Supervised Injection Sites (SIS) are facilities where drug users can bring privately acquired substances and use them in a sanitary environment run by professional staff who are available in the event of an overdose. These locations can provide supplies, including sterile needles, and manage the proper disposal of the supplies after use. A SIS is also a point of contact for treatment support. The purpose of this type of program is to reduce the number of overdose deaths, reduce transmission rates of infectious disease, and increase the number of individuals initiating treatment for substance use disorders. Other terms for this type of facility include:

  • Supervised / safe(r) consumption services
  • Supervised injection facility
  • Safer injection facility 
  • Supervised injecting center / facility
  • Syringe services program
  • Drug consumption room 
  • Drug consumption facility
  • Overdose prevention site
  • Temporary overdose prevention site

Currently, SIS are found in Europe, Canada and Australia. A small number of cities in the U.S. are exploring setting up such facilities.

 

CLICK EACH TOPIC BELOW TO OPEN/CLOSE

CDC: Syringe Services Programs (SSPs)

Drug Policy Alliance: Supervised Consumption Services

NOVA Recovery Center: Safe Injection Sites: Are They Helping or Hurting? (11/14/2018)

Portland, OR: Safer Spaces Portland

American Medical Association: AMA wants new approaches to combat synthetic and injectable drugs (6/12/2017)

City of Vancouver: Safe injection site and needle exchange

Toronto, Canada: Street Health / Overdose Prevention Site (OPS) Background and FAQ

CityNews, Toronto FAQ: Toronto's safe injection sites: your FAQs answered (8/14/2018)

Establishing Sanctioned Safe Consumption Sites in the United States: Five Jurisdictions Moving the Policy Agenda Forward, Alene Kennedy-Hendricks, Ph.D., Jenna Bluestein , B.A., Alex H. Kral , Ph.D., Colleen L. Barry , Ph.D., M.P.P., Susan G. Sherman , Ph.D., M.P.H. (February 13, 2019)

 

STATES

California

  • State bill authorizing sites in SF (in committee): Amended Bill

Colorado

  • Denver authorization of pilot program:  Ordinance

Maryland

Massachusetts

New York

Pennsylvania

Vermont

Washington

 

Belackova, V., A. M. Salmon, E. Schatz and M. Jauncey (2018). "Drug consumption rooms (DCRs) as a setting to address hepatitis C - findings from an international online survey." Hepatology, Medicine And Policy 3: 9-9.

Background: Prevalence of Hepatitis C Virus (HCV) among people who inject drugs (PWID) is high. Risky injecting behaviours have been found to decrease in drug consumption rooms (DCRs) and supervised injecting facilities (SIFs), yet HCV prevention and treatment in these settings have not been extensively explored.; Methods: To determine the range and scope of HCV prevention and treatment options in these services, we assessed DCR/SIF operational features, their clients' characteristics and the HCV-related services they provide. A comprehensive online survey was sent to the managers of the 91 DCRs/SIFs that were operating globally as of September 2016. A descriptive cross-country analysis of the main DCR/SIF characteristics was conducted and bivariate logistic models were used to assess factors associated with enhanced HCV service provision.; Results: Forty-nine valid responses were retrieved from DCRs/SIFs in all countries where they were established at the time of the survey (Australia, Canada, Denmark, France, Germany, Luxembourg, Netherlands, Norway, Spain and Switzerland). Internationally, the operational capacities of DCRs/SIFs varied in terms of funding, location, size and staffing, but their clients all shared common features of vulnerability and marginalisation. Estimated HCV prevalence rates were around 60%. Among a range of health and social services and referrals to other programs, most DCRs/SIFs provided HCV testing onsite (65%) and/or offered liver monitoring or disease management (54%). HCV treatment onsite was offered or was planned to be offered by 21% of DCRs/SIFs. HCV testing onsite was associated with provision of other services addressing blood-borne diseases and HCV treatment was linked to the provision of OST. HCV disease management was associated with employing a nurse at a DCR/SIF and HCV treatment was associated with employing a medical doctor.; Conclusions: DCRs/SIFs offer easy-to-access HCV-related services for PWID. The availability of onsite medical professionals and provision of support and education to non-medical staff are key to enhanced provision of HCV-related services in DCRs/SIFs. Funding and support for HCV treatment at the community level, via low-threshold services such as DCRs/SIFs, are worthy of action.;

 

Beletsky, L., C. S. Davis, E. Anderson and S. Burris (2008). "The law (and politics) of safe injection facilities in the United States." American Journal of Public Health 98(2): 231-237.

