A cost-benefit/cost-effectiveness analysis of proposed supervised injection facilities in Montreal, Canada

The implementation of safer drug consumption facilities in Scotland: a mixed methods needs assessment and feasibility study for the city of Edinburgh

BACKGROUND

Scotland currently has amongst the highest rates of drug-related deaths in Europe, leading to increased advocacy for safer drug consumption facilities (SDCFs) to be piloted in the country. In response to concerns about drug-related harms in Edinburgh, elected officials have considered introducing SDCFs in the city. This paper presents key findings from a feasibility study commissioned by City of Edinburgh Council to support these deliberations.

METHODS

Using a multi-method needs assessment approach, we carried out a spatial and temporal analysis of drug-related data in Edinburgh including health, mortality, consumption, crime and service provision indicators; and 48 interviews including 22 people with lived/living experience (PWLE) of drug use in the city, five family members affected by drug-related harms, and 21 professional stakeholders likely to be involved in commissioning or delivering SDCFs. Data were collected using a convergent parallel design. We carried out a descriptive analysis of quantitative date and a thematic analysis of qualitative data. Quantitative data provides an overview of the local context in terms of recorded harms, service provision and consumption patterns as reported in prior surveys. Qualitative PWLE and families data captures the lived experiences of people who use drugs, and affected loved ones, within that local context, including perceived consumption trends, views on the practicality of SDCF provision, and hopes and anxieties regarding potential service provision. Professional stakeholders data provides insights into how people responsible for strategic planning and service delivery view the potential role of SDCF provision within the context described in the quantitative data.

RESULTS

In Edinburgh, drug-related harms and consumption patterns are dispersed across multiple locations, with some areas of higher concentration. Reported levels of opioid use, illicit benzodiazepine use and cocaine injecting are high. Qualitative interviews revealed strong support for the provision of SDCFs, and a preference for services that include peer delivery. However, PWLE also expressed concerns regarding safety and security, and professional stakeholders remained uncertain as to the prioritisation of facilities and possible opportunity costs in the face of restricted budgets.

CONCLUSION

There is a strong case for the provision of SDCFs in Edinburgh. However, service design needs to reflect spatial distributions of consumption and harm, patterns of consumption by drug type, and expressed preferences for both informality and security among potential service users. Models of SDCF provision used elsewhere in Scotland would therefore need to be adapted to reflect such considerations. These findings may apply more broadly to potential SDCF provision in the UK and internationally, given changing patterns of use and harm.

The effect of Montreal's supervised consumption sites on injection-related infections among people who inject drugs: An interrupted time series

BACKGROUND

Between June and November 2017, four supervised consumption sites (SCS) began operating in Montreal, Quebec. Earlier studies on SCS focused on examining their effects on blood-borne viral infections and overdose mortality. Our objective was to examine the effect of Montreal's SCS on the incidence, health service use and outcomes of injection-related infections (IRI) in people who inject drugs.

METHODS

We used Quebec's provincial administrative health data to identify people who inject drugs in Montreal and calculated the incidence of IRI in this population between December 2014 and December 2019. We conducted a retrospective, population-based interrupted time series to estimate the effect of Montreal's four SCS on the monthly incidence rates of IRI-related hospitalizations, emergency department (ED) visits, physician visits, and mortality. We also examined the effects of SCS on average length of IRI-related hospitalizations and incidence of hospitalizations involving surgery.

RESULTS

The average age of Montreal's people who inject drugs was 41.84 years, and 66.41% were male. After the implementation of SCS, there was a positive level change in the incidence of hospitalizations (0.97; 95% confidence interval [CI]: 0.26, 1.68) for IRI. There was also a significant post-intervention decline in hospitalization trends (-0.05; 95% CI: -0.08, -0.02), with modest trend changes in ED visits (-0.02; 95% CI: -0.05, 0.02). However, post-intervention changes in level (0.72; 95% CI: -3.85, 5.29) and trend (0.06; 95% CI: -0.23, 0.34) for physician visits remained limited. SCS had no effect on the average length of hospitalizations, but there was a decreasing post-intervention trend in hospitalizations involving surgery (-0.03; 95% CI: -0.06, 0.00).

CONCLUSION

Following the opening of the SCS, there was a moderate decline in the rate of hospitalizations to treat IRI, but the impact of the sites on the rate of physician visits remained limited. These findings suggest that SCS may mitigate the incidence of more serious and complicated IRI over time.

Economic evaluation of the effect of needle and syringe programs on skin, soft tissue, and vascular infections in people who inject drugs: a microsimulation modelling approach

BACKGROUND

Needle and syringe programs (NSP) are effective harm-reduction strategies against HIV and hepatitis C. Although skin, soft tissue, and vascular infections (SSTVI) are the most common morbidities in people who inject drugs (PWID), the extent to which NSP are clinically and cost-effective in relation to SSTVI in PWID remains unclear. The objective of this study was to model the clinical- and cost-effectiveness of NSP with respect to treatment of SSTVI in PWID.

METHODS

We performed a model-based, economic evaluation comparing a scenario with NSP to a scenario without NSP. We developed a microsimulation model to generate two cohorts of 100,000 individuals corresponding to each NSP scenario and estimated quality-adjusted life-years (QALY) and cost (in 2022 Canadian dollars) over a 5-year time horizon (1.5% per annum for costs and outcomes). To assess the clinical effectiveness of NSP, we conducted survival analysis that accounted for the recurrent use of health care services for treating SSTVI and SSTVI mortality in the presence of competing risks.

RESULTS

The incremental cost-effectiveness ratio associated with NSP was $70,278 per QALY, with incremental cost and QALY gains corresponding to $1207 and 0.017 QALY, respectively. Under the scenario with NSP, there were 788 fewer SSTVI deaths per 100,000 PWID, corresponding to 24% lower relative hazard of mortality from SSTVI (hazard ratio [HR] = 0.76; 95% confidence interval [CI] = 0.72-0.80). Health service utilization over the 5-year period remained lower under the scenario with NSP (outpatient: 66,511 vs. 86,879; emergency department: 9920 vs. 12,922; inpatient: 4282 vs. 5596). Relatedly, having NSP was associated with a modest reduction in the relative hazard of recurrent outpatient visits (HR = 0.96; 95% CI = 0.95-0.97) for purulent SSTVI as well as outpatient (HR = 0.88; 95% CI = 0.87-0.88) and emergency department visits (HR = 0.98; 95% CI = 0.97-0.99) for non-purulent SSTVI.

