Although we agree that there is need for an expansion of treatment services in Canada, evidence from Germany, the Netherlands and Switzerland suggests that a continuum of services that includes low-threshold services (e.g., safe injection facilities) constitutes the most effective means of reducing drug-related harm.1,2 No intervention, be it abstinence-based treatment, methadone treatment or safe injection facilities, can stand alone as a panacea.2 We believe that safe injection facilities could serve a purposeful and complementary role in our continuum of services, and therefore a rigorous trial and evaluation of safe injection facilities is warranted.
With respect to the complementary effects of safe injection facilities, research from Switzerland has shown that low-threshold services such as safe injection facilities serve to increase the number of injection drug users entering treatment.1 During the mid-1980s Swiss medium- and high-threshold services (e.g., methadone and drug treatment) only contacted 20% of active injection drug users.1 Following the implementation of safe injection facilities and other low-threshold services, the number of injection drug users entering treatment increased to 65%, and by necessity, treatment services were expanded.1 According to Swiss reports, the remaining 35% of injection drug users were in regular contact with low-threshold services, which in turn served to minimize harm among people who continued to inject while reducing the impact of drug use on communities.1
Safe injection facilities have contributed to higher rates of referral to drug treatment. This can in part be attributed to increased opportunities for sustained contact between health care professionals and street-based injection drug users.3 Although needle exchange and street-outreach workers make frequent contact with injection drug users, the great majority of these interactions tend to be cursory and on-the-run.4,5 Safe injection facilities place trained staff in direct proximity with injection drug users while they are waiting to consume their drugs, as well as after they have done so and have returned to the waiting room. Moreover, safe injection facilities offer many needed services on-site: needle exchange, counselling, primary medical care, drug treatment, shower and laundry, and other services, depending on resources. There is substantial research that indicates that injection drug users will avail themselves of drug treatment and other services at much higher rates if they are offered on-site rather than externally.6,7 Although Gordon Brock and Vydas Gurekas may question the transferability of these effects, we can conceive of no reason why Canadian drug users would be less likely to avail themselves of these services when similar referral mechanisms are implemented.
Discussions concerning the costs and interventions associated with injection drug use should not be limited to health service budgets and the associated priorities. As the Auditor General pointed out in a recent report, the total cost of illicit drug use in Canada is estimated to be $5 billion.8 Of the $500 million devoted to enforcement, prevention, treatment and harm reduction, $475 million is used for enforcement. Perhaps what is needed is a redistribution of funds rather than increased investment in only one component of the health system. Clearly, a more comprehensive approach is needed to reduce the health, social and economic consequences of injection drug use in Canada.
Signatures
Thomas Kerr
Department of Psychology University of Victoria Victoria, BC
Anita Palepu
Centre for Evaluation and Outcome Sciences St. Paul's Hospital Vancouver, BC
References
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