Safe injection facilities (SIFs) have shown promise in reducing harms and social costs associated with injection drug use. Favorable evaluations elsewhere have raised the issue of their implementation in the United States. Recognizing that laws shape health interventions targeting drug users, we analyzed the legal environment for publicly authorized SIFs in the United States. Although states and some municipalities have the power to authorize SIFs under state law, federal authorities could still interfere with these facilities under the Controlled Substances Act. A state- or locally-authorized SIF could proceed free of legal uncertainty only if federal authorities explicitly authorized it or decided not to interfere. Given legal uncertainty, and the similar experience with syringe exchange programs, we recommend a process of sustained health research, strategic advocacy, and political deliberation. 

 

Davidson, P. J., A. M. Lopez and A. H. Kral (2018). "Using drugs in un/safe spaces: Impact of perceived illegality on an underground supervised injecting facility in the United States." International Journal of Drug Policy 53: 37-44.

Background: Supervised injection facilities (SIFs) are spaces where people can consume pre-obtained drugs in hygienic circumstances with trained staff in attendance to provide emergency response in the event of an overdose or other medical emergency, and to provide counselling and referral to other social and health services. Over 100 facilities with formal legal sanction exist in ten countries, and extensive research has shown they reduce overdose deaths, increase drug treatment uptake, and reduce social nuisance. No facility with formal legal sanction currently exists in the United States, however one community-based organization has successfully operated an ‘underground’ facility since September 2014. Methods: Twenty three qualitative interviews were conducted with people who used the underground facility, staff, and volunteers to examine the impact of the facility on peoples’ lives, including the impact of lack of formal legal sanction on service provision. Results: Participants reported that having a safe space to inject drugs had led to less injections in public spaces, greater ability to practice hygienic injecting practices, and greater protection from fatal overdose. Constructive aspects of being ‘underground’ included the ability to shape rules and procedures around user need rather than to meet political concerns, and the rapid deployment of the project, based on immediate need. Limitations associated with being underground included restrictions in the size and diversity of the population served by the site, and reduced ability to closely link the service to drug treatment and other health and social services. Conclusion: Unsanctioned supervised injection facilities can provide a rapid and user-driven response to urgent public health needs. This work draws attention to the need to ensure such services remain focused on user-defined need rather than external political concerns in jurisdictions where supervised injection facilities acquire local legal sanction.

 

Gaeta, J. M. and M. Racine (2018). "New Strategies Are Needed to Stop Overdose Fatalities: The Case for Supervised Injection Facilities." Annals Of Internal Medicine 168(9): 664-665.

 

Hood, J. E., Behrends, C. N., Irwin, A., Schackman, B. R., Chan, D., Hartfield, J. Hess, C. Banta-Green, L. Whiteside, B. Finegood, J. Duchin & Duchin, J. (2019). The projected costs and benefits of a supervised injection facility in Seattle, WA, USA. International Journal of Drug Policy, 67, 9-18.

Background: As one strategy to improve the health and survival of people who inject drugs, the King County Heroin & Opioid Addiction Task Force recommended the establishment of supervised injection facilities (SIF) where people can inject drugs in a safe and hygienic environment with clinical supervision. Analyses for other sites have found them to be cost-effective, but it is not clear whether these findings are transferable to other settings.

 

Kappel, N., E. Toth, J. Tegner and S. Lauridsen (2016). "A qualitative study of how Danish drug consumption rooms influence health and well-being among people who use drugs." Harm Reduction Journal 13.

