Supervised Injection Facilities Lara Wilson, MD

DisclosuresNothing to report

Learning Objectives• Review current evidence on efficacy of supervised

consumption facilities for harm reduction

• Review structure and services of various models of safe consumption facilities

Target Questions

What does accessing a SIF look like?

How do SIFs impact their clients and communities?

What is the current status of legislation and SIF efforts in the US?

Current Status of Opioid Epidemic

SOURCE: Agarwal, Vignesh

Opioid Deaths by Race/Ethnicity, 2000 - 2019

SOURCE: Kaiser Family Foundation

Rise in Synthetic Opioids

Supervised Injection Facilities

Medically supervised, hygienic locations to consume illicit drugs

intravenously

Video Tour

Accessing a SIF

Intake

• Injection education

• Needs assessment

• Collect kit of clean supplies

Use

• Ensure compliance

• Medical assistance in case of overdose

Support services

• Crisis management

• Shelter• Counseling• Encourage to seek treatment (sometimes on-site)

SOURCE: Insite, Vancouver

Client Experiences

• High willingness to use SIFs• Motivated by safety concerns

It’s like a home away from home. It’s like a support center for junkies. The staff listen to you; they actually hear you and feel what you’re going through. And I think an increasingly large numbers of people are coming there to get acknowledged

They’re gonna wait til you drop; then you’ll

get “duged” [robbed] … But at least at InSite

I feel like someone would dial 911 and help

me … Since then, I decided to always do it

here … at least I’m safe here.

Why would I share? Nurses have taught me so

much about disease transmission that I’m

scared to share again.

The guy suddenly dropped. Boom, right away, the

nurses Narcaned him. One nurse was holding his

hand, telling him that he was going to be OK … Or

how they treat you as human beings; it does

make you feel good. When I come to InSite, I

don’t feel that I’m a junkie anymore.

I come to InSite for few reasons. First you don’t catch

disease. Second if you OD you aren’t going to die.

Third everything is available. You might not have

alcohol, water or rig; but when you go there you can

get whatever you need for free. It’s like a

“supermarket” for junkies

Variety of Models

How do SIFs impact clients and community?

Reduce overdose deaths

• No overdoses (Vancouver, Germany)

• 25% decrease in deaths in neighborhood (Vancouver)

• Seattle SIF pilot projected to annually reverse 167 overdoses and prevent 6 overdose deaths

US Experience, 2014-2019

Kral AH, Lambdin BH, Wenger LD, Davidson PJ. Evaluation of an Unsanctioned Safe Consumption Site in the United States. N Engl J Med. 2020;383(6):589-590.

How do SIFs impact clients and community?

Increase safe practices

• 75% of clients report changing injection practices after exposure to SIF (Vancouver)

• 32% increase in condom use for women at 2 years (Vancouver)

Decrease disease transmission

• 1,100 HIV cases prevented over 10 years (Vancouver)

• Estimated 65 cases of HCV could be prevented annually by 1 SIF (Montreal, prospective)

How do SIFs impact clients and community?

Do not increase IVDU

• No increase in use following opening (Vancouver)

• 23% of respondents stopped using during 1-yr study (Vancouver)

• 53% entered treatment (Vancouver)

Increase engagement with other services

• 3,000 referrals annually (Switzerland)

How do SIFs impact clients and community?

No effect on crime rates

• No increase in crime (Vancouver, Sydney)

Decrease visibility of IVDU

• 42% reduction in disposed needles (Vancouver)• 50% reduction in public injections (Vancouver)

In sum,How do SIFs impact clients and community?

Deaths, from overdose and all cause

Disease transmission (HCV, HIV)

Risky sexual behavior

Isolation/alienation, formal and informal

Crime

Unsafe needle disposal

Outcomes of IVDU

How do the

finances play out?

VancouverCost effective by only prevented HIV cases from prevented needle sharing

Baltimore projectionOne SIF would save $6 million annually

Seattle pilot projection$5.1 million savings annually, $4.22 savings for every $1 spent

Ongoing Challenges

In implementation• Access hours

• Wait times

• Assisted injection

• Not allowed to share drugs

• ‘Nodding off’ less enjoyable

• Relationships with staff can become barrier

In opening• Legal/Political

120 Globally in 10 countries

How many Safe Injection Sites exist?

What is the current status of legislature in the US?

Ambiguous• “Crack House Statute” (1986) constrains

harm reduction approaches

• Recent legislative setbacks

US proposed

SIF sites

• San Francisco – planned start 2021

• Seattle – planned to start 2021

• Boston

• New York

• Philadelphia

• Denver

Takeaways• SIFs are effective tools for reducing

impacts of IVDU on patients, surrounding neighborhood, medical system

• SIFs face mainly political/legal obstacles to opening in the US

• Physician advocacy needed right now to support these efforts

REFERENCES

CDC. Understanding the Epidemic. Published online March 17, 2021. Accessed April 26, 2021. https://www.cdc.gov/drugoverdose/epidemic/index.html

Pardo B, Caulkins J, Kilmer B. Assessing the Evidence on Supervised Drug Consumption Sites. RAND Corporation; 2018.

European Monitoring Centre for Drugs and Drug Addiction. Drug consumption rooms: an overview of provision and evidence. Published online December 2020. https://www.emcdda.europa.eu/topics/pods/drug-consumption-rooms

Jozaghi E. “A Little Heaven in Hell”: The Role of a Supervised Injection Facility in Transforming Place. Urban Geography. 2012;33(6):1-XXX.

Vignesh Agarwal. Supervised Injection Facility: Will it see the light of day in America? Presented at the: ASAM Virtual 2021; April 23, 2021.

Kral AH, Lambdin BH, Wenger LD, Davidson PJ. Evaluation of an Unsanctioned Safe Consumption Site in the United States. N Engl J Med. 2020;383(6):589-590.

Drake J, Charles C, Bourgeois JW, Daniel ES, Kwende M. Exploring the impact of the opioid epidemic in Black and Hispanic communities in the United States. Drug Science, Policy and Law. 2020;6.

Park JN, Sherman SG, Rouhani S, et al. Willingness to Use Safe Consumption Spaces among Opioid Users at High Risk of Fentanyl Overdose in Baltimore, Providence, and Boston. J Urban Health. 2019;96(3):353-366.

Wood E. Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users. Canadian Medical Association Journal. 2004;171(7):731-734.

Hood JE, Behrends CN, Irwin A, et al. The projected costs and benefits of a supervised injection facility in Seattle, WA, USA. International Journal of Drug Policy. 2019;67:9-18.

Gostin LO, Hodge JG, Gulinson CL. Supervised Injection Facilities: Legal and Policy Reforms. JAMA. 2019;321(8):745.

Questions?

Thank you!

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