Drug and Alcohol Dependence 145 (2014) 48–68
Contents lists available at ScienceDirect
Drug and Alcohol Dependence
j ournal homepage: www.elsevier.com/locate/drugalcdep
Review
Supervised injection services: What has been demonstrated?
ଝ
A systematic literature review
a,b,∗ c,d e a,b
Chloé Potier , Vincent Laprévote , Franc¸ oise Dubois-Arber , Olivier Cottencin , a,b
Benjamin Rolland
a
Department of Addiction Medicine, CHRU de Lille, Univ Lille Nord de France, F-59037 Lille, France
b
University of Lille 2, Faculty of Medicine, F-59045 Lille, France
c
CHU Nancy, Maison des Addictions, Nancy F-54000, France
d
CHU Nancy, Centre d’Investigation Clinique CIC-INSERM 9501, Nancy F-54000, France
e
Institute of Social and Preventive Medicine, University Hospital Center and University of Lausanne, Chemin de la Corniche 10, 1010 Lausanne, Switzerland
a
r t i c l e i n f o a b s t r a c t
Article history: Background: Supervised injection services (SISs) have been developed to promote safer drug injection
Received 18 May 2014
practices, enhance health-related behaviors among people who inject drugs (PWID), and connect PWID
Received in revised form 14 October 2014
with external health and social services. Nevertheless, SISs have also been accused of fostering drug use
Accepted 14 October 2014
and drug trafficking.
Available online 23 October 2014
Aims: To systematically collect and synthesize the currently available evidence regarding SIS-induced
benefits and harm.
Keywords:
Methods: A systematic review was performed via the PubMed, Web of Science, and ScienceDirect
Supervised injection service
databases using the keyword algorithm [(“SUPERVISED” OR “SAFER”) AND (“INJECTION” OR “INJECT-
Safer injection facility
ING” OR “SHOOTING” OR “CONSUMPTION”) AND (“FACILITY” OR “FACILITIES” OR “ROOM” OR “GALLERY”
Supervised injecting center
Drug consumption room OR “CENTRE” OR “SITE”)].
Drug consumption facility Results: Seventy-five relevant articles were found. All studies converged to find that SISs were efficacious
Injection drug user in attracting the most marginalized PWID, promoting safer injection conditions, enhancing access to
primary health care, and reducing the overdose frequency. SISs were not found to increase drug injecting,
drug trafficking or crime in the surrounding environments. SISs were found to be associated with reduced
levels of public drug injections and dropped syringes. Of the articles, 85% originated from Vancouver or
Sydney.
Conclusion: SISs have largely fulfilled their initial objectives without enhancing drug use or drug traf-
ficking. Almost all of the studies found in this review were performed in Canada or Australia, whereas
the majority of SISs are located in Europe. The implementation of new SISs in places with high rates of
injection drug use and associated harms appears to be supported by evidence.
© 2014 Elsevier Ireland Ltd. All rights reserved.
Contents
1. Introduction ...... 49
2. Materials and methods ...... 49
3. Results ...... 50
3.1. Overall results ...... 50
3.2. Description of SIS users ...... 62
3.3. The impact of SISs on overdose-induced mortality and morbidity ...... 62
3.4. The impact of SISs on injection behaviors and their consequences ...... 62
3.5. The impact of SISs on reducing drug-related harms ...... 62
ଝ
Supplementary material can be found by accessing the online version of this paper at http://dx.doi.org/10.1016/j.drugalcdep.2014.10.012.
∗
Corresponding author at: Service d’Addictologie, Hôpital Fontan2, CHRU de Lille, CS70001, 59037 LILLE Cedex, France. Tel.: +33 666816587.
E-mail address: [email protected] (C. Potier).
http://dx.doi.org/10.1016/j.drugalcdep.2014.10.012
0376-8716/© 2014 Elsevier Ireland Ltd. All rights reserved.
C. Potier et al. / Drug and Alcohol Dependence 145 (2014) 48–68 49
3.6. The impact of SISs on access to addiction treatment programs ...... 62
3.7. The impact of SISs on the nuisance induced by drug use in public spaces ...... 63
3.8. The impact of SISs on local drug-related crime, violence, and trafficking ...... 63
3.9. Impact of SISs on the amount of local PWID...... 63
3.10. Medico-economic assessment of SISs ...... 63
3.11. The opinion of PWID on SISs ...... 63
3.12. The impact of SISs on the opinions of local residents and police ...... 63
4. Discussion ...... 64
Role of the funding source ...... 65
Contributors ...... 65
Conflict of interest ...... 65
Appendix A. Supplementary data ...... 65
References ...... 65
1. Introduction Germany, Switzerland, Spain, the Netherlands and Luxembourg
(Semaan et al., 2011).
Injection drug use represents a source of numerous harmful SISs were implemented complementarily to other harm reduc-
effects on both the health conditions of people who inject drugs tion measures for the following purposes (EMCDDA, 2009; INSERM,
(PWID) and their social environment. Drug injection is one of 2010; Noël et al., 2009): (1) to reach the most marginalized popu-
the main factors in the dissemination of blood-transmissible viral lations of PWID, who are least likely to obtain access to medical
infections such as human immunodeficiency virus or the hepatitis and social support, and connect them with health and social ser-
B and C viruses (EMCDDA, 2008; Joint United Nations Programme vices; (2) to reduce overdose-induced morbidity and mortality; (3)
on HIV/AIDS, 2002; WHO, 1997). In addition, numerous other to educate PWID to enhance their health behaviors; (4) to reduce
physical problems can result from drug injection, including other injection-related risks by promoting the prevention and education
viral and bacterial infections, cutaneous lesions, locomotive disor- of safe self-injecting practices; (5) to improve the global health
ders, and hepato-gastroenterological pathologies (INSERM, 2010; conditions of PWID by promoting the prevention, screening and
Klee and Morris, 1995; Palepu et al., 2001). Psychiatric disorders medical orientation of viral infections; (6) to foster the initiation of
are also more frequent in PWID (EMCDDA, 2008), who are sub- dependence care programs among PWID; and (7) to reduce the nui-
ject to reduced access to medical services (Kerr et al., 2005b). sances triggered by injection drug use in public spaces, e.g., urban
Moreover, PWID exhibit enhanced marginalization from society, violence and crime, drug trafficking and drug-use waste.
which increases their exposure to social precariousness, unem- SIS access is usually restricted and regulated (Hedrich, 2004;
ployment, homelessness, crime, and prostitution (DeBeck et al., INSERM, 2010). Most SISs are forbidden to subjects under 18 years
2007; EMCDDA, 2008). Thus, injection drug use induces consider- of age, pregnant women, irregular or unidentified PWID, and indi-
ably higher mortality. Partly because of its illegal nature, injection viduals who wish to experience their first drug injection. Internal
drug use is also responsible for numerous societal consequences, rules also forbid violence and drug selling. Moreover, many SISs
e.g., violence, traffic, crime, and public space degradation (Kerr prohibit drug sharing or helping other users with drug injection.
et al., 2005a; Renn and Lange, 1996; Singer et al., 2001). For these However, SISs have endured criticism. Some official organizations
reasons, injection drug use places a heavy burden on society. have argued that “any national, state or local authority that per-
During the early 1980s, PWID had to face the HIV epidemic. mits the establishment and operation of drug injection rooms or
Preventing viral infection became crucial, and, therefore, care pro- any outlet to facilitate the abuse of drugs (by injection or any other
fessionals had to consider the damage caused by drug use rather route of administration) also facilitates illicit drug trafficking” (INCB,
than focusing on drug use itself. Moreover, in face of the failure of 1999). The detractors of SISs often argue that SIS implementation
public policies that aimed to eradicate drug use and drug trafficking is equivalent to the tacit acceptance of injection drug use by public
(Drucker, 1999) and in consideration of the number of PWID who authorities, which will foster drug use, attract drug traffickers and
were not ready to enter into classical abstinence care, new preven- increase drug-related consequences in the surrounding area (Boyd,
tion and care paradigms emerged, constituting the ‘harm reduction’ 2013; Elliott et al., 2002; Gandey, 2003; Parliament of New South
approach (MacPherson, 2001; Wodak and Owens, 1996). The first Wales, 1998). This perception has often been shared by groups of
aim of these new care systems was to reduce the social and medical local residents and politicians in cities where new SISs were imple-
consequences of injection drug use and to stop the marginalization mented (Elliott et al., 2002) and has sometimes led to long court
spiral to which PWID were exposed (Berridge, 1999; MacPherson, procedures (Health Canada, 2006; Small, 2010; Wodak et al., 2003;
2001). In this context, the first syringe exchange programs and the Wood et al., 2007).
development of opiate maintenance therapies were implemented Twenty-eight years after the first legal opening of an SIS (Zobel
(WHO, 1998). and Dubois-Arber, 2004), we have performed a systematic review
Similarly, new facilities emerged at the end of the 1980s, and of the literature to collect the published data currently available on
the first objective was to allow PWID to inject self-provided drugs SISs and to synthesize these data to determine whether SISs have
within a supervised framework in enhanced aseptic conditions achieved their objectives and whether the fears raised against them
with medical monitoring and no risk of police control (EMCDDA, are justified.
