Vancouver's safe injection facilities
live up to their name

Study finds that BC's harm-reduction approach to battling
hard drugs is paying off

By Owen Dyer

Even the once-recalcitrant police have come to accept that safe injection facilities are a practical way to reduce the harm done by drugs as drug laws alone have utterly failed to curb rates of use. The officer in charge of the drug enforcement branch of the RCMP, Robert Lesser, said safe injection facillites are "something we need to look at." Toronto's former top cop, Julian Fantino, put it more bluntly when he said: "Our jails are already filled with druggies. Fighting drugs is like digging a hole in the Sahara desert."

POPULAR ACCEPTANCE
When, in September 2003, Vancouver became the first Canadian city to set up a safe injection facility, the plan was supported by 71% of residents, according to a poll reported in the Canadian Medical Association Journal (CMAJ). And a CMAJ editorial argued that "harm reduction is not a retreat from the high ground. It is the only ground on which to meet drug users in the here and now." Two years later, research published online on March 18 in the Lancet reviews the success of the city's safe injection facility and finds that a tolerant approach to dealing with drug users is paying dividends, as users of the facility are far less likely to share needles.

The key finding reported in the Lancet research letter is this: intravenous drug users who frequented the facility for "some, most or all" of their injections were only 30% as likely to have shared a needle in the previous six months as injectors who used the facility rarely or never, after adjustment for other risk factors.

The other risk factors that influence needle-sharing are age, older drug users being generally less careful; binge drug-taking; and inability to self-inject without another's help. All of these factors have been found to increase the risk of sharing both in previous studies and when the latest Vancouver data was broken down.

CAN WE TRUST THIS?
A potential weakness of the study is that drug users who go to the injection facility are likely to be more concerned about infection than those who do not, so the lower rates of needle-sharing among the facility's users could be due to their innately greater personal responsibility. But the authors foresaw this problem, so they questioned study participants on needle sharing just before the facility opened. At this stage, the injectors who later used the facility were as likely to share needles as those who later stayed away. All of the differences emerged after the needle-exchange centre was opened.

In fact, according to lead author Dr Thomas Kerr of the British Colombia Centre for Excellence in HIV/AIDS, the facility's users tend to have more risk factors for needle-sharing than the general injecting population. "They are more likely to be homeless or in unstable housing, and more likely to have been in prison."

The 431-strong study population is based on the Vancouver Injection Drug Users Study (VIDUS). This isn't a random sample, concedes Dr Kerr. "You could spend eternity trying to recruit a random sample of drug users in Vancouver." But it has been validated several times as a good representative sample. Ninety of the 431 subjects reported frequent use of the safe injection facility, but since the VIDUS cachement area is larger than that served by the Downtown Eastside facility, that figure probably under-represents the proportion of local drug users who visit the site.

HOW IT WORKS
The facility offers two services that can reduce needle-sharing. One is the provision of clean needles and the disposal of dirty ones. The other is the presence of supervising nurses. "Basically," says Dr Kerr, "it's a large room with 12 booths, each with a mirror that allows the nurses to check on users." The nurses don't examine the drugs before injection, but they are on hand in case there's an overdose.

"The evidence suggests that the needle-exchange aspect of the safe injection facility is being used more and more," says Dr Kerr. Research has shown that the great majority of Vancouver's intravenous drug abusers make extensive use of the needle-exchange program that the city has run since 1988, but it's had little effect on infection rates. It still only takes one dirty needle to ruin a life, particularly when 88% of the VIDUS population has hepatitis C and 23% are HIV-positive. "We've found that availability issues, such as inadequate opening hours, have lessened the effect of the program," he says. But users of the safe injection facility are sure of clean needles at the moment of injection.

The researchers might have proved their point better by measuring actual infection rates rather than self-reported needle-sharing, a sin that even addicts are sometimes embarrassed to admit to. But, said Dr Kerr, "the number of events is still too small to get adequate statistical power from looking at HIV or HCV infections. Needle-sharing is more than a good surrogate measure, it's the actual cause of these infections."

PROBLEMS OFTEN OVERLOOKED
In fact, the most common cause of hospitalization among injecting drug users in Canada is neither hepatitis nor AIDS, but bacterial infections at the injection site. "We will definitely be looking at bacterial infection rates in future research," says Dr Kerr, "as well as serious viral infections when we have enough data to work with."

But the greatest potential benefit of safe injection facilities could have nothing to do with infection or needle-sharing, because even among HIV-positive drug users in Canada, the leading killer is not infection but overdose. And it goes without saying that overdosing at a safe injection facility is a lot less dangerous than overdosing in an apartment or a back-alley. This effect, too, will be measured in later research.

For the moment, Vancouver's facility appears to have won over a lot of doubters. Its funding was initially approved for three years, with extensions subject to assessment of its early success. Dr Kerr and his colleagues' research will probably help to guarantee the centre's future, and lend support to those who want to see such facilities in other Canadian cities. Efforts to set up similar centres in Toronto and Montreal have so far floundered in the face of concerted opposition from neighbourhood associations.

Lancet published online Mar 18, 2005