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#195 Shooting the Breeze on Supervised Injection Sites


CLINICAL QUESTION
QUESTION CLINIQUE
Do supervised injection sites (SIS) reduce mortality, hospitalizations, ambulance calls, or disease transmission?


BOTTOM LINE
RÉSULTAT FINAL
Best evidence from cohort or modeling studies suggest that SIS are associated with lower overdose mortality (88 fewer overdose deaths/100,000 person years), 67% fewer ambulance calls for treating overdoses and a decrease in HIV infections. Effects on hospitalizations are unknown.  



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EVIDENCE
DONNÉES PROBANTES
  • Mortality:  
    • High quality cohort study examining overdose mortality before and after Vancouver SIS opening.1  
      • Of persons living within 500m of SIS (70% of SIS users): 
        • Overdose deaths decreased from 253 to 165/100,000 person years (PYs); absolute risk difference88 deaths/100,000 PYs. 
        • SIS one overdose death prevented annually for every 1,137 users. 
      • Rest of city: No change in mortality.   
  • Hospitalizations: 
    • Pre-SIS: 35% of 598 Vancouver intravenous drug users (IVDUs) admitted over three year period.2 
      • 15% for skin infections.  
    • Post-SIS: Of 1,083 SIS users over four years:3 
      • 9% admitted with cutaneous injection-related infections (including osteomyelitisendocarditis).  
      • While SIS nurse ‘referral’ to hospital increased likelihood of admission, average length of stay decreased by eight days (from 12 to 4).3 
    • Limitations: Indirect comparisons of different cohorts.  
  • Ambulance calls:  
    • In the vicinity of SIS, average monthly ambulance calls with naloxone treatment for suspected opioid overdose decreased from 27 to 9relative risk reduction = 67%.4  
  • Disease transmission: 
    • Mathematical modelling on HIV infection prevention by SIS: 
      • HIV infections prevented ranges from ~6 to 57 per year.5,6 
      • Limitations: Assumptions made about drug use/injecting practices and may include benefit of co-existent needle exchange program.6 
  • Systematic review had similar findings.7 
Context:  
  • Age standardized mortality rate among IVDU is ~8x higher than rest of population.8 
  • Benefit of SIS likely limited by site capacity:  
    • SIS assists only ~4% of all injections in Vancouver’s downtown eastside.5 
  • Educating SIS users likely contributes to decreased syringe borrowing (37% in 1996 to 2% in 2011).8 
  • At Vancouver SIS, ~1 overdose per 1,000 injections; no fatal overdose reported.9 
  • Cost effectiveness: All studies show healthcare savings for every SIS dollar spent.6,10,11 
  • Opening SIS does not increase arrests for drug trafficking, assaults, or robberies.12


DIANE ROTHON January 8, 2024

Great article. Confirmed what I know.


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Author(s)
Auteur(s)
  • Jennifer Ng BMSc
  • Michael R Kolber BSc MD CCFP MSc

1. Marshall B, Milloy M-J, Wood E, et al. Lancet. 2011; 377:1429-37.

2. Palepu A, Tyndall M, Leon H, et al. CMAJ. 2001; 165(4):415-20.

3. Lloyd-Smith E, Wood E, Zhang R, et al. BMC Public Health. 2010; 10:327.

4. Salmon A, van Beek I, Amin J, et al. Addiction. 2010; 105:676-83.

5. Pinkerton S. Int J Drug Policy. 2011; 22:179-83.

6. Andersen MA, Boyd N. Int J Drug Policy. 2010; 21:70-6.

7. Potier C, Laprévote V, Dubois-Arber F, et al. Drug Alcohol Depend. 2014; 145:48-68.

8. BC Centre for Excellence in HIV/AIDS. Drug Situation in Vancouver Report 2013. Available at: http://www.cfenet.ubc.ca/sites/default/files/uploads/news/releases/ war_on_drugs_failing_to_limit_drug_use.pdf. Last Accessed: June 1, 2017.

9. Kerr T, Tyndall M, Lai C, et al. Int J Drug Policy. 2006; 17:436-41.

10. Bouyami AM, Zaric GS. CMAJ. 2008; 179:1143-51.

11. Pinkerton SD. Addiction. 2010; 105:1429-36.

12. Wood E, Tyndall M, Lai C, et al. Subst Abuse Treat Prev Policy. 2006; 1:13.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.