CONCLUSIONS

Both the individuals and the healthcare system benefit from NSP through lower risk of SSTVI mortality and prevention of recurrent outpatient and emergency department visits to treat SSTVI. The microsimulation framework provides insights into clinical and economic implications of NSP, which can serve as valuable evidence that can aid decision-making in expansion of NSP services.

Cost-effectiveness of drug consumption rooms in France: a modelling study

BACKGROUND

People who inject drugs (PWID) experience many health problems which result in a heavy economic and public health burden. To tackle this issue, France opened two drug consumption rooms (DCRs) in Paris and Strasbourg in 2016. This study assessed their long-term health benefits, costs and cost-effectiveness.

METHODS

We developed a model to simulate two fictive cohorts for each city (n=2,997 in Paris and n=2,971 in Strasbourg) i) PWID attending a DCR over the period 2016-2026, ii) PWID attending no DCR. The model accounted for HIV and HCV infections, skin abscesses and related infective endocarditis, drug overdoses and emergency department visits. We estimated the number of health events and associated costs over 2016-2026, the lifetime number of quality-adjusted life-years (QALYs) and costs, and the incremental cost-effectiveness ratio (ICER).

RESULTS

The numbers of abscesses and associated infective endocarditis, drug overdoses, and emergency department visits decreased significantly in PWID attending DCRs (-77%, -69%, and -65%, respectively) but the impact on HIV and HCV infections was modest (-11% and -6%, respectively). This resulted in savings of €6.6 (Paris) and €5.8 (Strasbourg) millions of medical costs. The ICER of DRCs was €30,600/QALY (Paris) and €9,200/QALY (Strasbourg). In scenario analysis where drug consumption spaces are implemented inside existing harm reduction structures, these ICERs decreased to €21,400/QALY and €2,500/QALY, respectively.

CONCLUSIONS

Our findings show that DCRs are highly effective and efficient to prevent harms in PWID in France, and advocate extending this intervention to other cities by adding drug consumption spaces inside existing harm reduction centers.

Economic Evaluations of Establishing Opioid Overdose Prevention Centers in 12 North American Cities: A Systematic Review

OBJECTIVES

Overdose prevention centers (OPCs) provide a safe place where people can consume preobtained drugs under supervision so that a life-saving medical response can be provided quickly in the event of an overdose. OPCs are programs that are established in Canada and have recently become legally sanctioned in only a few United States jurisdictions.

METHODS

We conducted a systematic review that summarizes and identifies gaps of economic evidence on establishing OPCs in North America to guide future expansion of OPCs.

RESULTS

We included 16 final studies that were evaluated with the Consolidated Health Economic Evaluation Reporting Standards and Drummond checklists. Eight studies reported cost-effectiveness results (eg, cost per overdose avoided or cost per quality-adjusted life-year), with 6 also including cost-benefit; 5 reported only cost-benefit results, and 3 cost offsets. Health outcomes primarily included overdose mortality outcomes or HIV/hepatitis C virus infections averted. Most studies used mathematical modeling and projected OPC outcomes using the experience of a single facility in Vancouver, BC.

CONCLUSIONS

OPCs were found to be cost-saving or to have favorable cost-effectiveness or cost-benefit ratios across all studies. Future studies should incorporate the experience of OPCs established in various settings and use a greater diversity of modeling designs.

Modeling as Visioning: Exploring the Impact of Criminal Justice Reform on Health of Populations with Substance Use Disorders

In the context of historic reckoning with the role of the criminal-legal system as a structural driver of health harms, there is mounting evidence that punitive drug policies have failed to prevent problematic drug use while fueling societal harms. In this explainer article, we discuss how simulation modeling provides a methodological framework to explore the potential outcomes (beneficial and harmful) of various drug policy alternatives, from incremental to radical. We discuss potential simulation modeling opportunities while calling for a more active role of simulation modeling in visioning and operationalizing transformative change.

Highlights

This article discusses opportunities for simulation modeling in projecting health and economic impacts (beneficial and harmful) of drug-related criminal justice reforms.We call on modelers to explore radical interventions to reduce drug-related harm and model grand alternative futures in addition to more probable scenarios, with a goal of opening up policy discourse to these options.

Gaps in hepatitis C virus prevention and care for HIV-hepatitis C virus co-infected people who inject drugs in Canada

BACKGROUND

People who inject drugs (PWID) living with HIV are a priority population for eliminating hepatitis C virus (HCV) as a public health threat. Maximizing access to HCV prevention and treatment strategies are key steps towards elimination. We aimed to evaluate engagement in harm reduction programs and HCV treatment, and to describe injection practices among HIV-HCV co-infected PWID in Canada from 2003 to 2019.

METHODS

We included Canadian Coinfection Cohort study participants who reported injecting drugs between 2003 and 2019 in Quebec, Ontario, Saskatchewan, and British Columbia, Canada. We investigated temporal trends in HCV treatment uptake, efficacy, and effectiveness; injection practices; and engagement in harm reduction programs in three time periods based on HCV treatment availability: 1) interferon/ribavirin (2003-2010); 2) first-generation direct acting antivirals (DAAs) (2011-2013); 3) second-generation DAAs (2014-2019). Harm reduction services assessed included needle and syringe programs (NSP), opioid agonist therapy (OAT), and supervised injection sites (SIS).

RESULTS

Median age of participants (N = 1,077) at cohort entry was 44 years; 69% were males. Province-specific HCV treatment rates increased among HCV RNA-positive PWID, reaching 16 to 31 per 100 person-years in 2014-2019. Treatment efficacy improved from a 50 to 70% range in 2003-2010 to >90% across provinces in 2014-2019. Drug injecting patterns among active PWID varied by province, with an overall decrease in cocaine injection frequency and increasing opioid injections. In the most recent time period (2014-2019), needle/syringe sharing was reported at 8-22% of visits. Gaps remained in engagement in harm reduction programs: NSP use decreased (58-70% of visits), OAT engagement among opioid users was low (8-26% of visits), and participants rarely used SIS (1-15% of visits).

CONCLUSION

HCV treatment uptake and outcomes have improved among HIV-HCV coinfected PWID. Yet, this population remains exposed to drug-related harms, highlighting the need to tie HCV elimination strategies with enhanced harm reduction programs to improve overall health for this population.

Factors associated with injury and blood-borne infection risk when providing assisted injection among people who inject drugs

OBJECTIVE

Prior research has associated assisted injection with risk behaviors, but other risks such as injury, missed veins, and incidental exposures to blood-borne infections during an injection episode have not been assessed. In the following, we present the frequency of these other risks and determine factors associated with missing a vein and incidental blood exposure among people who inject drugs (PWID).