Background: Drug use contributes to higher rates of morbidity and mortality among people who use drugs compared to the general population. In 2012, Danish politicians passed a law that allowed drug consumption rooms (DCRs) to operate; among the objectives were to improve the well-being of vulnerable citizens and to reduce the number of overdoses. Five Danish DCRs are currently being operated. This article presents results from a national investigation focused on assessing the impact of Danish drug consumption rooms on the health and well-being of DCR clients and factors facilitating the acceptance of DCR clients in order to improve their health and refer them onward to social and health service providers. Methods: We conducted 250 h of participant observation in the DCRs, followed by in-depth qualitative interviews with 42 DCR clients and 25 staff members. Field notes and interviews were analysed and coded, and themes have been developed. Results: DCR clients experienced a sense of social acceptance while inside DCRs. Members of staff conveyed a welcoming, non-judgemental attitude, and DCR clients were predominantly satisfied with the facilities. They prioritized forging relations with drug users so as to foster a sense of social acceptance within DCRs. The primary goal of staff members is to prevent overdoses by informing clients about strong drugs and by intervening in cases of intoxication. DCRs provide security to clients. In cases of health-related problems, DCR clients were referred to local health clinics. Members of the staff build bridges for DCR clients by guiding them towards drug treatment programmes and services in the social and the health sectors. Conclusions: The study reveals a consistency between DCR clients and staff members with respect to appraisal of the importance of DCRs. Both clients and staff agreed that DCRs provide a safe haven in the environment in which DCR clients often live and that staff members’ approach to clients with the intention of promoting acceptance clears the path for the prevention and treatment of overdoses and providing referrals to healthcare facilities, to drug treatment centres and to social services. 

 

Katz, N., L. Leonard, L. Wiesenfeld, J. J. Perry, V. Thiruganasambandamoorthy and L. Calder (2017). "Support of supervised injection facilities by emergency physicians in Canada." International Journal of Drug Policy 49: 26-31.

Background: Despite evidence supporting the implementation of supervised injection facilities (SIFs) by multiple stakeholders, no evaluation of emergency physicians’ attitudes has ever been documented towards such facilities in Canada or internationally. The primary goal of our study was to determine the opinions and perceptions of emergency physicians regarding the implementation of SIFs in Canada. Methods: We conducted a national electronic survey of staff and resident emergency physicians in Canada using an iteratively designed survey tool in consultation with content experts. Invitations to complete the survey were sent via email by the Canadian Association of Emergency Physicians. Inclusion criteria required respondents to have treated an adult patient in a Canadian emergency department within the preceding 6 months. The primary measure was the proportion of respondents who would support, not support or were unsure of supporting SIFs in their community with the secondary measure being the likelihood of respondents to refer patients to a SIF if available. Results: We received 280 responses out of 1353 eligible physicians (20.7%), with the analysis conducted on 250 responses that met inclusion criteria (18.5%). The majority of respondents stated they would support the implementation of SIFs in their community (N = 172; 74.5%) while 10.8% (N = 25) would not and 14.7% (N = 34) did not know. The majority of respondents said they would refer their patients to SIFs (N = 198; 84.6%), with 4.3% (N = 10) who would not and 11.1% (N = 26) who were unsure. Conclusion: The findings from our study demonstrate that the majority of emergency physician respondents in Canada support the implementation of such sites (74.5%) while 84.6% of respondents would refer patients from the emergency department to such sites if they did exist. Given that many Canadian cities are actively pursuing the creation of SIFs or imminently opening such sites, it appears that our sample population of emergency physicians would both support this approach and would utilize such facilities in an effort to improve patient-centered outcomes for this often marginalized population. 

 

Kinnard, E. N., C. J. Howe, T. Kerr, V. Skjødt Hass and B. D. L. Marshall (2014). "Self-reported changes in drug use behaviors and syringe disposal methods following the opening of a supervised injecting facility in Copenhagen, Denmark." Harm Reduction Journal 11(1): 29-29.

