North America's first supervised injecting facility (SIF) in Vancouver, Canada has helped to reduce the number of fatal overdoses in the community by 35%. Thus, authorities should consider establishing SIFs wherever injection drug use is prevalent, particularly in areas with high densities of overdose. These are the conclusions of an Article published Online First and in an this week's Lancet, written by Dr Thomas Kerr and colleagues from the Urban Health Research Initiative, BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada.
Overdose from illicit drugs is a leading cause of premature mortality in North America. Internationally, more than 65 supervised injecting facilities (SIFs), where drug users can inject pre-obtained illicit drugs, have been opened as part of various strategies to reduce the harms associated with drug use.
In Vancouver, high rates of overdose mortality in the 1990s led to the establishment of North America's first medically supervised safer injecting facility (SIF) in the city's Downtown Eastside, a community known for its open drug market and massive HIV epidemic. The environment is characterised by high rates of multi-drug use, including heroin, cocaine, and metamfetamine injection in addition to crack cocaine smoking. The neighbourhood also has a high concentration of low-cost housing, large numbers of homeless people, and high levels of drug-related disorder, including public drug injecting.
With the assistance of the British Columbia Coroner's Service, the authors collected information on every drug-related overdose death that occurred in Vancouver between 2001 and 2005. A technique called geocoding was used to find out where each overdose death occurred in relation to the SIF. The authors then examined population-based overdose mortality rates for the period before (Jan 1, 2001, to Sept 20, 2003) and after (Sept 21, 2003, to Dec 31, 2005) the opening of the Vancouver SIF. The overdose fatality rates within a 500 m radius of the SIF and for the rest of the city were compared.
Of 290 drug overdose deaths, 229 (79•0%) were male, and the median age at death was 40 years. Just under a third (31%) of deaths occurred in city blocks within 500 m of the SIF. The fatal overdose rate in this area decreased by 35% after the opening of the SIF, from 254 to 165 deaths per 100 000 person-years. By contrast, during the same period, the fatal overdose rate in the rest of the city decreased by only 9%, from 7•6 to 6•9 deaths per 100 000 person-years.
The authors conclude: "Our results suggest that SIFs are an effective intervention to reduce community overdose mortality in Canada and in other cities internationally, and should be considered for assessment particularly in communities with high levels of injection drug use."
In a linked Comment, Dr Chris Beyrer, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, says: "This intervention also has a human-rights dimension, as does the legal controversy now surrounding it. A [Canadian] lower-court decision in favour of the supervised injection facility argued that closing the site would undermine Canada's Charter of Rights and Freedoms to life, liberty, and security of the person. Kerr and colleagues' report adds credence to this argument, because an intervention that reduces preventable deaths from overdose certainly helps to realise the rights to life and to security."
He concludes: "Supervised injection facilities clearly have an important part to play in communities affected by injection drug use. They should be expanded to other affected sites in Canada, on the basis of the life-saving effects identified in Vancouver. Moreover, such facilities should be taken to scale more broadly—wherever drug overdoses are a substantial cause of preventable losses of life. That such a move will be politically fraught in other settings is virtually assured. All the more reason, then, to begin action now."
Dr Thomas Kerr, Urban Health Research Initiative, BC Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, BC, Canada. T) please complete telephone number E) uhri-tk@cfenet.ubc.ca
Dr Chris Beyrer, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. T) please complete telephone number E) cbeyrer@jhsph.edu
Journal
The Lancet