Journal of Drug Issues

The ongoing public health crisis associated with injection drug use highlights the failure of prohibitionist policies. In contrast, harm reduction approaches aim to protect and promote the health of drug users. Supervised injection facilities (SIFs) are one important component of this approach. This article considers the international legal implications of establishing SIFs. It argues that implementing trials of SIFs is an appropriate measure that states should take pursuant to their international legal obligations to realize progressively the right of their nationals to the highest attainable standard of health. It argues that international drug control treaties do not prevent such measures, as is commonly claimed. The authors conclude that successful trials in Europe and Australia should be emulated elsewhere, in accordance with states' international obligations.

Although there have been repeated calls for the establishment of safe injection facilities (SIFs) in Vancouver since the early 1990s, questions remain concerning the feasibility of SIFs due to the high prevalence of injection cocaine and the concomitant problems cocaine use presents. Therefore, we determined the prevalence of willingness to attend SIFs among cocaine injectors in Vancouver and explored the factors associated with this willingness, using data from the Vancouver Injection Drug Users Study. After considering the results derived from this analysis, additional qualitative methods were employed to explore further willingness to use SIFs, barriers and facilitators of SIF utilization, and methods of maximizing use among selected subpopulations of cocaine injectors. The results suggest that a high proportion of cocaine injectors, including some of those most at risk, would attend an SIF if one were available. However, in order to better accommodate cocaine injectors, several modifications could be made to conventional SIF service design and delivery. The vast majority of these modifications relate to ensuring effective responses to cocaine toxicity. Given the acceptability of SIFs among cocaine injectors, it appears that an SIF pilot could result in significant and immediate benefits in terms of public health and community safety.

In shooting galleries, drug users are able to illegally rent cubicles to inject drugs. Established in Kings Cross, Sydney in the early 1990s, police grudgingly tolerated several such galleries. In 1997, a royal commission recommended that a parliamentary inquiry consider establishing an official medically supervised injecting center (MSIC). Despite strong evidence supporting an MSIC, a majority of the committee voted against a trial facility. As an act of civil disobedience, a group of concerned citizens established an unsanctioned MSIC. However, police soon closed the facility. At a subsequent parliamentary drug summit, delegates voted to support an official trial of an MSIC and invited a congregation of Roman Catholic nuns to establish the facility. When the nuns were instructed to withdraw, the Uniting Church was invited to establish the project. The MSIC opened in May 2001. It can be concluded that public health practitioners wishing to improve appalling outcomes from drug policies sometimes have to resort to civil disobedience in order to achieve their goals.

The Sydney Medically Supervised Injecting Centre (MSIC) is the first supervised injecting facility (SIF) in Australia and the English-speaking world. It commenced operations in May 2001 as a trial to be independently evaluated. The MSIC was to be the only SIF in Sydney's Kings Cross, a “red-light” area where the drug-using population had previously injected in public or in illegal “shooting galleries” that had proliferated in nearby commercial sex premises since 1990. The aim of the MSIC is to reduce the public health and public order issues arising from unsupervised and public injecting at a local community level. A clinical service model was developed, which would maximize the number of injecting episodes accommodated in a professionally supervised setting and integrate with the other harm reduction services nearby. In its first two years of operation 4,719 registered IDUs made 88,324 visits to inject at the MSIC. There were 553 drug overdoses (81% heroin) managed on site, with no fatalities. Among 1,852 client referrals made for further assistance, 44% were for the treatment of drug dependence. This early experience suggests that the MSIC's clinical model has been acceptable to a significant number of the street-based drug injecting population in this setting.

This paper describes characteristics of clients registered in the first 12 months of the Sydney Medically Supervised Injecting Centre's (MSIC) operation, as well as predictors of frequent attendance. The study is based on information collected from clients at their initial registration and subsequent service utilization. Most of the 2,719 clients were male (71%), almost half had previously experienced at least one nonfatal heroin overdose, and one quarter had accessed formal drug treatment in the previous 12 months. Characteristics associated with frequent attendance at the MSIC were reporting previous attendance at the local primary health service for injection drug users (IDU), injecting drugs other than amphetamine, reporting sex work, injecting at least daily, and injecting in a public place in the month before registration.

