State University, Winter 2002), Vol. 32, No. 1, p. 347-8.

19. Cost Effectiveness of Supervised Consumption Facilities

"Focusing on the base assumption of decreased needle sharing as the only effect of the supervised injection facility, we found that the facility was associated with an incremental net savings of almost $14 million and 920 life-years gained over 10 years. When we also considered the health effect of increased use of safe injection practices, the incremental net savings increased to more than $20 million and the number of life-years gained to 1070. Further increases were estimated when we considered all 3 health benefits: the incremental net savings was more than $18 million and the number of life-years gained 1175."

Bayoumi, Ahmed M. and Zaric, Gregory, "The cost-effectiveness of Vancouver’s supervised injection facility," Canadian Medical Association Journal (Ottawa, Ontario: November 18, 2008), Vol. 179, Issue 11, p. 1143.

20. Cost-Benefit Analysis of a Supervised Injection Facility

"The model used here [18], predicted the number of new HIV and HCV cases prevented based on the needle sharing rate. This included the impact of behavioral changes in injection activities outside of the SIF. The behavioral change, according to Table 2 and Table 3, was only considered twice (once for the first SIF and later for the second SIF)—this modeling decision is apparent in the marginal number of new HIV cases averted in Tables 3, 4 and 5. This calculation of behavioral impact is based on a conservative odds-ratio that falls within the limit specified by Kerr et al. (2005) [40].

"As expected, the results presented in Table 2 and Table 3 show that increasing the scope of SIFs through site expansion would result in a decrease of HIV infection cases. The model predicts: 14–53 fewer HIV cases and 84–327 fewer HCV cases annually, with the marginal range being much smaller: 5–14 fewer HIV cases and 33–84 fewer HCV cases annually.

"This range disparity, as outlined in Table 2 and Table 3, translates into substantial differences between the economic evaluation of SIFs with respect to the cumulative versus marginal estimates: the total effect of establishing SIFs and the effect of establishing each subsequent SIF, respectively.

"For example, according to Table 3, the cumulative annual estimates of new HIV cases averted, translates into a cost savings for society ranging from $0.764 million (benefit) for the first SIF to -$4.1 million (loss) for the seventh SIF. Benefit-cost ratios range from 1.35 to 0.73, and cost-effectiveness values range from $155,914 to $288,294 (cost per lifetime treatment). The cumulative annual estimates of new HCV cases averted translate into a cumulative cost savings that range from $0.769 million (benefit) for the first SIF to -$3.7 million (loss) for the seventh SIF. Benefit-cost ratios range from 1.35 to 0.73, and incremental cost-effectiveness values range from $25,986 to $46,727 (cost per lifetime treatment).

"In contrast, the marginal estimates of Montreal’s SIF expansion translate into a much smaller return. This is particularly true with respect to its benefit-cost and cost-effectiveness ratios. For instance, the marginal benefit-cost ratio varies from 1.35 to 0.77 for HIV and 1.35 to 0.76 for HCV. The marginal cost-effectiveness value for HIV ranges from $155,914 to $436,560 (cost per life- time treatment). The HCV marginal cost-effectiveness value ranges from $25,986 to $66,145 (cost per lifetime treatment)."

Jozaghi et al., "A cost-benefit/cost-effectiveness analysis of proposed supervised injection facilities in Montreal, Canada." Substance Abuse Treatment, Prevention, and Policy 2013 8:25. doi:10.1186/1747-597X-8-25.

21. States, Federal Law, and Supervised Consumption Sites

"States have clear legal authority to authorize SIFs, just as they can legalize the cultivation, distribution, and possession of marijuana for medical purposes.76 State authorization could make a SIF legal under state law and prevent state law enforcement officials from taking action against it. It is equally clear, however, that state authorization cannot nullify federal drug laws, and so does not protect a SIF against being shut down by federal law enforcement agencies through raids, arrests, or other legal proceedings.