2008; Jozaghi, 2012; Semaan et al., 2011). These facilities have had
different appellations, including ‘safer injection facilities,’ ‘super-
2. Materials and methods
vised injecting centers/sites/rooms/facilities,’ ‘drug consumption
rooms,’ and ‘supervised injection services’ (SISs) (Hedrich, 2004; A systematic search for relevant articles was conducted and is presented herein
according to the PRISMA statement (Liberati et al., 2009). The research was per-
Noël et al., 2009). Throughout the present article, we will indis-
formed using the PubMed, Web of Science, and ScienceDirect databases. To avoid
tinctly use the term ‘SISs’ to designate these facilities. The concept
selection bias, an inventory of the different English appellations for SIS was con-
of SISs rapidly spread in Western countries, and in 2010, there
ducted, which led to our use of the following keyword algorithm: (“SUPERVISED” OR
were more than 90 identified SISs in Canada, Australia, Norway, “SAFER”) AND (“INJECTION” OR “INJECTING” OR “SHOOTING” OR “CONSUMPTION”)
50 C. Potier et al. / Drug and Alcohol Dependence 145 (2014) 48–68
618 ar cles iden fied throught electronic sources (PubMed, Web of
Science, Sciencedirect), using keyword algorithm: ("SUPERVISED" OR
"SAFER ") AND ("INJECTION" OR "INJECTING" OR "SHOOTING" OR
"CONSUMPTI ON") AND ("FACILITY" OR "FACILITIES" OR "ROOM" OR
"GALLERY" OR "CENTRE" OR "SITE")
Databas es :
• Pubmed : 448 (23 January 2014) n fica on
e
• Web of Science : 119 (23 January 2014)
Id
• ScienceDirect.com: 51 (23 January 2014)
no other s ources used for the iden fica on of addi onal documents
g 476 articles sourced after duplicates removed creenin S
476 ar cles screened on tle review
312 ar cles excluded :
- 20 non-English ar cles
y
- 292 off-topic ar cles ibilit g
Eli
164 ar cles assessed for eligibility
89 ar cles excluded on full-text review :
- 75 non-original ar cles
- 1 non peer-reviewed ar cle
- 13 off-topic ar cles
Included 75 ar cles included in qualita ve synthesis
Fig. 1. Systematic selection process of relevant articles used for performing the review.
AND (“FACILITY” OR “FACILITIES” OR “ROOM” OR “GALLERY” OR “CENTRE” OR Table 1 lists the final selection of articles, which were clustered
“SITE”). All results up to January 26, 2014 were examined in the article selection
according to the specific subject they addressed: (1) the description
process.
of SIS users; (2) the impact of SISs on overdose-induced mortality
The article selection algorithm is described in Fig. 1. After eliminating duplicates,
and morbidity; (3) the impact of SISs on injection behaviors and
relevant publications were chosen through the individual and independent selection
of titles by three authors (C.P., B.R., V.L.). The articles selected had to be written in their consequences; (4) the impact of SISs on the adherence to care
English and be related to SISs. In cases of disagreement between the authors during of PWID; (5) the impact of SISs on the nuisances induced by drug use
the selection process, the three authors discussed the article until a consensus to
in public spaces; (6) the impact of SISs on local drug-related crime,
include it or exclude it was reached.
violence, and trafficking; (7) the impact of SISs on the number of
A second selection round was performed upon full-text reading. The selection
local PWID; (8) the medico-economic assessment of SISs; (9) the
criteria were as follows: (1) peer-reviewed articles that (2) contained original data
on SIS assessment. The full texts of all selected articles were independently read by opinion of PWID on SISs; and (10) the impact of SISs on the opinions
two authors (C.P. and B.R.). If one of the readers believed that the full-text article did
of local residents and local police.
not fit the eligibility and inclusion criteria, a final round of selection was performed
Approximately 68% of the articles came from SISs in Vancouver
through a consensual decision that included the same three authors identified above.
(n = 51), 17% from SISs in Sydney (n = 13) and 3% from SISs in Europe
The quality of all of the finally selected articles was evaluated using specific
tools. Observational studies were evaluated using the “Strengthening the Repor- (n = 2). Approximately 12% of the studies do not come from a SIS
ting of Observational Studies in Epidemiology (STROBE) statement” (Vandenbroucke (n = 9).
et al., 2007), and medical economic studies were evaluated using the “Consolidated
Different study designs were found.
Health Economic Evaluation Reporting Standards (CHEERS)” (Husereau et al., 2013).
Of the 75 finally selected articles, 32 articles were about cohort
Because there is currently no consensual assessment method for either qualitative
studies, among which 3 were descriptive studies (Kerr et al., 2006b;
studies or surveys (Bennett et al., 2011), we did not score these types of articles in
our review. Marshall et al., 2009; Stoltz et al., 2007a), 13 were analytical stud-
ies (Bravo et al., 2009; Hadland et al., 2014; Kerr et al., 2005c;
Lloyd-Smith et al., 2010, 2009, 2008; McKnight et al., 2007; Milloy
3. Results
et al., 2010, 2009; Wood et al., 2005d, 2003, 2008, 2005a), 12
3.1. Overall results were evaluative studies (DeBeck et al., 2008; Kerr et al., 2007c;
Kimber et al., 2008a; Milloy et al., 2008a; Petrar et al., 2007; Reddon
We initially found 618 articles using the aforementioned key- et al., 2011; Richardson et al., 2008; Stoltz et al., 2007b; Wood
word algorithm, among which 75 articles were finally included in et al., 2006d, 2005c, 2007, 2006c), 1 was both a descriptive and an
the review (cf. Fig. 1). analytical study (DeBeck et al., 2011), and 3 were cross-sectional
C. Potier et al. / Drug and Alcohol Dependence 145 (2014) 48–68 51 quality
CHEERS
STROBE
21/28 19/29 24/29 23/30
scores or
NAIs) 22/33
(S): (S): (S): S: (S): Studies assessment with (6 (5NAIs) (5NAIs) (4NAIs) (S) (C) (1NAI) a
in
for use
of the is
1.59,
1.9,
1.90, 3 or male
= =
in
=
for attend
having of
5.30,
they [0.2–0.9]). type
(OR private
heroin). Factors engaged = injections
to 4.9,
lived
HIV+ 2.5,
(aOR
= 20.43,
attending
site (aOR heroin
=
number
=
2.38, in
= 3.29, syringes
female.
types for
= SIS. of and =
not [1.34–4.45]
Vancouver’s
few
public
2.3,
the
(aOR small/medium with
already =
(OR which
[1.38–2.96]),
(OR
= Screening
with
Eastside
95%CI in injection having large
=
having (aOR the
income used
Four
the
inject
cocaine (aOR
on (aOR 33.8%
3.1,
of used (OR
= to 0.4, +2%. (13%):
or
and and users,
heroin; 95%CI
(31%),
reasons
= SIS
used
2
injection used
95%CI
1.56, days sex illegal
years 1x/week (OR [1.72–3.24]
injection
= homelessness injected
cocaine.
HIV:
years), associated the +
= (OR bisexuality of women.
2.44,
associated
type few home
Downtown of daily = major
>30 2.02,
associated:
regular
male
youth 2.7
[1.96–5.56]),
= use
(aOR at
and
28% HCV borrowing
± attendants subjects
= injections
especially
of ( the
and
95%CI
willingness
having homosexuality The and age
study
source
(aOR of of SIS Factors [1.08–2.25]) [1.53–2.84]) use:
of
in
Factors The a injection> speedball and
= (aOR =
(58%):
following: especially
cocaine; Factors
and the
years,
SIS 1 95%CI
2.36, years
42.3% 26% 39%
94%. with services surrounding
of =
prevalence
the injection 33
95%CI 95%CI injection,
weekly once. number type injections 22.8 with
injection 3.33,
(21%),
aOR
of
year: =
age: of injections. –
health [2.38–4.54]), [1.30–2.77]), [1.05–2.42]). [1.07–2.27]), [1.21–4.67]), [13.21–31.59]) [3.13–8.93]). [1.2–4.3]), [1.1–3.1]), [2.7–8.8]), [1.5–4.3]), [1.4–7.1]). injection,
2.08, 1.56, especially
======age:
time least
findings
of
large drug
= = of
place included included days
associated (aOR
at
local
Approximately Mean Approximately Self-reported Main Average SIS number 95%CI associated 95%CI and daily 95%CI previous 95%CI SISs 95%CI 95%CI inject, 95%CI (10%). Approximately not (aOR 95%CI cocaine 95%CI described: neighborhood of (aOR psychostimulants (4%): spent sex 95%CI 95%CI safe days SISs >25% 95%CI to to