METHODS

We conducted a cross-sectional analysis of data from PWID who were recruited using targeted sampling in Los Angeles and San Francisco, California, during 2016 and 2017. The analytic sample consist of 336 participants who reported providing injection assistance in the last 6 months. Multivariate logistic regression models were developed for reporting the following risks: missing a vein; getting the recipient's blood on the injection provider; and getting blood on clothes or surfaces.

RESULTS

In the last 6 months, the most common negative consequences were getting blood on clothes or surfaces (40%), getting the recipient's blood on the injection provider (23%), and missing a vein (17%). In multivariate logistic regression analysis, missing the vein was significantly associated with higher odds of assisting a leg injection while getting the injection recipient's blood on the provider or getting blood on clothes or nearby surfaces was associated with higher odds of assisting a groin injection injecting in the groin.

CONCLUSION

Providing injection assistance can result in incidental blood exposures and injury, particularly when injecting in sensitive locations on the body. Harm reduction interventions to reduce risks associated with this practice are essential to improving the well-being of PWID.

Health programmes and services addressing the prevention and management of infectious diseases in people who inject drugs in Canada: a systematic integrative review

OBJECTIVES

People who inject drugs (PWID) experience a high burden of injection drug use-related infectious disease and challenges in accessing adequate care. This study sought to identify programmes and services in Canada addressing the prevention and management of infectious disease in PWID.

DESIGN

This study employed a systematic integrative review methodology. Electronic databases (PubMed, CINAHL and Web of Science Core Collection) and relevant websites were searched for literature published between 2008 and 2019 (last search date was 6 June 2019). Eligible articles and documents were required to address injection or intravenous drug use and health programmes or services relating to the prevention or management of infectious diseases in Canada.

RESULTS

This study identified 1607 unique articles and 97 were included in this study. The health programmes and services identified included testing and management of HIV and hepatitis C virus (n=27), supervised injection facilities (n=19), medication treatment for opioid use disorder (n=12), integrated infectious disease and addiction programmes (n=10), needle exchange programmes (n=9), harm reduction strategies broadly (n=6), mobile care initiatives (n=5), peer-delivered services (n=3), management of IDU-related bacterial infections (n=2) and others (n=4). Key implications for policy, practice and future research were identified based on the results of the included studies, which include addressing individual and systemic factors that impede care, furthering evaluation of programmes and the need to provide comprehensive care to PWID, involving medical care, social support and harm reduction.

CONCLUSIONS

These results demonstrate the need for expanded services across a variety of settings and populations. Our study emphasises the importance of addressing social and structural factors that impede infectious disease care for PWID. Further research is needed to improve evaluation of health programmes and services and contextual factors surrounding accessing services or returning to care.

PROSPERO REGISTRATION NUMBER

CRD42020142947.

Feasibility, acceptability, concerns, and challenges of implementing supervised injection services at a specialty HIV hospital in Toronto, Canada: perspectives of people living with HIV

BACKGROUND

Substance use significantly impacts health and healthcare of people living with HIV/AIDS (PLHIV), especially their ability to remain in hospital following admission. Supervised injection services (SIS) reduce overdoses and drug-related harms, but are not often provided within hospitals/outpatient programs. Leading us to question, what are PLHIV's perceptions of hospital-based SIS?

METHODS

This mixed-methods study explored feasibility and acceptability of implementing SIS at Casey House, a Toronto-based specialty HIV hospital, from the perspective of its in/outpatient clients. We conducted a survey, examining clients' (n = 92) demand for, and acceptability of, hospital-based SIS. Following this, we hosted two focus groups (n = 14) and one-on-one interviews (n = 8) with clients which explored benefits/drawbacks of in-hospital SIS, wherein participants experienced guided tours of a demonstration SIS space and/or presentations of evidence about impacts of SIS. Data were analysed using descriptive statistics and thematic analysis.

RESULTS

Among survey participants, 76.1% (n = 70) identified as cis-male and over half (n = 49;54.4%) had been a hospital client for 2 years or less. Nearly half (48.8%) knew about clients injecting in/near Casey House, while 23.6% witnessed it. Survey participants were more supportive of SIS for inpatients (76.1%) than for outpatients (68.5%); most (74.7%) reported SIS implementation would not impact their level of service use at Casey House, while some predicted coming more often (16.1%) and others less often (9.2%). Most focus group/interview participants, believed SIS would enhance safety by reducing health harms (e.g. overdose), increasing transparency between clients and clinicians about substance use, and helping retain clients in care. Debate arose about who (e.g., in/outpatients vs. non-clients) should have access to hospital-based SIS and how implementation may shift organizational priorities/resources away from services not specific to drug use.

CONCLUSIONS

Our data showed widespread support of, and need for, hospital-based SIS among client stakeholders; however, attempts to reduce negative impacts on non-drug using clients need to be considered in the balance of implementation plans. Given the increased risks of morbidity and mortality for PLHIV who inject drugs as well as the problems in retaining them in care in a hospital setting, SIS is a key component of improving care for this marginalized group.

Perceptions of Syringe Service Programs and Supervised Use Sites Among a Sample of Registered Voters in a US State

CONTEXT

The decision to initiate a syringe service program or expand to a supervised use site is often influenced by local public support or opposition.

OBJECTIVE

The purpose of this study was to better understand public attitudes to local syringe service programs to inform the possibility of expanding services.

DESIGN, SETTING, AND PARTICIPANTS

We surveyed a sample of registered voters (n = 690) in the 8 counties in the state of Colorado with existing syringe service programs.

MAIN OUTCOME MEASURES

Respondents were asked about their awareness of and attitudes toward syringe service programs and supervised use sites.

RESULTS

More than three-fourths of respondents reported they were familiar with syringe service programs, but only a quarter knew they were legal, despite all survey respondents living near an operating program. Nearly one in 3 respondents thought a syringe service program or a supervised use site makes a community better, and a majority (57%) thought supervised use sites should be legal in their state. There were significant differences in attitudes toward the benefits and risks of syringe service programs by political party affiliation.

CONCLUSION

Understanding the level of community knowledge and support for syringe service programs, as well as the reasons for opposition, can be helpful in addressing community concerns when seeking to initiate or expand services.