"There are at least 2 sections of the federal Controlled Substances Act that could be interpreted to bar a SIF. Section 844 prohibits drug possession and so is violated by every client who appears at the clinic with drugs.77 Although federal law enforcement officials rarely if ever target simple possession by individuals,78 the law would allow them to do so if they wished to interfere with the operation of a SIF.

"A SIF authorized at the state or local level could also be deemed to violate Section 856, known as the Crack House Statute. This law makes it illegal to 'knowingly open or maintain . . . [or] manage or control any place . . . for the purpose of unlawfully . . . using a controlled substance.'"

Leo Beletsky, Corey S. Davis, Evan Anderson, and Scott Burris, "The Law (and Politics) of Safe Injection Facilities in the United States," American Journal of Public Health, (Vol. 98, No. 2) February 2008, p. 234.

22. Safe Injection Sites and International Drug Control Treaties

"23. It might be claimed that this approach [drug injection rooms] is incompatible with the obligations to prevent the abuse of drugs, derived from article 38 of the 1961 Convention and article 20 of the 1971 Convention. It should not be forgotten, however, that the same provisions create an obligation to treat, rehabilitate and reintegrate drug addicts, whose implementation depends largely on the interpretation by the Parties of the terms in question. If, for example, the purpose of treatment is not only to cure a pathology, but also to reduce the suffering associated with it (like in severe-pain management), then reducing IV drug abusers exposure to pathogen agents often associated with their abuse patterns (like those causing HIV-AIDS, or hepatitis B) should perhaps be considered as treatment. In this light, even supplying a drug addict with the drug he depends on could be seen as a sort of rehabilitation and social reintegration, assuming that once his drug requirements are taken care of, he will not need to involve himself in criminal activities to finance his dependence."

"Flexibility of Treaty Provisions as Regards Harm Reduction Approaches," Legal Affairs Section UNDCP (Vienna, Austria: International Narcotics Control Board, September 30, 2002), p. 5.

23. Evaluation of a Supervised Injection Center

"The only comprehensive evaluation of a medically supervised injecting centre was conducted during the 18 month trial of the Sydney centre. Staff intervened in 329 overdoses over one year with an estimate of at least four lives saved a year. There was no increase in reported hepatitis B or C infections in the area that the medically supervised injecting centre served despite an increase elsewhere in Sydney.

"The report described a decreased frequency of injecting related problems among clients. Half the centre's clients reported that their injecting practices had become less risky since using the centre. Furthermore, clients were more likely than other injectors to report that they had started treatment for their drug use; 11% of clients were referred to treatment for drug dependence. An economic evaluation of deaths averted by intervention of the medically supervised injecting centre showed that costs were comparable to those of other widely accepted public health measures.

"The centre also had benefits for the local community. Residents and business respondents reported fewer sightings of public injection and syringes discarded in public places, and syringe counts in the vicinity of the centre were lower after it opened than before. In addition, there was no evidence of an increased number of theft and robbery incidents in the area. Acceptance of the medically supervised injecting centre increased among both businesses and residents over the study period."

Wright, Nat M.J., Charlotte N.E. Tompkins, "Supervised Injecting Centres," British Medical Journal, Vol. 328, Jan. 10, 2004, p. 100.

24. Supervised Consumption Sites and Public Consumption

"Consumption rooms can reduce significantly the level of drug use in public. The extent to which this is achieved depends on their accessibility, opening hours and capacity to accommodate drug consumptions that would otherwise occur in public.

"The location of consumption rooms needs to be compatible with the needs of drug users but also to take account of the needs and expectations of local residents. A reduction in the number of public consumptions can contribute to improvements in the neighbourhood by helping to reduce public nuisance associated with open drug scenes. However, facilities near illicit drug markets are not able to solve wider nuisance problems that result from these markets.

