- Email: [email protected]
Supervised injecting facilities: time for scale-up?
Comment
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Nichol KL, Nordin JD, Nelson DB, Mullooly JP, Hak E. Effectiveness of influenza vaccine in the community-dwelling elderly. N Engl J Med 2007; 357: 1373–81. Jackson ML, Nelson JC, Weiss NS, Neuzil KM, Barlow W, Jackson LA. Influenza vaccination and risk of community-acquired pneumonia in immunocompetent elderly people: a population-based, nested case-control study. Lancet 2008; 372: 398–405. Falsey AR, Hennessey PA, Formica MA, Cox C, Walsh EE. Respiratory syncytial virus infection in elderly and high-risk adults. N Engl J Med 2005; 352: 1749–59. Flamaing J, Engelmann I, Joosten E, Van Ranst M, Verhaegen J, Peetermans WE. Viral lower respiratory tract infection in the elderly: a prospective in-hospital study. Eur J Clin Microbiol Infect Dis 2003; 22: 720–25. Kaye M, Skidmore S, Osman H, Weinbren M, Warren R. Surveillance of respiratory virus infections in adult hospital admissions using rapid methods. Epidemiol Infect 2006; 134: 792–98.
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v d Hoeven AM, Scholing M, Wever PC, Fijnheer R, Hermans M, Schneeberger PM. Lack of discriminating signs and symptoms in clinical diagnosis of influenza of patients admitted to the hospital. Infection 2007; 35: 65–68. Charles PG, Whitby M, Fuller AJ, et al. The etiology of community-acquired pneumonia in Australia: why penicillin plus doxycycline or a macrolide is the most appropriate therapy. Clin Infect Dis 2008; 46: 1513–21. de Roux A, Marcos MA, Garcia E, et al. Viral community-acquired pneumonia in nonimmunocompromised adults. Chest 2004; 125: 1343–51. Lim WS, Macfarlane JT, Boswell TC, et al. Study of community acquired pneumonia aetiology (SCAPA) in adults admitted to hospital: implications for management guidelines. Thorax 2001; 56: 296–301. Ruiz M, Ewig S, Marcos MA, et al. Etiology of community-acquired pneumonia: impact of age, comorbidity, and severity. Am J Respir Crit Care Med 1999; 160: 397–405.
Supervised injecting facilities: time for scale-up? The spread of infectious diseases and overdoses among injection drug users remain major public-health challenges globally. In response to these concerns, an increasing number of countries have implemented supervised injection facilities where drug users can inject pre-obtained illicit drugs under the supervision of health-care professionals.1 Despite a growing body of evidence which suggests that such facilities are effective in addressing various harms, few interventions have been as vigorously contested and difficult to implement. Supervised injection facilities first appeared in the 1980s as a pragmatic response to public injecting, overdoses, and syringe sharing.2 The first modest programmes opened in a few European cities, and included facilities that operated out of church basements.1 Since then, the facilities have become increasingly specialised, with newer ones offering a range of inhouse services, including care by physicians, addiction counselling, and detoxification. There are about 65 supervised injection facilities in eight countries, with Norway and Luxembourg being the latest to open facilities.1,3 However, proposals to establish facilities have been hotly debated and eventually dismissed in Austria, France, Portugal, Ireland, Denmark, and the Czech Republic.1,3 More recently, pilot supervised injection facilities were started in Sydney, Australia, and Vancouver, Canada, two cities that had historically favoured strict law enforcement over health-focused responses to injection drug use. Both small pilot programmes were allowed to proceed under intense public scrutiny and 354