Allocating treatment resources for hepatitis C in the UK: a constrained optimization modelling approach

Background and objective: Although the treatment of chronic hepatitis C (CHC) has significantly evolved with the introduction of direct-acting antivirals, the treatment uptake rates have been low especially among marginalized groups in the UK, such as people who inject drug (PWID) and men who have sex with men (MSM). Cutting health inequality is a major focus of healthcare agencies. This study aims to identify the optimal allocation of treatment budget for chronic hepatitis CHC among populations and treatments in the UK so that liver-related mortality in patients with CHC is minimized, given the constraint of treatment budget and equity issue. Methods: A constrained optimization modelling of resource allocation for the treatment of CHC was developed in Excel from the perspective of the UK National Health System over a lifetime horizon. The model was designated with the objective function of minimizing liver-related deaths by varying the decision variables, representing the number of patients receiving each treatment (elbasvir-grazoprevir, ombitasvir-paritaprevir-ritonavir-dasabuvir, sofosbuvir-ledipasvir, and pegylated interferon-ribavirin) in each population (the general population, PWID, and MSM). Two main constraints were formulated including treatment budget and the issue of equity. The model was populated with UK local data applying linear programming and underwent internal and external validation. Scenario analyses were performed to assess the robustness of model results. Results: Within the constraints of no additional funding over original spending in status quo and the consideration of the issue of equity among populations, the optimal allocation from the constrained optimization modelling (treating 13,122 PWID, 160 MSM, and 904 general patients with ombitasvir-paritaprevir-ritonavir-dasabuvir) was found to treat 2,430 more patients (relative change: 20.7%) and avert 78 liver-related deaths (relative change: 0.3%) compared with the current allocation. The number of patients receiving treatment increased 4,928 (relative change: 60.1%) among PWID and 42 (relative change: 35.8%) among MSM. Conclusion: The current allocation of treatment budget for CHC is not optimal in the UK. More patients would be treated, and more liver-related deaths would be avoided using a new allocation from a constrained optimization modelling without incurring additional spending and considering the issue of equity.

The effectiveness of substance use interventions for homeless and vulnerably housed persons: A systematic review of systematic reviews on supervised consumption facilities, managed alcohol programs, and pharmacological agents for opioid use disorder

BACKGROUND

Substance use is disproportionately high among people who are homeless or vulnerably housed. We performed a systematic overview of reviews examining the effects of selected harm reduction and pharmacological interventions on the health and social well-being of people who use substances, with a focus on homeless populations.

METHODS AND FINDINGS

We searched MEDLINE, EMBASE, PsycINFO, Joanna Briggs Institute EBP, Cochrane Database of Systematic Reviews and DARE for systematic reviews from inception to August 2019. We conducted a grey literature search and hand searched reference lists. We selected reviews that synthesized evidence on supervised consumption facilities, managed alcohol programs and pharmacological interventions for opioid use disorders. We abstracted data specific to homeless or vulnerably housed populations. We assessed certainty of the evidence using the GRADE approach. Our search identified 483 citations and 30 systematic reviews met all inclusion criteria, capturing the results from 442 primary studies. This included three reviews on supervised consumption facilities, 24 on pharmacological interventions, and three on managed alcohol programs. Supervised consumption facilities decreased lethal overdoses and other high risk behaviours without any significant harm, and improved access to care. Pharmaceutical interventions reduced mortality, morbidity, and substance use, but the impact on retention in treatment, mental illness and access to care was variable. Managed alcohol programs reduced or stabilized alcohol consumption. Few studies on managed alcohol programs reported deaths.

CONCLUSIONS

Substance use is a common chronic condition impacting homeless populations. Supervised consumption facilities reduce overdose and improve access to care, while pharmacological interventions may play a role in reducing harms and addressing other morbidity. High quality evidence on managed alcohol programs is limited.

Acceptability of safe drug consumption spaces among people who inject drugs in rural West Virginia

Aim

Safe consumption spaces (SCS) are indoor environments in which people can use drugs with trained personnel on site to provide overdose reversal and risk reduction services. SCS have been shown to reduce fatal overdoses, decrease public syringe disposal, and reduce public drug consumption. Existing SCS research in the USA has explored acceptability for the hypothetical use of SCS, but primarily among urban populations of people who inject drugs (PWID). Given the disproportionate impact of the opioid crisis in rural communities, this research examines hypothetical SCS acceptability among a rural sample of PWID in West Virginia.

Methods

Data were drawn from a 2018 cross-sectional survey of PWID (n = 373) who reported injection drug use in the previous 6 months and residence in Cabell County, West Virginia. Participants were asked about their hypothetical use of a SCS with responses dichotomized into two groups, likely and unlikely SCS users. Chi-square and t tests were conducted to identify differences between likely and unlikely SCS users across demographic, substance use, and health measures.

Results

Survey participants were 59.5% male, 83.4% non-Hispanic White, and 79.1% reported likely hypothetical SCS use. Hypothetical SCS users were significantly (p < .05) more likely to have recently (past 6 months) injected cocaine (38.3% vs. 25.7%), speedball (41.0% vs. 24.3%), and to report preferring drugs containing fentanyl (32.5% vs. 20.3%). Additionally, likely SCS users were significantly more likely to have recently experienced an overdose (46.8% vs. 32.4%), witnessed an overdose (78.3% vs. 60.8%), and received naloxone (51.2% vs. 37.8%). Likely SCS users were less likely to have borrowed a syringe from a friend (34.6% vs. 48.7%).

Conclusions

Rural PWID engaging in high-risk behaviors perceive SCS as an acceptable harm reduction strategy. SCS may be a viable option to reduce overdose fatalities in rural communities.

Drug consumption rooms: A systematic review of evaluation methodologies

ISSUES

Drug consumptions rooms (DCR) and supervised injecting facilities (SIF) are expanding internationally. Previous reviews have not systematically addressed evaluation methodologies.

APPROACH

Results from systematic searches of scientific databases in English until June 2017 were coded for paper type, country and year of publication. For evaluation papers, study outcome, methodology/study design and main indicators of DCR/SIF 'exposure' were recorded.

KEY FINDINGS

Two hundred and nineteen eligible peer-reviewed papers were published since 1999: the majority from Canada (n = 117 papers), Europe (n = 36) and Australia (n = 32). Fifty-six papers reported evaluation outcomes. Ecological study designs (n = 10) were used to assess the impact on overdose, public nuisance and crime; modelling techniques (n = 6) estimated impact on blood-borne diseases, overdose deaths and costs. Papers using individual-level data included four prospective cohorts (n = 28), cross-sectional surveys (n = 7) and service records (n = 5). Individual-level data were used to assess safer injecting practice, uptake into health and social services and all the other above outcomes except for impact on crime and costs. Four different indicators of DCR/SIF attendance were used to measure service 'exposure'.