"Police actions against drug markets and drug scenes in other neighbourhoods may sometimes increase public order problems near consumption rooms. This implies that, if rooms are to contribute to reducing public nuisance rather than be blamed for aggravating it, there needs to be consultation not only with local residents but also with police, so that action to discourage open drug scenes does not at the same time deter drug users from making use of the facilities."

Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 82.

25. No Evidence That Supervised Consumption Sites Lead To Acquisitive Crime

"There is no evidence that the operation of consumption rooms leads to more acquisitive crime. There is small-scale drug dealing in the vicinity of many services, which is not surprising given their location."

Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 82.

26. Supervised Consumption Sites Do Not Encourage Drug Use

"There is no evidence that consumption rooms encourage increased drug use or initiate new users. There is little evidence that by providing better conditions for drug consumption they perpetuate drug use in clients who would otherwise discontinue consuming drugs such as heroin or cocaine, nor that they undermine treatment goals.

"When managed in consultation with local authorities and police, they do not increase public order problems by increasing local drug scenes or attracting drug users and dealers from other areas. If consultation and cooperation between key actors does not take place, then there can be a risk of a'pull effect' and consumption rooms run the risk of being blamed for aggravating local problems of public order including drug dealing."

Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 83.

27. Supervised Consumption Sites Do Not Lead To Initiation Into Substance Use

"Consumption rooms reach a population of often older, long-term users some of whom have had no previous treatment contact. Services appear particularly successful in attracting groups that are difficult to reach. No evidence was found to suggest that naive users are initiated into injecting as a result of the presence of consumption rooms."

Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 41.

28. Effectiveness of Supervised Consumption Sites

"Evidence indicates SIFs [Safe Injection Facilities] are uniquely effective in sustaining contact with the most marginalised and chaotic users who inject drugs in public places. These users are at the greatest risk for disease and death, and are also the least likely to engage directly in a traditional abstinence-based health services. Evidence indicates that SIFs can reduce drug overdose deaths; minimize risks for abscesses, bacterial infections and endocarditis; minimise the risk of HIV, hepatitis C and hepatitis B transmission; and increase referral to drug treatment and other health services, while improving public order."

Barbara Tempalski and Hilary McQuie, "Drugscapes and the role of place and space in injection drug use-related HIV risk environments," International Journal of Drug Policy, (2009), p. 9.

29. Effectiveness of Supervised Consumption Sites and Public Perceptions

"Neighbourhood attitudes and perceptions. Surveys of local residents and businesses, as well as registers of complaints made to the police, generally show positive changes following the establishment of consumption rooms, including perceptions of decreased nuisance and increases in acceptance of the rooms. Police, too, often acknowledge that consumptions contribute to minimising or preventing open drug scenes.

"Open drug scenes and police policy. There are instances where consumption rooms have been blamed for increasing public nuisance, including open drug scenes and dealing. These arose where police actions in other areas had the effect of relocating drug markets and open scenes.

"Pull effect. Available evidence is not sufficient to draw conclusions on whether consumption rooms exert a 'pull-effect' by attracting drug users from other areas, thus adding to the situation already created by established drug markets. Attempts to decentralise drug scenes by dispersing consumption rooms have not led to increased nuisance around the rooms. However, they have not attracted large numbers of clients either."

Hedrich, Dagmar, "European Report on Drug Consumption Rooms" (Lisbon, Portugal: European Monitoring Centre on Drugs and Drug Addiction, February 2004), p. 81.

30. Supervised Consumption Facilities and Public Order

"We found significant reductions in public injection drug use, publicly discarded syringes and injection-related litter after the opening of the medically supervised safer injecting facility in Vancouver. These reductions were independent of law enforcement activities and changes in rainfall patterns.