period 09/2005 12/2005 05/01/2001
04/30/2007
2002 From 05/2008 03/2012 From Study From to publication.
of
HIV
by PWID among in among
and of of
date
factors
profiles of of use
Barcelona use use use
by
associated associated and associated
(16–24 street purposes HIV+ in
SIS SIS SIS
Madrid DCR
then
Factors Description Measure Description with years) testing with with Study Factors research young PWID PWID and PWID factors injection self-reported prevalence, associated and clusters,
by
study study study study and and
study
arranged
design
are
Study Analytical, longitudinal, prospective Descriptive Descriptive Analytical Descriptive cross-sectional prospective analytical, prospective analytical, prospective Articles
review. partici-
of
395 249 414 9778 Total pants 509 literature
Room
systematic profile:
and
ACCESS Drug Youth
the (Spain) Vancouver Vancouver
“ARYS’
cohort,
Geneva
of of
users of
PWID’s
Population Madrid Barcelone (At-Risk Cohort PWID MSIC Itinere PWID cohort, Consomtion Study), (DCR), (exhaustive population) synthesis
population, al.,
2014 result
et 2011 date
2009
al.,
al., al., target
et al., and
et et
the et
1
2009b publication 2008 Reach Authors Hadland Reddon Salmon Bravo Dubois-Arber Comprehensive Table
52 C. Potier et al. / Drug and Alcohol Dependence 145 (2014) 48–68 quality
CHEERS
STROBE
27/32 21/29 19/29 23/29 19/25 17/30
scores or
(S): (S): (S): (2NAIs) (5NAIs) (5NAIs) (5NAIs) (9NAIs) (4NAIs) Studies (S): (S): assessment with (S): (S) (C) to in
1.50,
= 2,
impact (OR=
1.27, 1.56, was
Cross
heroin
=
= = 0.47, years.
adjusted needle local
no
= kit. (OR
of
(OR in was King 2.38, 2.13,
HIV.
(OR
Factors (28%).
estimated the PWID The
consumption
(aOR and has
= =
(OR
injecting of meeting
]. in
36–40 . month. of
Approximately for
employment
on .
homeless injecting
SIS
. [1.99–13.71]),
(OR (OR use [
history were
= help
injection per binge injection of
cocaine
age: status
consumption
4.3%
(80%), PWID
cocaine involved
methadone
[1.24–3.35]).
history
MSIC daily an
injections
88% or
and
treatment =
of
regular
PWID
2.88,
Only and
use 95%CI
and
39% on
sharing the
= [1.33–83.46]). − [1.02–6.19])
[59.1–86.7]).
HCV cocaine heroin = needing [7.3–10.8]). =
= +/
median
of
seropositive
attendance:
= 95%CI
2.9%
methadone population (OR injection
5.24,
1.06). population
MSIC attendance (40%)
and
=
had =
obtaining
daily current no daily addiction needle study employment
95%CI
95%CI male, were women,
daily
2.04,
the aboriginal (range prevalence
the
[1.07–4.37]); [1.08–2.28), [2.50–4.73]) [0.43–0.86]),
(range (OR = PWID
HIV,
and = = =
=
the
to
of (aOR
coverage SIS
heroin
36.3% 73% 17% 30% with
between
2.55, Regular
of
(OR
10.52,
= [1.57–3.63]), 18% 70.7% 8.8%
total
= The
=
attendance: factors:
95%CI 95%CI 95%CI 95%CI with
(10%),
at at
incarceration
housing of
the drugs: calculated
(OR
entrants [1.06–1.52]). [1.29–6.40]), [1.65–3.44]), [1.07–2.10]), [1.49–3.06]), [1.12–2.17]), [1.44–2.78]), [0.32–0.69]. of
coverage
======of months.
findings
2.16, 1.57, 0.61, 3.44,
95%CI
of estimated associated 6 = = = =
employment new
Indirect Approximately Unstable Approximately Approximately Approximately Main 95%CI caregivers history estimated 2.39, rate 95%CI associated (OR incarceration last 11.3% (OR prostitution, 95%CI (OR Associated 95%CI be was estimated was sharing (OR on 95%CI population. 95%CI overdose(OR 95%CI Injected 95%CI Patterns
period 11/01/2001 12/01/2003 12/01/2003 10/03/2004 12/01/2003 12/01/2003
10/31/2002 12/31/2005 05/01/2005 04/30/2005 03/31/2005 06/30/2004
From From From From Study From From to to to to to to to SIS SIS and
use
of and of
a
for
to 29 and
obtain PWID factors for of SIS
with
SIS
PWID coverage to of
the
and
estimation
associated and
purposes of under attending PWID estimates attending
attendance
PWID impact
among MSIC SIS
compare a
To SIS’s Study Epidemiological characteristics the associated indirect HIV attending confined geographic location attendance these with PWID patterns PWID seropositivity mean Study methods injection Epidemiological characteristics factors calculate employment prevalence PWID epidemiological characteristics daily years prevalence of
study and
study
study
design
Study Evaluative observational study Evaluative observational study Descriptive, prospective Descriptive, exhaustive Descriptive, cross-sectional study Descriptive evaluative partici-
of
761 4764 pants Total 1090 1035 904 135 of of of of
Cross who
around cohort 2 King
cohort cohort cohort
Vancouver
users
in
km of
Population MSIC) live (=2 MSIC Participants Participants SIS Participants Participants SEOSI VIDUS SEOSI SEOSI users
)
al., date
2006c 2007a
et
al., al., al.,
al., al.,
and
et et
et
Continued et et
(
1
2006a 2006b 2008a 2008 publication Authors Kimber Richardson Stoltz Tyndall Tyndall Wood Table
C. Potier et al. / Drug and Alcohol Dependence 145 (2014) 48–68 53 NA NA NA NA
17/25 17/28 21/28
18/25 24/26
(S): Scores: S: S: (S): (S): (experimental study) (experimental study) (experimental study) (Qualitative study) Scores: Scores: Scores: (9NAIs) (6NAIs) (6NAIs) (9NAIs) (8NAIs) in an
of
87% of
calls
to
in the for
of
with the public in heroin
compared history injected
been
1.6, overdose,
injection
2.7, involved
injection
injection in in
Protective
of history
unstable
=
deaths.
=
syringe individuals. of
transfer
oxygen
and
53%
and overdoses
number 11% no
have
SIS 453 45% (OR 0.6, 605)
of (OR infection:
of public and = = public
attendance (30%).
associated
overdose
the observed
the N
( injection history were injection
HCV an given,
SIS years, reduction).
and not
of [1.5–4.4]). different
a
[1.0–2.7]),
deaths (aOR
prostitution [2.1–6.1]),
=
cases,
cocaine = injection,
31 for
[1.1–2.9]), were 40% = MSIC,
90
number including overdose daily
=
was of
or
1.05).
There
(9.3% infection
in
allowances,
advice of = [1.2–2.7]), age
first
the
the 95%CI heroin = vicinity
95%CI
reported
found:
daily, (35%) 27%
95%CI at
of
reported
HIV
Administration factors individuals
in
of overdose (OR
95%CI cases.
in care,
the 2.6,
SIS social
1.6, of male, [1.07–1.99]) [1.09–2.06]).
12%
of 3.7,
=
history and = of = = 95%CI
in
Risk 1.8, injections =
overdoses, inject
[1.7–3.9]), [1.3–3.2])
11.7
hours
overdoses. the
= Factors overdoses
= = Vancouver
88% 58.53% 70%
and of
21% with deaths.
). (OR
1.7,
of (aOR
68% 2 8 of
years-old
43%
and
injection = (aOR
in
95%CI 95%CI
1004
336 no HCV+
overdoses naloxone
m open
reductions (aOR
75% quality
live
by
km
19
95%CI 95%CI
1.9
conditions. rest in of
years (OR
[0.3–0.9]). [1.1–2.5]), [1.2–6.1]), months. the
500 daily 1.5
1.45, 1.50,
and
56% were were = = = were
than
2.6, 2.1,
=
the = =
<30 between six = = hospital
avoided
safety cases,
Speed During Approximately Age Approximately SIS Approximately There life-threatening Significant (aOR factor: of study more in 95%CI last within heroin. incarceration avoided. the (OR increase 95%CI There and 95%CI prostitution, (area decreased housing borrowing with prostitution (aOR (OR Between overdose, areas, to
to and to
after
before
05/1998 12/01/2003 12/01/2003 06/05/2001 01/01/2001 03/01/2004 12/01/2003 11/2005 03/01/2004 opening
months 09/21/2003
months 07/30/2004 05/01/2004 04/30/2002 09/20/2003 60 02/06/2008 12/31/2005 02/06/2008
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the the SIS
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2011 Wood Wood Kimber Marshall Salmon Milloy Milloy Kerr Kerr Reduce
54 C. Potier et al. / Drug and Alcohol Dependence 145 (2014) 48–68 quality NA NA
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03/2007
to
period Main 05/06/2001 05/01/2001 11/2005 03/01/2004 07/10/2004 12/01/2003
10/31/2002 04/30/2007 03/01/2005 06/30/2005 06/01/2004
From 02/2006 From From From From From to to to to to to
rate to
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syringe impact impact of
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et et Beek
1
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which 7.07, HIV+
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= 1.49,
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wide by
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in
= shooting
hospital
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help inject
were
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caused
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=
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orientation unstable requiring
= = HIV+ with injecting used
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95%CI
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95%CI main is = 1.52,
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received [1.16–2.75]), [1.32–2.64]), [1.03–2.48]), (95%CI
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one [2.16–23.13]) [1.62–2.98]), [1.09–2.16]) [1.16–2.43]), [1.10–2.03]), associated:
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03/22/2004 05/31/2003 01/01/2004 12/01/2003 12/2003 11/2005 01/01/2004
10/22/2004 10/22/2004 12/31/2005 01/31/2008 12/31/2005 12/31/2005
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56 C. Potier et al. / Drug and Alcohol Dependence 145 (2014) 48–68 quality NA NA
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of
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period 12/01/2003 05/2001 12/01/2003 12/01/2003
06/01/2006 03/01/2005 03/01/2005
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of
and
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2010 2007 2006d
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al., al.,
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al., al.,
al.,
and
et et
to et
Continued et et
et
(
1
2008b publication Authors Small DeBeck Milloy Kimber Wood Wood Access Table
C. Potier et al. / Drug and Alcohol Dependence 145 (2014) 48–68 57 NA
23/33 10/21 20/32 15/32
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94]
in
rest with at 57] = vs.