IMPLICATIONS

Research around DCRs/SIFs has used ecological, modelling, cross-sectional and cohort study designs. Further research could involve systematic inclusion of a control group of people who are eligible but do not access SIFs, validation of self-reported proportion of injections at SIFs or a stepped-wedge or a cluster trial comparing localities.

CONCLUSIONS

Methodologies appropriate for DCR/SIF evaluation have been established and can be readily replicated from the existing literature. Research on operational aspects, implementation and transferability is also warranted.

Management of endocarditis among persons who inject drugs: A narrative review of surgical and psychiatric approaches and controversies

BACKGROUND

People who inject drugs (PWID) represent a high-risk subgroup of endocarditis patients. This is highlighted by poorer post-operative outcomes in injection drug use-related infective endocarditis (IDU-IE), which is largely attributable to the increased vulnerability of prosthetic valves to re-infection. Consequently, many centres do not perform valve replacement on these patients. A parallel, but often underrecognized, component of care is the role of multidisciplinary management for individuals with IDU-IE, including perioperative addictions and psychiatric care. Consequently, surgical management options in IDU-IE remain a controversial topic.

OBJECTIVES

To determine the characteristics of optimal surgical and psychiatric care for individuals with IDU-IE.

METHODS

We conducted a narrative synthesis of the findings of literature retrieved from searches of computerized databases, hand searches, and authoritative text, organizing the findings into several key themes: clinical characteristics and factors associated with mortality in IDU-IE, alternative surgical management options, perioperative risk stratification techniques, principles of psychiatric and addictions management in IDU-IE, ethical considerations and controversies, and future research directions.

RESULTS/CONCLUSIONS

Managing IDU-IE involves the treatment of two comorbidities: the intra-cardiac infection and the underlying substance use disorder. Cardiac surgery represents a high-intensity intervention with appreciable risk, and the benefit it is not always clear. As patients often present acutely, it is not feasible to use drug abstinence as a prerequisite to surgery. Involvement of inpatient psychiatry and addictions teams, however, appears to be an evidence-based approach that can bridge IDU-IE patients with opioid agonist therapy in hospital and adequate outpatient treatment options for their underlying addiction upon their discharge from hospital. It is likely that a majority of these patients are not receiving optimal psychiatric management despite increasing recognition of efficacy. Further interdisciplinary studies are needed to elucidate optimal surgical and multidisciplinary protocols.

BACKGROUND

Infective endocarditis (IE) is an infection of the innermost lining of the heart often affecting the heart valves. Over the last few decades, the epidemiology of IE has shifted in the developed world and while it continues to be a significant cause of morbidity and mortality, there has been a significant increased incidence among persons who inject drugs (PWID). To date, well-conducted epidemiologic studies of IE among PWID have been sparse, which has limited our ability to fully characterize this disease phenomenon. To address this knowledge deficit, we conducted a narrative synthesis of the findings of literature retrieved from searches of computerized databases, hand searches, and authoritative text, and organized our findings into six key themes: clinical characteristics and factors associated with mortality in IDU-IE, alternative surgical management options, perioperative risk stratification techniques, principles of psychiatric and addictions management in IDU-IE, ethical considerations and controversies, and future research directions.

The projected costs and benefits of a supervised injection facility in Seattle, WA, USA

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.

METHODS

We utilized local estimates and other data sources deemed appropriate for our setting to implement a mathematical model that assesses the impact of a hypothetical SIF on overdose deaths, non-fatal overdose health service utilization, skin and soft tissue infections, bacterial infections, viral infections, and enrollment in medication assisted treatment (MAT). We estimated the costs and savings that would occur on an annual basis for a small-scale pilot site given current overdose rates, as well as three other scenarios of varying scale and underlying overdose rates.

RESULTS

Assuming current overdose rates, a hypothetical Seattle SIF in a pilot phase is projected to annually reverse 167 overdoses and prevent 6 overdose deaths, 45 hospitalizations, 90 emergency department visits, and 92 emergency medical service deployments. Additionally, the site would facilitate the enrollment of 41 SIF clients in medication assisted treatment programs. These health benefits correspond to a monetary value of $5,156,019. The annual estimated cost of running the SIF is $1,222,332. The corresponding cost-benefit ratio suggests that the pilot SIF would generate $4.22 for every dollar spent on SIF operational costs. The pilot SIF is projected to save the healthcare system $534,453. If Seattle experienced elevated overdose rates and Seattle SIF program were scaled up, the health benefits and financial value would be considerably greater.

CONCLUSION

This analysis suggests that a SIF program in Seattle would save lives and result in considerable health benefits and cost savings.

The value of harm reduction for injection drug use: A clinical and public health ethics analysis

The US is facing dual public health crises related to opioid overdose deaths and HIV. Injection drug use is fueling both of these epidemics. The War on Drugs has failed to stem injection drug use and has contributed to mass incarceration, poverty, and racial disparities. Harm reduction is an alternative approach that seeks to decrease direct and indirect harms associated with drug use without necessarily decreasing drug consumption. Although overwhelming evidence demonstrates that harm reduction is effective in mitigating harms associated with drug use and is cost-effective in providing these benefits, harm reduction remains controversial and the ethical implications of harm reduction modalities have not been well explored. This paper analyzes harm reduction for injection drug use using the core principles of autonomy, nonmaleficence, beneficence, and justice from both clinical ethics and public health ethics perspectives. This framework is applied to harm reduction modalities currently in use in the US, including opioid maintenance therapy, needle and syringe exchange programs, and opioid overdose education and naloxone distribution. Harm reduction interventions employed outside of the US, including safer injection facilities, heroin-assisted treatment, and decriminalization/legalization are then discussed. This analysis concludes that harm reduction is ethically sound and should be an integral aspect of our nation's healthcare system for combating the opioid crisis. From a clinical ethics perspective, harm reduction promotes the autonomy of, prevents harms to, advances the well-being of, and upholds justice for persons who use drugs. From a public health ethics perspective, harm reduction advances health equity, addresses racial disparities, and serves vulnerable, disadvantaged populations in a cost-effective manner.

Expanding supervised injection facilities across Canada: lessons from the Vancouver experience

The opioid crisis has led to an unprecedented rise in the number of overdose deaths across Canada. In response, there has been an expansion of supervised injection facilities (SIFs), with several new SIFs approved or under review across the country. Much of the evidence for the benefits of SIFs in reducing overdose mortality, infectious-related complications, and public disorder comes from Insite in Vancouver, North America's first SIF. While implementing SIFs in other Canadian cities is a major step forward in combating the opioid epidemic, the diversity within our country's socio-demographic and political landscape leaves the application of SIFs in these new settings a matter of uncertainty. This commentary highlights key lessons learned from Vancouver and the potential modifications required to enhance implementation in other cities to ensure the success of new SIFs across Canada.