were contingent on rigorous scientific evaluation.4,5 The evaluations showed that the facilities met their primary objectives of reducing public injecting, syringe sharing, and overdose risks, and increasing access to addiction treatment. The evaluations also revealed that the facilities were not encouraging drug use or increasing crime, and high levels of public support and costeffectiveness were also documented.5,6 The favourable evaluations of the Australian and Canadian facilities led to renewed interest in such centres. Recently, in England and Scotland, government-sponsored reports have called for pilot supervised injection facilities.7,8 Perhaps most surprising, however, were recent discussions among public-health officials and legal experts focused on the feasibility of establishing facilities in the USA.9 Despite the growing body of evidence that supports the effectiveness of these facilities, proposals to establish centres in these settings have been blocked by conservative forces. UK officials have gone as far as declaring supervised injection facilities unlawful,8 and a US Senator introduced a federal bill amendment, later defeated, that would have allowed for cuts to federal health funds for any locality that opened a facility.10 Much ideologically driven opposition to supervised injection facilities has been fuelled by well-orchestrated efforts by international organisations, including the UN’s International Narcotics Control Board (INCB) and the Drug Free America Foundation. In its 2007 annual report, the INCB stated that supervised injection facilities “contravene the most fundamental principle of the international drug control conventions” and www.thelancet.com Vol 372 August 2, 2008
went on to urge “governments of countries where drug injection rooms are operated…to close those facilities”.11 Ironically, the INCB has taken this stance despite a published UN legal opinion declaring that supervised injection facilities do not contravene UN drug-control treaties.12 A division of the Drug Free America Foundation, the Institute on Global Drug Policy and Practice, recently created a website13 that includes essays highly critical of evidence-based HIVprevention interventions for injection drugs users, such as needle exchange and supervised injection facilities. Not surprisingly, the conclusions of these essays are inconsistent with those of key international consensus documents, including those by WHO14 and UNAIDS.15 Unfortunately, these efforts have had some sway, with officials in several countries citing the UN treaties as a barrier to the implementation of supervised injection facilities.8,16 Further, in Canada, the Minister of Health quoted16 extensively from the Drug Free America Foundation’s website when he ordered his government officials to appeal a recent decision by the Supreme Court of the Province of British Columbia granting the supervised injection facility in Vancouver constitutional immunity from Canada’s drug laws. Ongoing harms among injection drug users, such as HIV infection, warrant innovative and swift action that is based on the best available scientific evidence. More than 25 years of experience with supervised injection facilities has shown that the time for the global scale-up of these programmes has come. Such scale-up, however, can only occur if political leaders are willing to take the courageous step of putting scientific evidence and public-health interests ahead of ideology.
Dan Small
Comment
Figure: First United Church, Vancouver, takes a stand in support of the city’s supervised injection site 4
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*Thomas Kerr, Julio Montaner, Evan Wood British Columbia Centre for Excellence in HIV/AIDS, St Paul’s Hospital; Vancouver, BC, Canada V6Z 1Y6; and Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada [email protected] We are responsible for the scientific evaluation of Vancouver’s supervised injection site. Some funding for the evaluation is provided by Canadian Institutes of Health Research grant HPR-85526 and Vancouver Coastal Health. 1 2 3
Kimber J, Dolan K, van Beek I, Hedrich D, Zurhold H. Drug consumption facilities: an update since 2000. Drug Alcohol Rev 2003; 22: 227–33. Strathdee S, Pollini R. A 21st-century Lazarus: the role of safer injection site in harm reduction and recovery. Addiction 2007; 102: 848–49. Lloyd C, Hunt N. Drug consumption rooms: an overdue extension to harm reduction policy in the UK? Int J Drug Policy 2007; 18: 5–9.
