Supervised injection in Toronto will improve the health of people who inject drugs

Over the past year, advocates or elected officials in Montreal, Ottawa, Victoria, Baltimore, New York City, Ithaca (NY), Seattle, San Francisco, Glasgow and four cities in Ireland have called  for the implementation of supervised injection services. More recently, Toronto’s Medical Officer of Health Dr. David McKeown recommended that the Board of Health start a community consultation process toward establishing supervised injection services within three existing facilities in the city. The Board voted unanimously in favour.  As the lead investigators of the TOSCA study  (the Toronto and Ottawa Supervised Consumption Assessment), we support Dr. McKeown’s proposal and look forward to the opening of these services in Toronto.

Moving drug use out of parks and alleys is one good reason for wanting supervised injection services, as are the economic benefits of incorporating these services into an existing health centre. But the main reason that we are advocating for supervised injection services is to improve the health of people who inject drugs.   People who inject drugs are more likely than the general population to die  prematurely and, if they don’t die, they are more likely to have a high burden of disease. Harm reduction interventions, such as supervised injection services, are an effective way to address the health issues of people who inject drugs − people who need something beyond conventional healthcare.

Supervised injection services save lives by decreasing deaths due to overdose.  It has been widely reported that overdose rates have increased markedly in Toronto over the last few years. What is less known, perhaps, is that overdose rates have increased even more rapidly in Western Canada and in parts of the United States. Because we are now starting to see the increased use of drugs like fentanyl and heroin in Ontario, overdose rates may soon increase more rapidly in Toronto, especially if there is no additional public health response like the opening of supervised injection services. The time to act to prevent further overdose-related deaths is now.

Like Dr. McKeown, we recommend that Toronto should establish supervised injection services within health centres where people who inject drugs are already receiving health services. There are several reasons why we favour this approach rather than having a single central facility:

• People who use drugs benefit from having services delivered in environments that are free of discrimination, where drug use is not stigmatized, and where their privacy is respected.
• An integrated model increases the potential to access a wide range of other health and social services, already offered in these centres, such as addiction, housing, and employment services.
• Because providers in existing facilities have already established relationships with people who use drugs, these facilities are well placed to rapidly build a client base for supervised injection.
• Integrating supervised injection services within facilities where people are already receiving harm reduction services will help address concerns about how to incorporate supervised injection into neighbourhood centres.
• When we conducted our economic analyses, we looked at the potential costs of operating a facility, the potential cost savings from averting adverse health effects associated with injecting drugs, and projected health benefits. . We projected that adding supervised injection services to existing harm reduction services would be cost-effective. However, integrating supervised injection into existing facilities may deliver these services at lower cost than in free-standing facilities. As we gain experience with the model being proposed in Toronto, it will be important to monitor the associated costs. It may very well be cost-effective to expand beyond three facilities in the future.

In the course of completing the TOSCA study, we analyzed public opinion polling data and conducted 124 interviews and focus groups with stakeholders. Here’s what we learned: First, support for supervised injection services has increased in the last decade. Second, only about 10% of the respondents said they would never support supervised injection. Third, most of the remaining 90% say they would be supportive if there were convincing evidence that supervised injection improves the health of people who use drugs and reduces neighbourhood problems.

People want to know more about what supervised injection entails, want an assurance that supervised injection fits into a comprehensive public health response to drug use, want to be consulted about implementation, and want to see that such services will be evaluated. Together, these findings suggest that there is an opportunity to have an important and respectful dialogue that is both educational and collaborative and, hopefully, to start a broader public dialogue about our society’s approach to drug use and addiction.

Dr. Ahmed Bayoumi is an internal medicine physician and expert in the delivery of health services for people who use drugs and people living with HIV at St. Michael’s Hospital’s Centre for Research on Inner City Health.

Dr. Carol Strike, PhD, is an associate professor at the University of Toronto’s Dalla Lana School of Public Health, with 15 years of experience in harm reduction, addiction treatment and health services research.