Research paperDrug-related overdoses within a medically supervised safer injection facility
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.
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