Supervised Injection Facilities as Harm Reduction: A Systematic Review

The opioid syndemic has challenged the existing healthcare infrastructure. “There are innumerable upstream structural determinants of health pressing down on this population that optimally would be addressed as part of their overall care if we are approaching their care as a medical system trying to pursue optimized individual and population health.” Given the number of patients who primarily need ID care (which is often limited outside of large urban areas), I would really like to partner with PCPs, psychiatrists, etc, who have this expertise and co-manage patients with OUD.” “I have no objections to counseling or providing services to assure safe injecting practices.

Screening and Immunization Practices

From this perspective, preventing a fatal overdose is the ethical priority that outweighs concerns about condoning drug use. The judge reasoned that Safehouse’s purpose was to save lives and provide medical care, not to facilitate illegal drug use. The application of this 1980s law to modern public health facilities was tested in the landmark case of United States v. Safehouse. Proponents also point to evidence that OPCs reduce public nuisance by moving drug consumption from public spaces like parks, restrooms, and sidewalks into a controlled, private setting and by reducing discarded drug paraphernalia.

However, 1 study found that an accelerated vaccination schedule (0, 1, and 2 months) offered through SSPs, with the initial vaccination dose given at screening, could improve completion rates . The caveat with HBV vaccination is the extended follow-up necessary for completion of the vaccination schedule (0, 1, and 6 months), which can be a barrier to care in this population . In an ID setting, clinicians can recommend prevaccination serologic testing in high-risk individuals including persons with HIV, MSM, and past or current IDU, per CDC recommendations . Additionally, it is important to offer HCV treatment as usual, even if IDU is ongoing, as lack of treatment will not break the cycle of HCV transmission and will decrease the likelihood of global eradication of HCV. The increasing mortality rate despite highly effective treatments is attributed to potential ineligibility due to co-infection with HIV, incomplete treatment, and economic burden, all of which are already particularly concerning in the context of IDU .

OPCs are professionally supervised healthcare settings where individuals can use pre-obtained illicit drugs in a clean, hygienic environment. ” it asks “How do we keep people alive and as healthy as possible while they are using drugs? A core principle involves providing care that is free of stigma and centered on the needs of people who use drugs. Grounded in social justice, harm reduction is based on several principles and includes treating people who use drugs with respect and compassion.

• Nearly three decades of research consistently show that comprehensive SSPs do not increase illegal drug use or crime.
• Unlike methods that focus solely on achieving total abstinence, harm reduction strategies prioritize the health and well-being of individuals, even if they continue to use substances.
• Embedding these harm reduction principles into treatment does not mean that abstinence has no place.
• Melissa J. Davoust was involved in most aspects of the systematic review and publication.
• Developing a tailored discharge plan that connects patients to community-based harm reduction services and other supports is also critical to ensuring the health and well-being of PWUS.
• The WAYFINDER study, published in The Lancet Respiratory Medicine today, is among long-standing research into severe asthma at King’s College London.

Implications for Practice

Whether administering an injection to yourself or another person, following a step-by-step process is essential for IV or IM injections. There are also other ways and techniques of injection (for example, subcutaneous), but we will focus on the above as the most common. This slower absorption rate can provide a sustained release of the medication over time, making IM injections suitable for vaccines, hormonal therapies, and long-acting medications. Intramuscular injections are given directly into muscle tissue.

This highlights the power of strategic communication in shaping public perception and political will. When Reducing injection harm they are framed as “overdose prevention sites,” support jumps significantly to 45%. When facilities are called “safe consumption sites,” they receive only 29% support from U.S. adults.

Decrease public injecting and increase public safety

In the US, approximately three-fourths of people who have SUD don’t engage in treatment. If people were not able to comply with that goal or weren’t interested, they didn’t fit in and were discharged from care. A lot of our treatment system has used strict and often punitive approaches toward people who use substances, with the idea that abstinence was the only acceptable outcome. We should support them in their health the way we support all of our patients, including those who have a chronic condition that may have some behavioral associations.

• Its methods are personalized to the individual (or community), regardless of their interest in treatment, and focus on diminishing the harmful effects of IDU rather than achieving abstinence or ignoring harms altogether .
• Timothy W. Levengood was involved in all aspects of the systematic review and publication.
• In fact, several included studies in this review documented decreases in crime following the opening of SIFs.
• That is an important first step, but we need to similarly embrace talking to patients about safer substance use and knowing how and where people can access harm reduction services in our communities.

Reduce infections

Two concerns arise from this practice—the injection technique and the type of bacteria injected. Lastly, individuals may be open to other routes of administration that carry less risk of ID complications and OD such as oral, intranasal, and smoking . A dry swab can be used to apply to the injection site, which allows for the blood vessels to heal and platelets to aggregate around the punctured vein 2, 34. Additionally, if the vein is missed, the injection will likely be painful and could lead to the formation of abscesses . After inserting the needle, the plunger should be pulled back to ensure that dark red, slow-moving blood comes up, which means a vein has been successfully punctured and injection may proceed 2, 34. The needle should be inserted at a 15°–35° angle with the bevel facing up to reduce trauma to the tissue and veins, and the injection should always be in the direction of the heart 2, 34.