180 drug
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use
1.77,
of firearm 0.99,
and the vs. when
in: or [SD = Sydney between
=
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order
time of injection [SD
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of
in 1.60, opening
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related in trends people
5.39,
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25]
=
cocaine
public Decrease vs. = (124
=
injection
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(aOR with rest
0.022),
of
estimations
the found injecting
(302
included stable
0.803)
[7.3–14.3] rest = in 601.7
frequent =
public
[305–317]).
and = =
heroin p
p [SD
3.63, 11.5 (aOR
steady waiting
the
trafficking [4.7–6.3])
=
p (aOR
rate
3.1, 305.3,
=
SIS
the theft
=
help
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were in
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vs.
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number
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[3.5–5.4])
=
p
of
KC and (aOR
trafficking
df
injecting and =
(95%CI remained
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burglaries
df
and unlike
syringes sharing
trend
(95%CI at
SIS. injection
(11.5,
11,
[1.5–3.0]; [2.11–5.6]). incarceration
possession follows: with
after
need were: =
= = level
car
KC
drug
rate
4.22, frequent
5.4
(up the as
outside 0.014). follow-up, PWID
before
df 305.3
0.26,
=
reductions
0.010) at of possession (95%CI
the = traffic
robberies and housing
= regression
significant
IQR
of
vs. =
and of
needle Associated public
p
and
vs. recent
daily
[1.84–3.98]) [1.11–1.71]). [1.01–2.54], p
or 95%CI for dropped
syringes
theft no 4.3, facility were [490.0–830.3]
rate -stat = = =
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-stat
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downward
stable
t
associated =
periods
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was
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24];
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and
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of
=
[1.46–6.58], [1.15–2.73]), [1.96–14.78]), [0.79–1.23]). [2.70–4.88]), [1.11–2.31]) found:
[SD [SD
33% (aOR was at in
= = =
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recent IQR = = = SIS predicted safer SIS number rest
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116 227 and
Sydney).
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weeks
12
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06/02/2004 6 01/1999 07/01/2004 10/01/2003
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58 C. Potier et al. / Drug and Alcohol Dependence 145 (2014) 48–68 quality NA NA NA NA NA
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C. Potier et al. / Drug and Alcohol Dependence 145 (2014) 48–68 59 NA NA NA NA NA
26/32 18/29 12/31
Scores: Scores: Scores: Scores: S: S: (qualitative study) (qualitative study) (qualitative study) (qualitative study) (Qualitative study) Scores: S: (2NAIs) (5NAIs) (3NAIs) in
an use
and 6
of HIV)
social More is to Initial
likely
use and
follows:
of of
spent
purchase of
allow as
the
as departure be violence,
factors: Other one. not
time except of
inject.
[1.6–4.1]),
being
of
a more
opening
= injections
previous to
willing professional time
>number
police, to
equipment
were
(including of
identity.
would were use of
Motivations:
be [1.4–4.5]).
the
place could
payment the were = decrease
equipment SISs causes 95%CI SIS MSIC in
Waiting
prohibition
risks of of SISs attended
safety, having
reported
the one’s sterile
later
structural
assisted
to
Associated 69%
MSIC.
SG at
settlement,
suspension.
months 2.6,
would
the
95%CI day
a fear assistance
= area. and
6
and
sterile who overdose.
with overdose.
the limitation people
the
health
prove therefore,
visits
SIS: the daily.
2.5, of SIS
during of
of disabilities
attending
attending >3
used
=
injection
(aOR
between
of after use
receiving
PWID’s
go by police.
and
public
in the in
with PWID subjects and, or
the practices
secondarily
SG.
to
case
a physical
SG case conditions.
advice.
and SIF reduce of with of of
to prohibition.
the (aOR
and
Obstacles: receiving
in [1.47–3.30]). in areas
PWID a of
in for
of
min had to
associated
= the
suffered absence safety,
would by
agree
PWID PWID
use
number
distance 72% 85% 31
interpersonal
OD. and
in use
and cameras
close care
of of >15 unsafe
wanted
SISs room
the injecting
injection people
inject
the of
50%
to public
hygiene
in by 95%CI source in
smoking
arrest by injection
live to care to
in
a Consequence: 68% collected collected
seeking
time and
media, safety violence
help
drugs
and
case
against to
months,
individuals and 2.20, SISs
3 two-thirds in
significantly access,
the adequate MSIC, purposes purposes = Assisted
injection SIS,
need
Women The The Approximately Waiting Approximately Refuge Approximately was increased interested speedball lookout having to SIS. benefits. adequate willingness from obstacles and theft, the help these months; Provides facility (OR follows: performed sharing than monitored syringes and after seeking free syringes injection and the to to to to to
from
to from
11/2005
to and to
from
12/2001 11/2005 02/2005 01/2001 09/2011 11/2005
03/2007
From from From from 09/01/2008 From From 12/2011 05/2003 02/2006 02/2006 10/2001 2008 11/2005 Interviews: 02/2006; datas: 08/31/2009 12/2003 to SIS SIS of
and a
SIS
use use
their
about
SIS street the
of and
and SG MSIC and
to
the
who
on
SIS
to and
suffered the injection
on on use.
Francisco
opening opinions motivations motivations opinion in
traffic use,
Vancouver’s impact
PWID women
attend attend San
PWID Description PWID Willingness, motivation SIS to to about Vancouver’s Vancouver the Estimating violence inject functioning attendance impact PWID PWID probability obstacles ethnographic observations drug MSIC’s practices by local in impact assisted by
study study, and study, study, and
study
survey survey
Sample Qualitative Qualitative Qualitative Cross-sectional repeated Qualitative Qualitative Qualitative representative sample descriptive cross-sectional study representative sample sample descriptive, prospective cross-sectional study 8
+
inter-
SIS’s
workers
+
PWID
PWID
PWID
connection
25 with in 23 640 602 (representative sample) 50 50 50 115 views health database
PWID
of of of
SEOSI
shooting of
(SG) VANDU VIDUS
cohort cohort cohort of
Fransisco
cohort Cohort Cohort Participants Participants Participants San Women PWID SEOSI SEOSI SEOSI gallery
2011 2013
Dolan, al., 2012 2011b 2011a
2010 al., al.,
et
al., al., al.,
et and et
al.,
et et et
et
2007 2008 McNeil DeBeck Small Small Small Kral Fairbairn Kimber
60 C. Potier et al. / Drug and Alcohol Dependence 145 (2014) 48–68 quality NA
CHEERS
STROBE
scores or
14/31 20/33 22/32 24/32 12/31 15/31
S: S: S: Scores: S: S: (qualitative study) S: Studies assessment with (S) (C) (3NAIs) (1NAI) (2NAIs) (2NAIs) (3NAIs) (3NAIs) as it 2,
did
=
or less were for
the (12%). of did with more
SIS,
about with
Factors
it
for a
who when position
SIS between
share (aOR if
and SIS an
existing (7%),
1.81,
disposal. 2.02, the
and
inject
who injection =
an
SIS solve
=
undermine give
presence, 71%
SIS
in SIS. to
and years
the
[1.24–4.42]),
[1.07–5.79].
areas an obtaining disease =
=
71% using an reasons injection 29% not
use to
Injecting
hours
the
SISs
the
messages (aOR
(aOR 3.72,
associated
3.07,
<20
in
distance
in in syringe
to frequently. =
use drugs, do =
of [1.35–3.17]), [2.27–11.28])
police
the public
[3.79–11.55]), 3.08, unanimous = =
that exacerbate 95%CI main Main to public 95%CI =
purchases, =
with
of
dependence in
reduce
safely.
