Literature Review

This paper adds to the existing literature on the impact of safe consumption sites in communities affected by drug misuse and the opioid epidemic. I have reviewed the most prominent existing studies on safe consumption sites and compiled data from several pilot SCSs as well as studies attempting to predict the impact of SCSs on specific communities in the United States. The result is a holistic summary of three primary areas which SCSs have found to improve: reducing physical harms of injectable drug use, reducing social harms of injectable drug use, and doing so in a manner that is cost-effective as compared to other interventions against drug misuse. With this compilation and review of existing research I seek to provide communities considering implementing safe consumption sites with a comprehensive yet accessible guide to the benefits of such programs.

Introduction

Opioid use is on the rise in the United States, with more than 130 deaths every day contributed to opioid overdose (CDC/NCHS, 2018). While opioids have approved medical uses and are regularly prescribed to medical patients for the treatment of pain, approximately 21-29% of patients who are prescribed opioids for chronic pain eventually misuse them, and 8-12% eventually develop an opioid use disorder (Vowles et al., 2015). Overdoses from opioids are on the rise, having increased in large cities by 54% in 16 states from July 2016- September 2017 (Vivolo-Kantor et al., 2018). People who engage in drug use are at higher risk of contracting and transmitting certain viral infections, such as hepatitis, a viral infection that can cause liver inflammation and if untreated lead to liver damage, failure, and in some cases death, as well as human immunodeficiency virus (HIV), which can lead to acquired immune deficiency syndrome (AIDS) (National Institute on Drug Abuse, June 2019). Opioid abuse and misuse, as well as the risk of infection, disease, and overdose that comes with injecting drugs, have become a public health crisis, costing the United States an estimated $78.5 billion annually, including healthcare costs, lost productivity, addiction treatment, and criminal justice involvement (Florence et al., 2016). Communities are looking for solutions, and some are beginning to implement a variety of public health interventions to reduce opioid misuse and decrease the harms associated with drug use. The harm reduction model of intervention is rising in popularity as a way to mitigate the risks that come with illicit drug use without trying to stop drug use altogether (Harm Reduction Coalition).

The Harm Reduction Model of Intervention

With the rising opioid epidemic, alternative interventions to decrease the risk of opioids and intravenous drug use have been proposed. Harm reduction, also known as risk reduction, is based on the idea that sometimes it is more productive to reduce the negative consequences of a behavior rather than attempt to stop the behavior altogether (Hawk, Davis, 2011). Harm reduction, when applied to drug use, accepts that both licit and illicit drug use happens, and focuses on minimizing the negative risks associated with the use of drugs, rather than attempting to eradicate drug use altogether. This calls for non-judgmental services that prioritize the voices of people who inject drugs (PWID) and recognizes the intersections between race, poverty, class, social isolation, sex discrimination, trauma, and other social factors on drug use (Harm Reduction Coalition). For example, an organization built on a harm reduction model might offer special housing or job guidance services to a client who injects drugs facing homelessness in addition to services and resources for safer drug injection, as they recognize that homelessness is an added risk factor for disease, infection, and overdose from drug use. In this way, harm reduction is viewed as a “combination intervention,” which must be tailored to the specific needs of each setting, and the individuals in the setting.

Some of the most common and effective approaches to harm reduction include syringe exchange programs, opioid substitution programs, and safe consumption sites. Syringe exchange programs reduce the risks associated with drug use by providing clean needles and works to inject drugs, preventing the risks associated with needle sharing (CDC, 2019). Safe consumption sites reduce the risks associated with drug use by providing a safe and sterile environment for people to inject drugs under medical supervision, thus reducing the risks of public injection and possible overdoses (Drug Policy Alliance). Both interventions accept that drug use will happen, and attempt to make it a more safe behavior rather than attempting to prevent it completely. This is controversial because some argue that a zero tolerance policy is the only acceptable policy, and that harm reduction programs enable PWID to continue using. However, due to their net positive effect in reducing the harms of disease, infection, and overdose, starting in the 1970s the World Health Organization began recommending harm reduction policies to “prevent or reduce the severity of problems associated with the non-medical use of dependence-producing drugs” (Ball, 2007).