The evidence shows that both SSPs and OPCs save lives and connect people to treatment while reducing disease transmission and improving public safety. By driving people into the shadows, increasing their risk of disease and death, and creating massive barriers to healthcare, the punitive approach causes far more damage than a health-centered one. The law was intended to target commercial drug dens where drugs were sold and consumed—not public health interventions, which didn’t exist in the U.S. at the time. While public health data on saving lives is compelling, community fears about safety and disorder remain a powerful political force.

Harm Reduction Services to Prevent and Treat Infectious Diseases in People Who Use Drugs

The 2017 study of Myer and colleagues46 examined crime in Vancouver, Canada using a quasi-experimental design (interrupted time series with comparison) following the opening of an SIF. Review authors determined one study (Myer and colleagues46) to be of greatest suitability and good quality, and another study (Salmon et al.47) to be of moderate suitability and fair quality. Patients were more likely to require ambulance transport for overdose when the SIF was closed for the day. Salmon and colleagues48 described a greater decline in opioid-related overdoses seen by ambulances in the vicinity of an SIF in Sydney, Australia after it opened compared with the rest of the state where it was located. Marshall et al.41 found 26% net reduction in overdose deaths in the area immediately surrounding an SIF in Vancouver, Canada after its establishment as compared with the rest of the city. The study with the greatest suitability of study design that examined crime as an outcome observed a sustained decrease in crime following the opening of a SIF; the reduction was only observed in the vicinity of the SIF and was not observed in the rest of the city.

Reduce cost

Milloy and colleagues45 (a prospective cohort study analyzed in a cross-sectional manner) found no association between frequent SIF use and recent incarceration. Salmon et al. took multiple snapshots of resident and business owner reports of crime and drug use–related nuisance indicators before and after an SIF opened in Sydney. The study authors found that crime did not meaningfully change in most of the city, except in the district where the SIF is located, which observed an abrupt, persistent decrease in crime following the SIF’s opening.

Harm reduction offers practical HIV prevention options for those who inject drugs, such as clean needle exchanges and access to safe injection sites. This systematic review of 22 effectiveness studies relayed evidence of the public health benefits of supervised injection facilities for SIF clients as well as surrounding communities. But at its core, harm reduction treats people with respect and makes sure they can access evidence-based services that support health and well-being.

In addition to increasing provider knowledge and training around PrEP prescribing,79 strategies such as developing electronic medical record-based algorithms to alert providers of potential PrEP candidates, colocating PrEP and other services, and creating pharmacist-led PrEP programs through collaborative practice agreements are feasible and acceptable approaches to integrating PrEP prescribing into clinical practice.80–82 Provision of supplies can not only help to ensure access to clean supplies, but also help to develop a therapeutic relationship with patients.73 In Canada, providers have been successful in providing clean drug equipment for their patients; however, in the United States, state laws vary in terms of (1) possession of drug equipment, such as the number of needles/syringes an individual can carry and (2) provider ability to prescribe needles, syringes, and other supplies. Counseling strategies to prevent overdoses are summarized in Table 4. In addition, providers should counsel patients on how to recognize the signs and symptoms of an overdose. PWID who used SIFs are less likely to report needle sharing (71%), to dispose of syringes unsafely (56%), and to inject in public places.

GovFacts is a nonpartisan site focused on making government concepts and policies easier to understand — and government programs easier to access. Please consult a qualified professional for financial, legal, or health advice specific to your circumstances. However, these programs face significant legal, political, and social barriers rooted in competing moral frameworks about drug use and the role of government in addressing it. They represent cost-effective interventions that can be part of a comprehensive approach to addressing the overdose crisis.

The inpatient setting is a critical place to have harm reduction strategies in place to keep PWUS in care and support them through the acute health crisis for which they were admitted. Regardless of the healthcare setting, it is critical to train all staff who interact with PWUS in harm reduction principles to reduce stigma and ensure that PWUS feel comfortable seeking care and stay engaged in healthcare services. Although many harm reduction services are delivered in the community, outpatient and inpatient settings represent other important opportunities to use these strategies. Drug-checking is a newer harm reduction intervention that emerged in response to rising overdose rates from contaminated or adulterated drugs.

However, institutionally and locally support services are minimal and personally it is not where I am going to invest my time, although I would definitely support development and availability of these services.” “I would love to see more joint ID fellowship/addiction medicine fellowships and I would like to see treatment of SUD become a core competency for all ID fellows.” There seems to be strong interest in the use of long-acting lipoglycopeptides as treatment in this population, which is stymied by a lack of evidence and guidance.

Categorised in: Sober Living

This post was written by Trishala Tiwari