Evaluating the Efficacy of Safe Injection Sites with Respect to Common Arguments in Support and Opposition

Daniel Doherty, BA

Lewis Katz School of Medicine at Temple University

SUMMARY POINTS

• Safe Injection Sites are facilities that use harm reduction principles to avoid the worst consequences of opioid use disorders.

• These facilities remain controversial in the US despite their apparent success in other parts of the world.

• Common arguments against Safe Injection Sites are not supported by existing evidence, while common arguments in favor are.

• Research into these facilities is limited by the nature of the work they do as well as the limited number of facilities available to be studied.

• Safe Injection Sites are not a perfect solution to the opioid epidemic, but their merits warrant further investigation.

ANALYSIS

Background

Safe Injection Sites (SIS) use harm reduction to combat the worst consequences of opioid use disorders. Specifically, they provide locations where people can safely inject previously acquired drugs under the supervision of healthcare professionals. The first opened in Europe in 1986, and while the strategy has gained traction there as well as Canada and Australia, their implementation in the US remains controversial (1).

There are many arguments both for and against US SIS expansion. A poll of US adults asked about arguments identified by researchers as the most common pro- and anti-SIS statements. Respondents were more likely to agree with anti-SIS arguments than pro-SIS arguments. Respondents most commonly agreed that funds would be better spent on treatment of substance use disorder, that sites condoning illegal activity should be illegal, that sites would encourage further drug use, and that implementation would increase illegal activity in the area. Among the arguments for, respondents most commonly agreed that SIS would present a better alternative to arrests for drug use, prevent the spread of infectious disease, reduce costs incurred by opioid-related ER visits and hospitalizations, and provide opportunities to refer people who inject drugs (PWID) to further treatment (2). Evaluating these arguments is difficult due to the limited number of sites available for study, but from research in other countries, this analysis will seek to evaluate the efficacy of SIS in reducing mortality, as well as qualify the merit of the above arguments.

Analysis

Data from existing SIS show efficacy in reducing mortality. Among PWID living within 500 meters of Insite, Vancouver’s first SIS, mortality decreased by 35% despite no change for the rest of the city. Previously, this area accounted for a third of overdose deaths in the city (3). While overdoses did occur at the site in 0.1% of injections, there have been no recorded deaths (4). 

Hospitalization length and infectious disease transmission similarly decrease when cities implement SIS. After the opening of Insite, hospitalized skin infection patients who had first been treated at the SIS stayed for an average of 4 days, compared to an average of 12 for those who had not. The first group were more likely to present to the hospital in earlier stages of infection, making hospitalizations shorter and less complex (5). Additionally, models of HIV infection rates estimate that Insite prevents an average of 35 new HIV cases annually (6). 

Evidence suggests that SIS attendance is likewise associated with a higher likelihood of seeking addiction treatment. In Vancouver after the opening of Insite, PWID were 30% more likely to use detoxification services, leading to a statistically significant decrease in rates of SIS usage (7). Studies in Barcelona additionally showed that PWID who visited the SIS at least once per day were 2.12 times more likely to access addiction services (8).

SIS are also cost effective. Estimates based on per-day costs of hospitalizations suggest that each skin infection referral from Insite saved CA$5,696 (5). Additional estimates suggest that the savings accrued from reductions in HIV transmission alone totaled up to CA$6 million annually (6). Overall, estimates of a hypothetical site in Baltimore suggest $1.8 million costs could yield savings of up to $7.8 million from prevention of infections and deaths, reduction in ambulance calls and ED visits, and decreased long term costs due to increases in addiction treatment (9).

One of the major concerns regarding SIS is that their presence will increase crime and disorder. However, existing data refute this. In the area surrounding Insite in Vancouver, comparing crime rates before and after the site was opened showed no change in drug trafficking, assault, or robbery, and decreased vehicle break-ins/thefts (10). Additional investigation into metrics of disorder showed that after the opening of the site, PWID injecting in public, publicly discarded syringes, and litter all decreased (11).