The willingness of people who inject drugs in Boston to use a supervised injection facility

BACKGROUND

In Massachusetts, the number of opioid-related deaths has increased 350% since 2000. In the setting of increasing overdose deaths, one potential intervention is supervised injection facilities (SIFs). This study explores willingness of people who inject drugs in Boston to use a SIF and examines factors associated with willingness.

METHODS

A cross-sectional survey of a convenience sample of 237 people who inject drugs and utilize Boston's needle exchange program (NEP). The drop-in NEP provides myriad harm reduction services and referrals to addiction treatment. The survey was mostly self-administered (92%).

RESULTS

Results showed positive willingness to use a SIF was independently associated with use of heroin as main substance (odds ratio [OR]: 5.47; 95% confidence interval [CI]: 1.9-15.4; P = .0004), public injection (OR: 5.09; 95% CI: 1.8-14.3; P = .002), history of seeking substance use disorder (SUD) treatment (OR: 4.99; 95% CI: 1.2-21.1; P = .05), having heard of SIF (OR: 4.80; 95% CI: 1.6-14.8; P = .004), Hispanic ethnicity (OR: 4.22; 95% CI: 0.9-18.8; P = .04), frequent NEP use (OR: 4.18; 95% CI: 1.2-14.7; P = .02), current desire for SUD treatment (OR: 4.15; 95% CI: 1.2-14.7; P = .03), hepatitis C diagnosis (OR: 3.68; 95% CI: 1.2-10.1; P = .02), posttraumatic stress disorder (PTSD) diagnosis (OR: 3.27; 95% CI: 1.3-8.4; P = .01), report of at least 1 chronic medical diagnosis (hepatitis C, human immunodeficiency virus [HIV], hypertension, or diabetes) (OR: 3.27; 95% CI: 1.2-8.9; P = .02), and comorbid medical and mental health diagnoses (OR: 2.93; 95% CI: 1.2-7.4; P = .02).

CONCLUSIONS

Most respondents (91.4%) reported willingness to use a SIF. Respondents with substance use behavior reflecting high risk for overdose were significantly more likely to be willing to use a SIF. Respondents with behaviors that contribute to public health burden of injection drug use were also significantly more likely to be willing to use a SIF. Results indicate that this intervention would be well utilized by individuals who could most benefit from the model. As part of a broader public health approach, SIFs should be considered to reduce opioid overdose mortality, decrease public health burden of the opioid crisis, and promote access to addiction treatment and medical care.

Use of on-site detoxification services co-located with a supervised injection facility

OBJECTIVES

Supervised injection facilities (SIFs) are increasingly being implemented worldwide in response to the harms associated with injection drug use. Although SIFs have been shown to promote engagement of people who use injection drugs (PWID) with external health services, little is known about the potential of co-locating on-site detoxification services with SIFs. The aim of this study was to characterize use of detoxification services co-located at Insite, North America's first SIF, among PWID in Vancouver, Canada.

METHODS

Data were derived from two prospective cohorts of PWID in Vancouver, Canada between November 2010 and December 2012. Using multivariable generalized estimating equation logistic regression, we identified factors independently associated with reporting use of detoxification services at the SIF.

RESULTS

Among 1316 PWID, 147 (11.2%) reported enrolling in detoxification services co-located with the SIF at least once during the two year study period. In multivariable analyses, after adjustment for other potential cofounders, factors independently and positively associated with use of this service included residence<5 blocks from the SIF (Adjusted Odds Ratio [AOR]=1.70), enrollment in methadone maintenance therapy (AOR=1.90), public injection (AOR=1.53), binge injection (AOR=1.93), recent overdose (AOR=1.90) and frequent SIF use (AOR=8.15) (all p<0.05).

DISCUSSION

Use of on-site detoxification services offered at the SIF was common among PWID and associated with frequent SIF use and various markers of vulnerability and drug-related risk. These findings highlight the potential role of SIFs as a point of access to detoxification services for high-risk PWID. Future studies should examine if co-location leads to higher uptake of addiction services in comparison to services that create geographic or other obstacles.

Mitigating the heroin crisis in Baltimore, MD, USA: a cost-benefit analysis of a hypothetical supervised injection facility

Background

In Baltimore, MD, as in many cities throughout the USA, overdose rates are on the rise due to both the increase of prescription opioid abuse and that of fentanyl and other synthetic opioids in the drug market. Supervised injection facilities (SIFs) are a widely implemented public health intervention throughout the world, with 97 existing in 11 countries worldwide. Research has documented the public health, social, and economic benefits of SIFs, yet none exist in the USA. The purpose of this study is to model the health and financial costs and benefits of a hypothetical SIF in Baltimore.

Methods

We estimate the benefits by utilizing local health data and data on the impact of existing SIFs in models for six outcomes: prevented human immunodeficiency virus transmission, Hepatitis C virus transmission, skin and soft-tissue infection, overdose mortality, and overdose-related medical care and increased medication-assisted treatment for opioid dependence.

Results

We predict that for an annual cost of $1.8 million, a single SIF would generate $7.8 million in savings, preventing 3.7 HIV infections, 21 Hepatitis C infections, 374 days in the hospital for skin and soft-tissue infection, 5.9 overdose deaths, 108 overdose-related ambulance calls, 78 emergency room visits, and 27 hospitalizations, while bringing 121 additional people into treatment.

Conclusions

We conclude that a SIF would be both extremely cost-effective and a significant public health and economic benefit to Baltimore City.

Willingness to use a supervised injection facility among young adults who use prescription opioids non-medically: a cross-sectional study

Background

Supervised injection facilities (SIFs) are legally sanctioned environments for people to inject drugs under medical supervision. SIFs currently operate in ten countries, but to date, no SIF has been opened in the USA. In light of increasing overdose mortality in the USA, this study evaluated willingness to use a SIF among youth who report non-medical prescription opioid (NMPO) use.

Methods

Between January 2015 and February 2016, youth with recent NMPO use were recruited to participate in the Rhode Island Young Adult Prescription Drug Study (RAPiDS). We explored factors associated with willingness to use a SIF among participants who had injected drugs or were at risk of initiating injection drug use (defined as having a sex partner who injects drugs or having a close friend who injects).

