EDITORIAL

doi:10.1111/j.1360-0443.2007.01859.x

A 21st-century Lazarus: the role of safer injection sites

in harm reduction and recovery
There are striking parallels between the politicized
research environments surrounding needle exchange
programs (NEPs) and safer injection facilities (SIFs),
both of which have been shown to be highly effective
interventions to reduce the health and social harms of
injecting drug use. The first NEP was introduced in
Amsterdam, the Netherlands, in 1984 by and for drug
users, but was not evaluated formally until 1988, when
declines in needle sharing were associated with NEP participation [1]. As NEPs sprang up in other settings, additional studies reported reductions in the incidence of
human immunodeficiency virus (HIV), hepatitis B virus
(HBV) and hepatitis C virus (HCV) infections, decreased
needle sharing and syringe re-use [2], as well as
increased entry into detoxification and maintenance
programs [35]. Despite vigorous opposition against
NEPsmost notably in the United Statesextensive
research has found no evidence that NEPs cause negative societal effects, such as increases in drug use, crime
or use of discarded needles [6]. In the face of this preponderance of evidence, one would expect that political
opposition to NEPs would wither; however, this is not
the case. The United States has maintained a ban on
federal funding for NEPs for nearly two decades [2,6]
and, for a short time in 1988, even banned the use of
US federal funds to evaluate NEPs. Currently, fewer than
half the countries reporting HIV among injecting drug
users have established NEPs [6].
By comparison, the first unofficial SIFs emerged in
the late 1960s and early 1970s in the Netherlands and
England, again by users groups [7]. Currently, SIFs
operate in more than half a dozen countries, including
Canada, where the first North American SIF opened in
Vancouver in 2003 [7]. As with NEPs, formal evaluations
of SIFs did not appear in peer-reviewed journals until
much later, giving ample time and opportunity for opponents to take aim. The scientific research community was
tasked with producing unequivocal evidence of the
public health benefits of SIFs while demonstrating simultaneously the absence of adverse impacts on surrounding
communities. Researchers from Vancouver, Sydney and
elsewhere have met this challenge, publishing at least 28
methodologically rigorous studies subjected to peer
review in leading medical journals. These manuscripts
have demonstrated consistently that SIFs are associated
with reductions in needle sharing, syringe re-use, overdoses, injecting in public and numbers of publicly discarded syringes [712]. The paper by Wood et al. [13],

published in this issue of Addiction, extends earlier

research [12] by demonstrating that participation in Vancouvers SIF was associated with a 30% increased rate of
entry into detoxification, which led in turn to increased
uptake of methadone maintenance and other forms of
addiction treatment, as well as reduced use of the Vancouver SIF.
Despite compelling evidence of the effectiveness of
SIFs, these programs continue to be stridently opposed at
the highest levels of government. Not content to rest on
its laurels in banning federal funding for NEPs, the US
government has extended its anti-drug hyperbole across
the northern border, with US drug czar John P. Waters
referring to Vancouvers SIF as state-sponsored personal
suicide [14]. Since the countrys only existing SIF was
established in Sydney in 2001 Australias prime minister,
John Howard, has been vigorously opposed to the center
despite a national policy of harm minimization [15]. In
Vancouver, a decision to grant the SIF a 3.5-year extension of its exemption from federal drug laws, scheduled
for 2006, was deferred to December 2007. In announcing the deferral, Canadian Federal Health Minister Tony
Clement cited a need for more research to answer the
question: Do safe injection sites contribute to lowering
drug use and fighting addiction? [16]. The accompanying article by Wood et al. confirms unequivocally that
they do, but the Canadian federal government has commissioned other independent evaluations to re-address
questions that clearly have already been answered. In a
startling dj vu harking back to the ban on NEP evaluation in the United States, the Canadian federal government recently placed a moratorium on SIF research in the
rest of the country.
In the United States, NEP evaluation studies were
hampered by continually having to defend their legitimacy. More recently, however, studies have addressed
which operational characteristics of NEPs optimize their
effectiveness [1719]. It is now time for SIFs to address
similar questions: is it more cost-effective for SIFs to
operate 24 hours a day or have fixed hours? Are standalone SIFs just as effective as those which operate in conjunction with medical establishments? Do SIFs that assist
clients with injecting save more lives than those who
adhere to a hands-off policy? In the face of ongoing
political opposition, these and other next generation
studies become harder to conduct, but these are the bestpractice questions that ultimately need to be answered to
inform decisions on SIFs in other settings.

2007 The Authors. Journal compilation 2007 Society for the Study of Addiction

Addiction, 102, 848849

Editorial

Injection drug users are more than potential users of

harm reduction services such as NEPs and SIFsthey are
citizens and constituents of the governments and politicians who represent them. Based on results from the
various evaluations of SIFs, many legislators in Canada,
Australia and elsewhere have supported their continuation and expansion. It is time for politicians who oppose
SIFs on the grounds that more research is needed to be
honest with their constituents: it is lack of political will,
not lack of data, that is keeping these life-saving public
health services out the hands of our drug-dependent
citizens.
STEFFANIE A. STRATHDEE

Professor and Harold Simon Chair, Chief, Division of

International Health and Cross Cultural Medicine,
University of California San Diego School of Medicine,
Adjunct Professor, Johns Hopkins Bloomberg School of
Public Health, 9500 Gilman Drive, mailstop 0622, La
Jolla, CA 92093, USA. E-mail: sstrathdee@ucsd.edu
ROBIN A. POLLINI

University of California San Diego School of Medicine,

Division of International Health and Cross-cultural
Medicine, University of California San Diego School of
Medicine, La Jolla, CA, USA
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2007 The Authors. Journal compilation 2007 Society for the Study of Addiction

Addiction, 102, 848849