[1.62–6.00]), [1.79–8.95]), this
associated:
Obstacles
SISs 66%
help(18%)
(aOR confidentiality/privacy or in (aOR
= =
illicit
and
1.52, distance opening Factors
to
unsafe
to do wished to injection = 83%
2.33, 95%CI
95%CI
of 2.43,
(aOR drug confusing think
injections that 95%CI [1.01–5.5]), =
more
=
Obstacles: difficulties fail the
willing interested interested severe
purchase,
less prostitution
=
(5%), 17% 95%CI 95%CI create inject. Factors satisfied injected
use
use
clients
(aOR strong
users 2.07, 5.06,
persons
send their
4,
SIS: and
to 6.62, a (aOR PWID early and heroin injection
=
=
(aOR study
and
area.
5
=
inject are were are were were of drug
[1.40–3.98]), [1.03–1.16]).
and the
= of and
settlement.
order,
time
3.12, 95%CI an
= =
drug interested. thought report
compared injection; male
of
them.
of sex = convenience,
the
had
prohibition
(5%),
of need (aOR the (aOR (34%).
75% 95% 76% 65% 37% 89% 71%
(aOR to more use (aOR of not
zone
56% injecting rates, -2.30]), 3.37,
they
private
with the
95%CI 95%CI
to
(aOR male place addiction,
anonymity.
public a
months,
recent waiting
with
the
overdoses
relief
maintain
mode drugs with
and 6
of
of
were
in in help
in (aOR [1.24–7.63]), [2.41–5.73]), [1.18–7.99]), [1.01 [1.27–3.16]), [1.22–2.68]) [1.31–3.12]). SISs; of
of and
to
syringes
injection: problems. 2.36, 1.09, presence
======
findings most = =
described agree immediate 49% lack participants syringe
main SIS acceptability
public
The Approximately Approximately Approximately Approximately Approximately Main Approximately and homelessness 95%CI and police needing the (aOR public 95%CI efforts use Obstacles: injected (aOR attendance: sterile the public injection against in injected 95%CI 95%CI associated: prostitution 80% problem 95%CI 95%CI injecting 95%CI transmission feeling located opiates accountability Approximately previous their the was willingness history and
to to to to to
08/1999
in
period 12/01/2003 04/2001 10/2002 06/2001 12/1999 12/2008
09/30/2005
days
2 From From From 01/2010 02/2000 02/2002 01/2003 06/2002 From From Study From to a
SIS to
of to SIS
use in (CSC)
PWID
PWID for
about on to
and and
wishing
of factors
use the of order
police
SIS SIS Supervised PWID the
associated
use
in a a
purposes of willingness expectations
SIS this
willingness
and
to use use this
Estimate PWID Characteristics PWID Estimate factors associated to and deduce characteristics associated with to to Study Evaluation Consumption implications Ottawa go perceptions Centers proportion opening satisfaction willingness public SIS
study
study Study
study
sample design
Study survey Evaluative Analytical prospective cross-sectional study Descriptive analytical prospective cross-sectional study Descriptive analytical prospective Descriptive prospective, cross-sectional study Descriptive, cross-sectional study, Qualitative SISs:
partici-
of
toward
251 18 178 pants 506 Total 1082 587 215 policies
in
of in
local
of of
needle program PWID
and
police
PWID PWID and PWID
cohort (SurvUDI
cohort
police
Population exchange study) Toronto attending Participants Montreal Ottawa Participants Sample Sydney Ottawa public SEOSI VIDUS officers public Melbourne (Australia)
residents, )
2012 date
2007 2003 2004 local
2000 2004
al.,
and of
al., al., al.,
and
and et
et Continued et et
(
Beek 2002 1
publication Leonard, Gilmour, Authors Petrar Green Navarro Wood Fry, Van Watson Opinions Table
C. Potier et al. / Drug and Alcohol Dependence 145 (2014) 48–68 61 Drugs;
NA NA
Vancouver
=
Inject
18/33 27/32 23/31 15/31
Scores: S: S: Scores: (qualitative study) (qualitative study) S: S: (1NAI) (2NAIs) (3NAIs) (3NAIs) Who
VIDUS
People of
Users; do
=
and 28%, and of with
to
least
the by
57%, SIS.
53%
SISs
disease, police. vs drug
the
program Drug the at
of
vs reduce political local attract 65% an public PWID
negative
for
them.
of
(residents: the and (residents:
crime,
those of
33% to
nuisances
by
by do local of
conditions.
suggested the and 72% use operators:
Views: injection, within
SIS
social fearing and SIS
of associated
approved to operators) 58%
but the
with
deals Wales; 25%
accepted PWID
infectious
feasible
an SIS. PWID follows: injection
supported
follows:
by
Many the
and with dropped Network
or
part for
levels
as (also as
from accepted Expectations
users to the drug
policies. operators: religious is
complicate business
most
South
willing mixed,
reassuring operators:
cautious of of
of about
create
SIS
Area public
(business
insecurity SIS nuisances
not in
were
and sent were
The
were
to
attracting with
appeared
favor. medical 0.01;
accepted
New
syringes feasible
the
were
being do less < overdose the
=
favor more 58%
in associated
achievable.
p education health of injections
business respondents the
laws
and
were
fears
inject in less public was
number
business
use, of et of are that
which
the from to NSW 38% and
opinion. use
19%, the those complaints
SIS
Vancouver
seemed the
with machines
programs. necessary
=
were
66% 16.7% 60% reported
vs 0.03), 0.80 0.01; opening:
drug
in
and
learned it
responses
nuisance
reduce
< < <
and less The
were
neighborhood,
and drug (75%),
collaborating changing
p p p
2005, deaths
public inconveniences 2%
Centre; nuisance three felt
improve believing syringes. MSIC
In and contact
the PWID of
and
approximately
NEP and
vending VANDU
public awareness
28%, 40%, 26%, and change policy
the of
the
the vs vs vs (residents) reduce of PWID
no encourage
public
0.01), 0.26).
2000,
< < Injecting
users); After In Ten Approximately Approximately 38% Approximately (residents:33% favorable health respondents. Syringe police, PWID. encouraging but SIS: 67% the Thirteen raising image professionals) dropping p one leaders, subjects respondents 70% 28% traffickers; p enforcement, structures. promote was reduce community, Professionals’ not strength injection,
drug Range
in in
Supervised
2006
and and
2007
(=injection
InterQuartile
August 12/01/2003
=
Medically
March 12/31/2005 10/2000
IQR
2003 From From 11/2005 10/2002 in10/2000, in10/2002 in to to Injectables Sydney
=
Interval;
MSIC SIS
policy and
and Drogues needle
of
of opening opening Dublin of
of SIS’s program local
de
SIS
in machines
of
syringe opinion opinion opinion on SIS’s SIS’s
Service;
SIS.
95%Confidence
Public Public Public Evaluation opening opening vending (NEP), regarding about about Exploring stakeholder perceptions Impact implications and acceptability exchange acceptance attendance feasibility police =
Utilisateurs
Coroners =
95%CI
UDI
study, Ratio; study study,
Columbia study
sampling
survey
Services; sample
Odds
British
=
Qualitative Descriptive, prospective, repeated cross-sectional study survey Qualitative Evaluative Prospective without Prospective repeated cross-sectional study, sample Ajusted
Injection
BCCS =
aOR
207
Services;
Supervised Ratio;
residents: residents: =
business
UDI minister
SIS
Odds
Local 40 2411 16 Local +1 +9profession- nals 1090 operators: 540–326 business operators: 269–210 540; Survival =
to
OR
Injecting; of
or
Item; and in
Exposure MSIC
in
and King the
and
direct
operators operators, field sample
interaction
adult (Mexico) of
of the
key makers cohort
local
residents PWID had Supervised
stakeholders
Applicable drug
evaluate
Of
to business Ontario Cross personnel policy the business Tijuana indirect Key SEOSI Representative sample PWID, Random Sample who population with local around Sydney residents
Not
=
NAI Study.
Cohort
Evaluation
2007 2008 2009
Users
Care
2005
2007 al., al., al.,
al.,
et et 2007 al., et AIDS
Drug
Applicable;
et = Scientific
et
=
Not
=
Philbin DeBeck Cruz O’Shea, Salmon Thein NA ACCESS Injection SEOSI
62 C. Potier et al. / Drug and Alcohol Dependence 145 (2014) 48–68
studies (DeBeck et al., 2012; Green et al., 2004; Tyndall et al., 3.3. The impact of SISs on overdose-induced mortality and
2006b). Among the 32 articles about cohort studies, 94% (n = 30) morbidity
were performed in Vancouver, 3% (n = 1) in Sydney, and 3% (n = 1)
in Barcelona. Seven studies evaluated whether SISs successfully reduced
Other non-cohort investigations consisted of 7 exhaustive pop- harm among SIS users (Kerr et al., 2006b, 2007b; Marshall et al.,
ulation studies [4 descriptive studies (Fry, 2002; Kimber et al., 2011; Milloy et al., 2008a, 2008b; Salmon et al., 2010; Van Beek
2003; Tyndall et al., 2006a; Van Beek et al., 2004), 3 descriptive et al., 2004). In the different studies, no death by overdose was ever
and analytical studies (Kimber et al., 2008b; Salmon et al., 2009a, reported within the SISs in which this parameter was evaluated
2009b)], 13 articles about qualitative studies (Fairbairn et al., 2008; (Kerr et al., 2006b; Milloy et al., 2008b; Van Beek et al., 2004). In
Fast et al., 2008; Jozaghi and Andresen, 2013; Kerr et al., 2007b; Vancouver, SIS implementation led to a 35% decrease in the num-
McNeil et al., 2013; O’Shea, 2007; Philbin et al., 2009; Small et al., ber of lethal overdoses in the vicinity of the SIS (Marshall et al.,
2009, 2008, 2012, 2011a, 2011b; Watson et al., 2012), 4 cross- 2011); thus, it was evaluated that between 2 and 12 cases of lethal
sectional studies (Dubois-Arber et al., 2008; Navarro and Leonard, overdose might have been avoided each year (Milloy et al., 2008b).