Results

Among 54 eligible participants, the median age was 26 (IQR = 24–28), 70.4% were male, and 74.1% were white. Among all participants, when asked if they would use a SIF, 63.0% answered “Yes”, 31.5% answered “No”, and 5.6% were unsure. Among the 31 participants reporting injection drug use in the last six months, 27 (87.1%) reported willingness to use a SIF; 15 of the 19 (78.9%) who injected less than daily reported willingness, while all 12 (100.0%) of the participants who injected daily reported willingness. Compared to participants who were unwilling or were unsure, participants willing to use a SIF were also more likely to have been homeless in the last six months, have accidentally overdosed, have used heroin, have used fentanyl non-medically, and typically use prescription opioids alone.

Conclusions

Among young adults who use prescription opioids non-medically and inject drugs or are at risk of initiating injection drug use, more than six in ten reported willingness to use a SIF. Established risk factors for overdose, including homelessness, history of overdose, daily injection drug use, heroin use, and fentanyl misuse, were associated with higher SIF acceptability, indicating that young people at the highest risk of overdose might ultimately be the same individuals to use the facility. Supervised injection facilities merit consideration to reduce overdose mortality in the USA.

Electronic supplementary material

The online version of this article (doi:10.1186/s12954-017-0139-0) contains supplementary material, which is available to authorized users.

A Cost-Benefit Analysis of a Potential Supervised Injection Facility in San Francisco, California, USA

Supervised injection facilities (SIFs) have been shown to reduce infection, prevent overdose deaths, and increase treatment uptake. The United States is in the midst of an opioid epidemic, yet no sanctioned SIF currently operates in the United States. We estimate the economic costs and benefits of establishing a potential SIF in San Francisco using mathematical models that combine local public health data with previous research on the effects of existing SIFs. We consider potential savings from five outcomes: averted HIV and hepatitis C virus (HCV) infections, reduced skin and soft tissue infection (SSTI), averted overdose deaths, and increased medication-assisted treatment (MAT) uptake. We find that each dollar spent on a SIF would generate US$2.33 in savings, for total annual net savings of US$3.5 million for a single 13-booth SIF. Our analysis suggests that a SIF in San Francisco would not only be a cost-effective intervention but also a significant boost to the public health system.

Cost-Effectiveness of Combined Sexual and Injection Risk Reduction Interventions among Female Sex Workers Who Inject Drugs in Two Very Distinct Mexican Border Cities

Background

We evaluated the cost-effectiveness of combined single session brief behavioral intervention, either didactic or interactive (Mujer Mas Segura, MMS) to promote safer-sex and safer-injection practices among female sex workers who inject drugs (FSW-IDUs) in Tijuana (TJ) and Ciudad-Juarez (CJ) Mexico. Data for this analysis was obtained from a factorial RCT in 2008–2010 coinciding with expansion of needle exchange programs (NEP) in TJ, but not in CJ.

Methods

A Markov model was developed to estimate the incremental cost per quality adjusted life year gained (QALY) over a lifetime time frame among a hypothetical cohort of 1,000 FSW-IDUs comparing a less intensive didactic vs. a more intensive interactive format of the MMS, separately for safer sex and safer injection combined behavioral interventions. The costs for antiretroviral therapy was not included in the model. We applied a societal perspective, a discount rate of 3% per year and currency adjusted to US$2014. A multivariate sensitivity analysis was performed. The combined and individual components of the MMS interactive behavioral intervention were compared with the didactic formats by calculating the incremental cost-effectiveness ratios (ICER), defined as incremental unit of cost per additional health benefit (e.g., HIV/STI cases averted, QALYs) compared to the next least costly strategy. Following guidelines from the World Health Organization, a combined strategy was considered highly cost-effective if the incremental cost per QALY gained fell below the gross domestic product per capita (GDP) in Mexico (equivalent to US$10,300).

Findings

For CJ, the mixed intervention approach of interactive safer sex/didactic safer injection had an incremental cost-effectiveness ratio (ICER) of US$4,360 ($310–$7,200) per QALY gained compared with a dually didactic strategy. Using the dually interactive strategy had an ICER of US$5,874 ($310–$7,200) compared with the mixed approach. For TJ, the combination of interactive safer sex/didactic safer injection had an ICER of US$5,921 ($104–$9,500) per QALY compared with dually didactic. Strategies using the interactive safe injection intervention were dominated due to lack of efficacy advantage. The multivariate sensitivity analysis showed a 95% certainty that in both CJ and TJ the ICER for the mixed approach (interactive safer sex didactic safer injection intervention) was less than the GDP per capita for Mexico. The dual interactive approach met this threshold consistently in CJ, but not in TJ.

Interpretation

In the absence of an expanded NEP in CJ, the combined-interactive formats of the MMS behavioral intervention is highly cost-effective. In contrast, in TJ where NEP expansion suggests that improved access to sterile syringes significantly reduced injection-related risks, the interactive safer-sex combined didactic safer-injection was highly cost-effective compared with the combined didactic versions of the safer-sex and safer-injection formats of the MMS, with no added benefit from the interactive safer-injection component.

Exploring the role of an unsanctioned, supervised peer driven injection facility in reducing HIV and hepatitis C infections in people that require assistance during injection

Background

Supervised consumption rooms or supervised injection facilities (SIFs) are venues that have reduced the risk of needle sharing and deaths caused by drug overdose among people who inject drugs (PWID). As a result of such a decline in the mortality rate, numerous studies have been able to illustrate its cost-effectiveness. However, studies have neglected to examine the same phenomena for unsanctioned SIFs that are run by peer drug users and provide assisted injections.

Methods

The current study will determine whether the former unsanctioned SIF, that provided assisted injection and was operated by the grass root organization called Vancouver Area Network of Drug Users (VANDU), cost less than the health care consequences of not having such a program in Vancouver, Canada. By analyzing data gathered in 2013, this paper relies on two mathematical models to estimate the number of new HIV and HCV infections prevented by the former unsanctioned facility in Vancouver’s Downtown Eastside.

Results

A conservative estimate indicates that the SIF location that provided assisted injections has a benefit-cost ratio of 33.1:1 due to its low operational cost. At the baseline sharing rate, the facility, on an average, reduced 81 HCV and 30 HIV cases among PWID each year. Such reductions in blood borne infections among PWID resulted in annual savings worth CAN$4.3 million dollars in health care expenditure. In addition to this, the current paper relies on a sensitivity analysis based on different needle sharing rate scenarios.

Conclusions

The sensitivity analysis and the baseline rates indicate that funding SIF facilities operated by peer drug users that facilitate assisted injection appear to be an efficient and effective use of financial resources in the public health domain since they lead to a significant decline in the rate of mortality within a vulnerable population.

