Commentary on Salmon et al. (2010): The case for safer inhalation facilities—waiting to inhale

Abstract

Commentary on Salmon et al. (2010):The case for safer inhalation facilities-waiting to inhalea dd_2917 684..685 In recent years, a flurry of scholarly reports have demonstrated the effectiveness of supervised injection facilities (SIFs) as a strategy to reduce physical and social harms associated with injection drug use. Empirical data on SIFs lagged well behind their scale-up, but SIFs have now been shown to decrease HIV risk behaviors [1], overdose deaths [2] and public disorder [3], and increase uptake of detoxification services [4]. In this issue, Salmon and colleagues [5] demonstrate dramatic decreases in ambulance attendances at opioid-related overdoses in the period following the opening of the Sydney SIF, a finding that supports program cost-effectiveness [6]. While SIFs remain controversial, there are at least 90 SIFs in 40 cities globally. To this end, SIFs are becoming increasingly viewed as a necessary component of a comprehensive strategy to reduce drug-related harms and facilitate uptake of medical care and drug treatment among streetbased drug users [3,7].A logical extension of SIFs are supervised inhalation rooms (SIRs), intended for individuals who smoke or snort drugs such as crack cocaine, heroin and methamphetamine; yet most supervised drug consumption programs target drug injectors exclusively. In fact, SIRs operate in only a few countries (e.g. Germany, Holland, Switzerland and Spain) [8][9][10][11], and none have been evaluated formally.The rationale for SIRs may be less obvious than that for SIFs, but is no less important. Sharing of crack pipesparticularly among individuals with sores on their lips as a result of burns and cuts-may contribute to infectious disease transmission [12,13]. Inhalation of methamphetamine has been associated independently with human immunodeficiency virus (HIV) infection among female sex workers, even after accounting for injection drug use [14]. A recent laboratory study suggests that methamphetamine accelerates HIV replication [15]. Furthermore, police crackdowns often drive drug users into clandestine spaces (e.g. abandoned buildings, etc.), where their health is placed at risk [16]. Displacement of drug users contributes to their low uptake of public health and social services [17]. Because many drug smokers are stimulant users who are historically very difficult to engage in drug treatment, SIRs represent a pivotal entrypoint where they can begin to be reached. In Vancouver, willingness to use an inhalation room was associated independently with working in the sex trade, sharing crack pipes, having crack pipes confiscated by police, smoking crack in public places and having burns from hurried drug consumption [9]. As many cities are witnessing decreasing numbers of drug injectors but increasing numbers of people who smoke/snort drugs [18], SIRs warrant a close second look.A powerful case can be made in support of SIRs based upon the personal experience of one of the authors of this commentary (J.R.N.), who helped to coordinate a drug consumption facilit...

Effectiveness of secondary prevention and treatment interventions for crack-cocaine abuse: A comprehensive narrative overview of English-language studies

“…As DCF services have been implemented (in Europe) or discussed (in the Americas) in several jurisdictions, this is a major gap for evidence-based intervention development and implementation aiming at crack users. Rigorous studies should urgently be implemented to determine whether DCF services could constitute a potentially beneficial intervention for health and other outcomes, yet also for improving crack users' integration with the help system (Fischer et al, 2006;Hedrich et al, 2010;Strathdee & Navarro, 2010 On the treatment side, a substantive body of -fairly welldesigned and controlled -studies suggests that psycho-social (e.g., cognitive-behavioral) treatment interventions can reduce drug use and health risks/harms, as well as improve social indicators for crack-cocaine use, at least to some extent. While studies are commonly limited in regards to treatment retention and a predominant focus on short-term effects, there appears to be a trend for tailored and more intensive interventions to result in superior efficacy.…”

“…A series of Canadian studies -conducted in Vancouver, Toronto and Ottawa -have found that largely majorities (ranging from 28% and 71%) of street-involved crack and other drug inhalers would use DCF services if offered, but did not measure any impacts of such interventions (Bayoumi et al, 2012;Collins et al, 2005;DeBeck et al, 2011;Shannon et al, 2006). Unfortunately, overall no rigorous evaluations on the discernable impacts of DCF programs targeting drug inhalers -including crack users -exist (Hedrich et al, 2010;Strathdee & Navarro, 2010).…”

“…However -despite crack's high prevalence in key risk populations, and different from well-established, evidence-based interventions for other forms of street drug use (e.g., needle exchange programs for injection drug use or opioid maintenance treatment [OMT] for opioid dependence) -targeted prevention and treatment measures specifically for crack use are rare, limited availability and underdeveloped (Santos Cruz et al, 2013a;European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), 2007;Mattick, Breen, Kimber, & Davoli, 2009;Strathdee & Vlahov, 2001;Strathdee & Navarro, 2010); moreover, comprehensive reviews on the state of interventions for crack use are lacking.…”

Risky and rushed public crack cocaine smoking: the potential for supervised inhalation facilities

“…Collectively, these findings suggest the potential for evidence-based public health interventions to reduce the harms associated with public crack use and rushed public crack use. While the evidence in support of supervised injection facilities is now well-established [ 41 – 45 ], the implementation of supervised inhalation rooms has been slow to follow suit, despite the overwhelming benefit that such facilities may offer in terms of providing a safe, non-rushed environment; sterile equipment to prevent disease transmission; direct access to health and social services for this hard-to-engage population prone to fatal overdose, infection, and other complex health concerns; immediate support for addiction treatment and counselling; reducing public drug use and related disorder; and affording considerable cost savings for health care systems [ 15 , 46 – 49 ]. Notably, the implementation of supervised inhalation rooms need not be separate from supervised injection facilities; in fact, the delivery of both supervised injection and inhalation (or other non-injection drug use) in a single ‘safe drug use facility’ may be a more feasible and accessible approach for this population.…”

Prospects for scaling‐up supervised injection facilities in Canada: the role of evidence in legal and political decision‐making

“…As such, several jurisdictions have implemented SIFs, and there are currently 92 facilities in 61 cities globally . Nevertheless, SIFs remain highly controversial in many parts of the world .…”