www.thelancet.com Vol 372 August 2, 2008
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Wood E, Tyndall MW, Montaner JS, Kerr T. Summary of findings from the evaluation of a pilot medically supervised safer injecting facility. CMAJ 2006; 175: 1399–404. MSIC Committee. Final report of the Sydney medically supervised injecting centre. Sydney: MSIC Evaluation Committee; 2003. http://www. druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_ report4.pdf (accessed July 16, 2008). Expert Advisory Committee on Supervised Injection Site Research. Vancouver’s Insite service and other supervised injection sites: what has been learned from research? Final report of the Expert Advisory Committee. 2008.http://www.hc-sc.gc.ca/ahc-asc/pubs/sites-lieux/indexeng.php (accessed July 16, 2008). Scotland’s Futures Forum. Approaches to alcohol and drugs in Scotland: a question of architecture. 2008. http://www.drugmisuse.isdscotland. org/publications/local/drug_futures.pdf (accessed July 16, 2008). Anon. Calls for drug ‘injecting rooms’. BBC News May 30, 2008. http:// news.bbc.co.uk/2/hi/uk_news/wales/south_west/7426040.stm (accessed July 16, 2008). Beletsky L, Davis CS, Anderson E, Burris S. The law (and politics) of safe injection facilities in the United States. Am J Public Health 2008; 98: 231–37. Piper B. A major victory, and a major fight ahead. Drug Policy News Nov 7, 2007. http://www.drugpolicy.org/news/110707hea.cfm (accessed July 16, 2008). International Narcotics Control Board. Report of the International Narcotics Control Board for 2007: March 5, 2008. http://www.incb.org/ pdf/annual-report/2007/en/annual-report-2007.pdf (accessed July 16, 2008). Csete J, Wolfe D. Closed to reason: the International Narcotics Control Board and HIV/AIDS. Feb 27, 2007. http://www.soros.org/initiatives/ health/focus/ihrd/articles_publications/publications/publications_ 20070227 (accessed July 16, 2008). Drug Free Foundation America, Inc. http://www.dfaf.org (accessed July 28, 2008). WHO. Policy and programming guide for HIV/AIDS prevention and care among injecting drug users. 2005. http://www.who.int/hiv/pub/prev_ care/policyprogrammingguide.pdf (accessed July 16, 2008). UNAIDS. Intensifying HIV Prevention: a UNAIDS policy position paper. , August, 2005. http://data.unaids.org/publications/irc-pub06/jc1165intensif_hiv-newstyle_en.pdf (accessed July 16, 2008). Clement T. Remarks for the Honourable Tony Clement before the House of Commons Standing Committee on Health on the subject of supervised injection sites. Ottawa, May 29, 2008. http://www.hc-sc.gc. ca/ahc-asc/minist/speeches-discours/2008_05_29-eng.php (accessed July 17, 2008).
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Nichol KL, Nordin JD, Nelson DB, Mullooly JP, Hak E. Effectiveness of influenza vaccine in the community-dwelling elderly. N Engl J Med 2007; 357: 1373–81. Jackson ML, Nelson JC, Weiss NS, Neuzil KM, Barlow W, Jackson LA. Influenza vaccination and risk of community-acquired pneumonia in immunocompetent elderly people: a population-based, nested case-control study. Lancet 2008; 372: 398–405. Falsey AR, Hennessey PA, Formica MA, Cox C, Walsh EE. Respiratory syncytial virus infection in elderly and high-risk adults. N Engl J Med 2005; 352: 1749–59. Flamaing J, Engelmann I, Joosten E, Van Ranst M, Verhaegen J, Peetermans WE. Viral lower respiratory tract infection in the elderly: a prospective in-hospital study. Eur J Clin Microbiol Infect Dis 2003; 22: 720–25. Kaye M, Skidmore S, Osman H, Weinbren M, Warren R. Surveillance of respiratory virus infections in adult hospital admissions using rapid methods. Epidemiol Infect 2006; 134: 792–98.
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v d Hoeven AM, Scholing M, Wever PC, Fijnheer R, Hermans M, Schneeberger PM. Lack of discriminating signs and symptoms in clinical diagnosis of influenza of patients admitted to the hospital. Infection 2007; 35: 65–68. Charles PG, Whitby M, Fuller AJ, et al. The etiology of community-acquired pneumonia in Australia: why penicillin plus doxycycline or a macrolide is the most appropriate therapy. Clin Infect Dis 2008; 46: 1513–21. de Roux A, Marcos MA, Garcia E, et al. Viral community-acquired pneumonia in nonimmunocompromised adults. Chest 2004; 125: 1343–51. Lim WS, Macfarlane JT, Boswell TC, et al. Study of community acquired pneumonia aetiology (SCAPA) in adults admitted to hospital: implications for management guidelines. Thorax 2001; 56: 296–301. Ruiz M, Ewig S, Marcos MA, et al. Etiology of community-acquired pneumonia: impact of age, comorbidity, and severity. Am J Respir Crit Care Med 1999; 160: 397–405.