Background: In Denmark, the first standalone supervised injecting facility (SIF) opened in Copenhagen's Vesterbro neighborhood on October 1, 2012. The purpose of this study was to assess whether use of services provided by the recently opened SIF was associated with changes in injecting behavior and syringe disposal practices among people who inject drugs (PWID). We hypothesized that risk behaviors (e.g., syringe sharing), and unsafe syringe disposal (e.g., dropping used equipment on the ground) had decreased among PWID utilizing the SIF.; Methods: Between February and August of 2013, we conducted interviews using a survey (in English and Danish) with forty-one people who reported injecting drugs at the SIF. We used descriptive statistics and McNemar's test to examine sociodemographic characteristics of the sample, current drugs used, sites of syringe disposal before and after opening of the SIF, and perceived behavior change since using the SIF.; Results: Of the interviewed participants, 90.2% were male and the majority were younger than 40 years old (60.9%). Three-quarters (75.6%) of participants reported reductions in injection risk behaviors since the opening of the SIF, such as injecting in a less rushed manner (63.4%), fewer outdoor injections (56.1%), no longer syringe sharing (53.7%), and cleaning injecting site(s) more often (43.9%). Approximately two-thirds (65.9%) of participants did not feel that their frequency of injecting had changed; five participants (12.2%) reported a decrease in injecting frequency, and only two participants (4.9%) reported an increase in injecting frequency. Twenty-four (58.5%) individuals reported changing their syringe disposal practices since the opening of the SIF; of those, twenty-three (95.8%) reported changing from not always disposing safely to always disposing safely (McNemar's test p-value < 0.001).; Conclusions: Our findings suggest that use of the Copenhagen SIF is associated with adoption of safer behaviors that reduce harm and promote health among PWID, as well as practices that benefit the Vesterbro neighborhood (i.e., safer syringe disposal). As a public health intervention, Copenhagen's SIF has successfully reached PWID engaging in risk behavior. To fully characterize the impacts of this and other Danish SIFs, further research should replicate this study with a larger sample size and prospective follow-up.

 

Kral, A. H. and P. J. Davidson (2017). "Addressing the nation’s opioid epidemic: Lessons from an unsanctioned supervised injection site in the U.S." American Journal of Preventive Medicine 53(6): 919-922.

Presents a study which aims to evaluate the impact of an unsanctioned supervised injection site in the U. S. The authors were approached by the agency, with whom they are not affiliated, to help evaluate their program. All evaluation activities were approved by the IRB of the University of California, San Diego. The unsanctioned supervised injection site has one large room dedicated solely to injection and an adjoining room that provides post-injection monitoring/supervision. Before each time a program participant injects drugs at the site, the staff person asks 12 questions, and the answers are recorded into an encrypted survey software package via a tablet computer. In the first 2 years of operation, there were 2,574 injections by over 100 participants. In the first 2 years of operation, there were 2,574 injections by over 100 participants. This rate is very similar to the overdose rate in the pre-fentanyl era at the main Vancouver supervised injection site, which had a rate of one overdose per 1,310 injections. This proof-of-concept evaluation has brought up a number of potential benefits for people who use the site and the surrounding community.

 

Lange, B. C., & Bach-Mortensen, A. M. (2019). A Systematic Review of Stakeholder Perceptions of Supervised Injection Facilities. Drug and alcohol dependence.

Background: Supervised injection facilities (SIFs) have been developed to address the public health burden associated with substance use. While these facilities have been associated with a number of positive outcomes, stakeholder opinion (the opinions of those potentially affected by these facilities) is likely to influence their future development. This systematic review aims to answer the question, “how do stakeholders perceive SIFs?”

 

León, C., L. J. P. Cardoso, S. Johnston, S. Mackin, B. Bock and J. M. Gaeta (2018). "Changes in public order after the opening of an overdose monitoring facility for people who inject drugs." International Journal of Drug Policy 53: 90-95.

Background: In the face of an increasingly fatal opioid crisis, Boston Health Care for the Homeless Program (BHCHP) opened the Supportive Place for Observation and Treatment (SPOT), a unique low-threshold harm reduction program for monitoring people who have injected drugs and are at imminent risk of overdose. This study examines the impact of the opening of the SPOT program on measures of injection drug-related public order in the neighborhood surrounding the facility. Methods: Data was collected at 10 weeks prior and 12 weeks post SPOT implementation on: number of over-sedated individuals in public, publicly discarded syringes, publicly discarded injection-related litter, and instances of active injection drug use or exchange of drugs. Changes were evaluated using Poisson log-linear regression models. Potential confounders such as weather and police presence were measured and controlled for. Results: The average number of over-sedated individuals observed in public significantly decreased by 28% (4.3 [95% Confidence Interval (CI) 2.7–6.9] v 3.1 [CI 1.4–6.8]) after SPOT opened. The opening of SPOT did not have a significant effect on the other measures of public order. The daily average number of publicly discarded syringes (28.5 [CI 24.5–33.1] v 28.4 [CI 22.0–36.5]), pieces of publicly discarded injection-related litter (376.3 [CI 358.6–394.8] v 375.0 [CI 345.8–406.6]), and observed instances of active use or exchange of drugs (0.2 [CI 0.1–0.9] v 0.1 [CI 0.0–0.1]) were not statistically significantly different after the opening of SPOT. Conclusions: The opening of SPOT was associated with a significant decrease in observed over-sedated individuals. Other measures of injection-drug related public order did not improve or worsen with the opening of SPOT, however, they have been shown to improve with the implementation of a supervised injection facility.

