A RAPID REVIEW OF THE EVIDENCE FOR THE EFFECTIVNESS OF SAFE INJECTION SITES

BACKGROUND

Safe injection sites (SISs)[synonyms = drug consumption rooms; supervised injection sites/centres]are professionally supervised health care facilities, where drug users can use drugs in safe, hygienic conditions. They comprise a highly specialised drugs service within a wider network of services for drug users and usually operate from separate areas located in existing facilities for drug users or the homeless.

The overall rationale for SISs is to reach and address the problems of specific, high-risk populations of drug users, especially injectors and those who consume in public.

The specific objectives of SISs are to:

  • establish contact with difficult to reach populations of drug users;
  • provide a safe and hygienic environment for drug consumption, in particular, injecting drug use;
  • reduce mortality and morbidity associated with drug use, as a result of overdose, transmission of HIV and hepatitis, and bacterial infections;
  • promote access to other social, health and drug treatment services;
  • reduce public drug use and associated nuisance[1]

Centres have been established world wide and are located in e.g. Australia, Canada, Netherlands, Germany andSwitzerland. .

The establishment of these centres iscontroversial and according to the Beckley Foundation there are three broad areas of controversy about SISs.[2]

  1. There is an issue of principle. How do policy makers justifyproviding a service that enables people to engagelegitimately in activities which are both harmful and illegal?
  2. There is an issue about messages. Do SISs legitimise druguse, encourage more people to use hard drugs or – at thelocal level – increase drug-related problems in the areaswhere they are situated?
  3. There is an issue of effectiveness. Do SISs reduce drugrelated harms and, even if they do, are they the mostappropriate and cost effective way of reducing these harms?

THE TECHNOLOGY/SERVICE DESIGN

SISs are official services, funded from local or regional budgets or by voluntary organizations. The rooms are supervised by social workers, nurses, doctors or other staff trained in emergency care and social assistance to drug users. They are distinct from illegal ‘shooting galleries’, which are run for profit by drug dealers, as well as from consumption facilities provided within the framework of drug prescription programmes, where drugs are supplied to users.

PATIENT GROUP

Illegal drug users of all ages

RESEARCH EVIDENCE

Table 1 shows the results of a rapid review of the literature using the major databases. Languagerestrictions in the search were French, German & Spanish. Review evidence was first sought; the primary studies contained in such reviews were not individually critically appraised.

TABLE 1

DATABASE / SEARCH TERM/S / NUMBER OF HITS/NUMBER SELECTED FOR RELEVANCE
OVID 1966-2006
Cochrane DSR
ACP Journal Club
DARE
CCTR
EMBASE
PsychINFO / Combination of :Community health services/HIV infections/Hepatitis C/Humans/Risk-taking/safety management/substance abuse, intravenous/syringes / 444/10
Sumsearch / Safe/secure/injection/sites; drug consumption rooms / 15/1
Google scholar / Safe/injection/sites; drug consumption rooms / 39/2
Google / Safe/injection/sites; drug consumption rooms / 39,000/9
HMIC / Combination of: Community health services/HIV infections/Hepatitis C/Humans/Risk-taking/safety management/substance abuse, intravenous/syringes / 2300/1
INAHTA
NICE
National Horizon Scanning Centre
National Research Register
Current Controlled Trials / Safe/injection/sites; drug consumption rooms / 6/0

The rapid review did not reveal any Level 1 (systematic review, meta-analyses, randomised controlled trial) type evidence. There were not any details of centres within the United Kingdom, apart from a centre in Greater Manchester, that has been nominated for an NHS Award 2006

The 2004 report from the European Monitoring Centre for Drugs and Drug Addiction1 evaluated the evidence for effectiveness of SIS. The review identified a large number of studies that describe the outcome of consumption rooms or discuss their relevance in the context of a local harm reduction strategy.

The results from this evaluation about the effectiveness of SISs are summarised below:-.

Ability to attract difficult to reach drug users

SISs reach their defined target population, including street users and older, long-term users who have never been in treatment. There is no evidence that they recruit drug users into injecting.

To achieve adequate coverage and high rates of regular use, it is necessary to provide sufficient capacity relative to the estimated size of the target population, to locate rooms on sites that are easily accessible and to ensure that opening hours are long enough to meet demand, especially in the evening. Rooms targeting drug-using sex workers also need to be appropriately situated and remain open in the evening and night.

Provide a safer injecting environment

SISs achieve the immediate objective of providing a safe place for lower risk, more hygienic drug consumption without increasing the levels of drug use or risky patterns of consumption.

Health education at SISs encourages sustainable changes in risk-taking behaviour by some clients and contributes to reducing drug-related health damage among a difficult to reach target group.

Decrease the incidence of infection associated with drug use

A lack of studies combined with methodological problems associated with isolating the effect of SISs, mean that no conclusions can be drawn about the direct impact on infectious disease incidence.

Decrease incidence of drug-related deaths

Where coverage is sufficient and access and opening hours are appropriate, SISs may contribute to reducing drug-related deaths at a city level.

Increase access to social, health and drug treatment services

SISs increase access to drug services and health and social care. In so doing, they promote the social inclusion of a group of extremely marginalised problem drug users.

Besides supervision of drug consumption, other services are usually delivered on site. Low-threshold medical care and psychosocial counselling services are especially well used and contribute to stabilisation of and improvement in the physical and psychological health of service users.