"Our findings are consistent with anecdotal reports of improved public order following the establishment of safer injecting facilities and are not surprising given that a commonly reported reason for public drug use is the lack of an alternative place to inject and that IDUs who go to safer injecting facilities are often homeless or marginally housed. Our findings are also highly plausible since more than 500 IDUs visited the facility daily after it opened, and several feasibility studies have suggested that IDUs who inject in public would be the most likely to use safer injecting facilities. Our observations suggest that the establishment of the safer injecting facility has resulted in measurable improvements in public order, which in turn may improve the liveability of communities and benefit tourism while reducing community concerns stemming from public drug use and discarded syringes. It is also noteworthy that we did not observe an increase in the number of drug dealers in the vicinity of the facility, which indicates that the facility's opening did not have a negative impact on drug dealing in the area. Although further study of these issues is necessary, the safer injecting facility may also offer public health benefits, since public injection drug use has been associated with an array of health-related harms."

Wood, Evan, Thomas Kerr, Will Small, Kathy Li, David C. Marsh, Julio S.G. Montaner & Mark W. Tyndall, "Changes in Public Order After the Opening of a Medically Supervised Safer Injecting Facility for Illicit Injection Drug Users," Canadian Medical Association Journal, Vol. 171, No. 7, Sept. 28, 2004.

31. Supervised Consumption Facilities Associated With Reductions in Public Use

"In summary, we documented significant reductions in the number of IDUs injecting in public, publicly discarded syringes and injection-related litter after the opening of the medically supervised safer injecting facility. These reductions appeared to be independent of several potential confounders, and our findings were supported by external data sources. Although the overall health impacts of the facility will take several years to evaluate, the findings from this study should be valuable to other cities that are contemplating similar evaluations and should have substantial relevance to many urban areas where public injection drug use has been associated with substantial public health risks and adverse community impacts."

Wood, Evan, Thomas Kerr, Will Small, Kathy Li, David C. Marsh, Julio S.G. Montaner & Mark W. Tyndall, "Changes in Public Order After the Opening of a Medically Supervised Safer Injecting Facility for Illicit Injection Drug Users," Canadian Medical Association Journal, Vol. 171, No. 7, Sept. 28, 2004, p. 734.

32. Proof of Insite's Success

"Since its inception, Insite has been subject to an independent review by a team of physicians and scientists put in place to provide an 'arm’s length' evaluation of the program. The results of this scientific evaluation have been published in peer-reviewed academic journals and have indicated that Insite has reduced unsafe injection practices, public disorder, overdose deaths and HIV/Hepatitis while increasing uptake of addiction services and detox [8]. To date, there have been over three-dozen peer-reviewed papers evaluating Insite published making it one of the most evaluated healthcare programs in the history of Canada [9-38]. In light of the evidence, the program has garnered widespread support from Canadian physicians, scientists and healthcare professionals."

Small, Dan, "An appeal to humanity: legal victory in favour of North America’s only supervised injection facility: Insite," Harm Reduction Journal (London, United Kingdom: October 2010), Vol. 7.

33. Insite, Canada's First Supervised Consumption Facility

"Insite opened on 21 September of 2003 under an exemption granting it status as a scientific pilot study until 12 September 2006. The primary goals of the program are: (1) to reach a marginalized group of IDUs with healthcare and supports who would otherwise be forced to use drugs in less safe settings (2) to reduce dangerous injection practices (syringe sharing) thereby reducing the risk of infectious diseases like HIV and HCV; and (3) to reduce fatal overdoses in the population of people that use the facility. The program also aims to provide referrals to treatment and detoxification, reduce public disorder (public injection) and validate the personhood of a deeply stigmatized target population."

Small, Dan, "An appeal to humanity: legal victory in favour of North America’s only supervised injection facility: Insite," Harm Reduction Journal (London, United Kingdom: October 2010), Vol. 7, p. 1.