Supervised injecting facilities: time for scale-up? The spread of infectious diseases and overdoses among injection drug users remain major public-health challenges globally. In response to these concerns, an increasing number of countries have implemented supervised injection facilities where drug users can inject pre-obtained illicit drugs under the supervision of health-care professionals.1 Despite a growing body of evidence which suggests that such facilities are effective in addressing various harms, few interventions have been as vigorously contested and difficult to implement. Supervised injection facilities first appeared in the 1980s as a pragmatic response to public injecting, overdoses, and syringe sharing.2 The first modest programmes opened in a few European cities, and included facilities that operated out of church basements.1 Since then, the facilities have become increasingly specialised, with newer ones offering a range of inhouse services, including care by physicians, addiction counselling, and detoxification. There are about 65 supervised injection facilities in eight countries, with Norway and Luxembourg being the latest to open facilities.1,3 However, proposals to establish facilities have been hotly debated and eventually dismissed in Austria, France, Portugal, Ireland, Denmark, and the Czech Republic.1,3 More recently, pilot supervised injection facilities were started in Sydney, Australia, and Vancouver, Canada, two cities that had historically favoured strict law enforcement over health-focused responses to injection drug use. Both small pilot programmes were allowed to proceed under intense public scrutiny and 354
were contingent on rigorous scientific evaluation.4,5 The evaluations showed that the facilities met their primary objectives of reducing public injecting, syringe sharing, and overdose risks, and increasing access to addiction treatment. The evaluations also revealed that the facilities were not encouraging drug use or increasing crime, and high levels of public support and costeffectiveness were also documented.5,6 The favourable evaluations of the Australian and Canadian facilities led to renewed interest in such centres. Recently, in England and Scotland, government-sponsored reports have called for pilot supervised injection facilities.7,8 Perhaps most surprising, however, were recent discussions among public-health officials and legal experts focused on the feasibility of establishing facilities in the USA.9 Despite the growing body of evidence that supports the effectiveness of these facilities, proposals to establish centres in these settings have been blocked by conservative forces. UK officials have gone as far as declaring supervised injection facilities unlawful,8 and a US Senator introduced a federal bill amendment, later defeated, that would have allowed for cuts to federal health funds for any locality that opened a facility.10 Much ideologically driven opposition to supervised injection facilities has been fuelled by well-orchestrated efforts by international organisations, including the UN’s International Narcotics Control Board (INCB) and the Drug Free America Foundation. In its 2007 annual report, the INCB stated that supervised injection facilities “contravene the most fundamental principle of the international drug control conventions” and www.thelancet.com Vol 372 August 2, 2008
went on to urge “governments of countries where drug injection rooms are operated…to close those facilities”.11 Ironically, the INCB has taken this stance despite a published UN legal opinion declaring that supervised injection facilities do not contravene UN drug-control treaties.12 A division of the Drug Free America Foundation, the Institute on Global Drug Policy and Practice, recently created a website13 that includes essays highly critical of evidence-based HIVprevention interventions for injection drugs users, such as needle exchange and supervised injection facilities. Not surprisingly, the conclusions of these essays are inconsistent with those of key international consensus documents, including those by WHO14 and UNAIDS.15 Unfortunately, these efforts have had some sway, with officials in several countries citing the UN treaties as a barrier to the implementation of supervised injection facilities.8,16 Further, in Canada, the Minister of Health quoted16 extensively from the Drug Free America Foundation’s website when he ordered his government officials to appeal a recent decision by the Supreme Court of the Province of British Columbia granting the supervised injection facility in Vancouver constitutional immunity from Canada’s drug laws. Ongoing harms among injection drug users, such as HIV infection, warrant innovative and swift action that is based on the best available scientific evidence. More than 25 years of experience with supervised injection facilities has shown that the time for the global scale-up of these programmes has come. Such scale-up, however, can only occur if political leaders are willing to take the courageous step of putting scientific evidence and public-health interests ahead of ideology.
