Safe injection facilities in Canada: Is it time?

About 100 000 Canadians are injection drug users (IDUs), and almost one-third live in Toronto, Montreal or Vancouver.¹ Illicit drug injection is associated with significant health and social consequences for drug users, their families and communities. The consequences include injection-related infections, overdose, bloodborne disease transmission, exposure to discarded needles, violence, property crime and sex trade.

Two articles in this issue of CMAJ highlight the continuing unsafe injection practices² and the health-related consequences³ that are occurring in a cohort of IDUs in Vancouver despite the availability of a large needle-exchange program.^4,5 In the first report (page 405), 214 (27.6%) of 776 participants from the Vancouver Injection Drug User Study (VIDUS) stated that they had recently shared needles.² Factors associated with this high-risk behaviour included difficulty getting sterile needles, requiring help injecting, needle reuse, and frequent cocaine and heroin injection. In the second report (page 415), the downstream health effects of such behaviour are reflected in high rates of emergency department use and hospital admission: during a 39-month period 440 VIDUS participants made 2763 emergency department visits, and 210 participants were admitted to hospital 495 times.³ The most common reasons for emergency department visits were soft-tissue infections and other problems related to illicit drug use, such as overdose, intoxication and withdrawal. Most of the hospital admissions were the result of bacterial infections related to drug injection; these cases might have been prevented if safe injection techniques had been used.

In Canada, British Columbia has the highest number of fatal overdoses, about 4.7 per 100 000 population annually, and in recent years illicit drug use has been the leading cause of death among adults 30 to 49 years of age.⁶ In the VIDUS cohort, overdose is the leading cause of death, regardless of HIV status.⁷ In terms of bloodborne infections, IDUs have recently accounted for 26% of all new cases of HIV infection in Canada,¹ and HIV-positive IDUs typically incur substantial medical costs.^3,8 In addition, 35% of IDUs among Montreal street youth and 88% of VIDUS participants have hepatitis C.^4,9 IDUs who congregate in public areas to inject drugs are at increased risk of injection-related complications and bloodborne infections because of the lack of clean water or sterile injection equipment, and the presence of discarded needles.¹⁰ In addition, the concentration of IDUs in public areas affects nearby small businesses and discourages people from using public amenities.^10,11,12,13

In light of these circumstances, safe injection facilities must be considered. They have been part of a pragmatic harm reduction strategy in the Netherlands,¹³ Switzerland¹⁴ and Germany,^15,16 and a facility has recently been established in Australia on a trial basis.^16,17 A number of Canadian reports have called for the need to establish and evaluate such facilities.^1,18,19 Recently, Health Canada, in partnership with the Federal, Provincial and Territorial Task Group on Population Health, has created a task force that is examining the feasibility of a trial of safe injection facilities in Canada.¹ Experience in Europe and Australia indicates that there has been considerable acceptance of the facilities by health care professionals and IDUs.^12,15 Since offering a range of programs to address problems associated with illicit drug use, Switzerland and Germany have observed declines in HIV infection rates, drug-related overdoses and crime in the last decade.^20,21 During the same period, drug-related harm has increased in Canada.²¹

Programs for the management of people who inject illicit drugs can be categorized as high-, medium- and low-threshold. “Threshold” refers to the eligibility criteria for program entrance and the state of readiness to participate and meet program demands. For example, abstinence-based programs are high-threshold, standard methadone maintenance programs are considered medium-threshold, and needle-exchange and street-based outreach programs are low-threshold programs. The inclusion of a range of low-threshold harm reduction services such as safe injection facilities has been crucial to the success of comprehensive drug strategies in Europe. Unlike illegal “shooting galleries” run by drug dealers, safe injection facilities are controlled health care settings where people can inject pre-obtained drugs under staff supervision and receive sterile injecting equipment, primary health care, counselling, and referral to health and social services.

The goals associated with the establishment of safe injection facilities are to reduce the incidence of bloodborne disease transmission, overdoses and public nuisance associated with injection drug use; to improve the general health of IDUs; and to increase their use of appropriate primary health care and social services.

Typically, safe injection facilities achieve these goals by supervising injections in a controlled setting to ensure safety and quick response to overdoses; providing sterile injecting equipment and condoms, and collecting used needles and syringes; providing information on safer sex and injecting practices; providing counselling, primary health care and, in some cases, food; and maintaining and improving contact with marginalized IDUs and facilitating their reintegration into society through referral to various drug treatment services.

Safe injection facilities serve a unique and important function, particularly in terms of providing immediate response to overdoses,^17,22 increasing use of health and social services, and reducing the problems described earlier that are associated with injecting drugs in public.^10,11,12,13 Although outreach services and needle-exchange programs are able to provide sterile injecting equipment, and in some cases referrals, there are no indications that these services reduce the amount of injection drug use occurring in public spaces.¹⁰ As well, safe injection facilities offer more direct and sustained contact with IDUs. Within these sites, staff are better able to encourage people to seek help, to discuss health concerns with them and to provide them with immediate medical care, counselling or referrals.¹⁰ IDUs are allowed to return to the facilities throughout the day, which is beneficial to those who inject cocaine frequently. Before a range of low-threshold harm reduction services were introduced in Switzerland, data indicated that medium- and high-threshold services reached only 20% of IDUs.²¹ Safe injection facilities were established as a way of increasing contact with the most marginalized IDUs.^13,23

Given the ongoing harm associated with injection drug use and the lack of controlled outcome studies of safe injection facilities, there is a great need for rigorous evaluation to assess whether they will serve a useful role in Canada. The ethical imperative to provide more comprehensive care for IDUs is also evident.²⁴ Increased integration of low- and medium-threshold harm reduction strategies with primary care and expanded drug treatment options are the next steps Canada must take to curb the morbidity and mortality associated with illicit drug use.