By Ayden Scheim and Dan Werb | CMAJ

KEY POINTS

  • Supervised-consumption services are known to be effective in reducing drug-related harms, and several dedicated services now exist in Canada.

  • It is now time to move from asking whether such services are effective to asking whether, how and under what conditions their benefits can be maximized.

  • Integrated and co-located health service models — effectively “one-stop shops” — could improve health outcomes for people who inject drugs by combining the prevention of immediate drug-related harms with access to primary care, mental health care and social service programs.

The opioid overdose crisis in North America demonstrates a need to scale up supervised-consumption services, as well as to experiment with a mix of potential service models. A range of new-to-Canada models have been implemented over the past two years. In some cities, including Toronto and Ottawa, health authorities initially focused on embedding the services within community health agencies to provide a continuum of health care and treatment for substance use disorders, but there are no data on the effectiveness of this model. With an increasing diversity of models of supervised-consumption services in operation, there exists a window of opportunity for a second generation of research in this area that moves from asking whether such services are effective in reducing drug-related harms — which we know them to be1 — to asking whether, how and under what conditions their benefits can be maximized.

Models of supervised-consumption services operating in Canada include peer-run “overdose-prevention sites,” stand-alone storefronts, mobile vans, co-location with harm-reduction programs or social housing, in-hospital services, women-only sites and the aforementioned integrated model. Some of these operate within community health centres that also offer services for populations that do not use drugs. The plurality of models raises questions as to their relative effectiveness. These questions are not answered by the existing scientific literature, which is dominated by reports from two stand-alone sites in Vancouver and Sydney, Australia, employing comparable models.1 The evidence base on alternative models is insufficient to guide policy in this area, and it would be premature to consider service models interchangeable. Nevertheless, officials in Seattle recently announced they will operate a mobile supervised-consumption service because no fixed location could be secured.

Insite, Canada’s first formal supervised-consumption service, opened in Vancouver in 2003 and remained the only sanctioned site in Canada for 12 years.2 Insite is a stand-alone, storefront model that offers basic nursing care (including initial prescriptions for opioid agonist therapy) and a small co-located medically supervised detoxification facility. Extensive evaluation has established Insite’s public health benefits.1 However, it is also evident that stand-alone models have limited reach.3They serve a small geographic area (the distance clients will walk), and even among regular service users, only a proportion of injections are covered (43% of Insite users accessed the site for fewer than one-quarter of injections4). Moreover, stand-alone models attract a highly socially vulnerable population,5 and clients continue to face disparities in health status, homelessness and access to opioid agonist therapy.6 This suggests a need for greater scale-up of existing models as well as for new models that offer a larger suite of on-site health services.