Dan Small
Comment
Figure: First United Church, Vancouver, takes a stand in support of the city’s supervised injection site 4
5
6
7
8
9
10
11
*Thomas Kerr, Julio Montaner, Evan Wood British Columbia Centre for Excellence in HIV/AIDS, St Paul’s Hospital; Vancouver, BC, Canada V6Z 1Y6; and Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada [email protected] We are responsible for the scientific evaluation of Vancouver’s supervised injection site. Some funding for the evaluation is provided by Canadian Institutes of Health Research grant HPR-85526 and Vancouver Coastal Health. 1 2 3
Kimber J, Dolan K, van Beek I, Hedrich D, Zurhold H. Drug consumption facilities: an update since 2000. Drug Alcohol Rev 2003; 22: 227–33. Strathdee S, Pollini R. A 21st-century Lazarus: the role of safer injection site in harm reduction and recovery. Addiction 2007; 102: 848–49. Lloyd C, Hunt N. Drug consumption rooms: an overdue extension to harm reduction policy in the UK? Int J Drug Policy 2007; 18: 5–9.
www.thelancet.com Vol 372 August 2, 2008
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13 14
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Wood E, Tyndall MW, Montaner JS, Kerr T. Summary of findings from the evaluation of a pilot medically supervised safer injecting facility. CMAJ 2006; 175: 1399–404. MSIC Committee. Final report of the Sydney medically supervised injecting centre. Sydney: MSIC Evaluation Committee; 2003. http://www. druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_ report4.pdf (accessed July 16, 2008). Expert Advisory Committee on Supervised Injection Site Research. Vancouver’s Insite service and other supervised injection sites: what has been learned from research? Final report of the Expert Advisory Committee. 2008.http://www.hc-sc.gc.ca/ahc-asc/pubs/sites-lieux/indexeng.php (accessed July 16, 2008). Scotland’s Futures Forum. Approaches to alcohol and drugs in Scotland: a question of architecture. 2008. http://www.drugmisuse.isdscotland. org/publications/local/drug_futures.pdf (accessed July 16, 2008). Anon. Calls for drug ‘injecting rooms’. BBC News May 30, 2008. http:// news.bbc.co.uk/2/hi/uk_news/wales/south_west/7426040.stm (accessed July 16, 2008). Beletsky L, Davis CS, Anderson E, Burris S. The law (and politics) of safe injection facilities in the United States. Am J Public Health 2008; 98: 231–37. Piper B. A major victory, and a major fight ahead. Drug Policy News Nov 7, 2007. http://www.drugpolicy.org/news/110707hea.cfm (accessed July 16, 2008). International Narcotics Control Board. Report of the International Narcotics Control Board for 2007: March 5, 2008. http://www.incb.org/ pdf/annual-report/2007/en/annual-report-2007.pdf (accessed July 16, 2008). Csete J, Wolfe D. Closed to reason: the International Narcotics Control Board and HIV/AIDS. Feb 27, 2007. http://www.soros.org/initiatives/ health/focus/ihrd/articles_publications/publications/publications_ 20070227 (accessed July 16, 2008). Drug Free Foundation America, Inc. http://www.dfaf.org (accessed July 28, 2008). WHO. Policy and programming guide for HIV/AIDS prevention and care among injecting drug users. 2005. http://www.who.int/hiv/pub/prev_ care/policyprogrammingguide.pdf (accessed July 16, 2008). UNAIDS. Intensifying HIV Prevention: a UNAIDS policy position paper. , August, 2005. http://data.unaids.org/publications/irc-pub06/jc1165intensif_hiv-newstyle_en.pdf (accessed July 16, 2008). Clement T. Remarks for the Honourable Tony Clement before the House of Commons Standing Committee on Health on the subject of supervised injection sites. Ottawa, May 29, 2008. http://www.hc-sc.gc. ca/ahc-asc/minist/speeches-discours/2008_05_29-eng.php (accessed July 17, 2008).
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