Safer injection facilities (SIFs) for injection drug users (IDUs) in Canada. A review and call for an evidence-focused pilot trial.

As evidenced through numerous studies in recent years, injection drug use (IDU) is a major public health and order problem in Canada. The estimated population of 125,000 injection drug users (IDUs) – approximately one third of whom are living in the three major cities of Toronto, Montreal and Vancouver – is characterized by high levels of drug-related mortality (overdose); prevalence of blood-borne viruses (BBV) and other physical health problems; extensive utilization of health system resources and involvement in crime and public disorder. Since 1990, overdose mortality rates as well as prevalence and sero-conversion rates of HIV and hepatitis among IDUs have risen in most Canadian cities. Injection drug-related problems are particularly severe in Vancouver, where an IDU population of a few thousand injectors is concentrated in the small Downtown Eastside corridor, further described by poverty, and lack of housing and addiction treatment services. These closely networked IDUs typically engage in high-frequency (cocaine and opiate) injection habits involving patterns of high-risk behaviour. Despite the availability of needle exchange services in Vancouver, needle sharing, needle reuse and injecting in public places are still prevalent among IDUs. These factors have contributed to record high rates of: an annual average of 312 overdose deaths; HIV incidence rates of 13.4 to 18.6 per 100 person-years; and hepatitis C incidence rates of 29.1 per 100 person-years among IDUs over the past five years in Vancouver. The dire need for effective responses to this desperate situation related to IDU, mirrored in other Canadian cities, has led a number of health research and policy authorities to call for the establishment of ‘Safer Injection Facilities’ (SIFs) in Canada. On the political level, a recent Federal/Provincial/Territorial (F/P/T) report under the auspices of Health Canada recommended the implementation of a SIF pilot trial, establishing a Task Force to examine the feasibility, operational and legal parameters of such facilities. Furthermore, the Federation of Canadian Municipalities endorsed a resolution to establish SIFs on an experimental basis in four to six Canadian cities. SIFs are the creation of a number of European countries – specifically Germany, the Netherlands and Switzerland – which were facing intravenous drug-related public health and order crises similar to those currently experienced in Canada. The rise of injection drug-related overdose deaths, spread of HIV infection and increasing public pressure to dissolve ‘open drug scenes’ (involving both drug use and dealing in public spaces) triggered an overall change in local drug policy practices in these countries. This change included substantive expansion of addiction treatment services and needle exchange programs, as well as adjustments to law enforcement practices. However, these measures did not prove sufficient to effectively deal with the acute problems of injection drug-related overdose deaths, BBV incidence and public disorder, especially for those IDUs not reached by ‘higher threshold’ treatments or other interventions. These circumstances led local health service providers in the above countries to establish SIFs as a pragmatic measure to reduce these acute problems by providing protected and clean spaces for IDUs. Generally, all SIFs operate under the umbrella of three major objectives: a) to reduce acute mortality and morbidity risks among IDUs, b) to bring IDUs in contact with social, health and treatment services, and c) to reduce public order problems (drug use in public, discarded needles) related to IDU. Currently, there are approximately 40-45 SIFs in existence in Germany, the Netherlands and Switzerland, with plans for similar facilities in Austria and Spain. Furthermore, an 18-month scientific SIF pilot trial was started in Sydney, Australia, in July 2001. On the basis of a recent decision by the New South Wales government, this SIF trial will be extended for a further 12 months following the conclusion of the current study. Despite local differences between facilities, the majority of SIFs operate on the basis of similar operational practices and rules. They are usually run by social or health workers (nurses) who provide clean injection equipment but no drugs or injection aid; access is limited to local or registered users; restrictions are placed on duration and frequency of use; and drug sharing and violence on-site are prohibited. Existing SIFs have also seen operational challenges recently, with an increase in the proportion of cocaine users in Europe, and opiate injectors switching to inhalable modes of drug use. While problems have occurred because of the parallel existence of opiate and cocaine use in SIFs due to the different service needs and behavioural characteristics of these two drug cul1. Social, Prevention, Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON 2. Department of Public Health Sciences, University of Toronto 3. Centre of Criminology, University of Toronto 4. Addiction Research Institute, Zürich, Switzerland Correspondence and reprint requests: Dr. Benedikt Fischer, Centre for Addiction and Mental Health, 33 Russell Street, Room 2036, Toronto, ON M5S 2S1, Tel: 416-535-8501, ext. 4502, Fax: 416-2604156, E-mail: [email protected] Acknowledgement: The authors acknowledge funding support from the Canadian Institutes of Health Research (CIHR) and the Connaught Fund, University of Toronto.