In order to evaluate the impact of consumption rooms (CRs) on the promotion of health among drug users and the reduction of the public nuisance of drug use, a study examining CRs in three countries was carried out in 2000. The study, supported by the European Commission, examined CRs in Rotterdam (The Netherlands), Innsbruck (Austria), and Hamburg (Germany). This paper evaluates the findings from the study of Hamburg CRs. In order to get evidence-based information on the effects of CRs, 616 drug users in the Hamburg drug scene or in the vicinity of low-threshold institutions were investigated with a standardized questionnaire. Qualitative problem-centered interviews were also carried out with staff members of the CRs, and representatives from the community, including neighborhood residents, business people, police, and politicians. Research findings show that the Hamburg CRs reached the target group of drug users who practice risky behaviors and engage in public drug use. Findings also show that the Hamburg CRs lead to positive changes in health-related behavior for drug users. In addition, the findings indicate that the Hamburg CRs played an important role in the reduction of public disturbances in the vicinity of open drug scenes.

EVA – Espacio de Venopunción higiénica Asistida – is the first safe injection facility (SIF) in Barcelona, Spain. Started on September 12, 2001, it began as a “poor relative” of DAVE –Dispositivo Asistencial de Venopunción – in Madrid. EVA suffers from the general underfunding of its parent program, the Can Tunis outreach program, and it has no formal or material support from municipal authorities. This SIF can accommodate five drug injectors at one time and also operates as a mobile room for shelter, contact, and health education, addressing mainly those drug users who are at highest risk of overdose, HIV infection, violence, and death. The project offers consistent services provided by an array of health care and welfare professionals, and it is ready to intervene in overdose and/or crisis situations. To date, it has an excellent record in providing a safe environment for both its staff of health care professionals and its clients. Below the Can Tunis area in general, the outreach program, and EVA are described. The advantages, disadvantages, and what has been learned from working in this quarter of Barcelona with the injection drug using community is discussed. In closing, questions and proposals for future efforts are addressed.

Empirical evidence suggests that a key prerequisite for a supervised injection facility (SIF) utilization is the existence of an “open drug scene,” where users publicly inject drugs. This study seeks to determine the extent and profile of public injecting among injecting drug users (IDUs) in Montreal, Canada, where pilot SIFs are under consideration. A cross-sectional study of IDUs who injected publicly at least once in the previous month was appended to an HIV-risk surveillance study among Montreal IDUs (SurvUDI study). Of 650 SurvUDI participants interviewed between June 2001 and February 2002, 59% were eligible. A dose-response relationship emerged between intensity of public injecting and several drug-use and risk-related characteristics. Regardless of housing stability, IDUs persistently and, often preferably, publicly injected due to habit, dependence, or need to conceal their status. Despite lacking a classical open drug scene, public injecting is common among Montreal IDUs, warranting the consideration of an SIF for this population.

HIV, hepatitis B & C, drug overdose, and other drug-related health problems still pose significant health risks to injection drug users (IDUs) and their sexual partners, indicating the need for further development of innovative public health interventions. A relatively new intervention implemented in many municipalities throughout the world is the “safer injection site” (SIS). An SIS is a legal facility that allows people to prepare and inject pre-obtained drugs in a hygienic, anxiety-free atmosphere under the supervision of health personnel. This paper examines the responses of a sample of IDUs in New York City to whether they would use an SIS should one be implemented in mid-town Manhattan. The SIS would be part of a comprehensive harm reduction project that already offers needle-exchange, street outreach, testing and counseling, support groups, referral services including drug treatment, and on-site primary medical and dental services. The results of our study indicate that a large majority of the IDUs sampled would utilize an SIS should one be implemented, and that those most likely to use it are IDUs at the highest risk for contracting or spreading blood-borne diseases such as HIV and hepatitis, and for experiencing a drug overdose.

Recognizing that HIV transmission occurs within situated interactions between two or more people, prevention research has increasingly begun to focus on identifying the influence of situations and settings on the spread of HIV. Examination of the social geography of risk has emerged as a powerful tool for understanding where and among whom risky practices occur. In this regard, shooting galleries represent interactional territories where the normative expectations of participation within their spatial boundaries can both encourage and reinforce sex- and drug-related risky behavior. Indeed, research shows that those who inject in shooting galleries tend to be at a higher risk of transmitting HIV than those who inject elsewhere. Drawing upon data from a sample of 1,113 active injecting drug users, we examined the demographic and psychosocial factors that predict shooting gallery use. Next, we compared shooting gallery users with nonusers in terms of drug use, followed by an examination of differences in sex- and drug-related HIV risk behaviors. Then, we explored preventive practices that possibly differentiate those who use shooting galleries from those who do not. We end our analysis by discussing the implications of our results for HIV prevention and social policy.