Safer drug consumption facilities: evidence paper

Drug-related deaths

A 10- year evaluation^[7] of an Australian SDCF took place between May 2001 and April 2010 in Sydney. It showed a success in decreasing drug overdose deaths. There were no deaths on the site despite 3426 overdoses occurring in the SDCF. Also, analysis of external data sets suggested that the SDCF reduced public opioid overdoses in the local area.

A more recent 18-month trial of a SDCF in Melbourne, Australia, starting on 30^th June 2018 took place and recorded no deaths onsite although 2657 overdoses occurred within the SDCF. Of these responses, 271 required the use of naloxone and 2615 required oxygen and other measures to respond to breathing difficulties as a result of an overdose. There was also a 36% reduction in ambulance attendances involving naloxone in the 1km vicinity of the SDCF during opening hours^[8].

There have been no deaths from overdose recorded in SDCFs since they began, despite the millions of injecting episodes^[9].

Injecting-related harms

Due to the Coronavirus pandemic it has been difficult to indicate a direct number of those affected with injecting related harm within Glasgow, as BBV testing has been disrupted. However, data from the NHS Glasgow and Greater Clyde WAND initiative for September 2020 showed that for 377 individuals, who reported preparing and injecting their drugs within the city centre, 53% of those had not been tested for HIV and 50.1% had not been tested for Hepatitis C.

Glasgow City Council are aware that there is direct sharing of needles and that batch preparation remains a concern. A recent study from Glasgow Caledonian University in 2019 identified the key drivers of HIV infection in Glasgow to be 'an increase in cocaine injecting and homelessness'^[10].

Further data from the WAND initiative also indicated that the most common injecting injuries were missed hits 21.8% (82), abscesses 17% (64), infections 12.5% (47), DVT 12.2% (46) and open wounds 9% (34).

Both the review by Potier et al^[11], published in December 2014 and the earlier review by the European Monitoring Centre for Drug and Drug Addiction (EMCDDA)^[12] found SDCFs were associated with significant reductions in risky injecting practices.

SDCFs also appear to significantly reduce the sharing of injecting equipment, and consequently reduces the behaviours that increase the risk of HIV and hepatitis C transmission. Furthermore, they provide sterile injection equipment and harm reduction advice.

During the 10 year evaluation in Sydney there was a notable decline observed in HIV and hepatitis C infections in the local area of the SDCF and from the NSW Health Further evaluation of the Medically Supervised Injecting Centre during its extended Trial period (2007-2011) Final Report, found that 97% of clients surveyed reported that since attending the SDCF in Sydney they now inject more safely. Almost 80% of clients interviewed reported that they had changed their behaviour to reduce the risk of overdoses and were able to identify early signs of an overdose in other people or themselves.

With regard to public injecting, cross-sectional community surveys among people who inject drugs in Sydney have suggested modest reductions in the prevalence of injecting in the street (47% in 2000 to 40% in 2002, p=0.06) or in public toilets (39% to 29%, p=0.01) following introduction of a SDCF^[13].The Melbourne Safer Drug Consumption Facility also found a reduction in reports of public injecting by residents and local business respondents. A decrease in the proportion of residents from 24% to 20% and business respondents from 27% to 22% who saw public injecting ^[14].

From the 2007 evaluation from Vancouver, Canada, a randomly selected cohort of 1082 people from the SDCF were surveyed. The survey found that 75% reported that their injecting behaviour had changed as a result of the SDCF. 71% indicated that the SDCF had led to less outdoor injecting and 56% reported less unsafe syringe disposal^[15].

Treatment

Reviews also found that attendance at SDCF to be associated with increased uptake of addictions care. At the Sydney SDCF it was able to reach a socially marginalised and vulnerable population group of long-term injecting drug users, of whom 40% has no previous interaction with any form of drug treatment. Staff were able to make 8508 referrals, nearly half of which were related to drug treatment (3871). They also found that the more frequently a client visited the SDCF, the more likely they were to have accepted a referral to a drug treatment service^[16].During the 18-month review of a SDCF in Melbourne it provided or referred 10,540 additional services beyond supervision of injecting as well as providing specialist clinics.

The same was also found in Vancouver, Canada, among a cohort of people who inject drugs recruited from the Vancouver SDCF, regular attendance was associated with a 33% greater likelihood of initiating addictions treatment (hazard ratio 1.33, 95% CI 1.04 – 1.72) and a 72% greater likelihood of entering a detoxification programme (hazard ratio 1.72, 95% CI 1.25 – 2.38)^[17].

There have been concerns that SDCFs could promote drug injecting use, but these have been unfounded. Evaluations from both Australian sites and Vancouver, as well as several other cities across the world have found no change in the local prevalence of injecting drug use after the introduction of a SDCF to the area.

We understand from this information that SDCF are unlikely to encourage individuals to begin to recommence drug use. They may however, play an important role in facilitating access to treatment and recovery services.

Public Injecting

Glasgow City Council continues to receive complaints regarding public injecting. There are around 10-20 calls from the public for needle uplifts per month. These create tensions between the local communities, pharmacies, IEPs and People who use drugs within the city centre.

When North America's first SDCF was opened in Vancouver in September 2003, they used a standardised prospective data collection protocol. They measured injection-related public order problems during 6 weeks before and the 12 weeks after the opening of the SDCF.

The results found from the 12 weeks after the facility was opened were independently associated with reductions in the numbers of publically discarded syringes and injection-related litter. By comparing the data collected from before the SDCF opened to afterwards, statistically it was found to show significant reductions in publically discarded syringes (average daily publically discarded syringes from 11.5 - 5.4) and injection related litter^[18].

The SDCF in Sydney also saw similar reductions throughout its 10-year study. It found there was a steady decline in the proportion of residents who reported seeing publicly discarded syringes. This has declined from two thirds of residents prior to the opening of the SDCF (66% in 2000) to 46% of respondents in 2010. There has been a similar decline amongst business respondents, from 80% of respondents in 2000 to 46% in 2010. Data on needle and syringe collections suggests that since the commencement of the SDCF services there has been a considerable reduction of the total number of needles and syringes collected in its vicinity during the period 2004 to 2009. Moreover, the greatest reduction has been in the areas immediately adjacent to the SDCF. Nearly all (92%) current clients of the SDCF interviewed reported that the facility had helped them reduce injecting in public places. Based on information analysed, since the commencement of the trial in 2001, there has been reduced problems with public injecting and discarded needles and/or syringes.

Overall, the data on discarded needles and syringes collected in the relevant sectors indicated a decline in the total number of needles and syringes collected during the period reported from 2003-04 to 2008-09. Specifically, the number of needles and syringes collected across all relevant sectors more than halved from 28,231 in 2003-04 to 12,646 in 2008-09. In addition, it is highlighted that the majority (81%) of surveyed clients agreed with the statement: Since coming here, the SDCF has helped me to not leave injecting equipment in public^[19].