Illicit drug use and harms, and related interventions and policy in Canada: A narrative review of select key indicators and developments since 2000

BACKGROUND

By the year 2000, Canada faced high levels of illicit drug use and related harms. Simultaneously, a fundamental tension had raisen between continuing a mainly repression-based versus shifting to a more health-oriented drug policy approach. Despite a wealth of new data and numerous individual studies that have emerged since then, no comprehensive review of key indicators and developments of illicit drug use/harm epidemiology, interventions and law/policy exist; this paper seeks to fill this gap.

METHODS

We searched and reviewed journal publications, as well as key reports, government publications, surveys, etc. reporting on data and information since 2000. Relevant data were selected and extracted for review inclusion, and subsequently grouped and narratively summarized in major topical sub-theme categories.

RESULTS

Cannabis use has remained the principal form of illicit drug use; prescription opioid misuse has arisen as a new and extensive phenomenon. While new drug-related blood-borne-virus transmissions declined, overdose deaths increased in recent years. Acceptance and proliferation of - mainly local/community-based - health measures (e.g., needle exchange, crack paraphernalia or naloxone distribution) aiming at high-risk drug users has evolved, though reach and access limitations have persisted; Vancouver's 'supervised injection site' has attracted continued attention yet remains un-replicated elsewhere in Canada. While opioid maintenance treatment utilization increased, access to treatment for key (e.g., infectious disease, psychiatric) co-morbidities among drug users remained limited. Law enforcement continued to principally focus on cannabis and specifically cannabis users. 'Drug treatment courts' were introduced but have shown limited effectiveness; several attempts cannabis control law reform have failed, except for the recent establishment of 'medical cannabis' access provisions.

CONCLUSIONS

While recent federal governments introduced several law and policy measures reinforcing a repression approach to illicit drug use, lower-level jurisdictions (e.g., provincial/municipal levels) and non-governmental organizations increasingly promoted social- and health-oriented intervention frameworks and interventions, therefore creating an increasingly bifurcated - and inherently contradictory - drug policy landscape and reality in Canada.

Examining the potential role of a supervised injection facility in Saskatoon, Saskatchewan, to avert HIV among people who inject drugs

BACKGROUND

Research predicting the public health and fiscal impact of Supervised Injection Facilities (SIFs), across different cities in Canada, has reported positive results on the reduction of HIV cases among People Who Inject Drugs (PWID). Most of the existing studies have focused on the outcomes of Insite, located in the Vancouver Downtown Eastside (DTES). Previous attention has not been afforded to other affected areas of Canada. The current study seeks to address this deficiency by assessing the cost-effectiveness of opening a SIF in Saskatoon, Saskatchewan.

METHODS

We used two different mathematical models commonly used in the literature, including sensitivity analyses, to estimate the number of HIV infections averted due to the establishment of a SIF in the city of Saskatoon, Saskatchewan.

RESULTS

Based on cumulative cost-effectiveness results, SIF establishment is cost-effective. The benefit to cost ratio was conservatively estimated to be 1.35 for the first two potential facilities. The study relied on 34% and 14% needle sharing rates for sensitivity analyses. The result for both sensitivity analyses and the base line estimates indicated positive prospects for the establishment of a SIF in Saskatoon.

CONCLUSION

The opening of a SIF in Saskatoon, Saskatchewan is financially prudent in the reduction of tax payers' expenses and averting HIV infection rates among PWID.

Supervised injection services: what has been demonstrated? A systematic literature review

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.

A cost-benefit/cost-effectiveness analysis of an unsanctioned supervised smoking facility in the Downtown Eastside of Vancouver, Canada

BACKGROUND

Smoking crack involves the risk of transmitting diseases such as HIV and hepatitis C (HCV). The current study determines whether the formerly unsanctioned supervised smoking facility (SSF)-operated by the grassroot organization, Vancouver Area Network of Drug Users (VANDU) for the last few years-costs less than the costs incurred for health-care services as a direct consequence of not having such a program in Vancouver, Canada.

METHODS

The data pertaining to the attendance at the SSF was gathered in 2012-2013 by VANDU. By relying on this data, a mathematical model was employed to estimate the number of HCV infections prevented by the former facility in Vancouver's Downtown Eastside (DTES).

RESULTS

The DTES SSF's benefit-cost ratio was conservatively estimated at 12.1:1 due to its low operating cost. The study used 70% and 90% initial pipe-sharing rates for sensitivity analysis. At 80% sharing rate, the marginal HCV cases prevented were determined to be 55 cases. Moreover, at 80% sharing rate, the marginal cost-effectiveness ratio ranges from $1,705 to $97,203. The results from both the baseline and sensitivity analysis demonstrated that the establishment of the SSF by VANDU on average had annually saved CAD$1.8 million dollars in taxpayer's money.

CONCLUSIONS

Funding SSFs in Vancouver is an efficient and effective use of financial resources in the public health domain; therefore, Vancouver Coastal Health should actively participate in their establishment in order to reduce HCV and other blood-borne infections such as HIV within the non-injecting drug users.

A cost-benefit/cost-effectiveness analysis of proposed supervised injection facilities in Ottawa, Canada

BACKGROUND

Supervised injection facilities (SIFs) are venues where people who inject drugs (PWID) have access to a clean and medically supervised environment in which they can safely inject their own illicit drugs. There is currently only one legal SIF in North America: Insite in Vancouver, British Columbia, Canada. The responses and feedback generated by the evaluations of Insite in Vancouver have been overwhelmingly positive. This study assesses whether the above mentioned facility in the Downtown Eastside of Vancouver needs to be expanded to other locations, more specifically that of Canada's capital city, Ottawa.

METHODS

The current study is aimed at contributing to the existing literature on health policy by conducting cost-benefit and cost-effective analyses for the opening of SIFs in Ottawa, Ontario. In particular, the costs of operating numerous SIFs in Ottawa was compared to the savings incurred; this was done after accounting for the prevention of new HIV and Hepatitis C (HCV) infections. To ensure accuracy, two distinct mathematical models and a sensitivity analysis were employed.

RESULTS

The sensitivity analyses conducted with the models reveals the potential for SIFs in Ottawa to be a fiscally responsible harm reduction strategy for the prevention of HCV cases--when considered independently. With a baseline sharing rate of 19%, the cumulative annual cost model supported the establishment of two SIFs and the marginal annual cost model supported the establishment of a single SIF. More often, the prevention of HIV or HCV alone were not sufficient to justify the establishment cost-effectiveness; rather, only when both HIV and HCV are considered does sufficient economic support became apparent.

CONCLUSIONS

Funded supervised injection facilities in Ottawa appear to be an efficient and effective use of financial resources in the public health domain.