The UK Harm Reduction Alliance (UKHRA) was funded by the National TreatmentAgency (NTA), to carry out a consultation exercise in March 2005[3]. This consultationaimed to gather the views of key stakeholder organisations on what action is required inrelation to drug treatment and harm reduction to reduce the impact of blood bornevirusesand overdose. The piloting of SISs and safer injecting spaces was indicated as one of the priorities within a national treatment strategy based upon harm reduction.

In the 2004 report, produced by the UK organisation DrugScope for the Beckley Foundation Drug Policy Programme2, the situation in the UK for the establishment of SISs is discussed. They cite the fact that the report of the Home Affair’s Select Committee in 2001[4]concluded ‘that thereis a strong case for bringing heroin use above ground, so thatthose who wish to be helped can at least indulge their habit atminimum risk to their own health and that of the public andtheobvious first step is the introduction of safe injecting houses’.

A comprehensive review of the evidence-base has concluded that SISs ‘showpromise and require cautious expansion with evaluation inways that are adapted to local settings’.[5]

A review by Kimber[6] et al concluded that the available evidencesuggests thatSISs are:-

  • engaging the targeted clientgroups,
  • reducing public nuisance associated with opendrug scenes,
  • reasonably well accepted in their localcommunities,
  • successfully managing drug overdose,
  • contributing to stabilization or improvements in healthand risk behaviours
  • interfacing between relevanthealth and social welfare services.
  • reducing overdose deaths in several German cities.

There has been considerable work performed on SISs in Australia and the 18 monthevaluation of a SIS in Sydney[7]illustrates the problems of evaluating SISs. Table 2 shows the results of the evaluation. It can be seen thatonly modest benefits were demonstrated and further analysis has concluded that the evaluation was hampered by the confounding effect of a reduction in supply of heroin to Australia that had occurred prior to the study. Formal clinical trials of SISs are required with control of potential confounding but these will be difficult to perform.

TABLE 2

Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre (MSIC)
Some key statistics
• During the 18 month trial 3,810 individuals registeredto use the MSIC. Around two thirds had been intreatment at some time, and about one quarter in the previous 12 months
• 73% were male, the average age was 31 and the averageperiod they had been injecting was 12 years.
• Heroin accounted for 61% of visits, cocaine for 30%.
• Additional health care services were provided to clientsin approximately one in four visits.
• 1,385 referrals for further assistance were made on behalfof 577 clients, 43% were for drug treatment, 32% forprimary health-care and 25% for social welfare services. 20% were confirmed to have resulted in the clientmaking contact with the relevant agency.
• 409 drug-overdose related incidents requiring clinicalmanagement occurred at the MSIC, a rate of 7.2overdoses per 1000 visits.
• Following the opening of the MSIC, there werereductions in opioid overdose ambulance attendances inthe Kings Cross Area, but these had already been falling,and it was not possible to distinguish the role of theMSIC from the effect of a continued reduction in heroinavailability.
• There was no evidence that the operation of the MSICaffected the number of heroin overdose deaths in theKings Cross area. But, on the basis of clinical andepidemiological data on heroin overdose outcomes, atleast four deaths per year are estimated to have beenprevented by clinical intervention of staff at the MSIC.
• There was a small decrease in the frequency of injectingrelatedproblems among MSIC clients.
• Nearly half of MSIC clients reported that their injectingpractices had become less risky.
• The frequency of public injection among MSIC clientsdecreased.
• In 2002, 9% said that they injected more frequently and22% less frequently since using the facility.
• Kings Cross residents and businesses reported sightingfewer episodes of public injecting and syringes discardedin public places.
• Syringe counts in Kings Cross were generally lower afterthe MSIC opened than before.

COST EFFECTIVENESS

No data of relevance to the UKwere identified..

ONGOING RESEARCH

No trials were identified.

CONCLUSIONS

  • There was no Level 1/high quality evidence found for the effectiveness of SISs.
  • Theavailable evidence indicated that SISsonly have a modest effect on outcomes when taken in isolationfrom other policy and service initiatives.
  • Evidence from both Europe andAustraliasuggests that SISscan have an important role to play in harm reduction.
  • There is a need for well designed clinical trials of SISs in the UK. The performance of such trials will however be difficult.

1

Dr M Webb, Vesion 1, April 2006

[1]European Monitoring Centre for Drugs and Drug Addiction (2004), European report on drug consumption rooms, EMCDDA, Luxembourg: Office for Official Publications of the European Communities. Available at: Accessed 09/04/06

[2] Roberts M; Klein A; Trace M. Drug Consumption Rooms. DrugScope and The Beckley Foundation . A DrugScope Briefing Paper 2004

[3]UK Harm Reduction Alliance Consultation Exercise. Available at: Accessed 07/04/06

[4]Home Affairs Select Committee (2001), The Government’s drug policy – Is it working?, HASC, London.

[5] Hunt N. A review of the evidence-base for harm reduction approaches to drug use ( and Summary), Forward Thinking on Drugs 2003, Release, London

[6]Kimber J, Dolan K, Van Beek I, et al. Drug consumption facilities: an update since 2000. Drug and Alcohol Review,2003; 22: 227-233.

[7]MSIC Evaluation Committee (2003), Final report on the evaluation of the Sydney Medically Supervised Injecting Centre, Sydney. Available at: Accessed 08/04/06