34. Medical Care Cost Savings Associated With Supervised Consumption Facilities

"Lifetime HIV-related medical care costs are approximately $210,555 in 2008 Canadian dollars (Pinkerton, 2010). Consequently, by preventing 5–6 HIV infections per year, the Insite SIF averts more than $1,000,000 in future HIV-related medical care costs. Andresen and Boyd (2010) estimate that the SIF generates $660,000 in additional cost savings by preventing 1.08 overdose deaths per year. The total savings due to averted HIV-related medical care costs and prevented overdose deaths (approximately $1.7 to $1.9 million per year), in and of itself, is just slightly greater than the estimated $1.5 million annual operating cost of the Insite SIF."

Pinkerton, Steven D., "How many HIV infections are prevented by Vancouver Canada’s supervised injection facility?" International Journal of Drug Policy (London, United Kingdom: International Harm Reduction Association, March 11, 2011), p. 5.

35. Studies Show Many Positive Benefits From Supervised Consumption Facilities

"The British Columbia Centre for Excellence in HIV/AIDS was commissioned to evaluate Insite. A study published in 2006 showed that there was an increase in uptake of detoxification services and addiction treatment.13 Another study published that year showed that Insite did not result in increased relapse among former drug users, nor was it a negative influence on those seeking to stop drug use.14 Results of studies using mathematical modelling showed that about one death from overdose was averted per year by Insite.1 A subsequent study estimated 2–12 deaths averted per year.15 Although these studies did not have sufficient power to detect any difference in incidence of blood-borne infections, Kerr and colleagues did find that Insite users were 70% less likely to report needle-sharing than those who did not use the facility.16 Before the opening of Insite, those same individuals reported needle-sharing that was on par with cohort averages. As for public order, Wood and colleagues found that there was no increase in crime following the opening of the facility.17 In fact, there had been statistically significant decreases in vehicle break-ins and theft, as well as decreases in injecting in public places and injection-related litter."

Dooling, Kathleen and Rachlis, Michael, "Vancouver’s supervised injection facility challenges Canada’s drug laws," Canadian Medical Association Journal (Ottawa, Ontario: September 21, 2010), Vol. 182, Issue 13, p. 1441.

36. Detox Service Use Among People Using A SIF

"The present study demonstrates that the opening of the Vancouver SIF was associated with a greater than 30% increase in the rate of detoxification service use among SIF users in comparison to the year prior to the SIF's opening. Subsequent analyses demonstrated that detoxification service use was associated with increased use of methadone and other forms of addiction treatment, as well as reduced injecting at the SIF."

Wood, Evan, Tyndall, Mark W., Zhang, Ruth, Montaner, Julio S.G., and Kerr, Thomas, "Rate of Detoxification Service Use and its Impact among a Cohort of Supervised Injecting Facility Users," Addiction (2007), Vol. 102, p. 918.

37. Services Provided By SIFs May Contribute To Reduced Rates Of Injection Drug Use

"In summary, the present study demonstrates that the SIF was associated with increased use of detoxification service use and that residential detoxification was associated with increased rates of methadone use and other forms of addiction treatment. Given the known role of methadone and other forms of addiction treatment in reducing levels of injection drug use, and given that detoxification programme use was associated with reduced injecting at the SIF, our findings imply that the SIF has probably helped to reduce rates of injection drug use among users of the facility."

Wood, Evan; Tyndall, Mark W.; Zhang, Ruth; Montaner, Julio S.G.; and Kerr, Thomas, "Rate of Detoxification Service Use and its Impact among a Cohort of Supervised Injecting Facility Users," Addiction (2007), Vol. 102, p. 918.

38. Benefits of a Supervised Consumption Facility

"Our study indicates that the opening of North America's first supervised injection facility was not associated with measurable negative changes in the use of injected drugs. Indeed, we found a substantial reduction in the starting of binge drug use after the opening of the facility, suggesting that it had not prompted 'risk compensation' among local injecting drug users, whereby the benefits of a safer environment are overcome by more risky behaviours such as higher intensity drug use."