 

Ng, J., C. Sutherland and M. R. Kolber (2017). "Does evidence support supervised injection sites?" Canadian Family Physician Medecin De Famille Canadien 63(11): 866-866.

 

Notta, D., B. Black, T. Chu, R. Joe and M. Lysyshyn (2019). "Changing risk and presentation of overdose associated with consumption of street drugs at a supervised injection site in Vancouver, Canada." Drug and Alcohol Dependence 196: 46-50.

Background: British Columbia is experiencing a public health emergency due to overdoses resulting from consumption of street drugs contaminated with fentanyl. While the risk of overdoses appears to be increasing, the overdose rate and severity of overdose presentations have yet to be quantified.; Methods: Insite is a supervised injection site in Vancouver. Data from Insite's client database from January 2010 to June 2017 were used to calculate overdose rates as well as the proportion of overdoses involving rigidity and naloxone administration over time in order to estimate changes in the risk and severity of overdose resulting from changes in the local drug supply.; Results: The overdose rate increased significantly for all drug categories. Heroin used alone or with other drugs continues to be associated with the highest overdose rate. The overdose rate associated with heroin increased from 2.7/1000 visits to 13/1000 visits over the study period, meaning that clients were 4.8 times more likely to overdose in the most recent period as in the baseline period. The proportion of overdose events involving rigidity, a known complication of intravenous fentanyl use, increased significantly from 10.4% to 18.9%. The proportion of overdoses requiring naloxone administration increased significantly from 48.4% to 57.1% and is now similar across all drug categories.; Conclusions: The risk and severity of overdoses at Insite have increased since the emergence of illicit fentanyl. This information derived from supervised injection site data can be used to inform local harm reduction efforts and the response to the overdose emergency.

 

Pardo, Bryce, Jonathan P. Caulkins, and Beau Kilmer, Assessing the Evidence on Supervised Drug Consumption Sites. Santa Monica, CA: RAND Corporation, 2018.

Current levels of opioid-related morbidity and mortality in the United States are staggering. Data for 2017 indicate that there were more than 47,000 opioid-involved overdose deaths (roughly similar to deaths from AIDS at its peak in 1995), and 1 in 8 adults now report having had a family member or close friend die from opioids. There has been a near universal call from blue-ribbon commissions and expert panels for increasing access to Food and Drug Administration-approved medications for those with an opioid use disorder; however, jurisdictions addressing opioid use disorder and overdose may wish to consider additional interventions beyond increasing access to these medications. Two interventions that are implemented in some other countries but not in the United States are heroin-assisted treatment (HAT) and supervised consumption sites (SCSs). Given the severity of the opioid crisis, there is urgency to evaluate tools that might reduce its impact and save lives. This working paper is part of a series of reports assessing the evidence on and arguments made about HAT and SCSs and examining some of the issues associated with implementing them in the United States. The target audiences include decision makers in rural and urban areas grappling with opioids as well as researchers and journalists. This working paper assesses evidence on and arguments made about SCSs. It also offers a descriptive assessment of SCSs and the logic model behind their implementation. The other parts of this series of reports include: (1) a summary report of all the components of the research study; (2) a review of the HAT literature; (3) a report on key informant views on the acceptability and feasibility of implementing HAT and SCSs in selected U.S. jurisdictions heavily affected by the opioid crisis and (4) a report on international experience with the implementation of HAT and SCSs.

 

Potier, C., V. Laprévote, F. Dubois-Arber, O. Cottencin and B. Rolland (2014). "Supervised injection services: What has been demonstrated? A systematic literature review." Drug and Alcohol Dependence 145: 48-68.

