Research paper
Drug-related overdoses within a medically supervised safer injection facility

https://doi.org/10.1016/j.drugpo.2006.05.008Get rights and content

Abstract

Background

In September 2003, North America's first supervised injection facility (SIF) opened in Vancouver, Canada. We sought to examine the incidence and characteristics of overdose events at the SIF.

Methods

The Vancouver SIF evaluation involves a comprehensive database within the SIF and the Scientific Evaluation of Supervised Injection (SEOSI) cohort consisting of 1046 SIF users. We examined the incidence and features of overdoses at the SIF and the responses made by SIF staff. Cox regression was used to examine factors associated with time to overdose among SEOSI participants.

Results

Between 1 March 2004 and 30 August 2005, there were 336 overdose events at the SIF, yielding a rate of 1.33 (95% CI: 0.0–3.6) overdoses per 1000 injections. The most common indicator of overdose was depressed respiration (60%), and the most common intervention involved the administration of oxygen (87%). In total, 90 SEOSI participants had an overdose at the SIF during the study period. Factors independently associated with time to overdose included fewer years injecting (RH = 0.98, 95% CI: 0.96–1.00 per year), daily heroin use (RH = 1.82, 95% CI: 1.16–2.85), and having a history of overdose (RH = 1.92, 95% CI: 1.21–3.06).

Conclusions

There have been a large number of overdoses within the SIF, and it is noteworthy that none of these overdoses resulted in a fatality. These findings suggest that SIF can play a role in managing overdoses among IDU and indicate the need for further evaluation of the impact of SIF on morbidity and mortality associated with overdose.

Introduction

Illicit drug-related overdose has been recognised as a common cause of morbidity and mortality among injection drug users (IDU) (Davidson et al., 2003; Warner-Smith, Darke, & Day, 2002; Wood et al., 2003). In many countries, fatal overdose is a leading cause of death among IDU, and in response a variety of overdose interventions have been implemented (Perucci et al., 1991, Tyndall et al., 2001). For instance, in New York City drug overdoses have recently overtaken homicide as the number one cause of death (Coffin et al., 2003), and in Baltimore overdose deaths increased by more than 425% between 1990 and 1997 (Garfield & Drucker, 2001).

In light of the ongoing harms associated with overdose, several studies identifying the determinants of overdose have been undertaken, with most of these studies focusing on heroin-related overdoses. Among the more consistent predictors of overdose are: polysubstance use (in particular, the concomitant use of central nervous system depressants); greater number of years injecting; recent release from prison; and injection in public spaces (Bennett & Higgins, 1999; Darke, Ross, & Hall, 1996; Sporer, 1999; van Beek, Dakin, Kimber, & Glimour, 2004; Warner-Smith, Darke, Lynskey, & Hall, 2001). An array of overdose prevention interventions have been initiated, with most of these focused on educating drug users about the risks for overdose (Seal et al., 2003). However, the limitations of education-based overdose prevention programs have been highlighted previously, with critics suggesting that these programs fail to consider the social and contextual factors that drive risks such as polysubstance use (Moore, 2004). Such criticisms have led to the call for structural interventions that modify the broader risk environment of IDU (Moore, 2004, Rhodes, 2002).

Medically supervised safer injection facilities (SIF), where IDU can inject pre-obtained illicit drugs, have been implemented in various cities to reduce the public health impacts of injection drug use (Kimber, Dolan, van Beek, Hedrich, & Zurhold, 2003; Kimber, Dolan, & Wodak, 2005). A primary motivation for establishing such facilities is to reduce the incidence and severity of overdose, and a key feature of these facilities involves the provision of emergency response in the event of an overdose. A recent ecological study that employed a time-series analysis involving data from four German cities found a positive effect of SIF on the rate of drug-related deaths (Poschade, Höger, & Schnitzler, 2003).

While available evidence and anecdotal reports indicate that SIF have the potential to reduce overdose morbidity and mortality, there have been few formal epidemiological evaluations of overdose events within SIF (van Beek et al., 2004). In light of this, we undertook these analyses to determine the incidence and characteristics of overdose events in North America's first SIF and to provide an account of the overdose interventions undertaken by SIF staff, along with a profile of the characteristics of individuals who overdose within the facility.

Section snippets

Methods

The Vancouver SIF, known as Insite, is centrally located in Vancouver's Downtown Eastside, which is one of the most impoverished urban neighbourhoods in Canada and home to well documented overdose and infectious disease epidemics among the estimated 5000 IDU who reside there (Strathdee et al., 1997, Wood et al., 2000).

The methods used to examine Insite have been described in detail previously (Wood et al., 2004a). One key component of the evaluation approach is a comprehensive on-site database

Results

Between 1 March 2004 and 30 August 2005, there were 336 overdose events at the SIF, yielding a rate of 1.33 (95% CI: 0.0–3.6) overdoses per 1000 injections (see Fig. 1). The monthly median number of overdoses was 16, with monthly overdose totals ranging from 9 (September 2004) to 35 (March 2005). In total, 285 unique participants accounted for these overdoses. Data concerning the drugs involved in the overdose were available for 318 (95%) overdoses. Of these, 282 (89%) involved only one

Discussion

In the present analysis we found that overdose events were not uncommon at the Vancouver safer injection facility. During an 18-month period, 285 individuals accounted for 336 overdose events, yielding an overdose rate of 1.33 (95% CI: 0.0–3.6) overdoses per 1000 injections. Heroin was involved in approximately 70% of all overdoses, and opiates considered together were involved in 88% of overdoses. It is notable, however, that approximately one-third of overdoses involved stimulants. The most

Acknowledgements

The authors wish to thank the staff of the Insite SIF and Vancouver Coastal Health (Chris Buchner, Heather Hay). We also thank Bonnie Devlin, Aaron Eddie, Suzy Coulter, Megan Oleson, Peter Vann, Dave Isham, Steve Gaspar, Carl Bognar, Deborah Graham and Evelyn King for their research and administrative assistance. The SIF evaluation has been made possible through a financial contribution from Health Canada, though the views expressed herein do not represent the official policies of Health Canada.

References (31)

  • A. Gandey

    US slams Canada over Vancouver's new drug injection site

    Canadian Medical Association Journal

    (2003)
  • J. Garfield et al.

    Fatal overdose trends in major US cities: 1990–1997

    Addictions Research and Theory

    (2001)
  • T.C. Green et al.

    My place, your place, or a safer place: The intention among Montreal injecting drug users to use supervised injecting facilities

    Canadian Journal of Public Health

    (2004)
  • T. Kerr et al.

    Factors associated with non-fatal overdose among a cohort of injection drug users in Vancouver

    Canadian Journal of Infectious Diseases

    (2005)
  • J. Kimber et al.

    Drug consumption facilities: An update since 2000

    Drug and Alcohol Review

    (2003)
  • Cited by (66)

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

      2020, Infectious Disease Clinics of North America
      Citation Excerpt :

      PWID who use SIFs frequently practice safer injection, and there have been significant decreases in prolonged hospitalizations for IDU-associated infections.41,42 Modeling studies have shown that SIFs can decrease incident HIV and HCV infections43 and the costs incurred to provide lifelong HIV care and expensive HCV treatment.37,38,41,42,44–46 Studies have shown that SIFs are cost effective.

    View all citing articles on Scopus
    View full text