Last winter, the mayor of Ithaca, New York, Svante Myrick, proposed to provide a safe and legal space in which people could inject heroin. It may sound like a radical and desperate way to reduce the harms of drug use. But its effectiveness—and cost-effectiveness—is well supported by research.
Supervised injection facilities (SIFs) such as the one proposed by Mayor Myrick are a close cousin to syringe exchange programs (SEPs). The difference is that SIFs don’t just provide clean injection equipment, as SEPs do, but also medical staff for supervision of injection of preobtained drugs, which can prevent unsafe techniques and drug overdoses.
These interventions are controversial. Critics charge that they merely encourage injection drug use, exacerbating the problems their proponents claim they solve.
What Studies Show
However, studies of SEPs don’t support this view. For example, according to research, SEPs reduce sharing of (potentially) contaminated injection equipment, thereby reducing incidence of HIV and hepatitis infection.
Furthermore, SEPs have not been linked to greater use of injection drugs. Although they do not directly address the underlying cause of injection drug use, SEPs do facilitate entry into drug treatment programs. None of these benefits cost more, when you factor in savings from averted cases of HIV and hepatitis. In fact, many studies have found SEPs to be cost saving.
What does the evidence say about SIFs? Dozens of cities around the world host SIFs, and 2 are planned in Seattle. A SIF that opened Vancouver, Canada, in September 2003, has been extensively researched. Studies have found the Vancouver SIF and its use were associated with safer injection techniques and practices, reduced syringe reuse and sharing, fewer injections in public and publicly discarded syringes, increased entry into drug detoxification programs, no overdose deaths, and no evidence of increases in drug-related crime.
Like SEPs, SIFs do not appear to promote injection drug use. Using data from a prospective study of drug users, Thomas Kerr, PhD, and colleagues examined changes in drug use over a 1-year period before the Vancouver SIF opened and a 1-year period that spanned its opening. They found no substantial differences in rates of starting or stopping injecting drug use between the 2 periods, although they did find a decrease in binge drinking relapse and an increase in crack cocaine smoking. (Because the SIF principally serves injection drug users, it’s not evident that these changes are related to it.) Another study led by Kerr found that only 1 of a random sample of 1065 Vancouver SIF users performed his first injection at the site.
With medical personnel on hand to administer agents to reverse an overdose, it seems plausible that SIF users would take greater risks and experience more nonfatal overdoses, but a study found that this doesn’t occur. Another study found that overdose mortality decreased in the area around the Vancouver SIF, relative to more remote areas where injection drug users have diminished access to it.
Health and Community Benefits
Consistent with these findings, a summary of early evaluations of the Vancouver SIF concluded that it is associated with “a large number of health and community benefits” with “no indications of community or health-related harms.” Findings like these are not unique to the Vancouver SIF. A global analysis of SIFs—including those in Europe and Australia—came to the same conclusions. For example, an early evaluation of a SIF in Sydney, Australia, estimated that the facility prevented 4 deaths per year and was associated with an increase in substance use disorder treatment, fewer episodes of public injection, and fewer discarded syringes. The Sydney SIF is supported by a majority of members of the community in which it operates.
The Vancouver SIF, like SEPs, saves money. A study by Martin Andresen, PhD, and Neil Boyd, LLM, found that Vancouver’s SIF provides benefits worth 5 times more than it costs to run. They conservatively estimated that it saves money by preventing 35 HIV cases per year. Contributing to its societal value, it also prevents 3 deaths per year. Likewise, Ahmed Bayoumi, MD, MSc, and Gregory Zaric, PhD, estimated that, over a decade of operation, the Vancouver SIF saved up to $20 million and over 1000 years, principally through reduced HIV infection. Furthermore, another study by Steven Pinkerton, PhD, found the same thing.
Injection drug users report challenges receiving health care. They say they are discriminated against and not listened to by clinicians. This stigma is an additional barrier to care, even care that would help injection drug users stop using drugs. It also blinds some policy makers and citizens to effective, cost-saving programs, like SIFs and SEPs, among others, to reduce individual and societal harms of drug use.
About the author: Austin B. Frakt, PhD, is the Associate Director of the Partnered Evidence-based Policy Resource Center, Veterans Health Administration; an Associate Professor at Boston University’s School of Medicine and School of Public Health; and a Visiting Associate Professor with the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health. He blogs about health economics and policy at The Incidental Economist and tweets at @afrakt. The views expressed in this post are that of the author and do not necessarily reflect the position of the Department of Veterans Affairs, Boston University, or Harvard University.
About the JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.