2004; Salmon et al., 2007; Thein et al., 2005), 3 surveys (Cruz In Sydney, the number of calls for ambulances related to overdose
et al., 2007; Kral et al., 2010; Van Beek and Gilmour, 2000), 3 was 68% lower during the operational hours of the SIS (Salmon et al.,
evaluative studies (Freeman et al., 2005; Kerr et al., 2006a; Wood 2010; Van Beek et al., 2004).
et al., 2006a), 5 evaluative experimental studies (Kimber and Dolan,
2007; Marshall et al., 2011; Salmon et al., 2010; Small et al., 2011b; 3.4. The impact of SISs on injection behaviors and their
Wood et al., 2004), 1 meta-analysis (Milloy and Wood, 2009), 1 consequences
case-control study (Wood et al., 2005b), 2 mathematical model-
ing studies (Pinkerton, 2011, 2010), 3 cost-benefit/effectiveness Eight studies addressed the reduction in other harms, especially
studies (Andresen and Boyd, 2010; Bayoumi and Zaric, 2008; syringe sharing during injection (Fast et al., 2008; Kerr et al., 2005c;
Jozaghi et al., 2013), and 1 simulation study (Milloy et al., Milloy and Wood, 2009; Salmon et al., 2009a; Stoltz et al., 2007b;
2008b). Wood et al., 2005b, 2005d, 2008). Studies conducted in Vancou-
Concerning the qualitative assessment of each study using the ver and Sydney showed that the regular use of SISs was associated
STROBE and CHEERS scales, the final score is reported in Table 1. with decreased syringe sharing (aOR = 0.30, 95%CI = [0.11–0.82])
This score was calculated from the sum of the applicable items (Kerr et al., 2005c), syringe reuse (aOR = 2.04, 95%CI = [1.38–3.01]),
for each study. The number of applicable items for each study can and public-space injection (aOR = 2.79, 95%CI = [1.93–3.87]) (Stoltz
be found in the denominator. The details of each evaluation are et al., 2007b). In a meta-analysis, Wood and Milloy estimated that
available in the supplementary material. Twenty-two studies were frequent use of SISs was associated with a 69% reduced likelihood
not evaluated: 13 were qualitative studies, 6 were experimental of syringe sharing (Milloy and Wood, 2009). The main injection-
studies, 2 were mathematical modeling studies and 1 was a meta- related issues reported by PWID were difficulty finding a vein, the
analysis. infectious aftermath of injections, and lack of education on safer
injection practices (Fast et al., 2008; Salmon et al., 2009a). Concomi-
tantly, regular SIS use fostered the use of sterile injection materials
3.2. Description of SIS users
and the elimination of soiled materials (Fast et al., 2008; Stoltz et al.,
2007b) and was associated with more frequent requests for edu-
We identified 14 articles that aimed to depict the profile of the
cation on safer injection practices (aOR = 1.47, 95%CI = [1.22–1.77])
most frequent SIS users. Eight of these studies were performed
(Wood et al., 2008).
in a SIS in Vancouver (Hadland et al., 2014; Reddon et al., 2011;
Richardson et al., 2008; Tyndall et al., 2006a, 2006b; Wood et al.,
3.5. The impact of SISs on reducing drug-related harms
2006c, 2005a, 2005c), while the others were performed in SISs in
Sydney (Kimber et al., 2008a, 2003; Salmon et al., 2009b; Stoltz
We found 6 studies that addressed this issue (Lloyd-Smith et al.,
et al., 2007a), Geneva (Dubois-Arber et al., 2008), Madrid and
2010, 2009, 2008; Marshall et al., 2009; Small et al., 2009, 2008).
Barcelona (Bravo et al., 2009).
All of the studies were sourced from the Vancouver cohort of SIS
In these studies, it was found that the majority of SIS users
users. There was no direct finding that SIS use induced a decrease in
were male, ranging from 30 to 35 years of age (Dubois-Arber et al.,
viral transmission. However, SIS use was associated with increased
2008; Kimber et al., 2003; Tyndall et al., 2006a; Wood et al., 2006c),
condom use during intercourse (8% in 2 years) (Marshall et al.,
with frequent housing insecurity and unemployment (Kimber et al.,
2009). Moreover, approximately 25% of the SIS users received care
2003; Richardson et al., 2008) and with a previous history of incar-
for injection-related cutaneous lesions (Lloyd-Smith et al., 2009).
ceration. Resorting to prostitution was identified in 10–39% of
PWID reported that the SISs assessed, cared for and oriented them
users (Kimber et al., 2003; Wood et al., 2006c). The most frequent
quickly, efficaciously, and without any judgment (Small et al., 2009,
drugs used were, in descending order, heroin, cocaine, opiates, 2008).
amphetamines, and their derivatives (Kimber et al., 2003; Tyndall
et al., 2006a). In Vancouver, compared with other PWID, SIS users
3.6. The impact of SISs on access to addiction treatment programs
exhibited more episodes of overdose (OR = 2.7, 95%CI = [1.2–6.1])
and a higher frequency of daily drug injection (heroin: OR = 2.1,
This issue was assessed in 5 studies, among which 4 were
95%CI = [1.3–3.2]), cocaine: OR = 1.6, 95%CI = [1.1–2.5]) and of pub-
cohort studies from the Vancouver team and 1 was an exhaus-
lic injecting (OR = 2.6, 95%CI = [1.7–3.9]) before the opening of the
tive population study in Sydney. These publications stated that SIS
SIS (Wood et al., 2005c). Eighty-eight percent of SIS users were
attendance was associated with a global increase in diverse types of
seropositive for HCV (Wood et al., 2005a), and between 2% (Salmon
dependence care, i.e., referral to an addiction treatment center, ini-
et al., 2009b) and 30% (Wood et al., 2005c) of them were positive for
tiation of a detoxification program (OR = 1.32, 95%CI = [1.11–1.58];
HIV. For these PWID, syringe sharing was more regular before SIS
p = 0.002 (Wood et al., 2007)), and initiation of methadone ther-
use (OR = 2.13, 95%CI = [1.49–3.06])(Tyndall et al., 2006b) and was
apy (aHR = 1.57, 95%CI = [1.02–2.40; DeBeck et al., 2011; Kimber
a factor associated with these blood-transmissible viral infections
et al., 2008b; Milloy et al., 2010; Wood et al., 2007, 2006d). Approx-
(aOR = 1.8, 95%CI = [1.1–2.9]) (Wood et al., 2005a).
imately 20% of PWID were interested in joining a dependence care
C. Potier et al. / Drug and Alcohol Dependence 145 (2014) 48–68 63
program (Milloy et al., 2010; Wood et al., 2006d), and in Syd- 3.10. Medico-economic assessment of SISs
ney’s SIS, 25% of the interested subjects started such a program
(Kimber et al., 2008b). Among the PWID who used the Vancouver Four studies were performed to assess whether the SIS was a
SIS, 18% secondarily engaged in a detoxification program (Wood cost-saving system. All of them were carried out on the Vancouver
et al., 2006d), 57% started an addiction treatment, and 23% stopped SIS (Andresen and Boyd, 2010; Bayoumi and Zaric, 2008; Pinkerton,
injecting drugs (DeBeck et al., 2011). 2011, 2010). The authors calculated that the SIS could prevent 5–35
new HIV infections (Andresen and Boyd, 2010; Pinkerton, 2011)
and 3 deaths by overdose per year (Andresen and Boyd, 2010).
3.7. The impact of SISs on the nuisance induced by drug use in
Over 10 years, this prevention would represent a cost savings of
public spaces
$14 million, a gain of 920 years of life, and an avoidance of 1191
new HIV infections and 54 new HCV infections (Bayoumi and Zaric,
Six studies addressed these questions, of which 4 were per-
2008). Similarly, a study that used mathematical modeling found
formed in the Vancouver SIS (McKnight et al., 2007; Petrar et al.,
that opening a SIS in Montreal may be viable in terms of the cost-
2007; Stoltz et al., 2007b; Wood et al., 2004) and 2 in the Sydney
benefit and cost-effectiveness (Jozaghi et al., 2013).
SIS (Salmon et al., 2007; Thein et al., 2005). In Wood et al. (2004),
the number of syringes dropped in the hereabouts of the Vancou-
3.11. The opinion of PWID on SISs
ver SIS was counted and compared before and after the SIS opened.