Discussion

As shown above, research into the effects of SIS yields positive results and addresses many of the most relevant issues identified by US poll respondents. The claim that sites condoning illegal activity should be illegal is out of scope, as this concerns drug scheduling and enforcement. However, evidence contradicts two of the four listed arguments against SIS, that sites would increase illegal activity and that money would be better spent on treatment. Sites have increased the rates of individuals seeking treatment, pay for themselves, and have not increased illegal activity. The argument that SIS increases drug use should be studied further. Regarding positive arguments, data suggest that SISs prevent the spread of disease, reduce costs, and provide opportunities to refer individuals to further treatment. The argument that SIS are a better alternative to arrests is based more on values than data and is thus difficult to dispute or support.

Despite this evidence, these studies have limitations. First, there are a limited number of sites and researchers producing much of the research. More research should be done at other sites in order to ensure generalizability, and by more researchers to limit potential bias. Additionally, the sites themselves are not designed with research in mind. Randomized control trials of these facilities are not possible, making observational studies the primary method of data collection. Of further note, universal healthcare may impact outcomes, as the SIS that currently exist and have been studied are located in countries with such a program.

Nevertheless, the data are promising, and notably misaligned with public opinion in the US. In addition to a need for further research, there is a need for improved public health messaging to assuage societal fears about these programs and ensure policy matches evidence. Studies cannot be performed on sites that do not exist. Thus, more sites in more places will allow more research in diverse settings, improving the quality of knowledge. Sites opened in the US should be heavily studied both to ensure harm reduction and reproducibility of successes. These sites are a potential benefit with potential risk, and are neither a perfect nor hopeless strategy in combating the opioid epidemic.

REFERENCES

1. Hedrich D, Kerr T, Dubois-Arber F. Drug consumption facilities in Europe and beyond.

2. In: Harm reduction: Evidence, impacts and challenges. European Monitoring Centre for Drugs & Drug Addiction; 2010.

3. Barry CL, Sherman SG, Stone E, et al. Arguments supporting and opposing legalization of safe consumption sites in the U.S. International Journal of Drug Policy. 2019;63:18-22. doi:https://doi.org/10.1016/j.drugpo.2018.10.008

4. ‌Marshall BD, Milloy MJ, Wood E, Montaner JSG, Kerr T. Reduction in overdose mortality after the opening of North America’s first medically supervised safer injecting facility: a retrospective population-based study. Lancet. 2011;377(9775):1429–37.

5. Kerr T, Tyndall MW, Lai C, Montaner JSG, Wood E. Drug-related overdoses within a medically supervised safer injection facility. Int J Drug Policy. 2006;17(5):436–41.

6. Lloyd-Smith E, Wood E, Zhang R, Tyndall MW, Sheps S, Montaner JSG, et al. Determinants of hospitalization for a cutaneous injection-related infection among injection drug users: a cohort study. BMC Public Health. 2010;10:327.

7. Andresen MA, Boyd N. A cost-benefit and cost-effectiveness analysis of Vancouver’s supervised injection facility. Int J Drug Policy. 2010;21(1):70–6.

8. E Wood, MW Tyndall, R Zhang, JS Montaner, T. Kerr. Rate of detoxification service use and its impact among a cohort of supervised injecting facility users. Addiction, 102 (6) (2007), pp. 916-919.

9. C Folch, N Lorente, X Majó, et al. Drug consumption rooms in Catalonia: a comprehensive evaluation of social, health and harm reduction benefits. Int J Drug Policy, 62 (2018), pp. 24-29.

10. Finke J, Chan J. The Case for Supervised Injection Sites in the United States. Am Fam Physician. 2022 May 1;105(5):454-455. PMID: 35559640.

11. Wood E, Tyndall MW, Lai C, Montaner JS, Kerr T. Impact of a medically supervised safer injecting facility on drug dealing and other drug-related crime. Subst Abuse Treat Prev Policy. 2006 May 8;1:13. doi: 10.1186/1747-597X-1-13. PMID: 16722550; PMCID: PMC1471778.

12. Wood E, Kerr T, Small W, Li K, Marsh DC, Montaner JS, Tyndall MW. Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users. CMAJ. 2004 Sep 28;171(7):731-4. doi: 10.1503/cmaj.1040774. PMID: 15451834; PMCID: PMC517857.