Background: Supervised injection services (SISs) have been developed to promote safer drug injection practices, enhance health-related behaviors among people who inject drugs (PWID), and connect PWID with external health and social services. Nevertheless, SISs have also been accused of fostering drug use and drug trafficking. Aims: To systematically collect and synthesize the currently available evidence regarding SIS-induced benefits and harm. Methods: A systematic review was performed via the PubMed, Web of Science, and ScienceDirect databases using the keyword algorithm [('SUPERVISED' OR 'SAFER') AND ('INJECTION' OR 'INJECTING' OR 'SHOOTING' OR 'CONSUMPTION') AND ('FACILITY' OR 'FACILITIES' OR 'ROOM' OR 'GALLERY' OR 'CENTRE' OR 'SITE')]. Results: Seventy-five relevant articles were found. All studies converged to find that SISs were efficacious in attracting the most marginalized PWID, promoting safer injection conditions, enhancing access to primary health care, and reducing the overdose frequency. SISs were not found to increase drug injecting, drug trafficking or crime in the surrounding environments. SISs were found to be associated with reduced levels of public drug injections and dropped syringes. Of the articles, 85% originated from Vancouver or Sydney. Conclusion: SISs have largely fulfilled their initial objectives without enhancing drug use or drug trafficking. Almost all of the studies found in this review were performed in Canada or Australia, whereas the majority of SISs are located in Europe. The implementation of new SISs in places with high rates of injection drug use and associated harms appears to be supported by evidence.

 

Wallace, B., Pagan, F., & Pauly, B. B. (2019). The implementation of overdose prevention sites as a novel and nimble response during an illegal drug overdose public health emergency. International Journal of Drug Policy, 66, 64-72.

Background: Drug-related overdoses were declared a public health emergency in British Columbia, Canada in April, 2016 facilitating the scale-up of responses including rapid sanctioning and implementation of overdose prevention sites (OPSs). OPSs are a health service providing supervised injection and immediate overdose response. In BC, OPSs were operational within weeks of sanctioning. In the first year of operation over 20 OPSs were established with approximately 550,000 visits and no overdose deaths at any site. In this paper, we examine the implementation of OPSs as a novel and nimble response to prevent overdose deaths as a result of injection drug use.

 

Wolfson-Stofko, B., L. Elliott, A. S. Bennett, R. Curtis and M. Gwadz (2018). "Perspectives on supervised injection facilities among service industry employees in New York City: A qualitative exploration." The International Journal On Drug Policy 62: 67-73.

Background: Approximately 100 supervised injection facilities (SIFs) operate in 66 cities around the world to reduce overdose deaths, the spread of disease and public disorder, though none legally exist in the United States. Public bathrooms are among the most common public places for injection reported by people who inject drugs in New York City (NYC) and service industry employees (SIEs) inadvertently become first-responders when overdoses occur in business bathrooms. The goal of this study was to assess SIE acceptability of SIFs and the perceived effects that SIFs would have on them, their colleagues, their businesses and communities.; Methods: Semi-structured qualitative interviews were conducted with 15 SIEs recruited through convenience sampling throughout NYC. Participants were provided with peer-reviewed scientific evidence prior to discussing SIFs. Data were analysed using a hybrid deductive and inductive approach.; Results: Most SIEs had encountered drug use (93%, n = 14/15) and syringes (73%, n = 11/15) in their business bathrooms and three had encountered unresponsive individuals. Nearly all workers (93%, n = 14/15) were supportive of SIFs and believed SIFs would reduce injection drug use in their business bathrooms. Participants also believed that 'not in my backyard' arguments from community boards may impede SIF operation.; Conclusions: Service industry employees are critical stakeholders due to their exposure to occupational health hazards related to public injection. Those interviewed were amenable to SIF operation as a form of occupational harm reduction and their experiences provide an important dimension to the political debate surrounding SIFs.

 

Zlotorzynska, M., E. Wood, J. S. Montaner and T. Kerr (2013). "Supervised injection sites: prejudice should not trump evidence of benefit." CMAJ: Canadian Medical Association Journal = Journal De L'association Medicale Canadienne 185(15): 1303-1304.

 

Rapid Response Service. Rapid Response: What is the effectiveness of supervised injection services? Toronto, ON: Ontario HIV Treatment Network; May 2014.

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07/26/2019 - 4:46 pm