After the SIS was opened, the authors found a reduction in the daily
Fifteen surveys aimed to evaluate the opinion of PWID on the
mean number of PWID injecting in public (4.3, IQR = [4.0–4.3] vs. 2.4
pros and cons of SISs in numerous cities: Vancouver (DeBeck et al.,
IQR = [1.5–3.0]; p = 0.022), syringes dropped (11.5, IQR = [7.3–14.3]
2011; Fairbairn et al., 2008; Jozaghi and Andresen, 2013; McNeil
vs. 5.3, IQR = [3.0–8.0]; p = 0.010) and injection-related lit-
et al., 2013; Petrar et al., 2007; Small et al., 2012, 2011a, 2011b;
ter (601.7, IQR = [490.0–830.3] vs. 305.3, IQR = [246.3–387.0];
Wood et al., 2003), Sydney (Kimber and Dolan, 2007; Van Beek
p = 0.014).
and Gilmour, 2000), Ottawa (Navarro and Leonard, 2004), Mon-
The other studies were surveys carried out among PWID in
treal (Green et al., 2004), Melbourne (Fry, 2002) and San Francisco
Vancouver (McKnight et al., 2007; Petrar et al., 2007; Stoltz et al.,
(Kral et al., 2010). Before the opening of the first SISs in Canada and
2007b) or among non-drug users who lived or worked in the vicin-
Australia, between 54% and 89% of the local PWID declared that they
ity of the SIS in Sydney (Salmon et al., 2007; Thein et al., 2005).
were willing to use such services (Fry, 2002; Van Beek and Gilmour,
Between the periods before and after the opening of the Syd-
2000). One survey found that 72% of the same PWID interviewed
ney SIS, this population noted less public injection (residents: 33%
actually visited the SIS (DeBeck et al., 2012). The main factors asso-
vs. 19%, p < 0.01; business operators: 38% vs. 28%, p < 0.03), less
ciated with visiting the SIS were the desire to inject safely and
syringes dropped (residents: 67% vs. 40%; business operators: 72%
quietly, the desire to avoid public spaces, previous episodes of over-
vs. 57%, p < 0.01) and less complaints about PWID nuisances, but no
dose, and the need for help to inject (Fry, 2002; Green et al., 2004;
change in the number of drug deals (residents: 28% vs. 26%, p < 0.80;
Van Beek and Gilmour, 2000). The main reasons reported for not
business operators: 33% vs. 28%, p < 0.26) (Salmon et al., 2007).
visiting the SIS were the prohibitions against sharing drugs and
In Vancouver, SIS attendance was associated with a reduction in
helping other PWID inject drugs within the SIS (Fry, 2002; Van Beek
self-declared public drug injecting (aOR = 2.79, 95%CI = [1.93–3.87])
and Gilmour, 2000).
and syringe dropping (aOR = 2.13, 95%CI = [1.47–3.09]) (Petrar et al.,
Seven surveys were published regarding the opinions of PWID
2007; Stoltz et al., 2007b).
on SISs (DeBeck et al., 2012; Fairbairn et al., 2008; McNeil et al.,
2013; Petrar et al., 2007; Small et al., 2012, 2011a, 2011b). Approx-
imately 75% of the PWID in Vancouver reported that using the SIS
3.8. The impact of SISs on local drug-related crime, violence, and
trafficking induced positive changes in their behaviors, notably in terms of
public nuisance and safe injection practices (Petrar et al., 2007).
Qualitative studies in Vancouver revealed that their motivation for
Four studies evaluated this issue in Vancouver (Milloy et al.,
using the SIS were similar before and after visiting the SIS, i.e., to
2009; Wood et al., 2006a) and Sydney (Fitzgerald et al., 2010;
inject in safe and quiet conditions without suffering violence or
Freeman et al., 2005), among which 3 included local police data
having to share drugs with others and to avoid the police (Fairbairn
(Fitzgerald et al., 2010; Freeman et al., 2005; Wood et al., 2006a).
et al., 2008; McNeil et al., 2013; Small et al., 2012, 2011a). The main
In Vancouver, no increase in crime, violence or drug trafficking
concerns of PWID concerning the SIS were the length of the waiting
around the SIS was found after the opening of the SIS (Wood et al.,
time to access the SIS, the prohibition of sharing drugs and helping
2006a). In Sydney, compared to the other cities, data collected
others inject, the suspensions of access in cases of non-compliance
over a period of 10 years also revealed no increase in offenses
with the rules, their distance from the SIS, and the presence of
related to the trafficking or consumption of drugs in the areas
police in the surrounding area (Kimber and Dolan, 2007; Petrar
that surrounded the SIS (Fitzgerald et al., 2010; Freeman et al.,
2005). et al., 2007; Small et al., 2011a).
3.12. The impact of SISs on the opinions of local residents and
3.9. Impact of SISs on the amount of local PWID police
Two studies performed in the Vancouver SIS addressed whether Seven surveys sought the opinions of local residents, police and
the SIS induced an increase in the number of local PWID (Kerr et al., professionals in the drug field (Cruz et al., 2007; DeBeck et al., 2008;
2007c, 2006a). These studies reported that 25 months after the O’Shea, 2007; Philbin et al., 2009; Salmon et al., 2007; Thein et al.,
SIS opened, there was no increase in the local number of PWID 2005; Watson et al., 2012). Although there was no SIS in Ontario,
(Kerr et al., 2007c), no decrease in the number of PWID who started 60% of the local population favored the existence of an SIS (Cruz
methadone therapy (11% vs. 7%), and no increase in relapse rates et al., 2007), whereas the police forces in Toronto and Ottawa pre-
(17% vs. 20%; Kerr et al., 2006a). Nevertheless, the opening of the dominantly opposed SISs (Watson et al., 2012). In Sydney, two
SIS did not reduce the number of PWID who injected drugs (17% vs. random sample studies found that more than 70% of the local resi-
15%; Kerr et al., 2006a). dents and 58% of the companies located around the SIS were in
64 C. Potier et al. / Drug and Alcohol Dependence 145 (2014) 48–68
favor of the SIS (Thein et al., 2005) and deemed that there was less 2014; Pinkerton, 2011, 2010). Although Des Jarlais discussed the
drug use and syringe waste in public places (Salmon et al., 2007). importance of achievable gains, he agreed that the SIS of Vancouver
However, a majority of the companies and residents nonetheless would continue to be cost-effective (Des Jarlais et al., 2008).
thought that the SIS contributed to a negative image of the district, Some critics have argued that SISs, by promoting safer and thus
fostered drug use, attracted drug users and dealers, and increased more comfortable injection conditions, might foster risk-taking in
crime and insecurity (Salmon et al., 2007). PWID and thus expose them to increased risks of overdose (Selby
et al., 2007). However, the global rate of overdoses in SISs was found
to be very low (Kerr et al., 2006b; Van Beek et al., 2004), and the
4. Discussion outcomes of overdose cases were improved due to the presence of
healthcare workers (Kerr et al., 2006b, 2007b). In addition, different
The aim of this review was to depict the currently available evi- surveys that evaluated the number of overdoses have shown that
dence regarding the positive and negative consequences of SISs. the rates of overdoses did not increase after the implementation of
Several literature reviews have evaluated the multiple impacts of SISs (Marshall et al., 2011; Milloy et al., 2008a; Salmon et al., 2010).
SISs on PWID or on their local environment (Hyshka et al., 2013; However, no similar observation was found in our results con-
Kelly and Conigrave, 2002; Kerr et al., 2007a; Semaan et al., 2011; cerning the European SISs. A German departmental report found
Tyndall, 2003; Wood et al., 2006b). However, the present review the same results, but it has not been referenced in any database
is the first to systematically embrace the full scope of SIS-related (Poschadel et al., 2003).