Introduction to Syringe Exchange Programs

Syringe exchange programs (SEPs) help reduce the risk of preventable diseases by handing out sterile supplies to people who inject drugs (CDC, 2019). SEPs provide supplies such as sterile needles, syringes, and other “works” used to inject drugs, including but not limited to cotton balls, alcohol swabs, cookers, and tourniquets. Additionally, most SEPs can help link patients to other critical services if requested, including drug rehabilitation services and HIV care, pre-exposure prophylaxis and post-exposure prophylaxis (CDC, 2019).

Different clinical studies of needle exchange programs have shown high success rates in preventing the spread of hepatitis and preventing and treating HIV and AIDS. A study on the effect of a harm reduction housing and syringe exchange program on the viral loads of homeless individuals living with HIV/AIDS showed that after the intervention, 95% of patients were prescribed antiretroviral therapy and 87% of patients were virally suppressed after treatment (Hawk, Davis, 2011). A comprehensive international review of syringe exchange programs done in 2005 found that SEPs provide a substantial benefit by reducing HIV transmission safely, effectively, and cost-effectively. The program was evaluated using the Bradford Hill criteria, a common and robust method of assessing public health interventions that analyzes the intervention on a set of nine criteria to provide epidemiologic evidence of a causal relationship between intervention (presumed cause) and observed effect. This particular program was found to fill six of the nine criteria, providing some evidence for a causal relationship between SEP initiation and observed reduction in harms. The study concluded that communities with high rates of drug injection should implement syringe exchange programs to combat the harms of the behaviors (Wodak, Cooney, 2005).

Introduction to Safe Consumption Sites

Safe Consumption Sites (SCS), otherwise known as supervised consumption facilities or safe injection facilities, help reduce the risk of preventable disease, infection, and overdose from injectable drug use by providing a medically supervised room for people to inject drugs hygienically and with care available in the case of overdose complications or risk of death (Drug Policy Alliance). A study done in Vancouver on the lessons learned after the initiation of their first syringe exchange program found that, after the introduction of the program, the prevalence of HIV, hepatitis C, and other risk behaviors were still high, concluding that a more comprehensive program was still necessary (Strathdee, 1997). One such program is the safe consumption site, which was later implemented in Vancouver. Since then, SCSs have become an increasingly popular intervention used by cities facing opioid epidemics for their success at reducing risks of disease, infection, overdose, and social harms from injectable drug use in a cost-effective manner.

Reducing Physical Harm

A review of the literature on structural interventions to reduce HIV transmission among people who inject drugs found that some policies that are designed to reduce drug use might actually increase rates of HIV transmission, but that SCSs (and SEPs) usually lead to large reductions in HIV risk-behavior (Jarlais, 2000). One major HIV risk-behavior is syringe sharing. One study on safer injection facility use and syringe sharing in injection drug users found that the use of safe consumption sites was independently associated with reductions in syringe sharing (Kerr et al., 2005). A study on the HIV infections prevented by Vancouver, Canada’s safe consumption site used mathematical modelling to estimate how many HIV infections were prevented by the introduction of the program. It found that 5-6 infections were prevented annually, give or take 2 (Pinkerton, 2011). The official report of the first safe consumption sites in Ottawa and Toronto, Canada estimated the number of HIV infections prevented in the two cities combined was about 8-13 per facility per year. The estimated number of hepatitis C virus infections prevented in the two cities combined was about 35-55 per facility per year (Bayoumi et al., 2012). A retrospective study analyzing the reduction in overdose mortality rates in Vancouver in areas around safe consumption sites found a decrease in mortality of 35% after opening. Mortality rates in the general city decreased as well, but the decrease in areas around SCSs were considerably higher. The study suggested other cities consider the implementation of an SCS in areas where injectable drug use is prevalent (Marshall et al., 2011). Another study on estimated drug overdose deaths averted by Vancouver’s first SCS found that 8-51 deaths were prevented from the implementation of the SCS by the most conservative estimates, and 6-37% of all fatal overdoses were prevented (Milloy et al., 2008).

In addition to decreasing rates of infection and disease transmission, safe consumption sites have been shown to improve injecting practices in patients. A study on changes in injecting practicies associated with the use of an SCS randomly selected SCS users found that patients that more consistently visited a safe consumption site had more positive changes in their injecting practices, including decresed syringe borrowing, sex trade, public injecting, and daily injections, and increased use of sterile water for injections, swabbing injection sites, filtering drugs, less rushed injections, and more safe syringe disposal (Stoltz et al., 2007). Further, a study on the impact of safe consumption sites on community HIV levels reviewed the potential impact of SCSs on HIV transmission as compared to current HIV prevention initiatives. The study highlighted the harms of HIV infection from drug use, arguing that reducing HIV infections among PWID through initiatives like SCSs will reduce HIV in the community at large, particularly as transmitted through sex (Tyndall, 2003).