Kerr, Thomas, Jo-Anne Stoltz, Mark Tyndall, Kathy Li, Ruth Zhang, Julio Montaner, Evan Wood, "Impact of a medically supervised safer injection facility on community drug use patterns: a before and after study," British Medical Journal, Vol. 332, Jan. 28, 2006, pp. 221-222.

39. Benefits From Supervised Consumption Facilities

"Evaluation of the Vancouver facility has shown that its opening has been associated with reductions in public drug use and publicly discarded syringes and reductions in syringe sharing among local injecting drug users. Our study suggests that these benefits have not been offset by negative changes in community drug use."

Kerr, Thomas, Jo-Anne Stoltz, Mark Tyndall, Kathy Li, Ruth Zhang, Julio Montaner, Evan Wood, "Impact of a medically supervised safer injection facility on community drug use patterns: a before and after study," British Medical Journal, Vol. 332, Jan. 28, 2006, p. 222.

40. Safe Injection Facilities and Overdose Mortality

"In summary, there have been many overdose events within Vancouver's SIF [safe injection facility], although the rate of overdoses is similar to rates observed in SIF in other settings. The majority of these overdoses involved the injection of opiates, and most events were successfully managed within the SIF through the provision of oxygen. It is noteworthy that none of the overdose events occurring at the SIF resulted in a fatality. These findings suggest that SIF can play a role in managing overdoses among IDU [injection drug users] and indicate the potential of SIF to reduce morbidity and mortality associated with illicit drug related overdoses."

Thomas Kerr, Mark W. Tyndall, Calvin Lai, Julio S.G. Montaner, Evan Wood, "Drug-related overdoses within a medically supervised safer injection facility," International Journal of Drug Policy 17 (2006) p. 440.

41. Supervised Consumption Sites and Overdose Mortality

"In this population-based analysis, we showed that overdose mortality was reduced after the opening of a SIF. Reductions in overdose rates were most evident within the close vicinity of the facility—a 35% reduction in mortality was noted within 500 m of the facility after its opening. By contrast, overdose deaths in other areas of the city during the same period declined by only 9%. Consistent with earlier evidence showing that SIFs are not associated with increased drug injecting (panel),38,39 these findings indicate that such facilities are safe and effective public-health interventions, and should therefore be considered in settings with a high burden of overdose related to injection drug use.

"In both the primary and sensitivity analyses, we saw no significant reductions in overdose mortality further than 500 m from the SIF. This finding is not surprising, since over 70% of frequent SIF users reported living within four blocks of the facility. Although the facility operates at capacity with over 500 supervised injections per day on average,23 it is a pilot programme with only 12 injection seats in a neighbourhood with about 5000 injection drug users.40 Therefore, and since previous studies have shown that waiting times and travel distance to the facility are barriers to SIF use,41 larger reductions in community overdose mortality would probably require an expansion of SIF coverage."

Marshall, Brandon D L; Milloy, M-J; Wood, Evan; Montaner, Julio S G; Kerr, Thomas, "Reduction in overdose mortality after the opening of North America's first medically supervised safer injecting facility: a retrospective population-based study," The Lancet (London, United Kingdom: April 18, 2011) Volume 377, Issue 9775, pp. 1429-1437.

42. Insite Users and Other Drug Use

"Although there was a substantial increase in the number of participants who started smoking crack cocaine, it is unlikely that the facility, which does not allow smoking in the facility, prompted this change. These findings are relevant to a recent review of supervised injection facilities by the European Monitoring Centre on Drugs and Drug Addiction, which highlighted concerns that these facilities could potentially 'encourage increased levels of drug use' and 'make drug use more acceptable and comfortable, thus delaying initiation into treatment.'"

Kerr, Thomas, Jo-Anne Stoltz, Mark Tyndall, Kathy Li, Ruth Zhang, Julio Montaner, Evan Wood, "Impact of a medically supervised safer injection facility on community drug use patterns: a before and after study," British Medical Journal, Vol. 332, Jan. 28, 2006, p. 222.