issues using a reproducible keyword algorithm research. SISs were also implemented to reduce the problems induced by
The studies that depict the profile of SIS users were performed drug injection in public spaces. The Canadian studies (McKnight
internationally, and their results were quite homogeneous among et al., 2007; Wood et al., 2004) found that SISs contributed to a sig-
the different countries. PWID using SISs globally exhibited a similar nificant reduction of drug injection in public spaces. This reduction
profile of social precariousness and poor life conditions, which sug- was congruent with the results of surveys of local residents in Syd-
gests that SISs were successful in attracting the most marginalized ney (Cruz et al., 2007; Salmon et al., 2007) and with measures of
fringes of PWID. Nonetheless, some experts (Noël et al., 2009) and the amount of waste resulting from drug injection in public spaces
one study (McNeil et al., 2013) have noted that because there was (Wood et al., 2004). In our results, we found no European studies
no assistance for drug injection in SISs, PWID who are unable to on this issue; however, European studies have actually been per-
self-inject, especially those whose conditions are too deteriorated, formed and have found similar results (Hedrich, 2004; Kemmesies,
would be unable to frequent SISs. Moreover, because most SISs do 1999). In some European SISs, e.g., in Switzerland and Germany,
not accept individuals under 18 or pregnant women, it remains however, the reduction in the amount of injection-related waste
difficult to conclude anything regarding these specific subpopula- in the areas surrounding the SIS also resulted from active collec-
tions, which are particularly vulnerable and require specific care tion by both SIS users and SIS personnel (Benninghoff et al., 2003;
and support. These conditions of accessibility have been discussed Schu et al., 2005). Moreover, it has been noted that external fac-
among the staff of a Swiss SIS (Solai et al., 2006). tors without any link to SISs could also reduce drug use in public
Similarly ubiquitous and homogeneous were the findings that spaces, e.g., factors related to local homeless housing programs
SISs allowed safer injection conditions and promoted enhanced (Noël et al., 2009), local police surveillance, or local policy changes
health education among PWID regarding injection techniques and (Government of Canada, 2008). Therefore, the direct impact that
asepsis rules. Given the high rates of HIV and HCV infections in SISs may have on reducing drug injection in public spaces was
PWID, the reduction of syringe sharing in PWID using SISs indicates sometimes difficult to assess because the use of drugs in pub-
that SISs are effective tools against the spread of these epidemics. lic spaces results from numerous factors that remain difficult to
With the aim of promoting safer injection behaviors, SISs proposed control within scientific studies. Furthermore, local or contextual
or directed PWID to specific health and social services (Hedrich, features related to the function of the SIS may also influence out-
2004). Because these services varied significantly between SISs, it door drug injection practices. For example, the rates of outdoor
was difficult to globally compare and evaluate this subject. From drug injection increase with the average wait to access the SIS
analyzing different studies, it appeared that most PWID had used (Benninghoff et al., 2003; Small et al., 2011b). Consequently, if SISs
such services. However, the benefits of social services remained can reduce injection practices in public spaces, this impact might
insufficiently assessed within the different SISs. Most SISs were largely depend on their accessibility (EMCDDA, 2009; Hedrich,
linked to addiction care services, which were found to facilitate 2004).
the start of addiction care among PWID. However, a proportion Another fear that emerged with the opening of SISs was the
of PWID who attended SISs were already undergoing treatment increase of drug trafficking and drug-related crime in the direct
with methadone, although they continued to self-inject drugs. This vicinity of the SIS. This effect was not highlighted in the studies
finding suggests that SISs and opiate replacement therapies are dif- found in our review, which were performed in Canadian and Aus-
ferent, albeit complementary, measures for harm reduction among tralian SISs (Fitzgerald et al., 2010; Freeman et al., 2005; Milloy
PWID. et al., 2009; Wood et al., 2006a). Furthermore, no European data
Moreover, it was feared that SISs might foster the initiation were found in our review, whereas the European report on drug
of new users into intravenous drug use, but no study found any consumption rooms cited unreferenced studies that found no
increase in the total number of local PWID, irrespective of the SIS increase in acquisitive crime in Swiss or Dutch SISs (Hedrich et al.,
studied. Equally univocal was the global satisfaction with the use 2010). A few European studies reported small-scale drug traffic-
of SISs among PWID in the different surveys (Jozaghi and Andresen, king in the immediate vicinity of the SISs (Hedrich, 2004). However,
2013; Kimber and Dolan, 2007; Petrar et al., 2007; Small et al., 2012, as noted by the European report, “As many rooms are deliber-
2011a). However, most of the surveys were performed among SIS ately located near places where illicit drugs are sold, it is difficult to
users, which may not reflect the overall population of PWID. No claim that the existence of such rooms leads per se to drug dealing”
survey investigated the subjective assessment of SISs among PWID (Hedrich, 2004). Moreover, there are numerous external factors
who no longer attended SISs; this population may exhibit different that may influence drug trafficking and criminality. In Vancouver,
opinions on these facilities. On a medico-economic level, stud- for instance, the SIS and police services work in close collaboration,
ies have demonstrated that SISs are economically cost-effective which may explain why there was no increase in drug traffic-
(Andresen and Boyd, 2010; Bayoumi and Zaric, 2008; Hadland et al., king in the related study (DeBeck et al., 2008; Hedrich, 2004). This
C. Potier et al. / Drug and Alcohol Dependence 145 (2014) 48–68 65
collaboration seems important for the effect on the level of the in Europe to counterbalance the disproportion of the currently
criminality around the SIS (Hedrich et al., 2010). The surveys among available data among centers and countries; thereby, if SISs con-
local residents have all noted that numerous prejudices against tinue to develop in Europe, their scientific legacy will be based on
drug users accompanied the implementation of a SIS within the local evidence. Lastly, the well-known bias of “socially desirable
neighborhood and that these beliefs might last even after the imple- answers” in surveys of PWID may limit the scope of the survey
mentation of the SIS. Consequently, it has been recommended that results on several subjects, e.g., overdose (Milloy et al., 2008a) and
any implementation of a new SIS be preceded by a campaign that syringe sharing (Stoltz et al., 2007b). However, studies with data
aims to inform and educate people living in the vicinity of the SIS sources other than self-reports found approximately the same con-
(Hedrich, 2004; INSERM, 2010). It should be demonstrated that clusions as the surveys. Consequently, this bias most likely had a
such preparation for the implementation of a SIS in a specific district weak impact on the overall findings of this review.
is highly effective in facilitating its acceptance by local residents and In conclusion, despite significant operating differences, SISs
police services. In addition, the implementation of a SIS is depend- ubiquitously and effectively succeeded in attracting the most
ent on the political prejudgment of a country or city, which may be marginalized PWID, i.e., those who generally have not joined any
a hindrance to the development of SISs. The example of the SIS in already existing care system. However, some parts of this popu-
Vancouver, where the accumulation of scientific evidence has had lation still do not have access to the majority of SISs, especially
little influence on the elected political party (Hyshka et al., 2013; people under the age of 18, pregnant women, and people who can-
Small, 2010), reflects the controversy of SISs (Keller, 2008; Picard, not self-inject. Their interest in SISs remains to be demonstrated,
2008) and the need for local and national political support. and further SIS developments are expected to address these sub-
This systematic literature review on SISs has several limitations. populations.
First, encompassing the entire scope of the relevant articles con- SISs were found to provide numerous benefits to PWID: safer
cerning SISs was complex because there are many synonymous injection conditions and safe injection equipment, efficacious
terms referring to SISs in the international literature. To date, no overdose management, injection technique education, of blood-
consensual appellation has been defined, which explains why we transmissible infection prevention, and enhanced connections with
used such a complex keyword algorithm to include the most com- addiction and social services. Their interventions are deemed effi-
mon appellations in the results. Despite this, a few articles that refer cacious because they induce positive changes in risk behaviors of
to SISs using more unusual terms might have been missed in this PWID.
systematic review. Another limitation of the present work is the Moreover, SISs generate public benefits such as a decrease in
presence of important differences in the functioning of SISs around the number of PWID injecting in public and a reduction of dropped
the world and gaps in the cultural and political contexts between syringes in public places. Contrary to what was feared, SISs do not
countries. This fact could introduce important variations in what promote drug use and do not increase crime or drug trafficking
was synthesized with respect to the different studies selected or the number of PWID. In addition, they seem to be economi-
herein. cally cost-effective. Thus, SISs can be considered effective measures
Moreover, the types and designs of the studies themselves were complementary to other harm reduction interventions.
highly variable, depending on the question addressed. Notably,
there were significant disproportions in the quantity and fea- Role of the funding source
tures of the data published on the different active SISs around the
world. Although most SISs are currently located in Europe (Hedrich Nothing declared.
et al., 2010), the majority of the systematically identified publica-
tions were related to the Canadian or Australian SISs, which have Contributors
received significant means to evaluate their structures. Some sub-
jects were addressed ubiquitously, i.e., the depiction of profiles of B. Rolland and C. Potier designed the study. C. Potier, B. Rolland
PWID, the effect of safety and hygienic conditions for injection, sat- and V. Laprevote conducted the literature searches and summaries
isfaction surveys among PWID and residents, and the effects of the of previous related work. C. Potier and B. Rolland wrote the first
SIS on overdoses, injection in public areas and crime. Conversely, draft of the manuscript. F. Dubois-Arber, V. Laprevote and O. Cot-
the imbalance in studies was particularly notable regarding other tencin corrected the first draft of the manuscript. All authors
subjects, i.e., the morbidity secondary to injection-related prob- contributed to and have approved the final manuscript.
lems and the economic efficiency of the SISs. However, there are
European data on these subjects because they were mentioned in Conflict of interest
previous comprehensive reviews issued by different official institu-
tions (EMCDDA, 2009; Hedrich, 2004; Hedrich et al., 2010; INSERM, No conflict declared.
2010; Joseph Rowntree Foundation, 2006; Noël et al., 2009). The
conclusions of these reports were globally similar to those we found Appendix A. Supplementary data
in our review regarding each of the different questions. Regard-
less, if many investigations were performed in European SISs, the Supplementary data associated with this article can be found,
results of these investigations were not found in the databases used in the online version, at http://dx.doi.org/10.1016/j.drugalcdep.
for the present review, although these databases are among the 2014.10.012.
most commonly used for literature research. For example, 40 Euro-
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