Additionally, although the goal of SCSs is to reduce the risks of drug use, rather than to decrease drug use altogether, some research has found that SCSs can complete both goals. A study on North America’s first medically supervised safe consumption site found that SCSs reduce overall rates of drug use, and potentially promote an increase in addiction treatment and thus injection cessation, which improves individual health long term (Debeck et al., 2011). For their impact at reducing rates of infection and disease, as well as improving clients injecting practices long term and decreasing the risk of HIV spread in the community, safe consumption sites are recommended to decrease the physical risks of injecting drugs.

Reducing Social Harm

In addition to decreasing adverse health effects of drug use, such as infection, overdose, and disease, safe consumption sites have been shown to decrease many of the social harms of injectable drug use in communities as well. A study focussing on an urban district of Melbourne, Australia found that public areas with high rates of drug use carry risks for both the community at large and the individual using drugs, such as risks related to public injection, publicly discarded syringes and injection-related litter, and drug-related crime rates (Dovey et al. 2001). Thus, it is in everyone’s best interest to find an alternative to public drug use.

A study summarizing the findings from the evaluation of the pilot supervised consumption site in Vancouver, Canada found that public order in the area surrounding the facility increased by several measures after the initiation of the facility. There was a decrease in publicly discarded syringes, public injection drug use, injection-related litter, and presence of suspected drug dealers after the initiation of SCSs (Wood et al. 2006). Another similar study on safe consumption sites in North America and their place in public policy and health initiatives outlined the possible benefit of implementing SCSs in North America using data from existing SCSs. This study concluded that safe consumption sites decreased rates of public drug use, which is both more safe for the person injecting, and can make community members feel more safe. Additionally, this study found that the volume of discarded litter pertaining to drug use decreased after the implementation of SCSs, as well as rates of public congregations of PWID, increasing the quality of public spaces and safety for individual users (Broadhead et al., 2002). A study on a pilot observation and treatment center in Boston, MA found that after the initiation of the clinic, the average number of over-sedated individuals in public decreased by a sizeable 28% (León et al., 2018).

The decrease in social harms has been found to be particularly attractive to both PWID and SCS stakeholders, with the interest of increasing both public and individual safety. A series of semi-structured interviews with participants in Philadelphia found that PWID and healthcare providers expressed support for a potential SCS, suggesting that an SCS would improve the health of PWID while reducing the public disorder and crime that are often associated with public drug use. Many SCS participants seemed particularly interested in the creation of a safe, private place to inject drugs, motivated by a desire to not upset other community members and children (Harris et al., 2018). A similar study on perspectives on SCSs among service industry employees in New York City, sampled from 13 different businesses that do not hold a liquor license, found a similar positive attitude toward SCSs, particularly for their influence on reducing the social harms of public injection drug use (Wolfson-Stofko et al., 2018).

A common argument against safe consumption sites is that the draw of PWID to SCSs will increase crime rates and unfavorable behaviors in the surrounding areas. This isn’t the case, as SCSs are most effective when implemented in areas with already high rates of injectable drug use. Thus, PWID aren’t displaced to areas where they didn’t already inhabit, but rather given a safer more concealed area to inject drugs within those neighborhoods. Additionally, safe consumption sites have a net positive result on the communities in which they reside. SCSs have been shown to decrease drug-related crime (Wood et al., 2006; Broadhead et al., 2002; Dovey et al. 2001), decrease the volume of publicly discarded syringes and injection-related litter (Wood et al., 2006; Broadhead et al., 2002; Dovey et al. 2001) decrease rates of public drug use (Wood et al., 2006; Broadhead et al., 2002; Dovey et al. 2001), and decrease the number of suspected drug dealers and over-sedated individuals in public (León et al., 2018). This increases health and safety for both the individuals injecting drugs as well as the surrounding community members, and increases the perceived safety and value of the area of the SCS.

Cost-effectiveness

Safe consumption sites have been shown to decrease both public order and personal health risks of drug use. In addition to being effective at completing these goals, SCSs have been shown to be an increasingly cost-effective intervention. A study comparing Vancouver’s safe consumption sites to other interventions for the prevention of HIV, such as syringe exchange programs and methadone maintenance treatment facilities, found that SCSs were highly cost effective in comparison to other interventions. The study concluded that SCSs would be cost effective even if they only prevented a modest number of HIV infections per year due to the high cost of lifetime medical treatment for an individual with HIV (Jarlais et al., 2008). The official report of the Toronto and Ottawa Supervised Consumption Assessment Study used mathematical modeling to determine the benefit of SCSs on reducing HIV and hepatitis C infection rates, and concluded that the intervention had high effectiveness and relatively low cost. It is estimated that the amount of money saved per each HIV infection averted with the first SCS was $323,496 in Toronto and $66,358 in Ottawa. The savings per hepatitis C infection prevention is estimated to be $47,489 in Toronto and $18,591 in Ottawa. The same study estimated the optimal cost-effectiveness as measured by the extra cost of intervention divided by the extra health gain, expressed as a ratio of dollars per quality adjusted life years (QALY). There is debate over whether the threshold for cost-effectiveness lies at $50,000/QALY or $100,000/QALY, but it was found that these thresholds would be met with 3-4 facilities in Toronto and 2-3 facilities in Ottawa. (Bayoumi et al., 2012) A third study on the cost-effectiveness of Vancouver’s SCS similarly found that the program was very cost-effective as an intervention to prevent HIV infection, with an incremental net savings of almost $14 million and 920 life-years gained for patients over 10 years (Bayoumi and Zaric, 2008).

A study on the predicted cost and benefits of an SCS in San Francisco, California, used mathematical models to estimate potential savings from five different outcomes, including averted HIV and hepatitis C infections, reduced skin and tissue infections, averted death from overdose, and increased medication-assisted treatment. The authors estimated that each dollar spent on an SCS would generate $2.33 in savings for a net savings of $3.5 to $2.2 million annually for a single facility (Irwin et al., 2016). A similar study was done in Baltimore, MD, of a cost-benefit analysis of a hypothetical SCS. The study estimated the benefits of an SCS using local health data and existing data measuring the efficacy of SCSs on six different outcomes, similar to those explored in the previous study on San Francisco. The study predicted that for $1.8 million in spending, a single SCS would generate $7.8 million in savings and prevent large numbers of infections and 5.9 overdose deaths annually (Irwin et al. 2017). Another similar study predicted a cost-benefit analysis of an SCS in Seattle, WA using a mathematical model and estimated that a pilot SCS would generate $4.22 in savings for every dollar spent, for a total savings of $534,453 annually. Hypothetically, if overdose rates continued to rise in Seattle and more SCSs were implemented, the benefit and efficacy would be even greater (Hood et al. 2019).

Safe consumption sites don’t only decrease government spending treating HIV infections, but have also been shown to decrease other public burdens and costs. A study done on the SCSs in Sydney, Australia found that the burden on ambulances of attending to opioid-related overdoses and emergencies declined significantly in the vicinity of the SCS after opening (Salmon et al., 2010). A study analyzing the potential impact of an SCS in Baltimore, MD, estimated that the introduction of a single facility would avert 108 overdose-related ambulance calls, 78 emergency room visits, and 27 hospitalizations (Irwin et al., 2017). A similar study on the potential impact of an SCS in Seattle, WA estimated that a facility would prevent 45 hospitalizations, 90 emergency room visits, and 92 emergency medical service deployments (Hood et al., 2019). SCSs can free ambulances and emergency medical facilities to attend to other emergencies in the community, and also decreased emergency medical costs for people injecting drugs.

Conclusion

Harm reduction interventions, specifically syringe exchange programs and safe consumption sites, have been shown to greatly reduce the harms associated with injectable drug use. Researchers have studied safe consumption sites for efficacy in three primary areas; 1) reducing individuals’ physical harms associated with drug use, such as the spread of HIV and hepatitis C, infections, and overdose, 2) reducing social harms associated with drug use, such as publicly discarded syringes and injection related litter, public crime, public drug use, and public overdose, 3) cost-effectiveness as compared to other similarly effective interventions and the price of tertiary treatment and prevention. Nearly every study on supervised injection facilities recommends the intervention for areas where drug use is prevalent. From the body of evidence, the advantage of SCSs should be heavily considered when a community is trying to prevent the harms associated with drug use.

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