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FactCheck: Do supervised injection centres reduce drug-related deaths?

In the final instalment of our three-part series on drug policy, FactCheck examines a claim made by Dublin City Councillor Mannix Flynn on Tonight With Vincent Browne.

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THE GOVERNMENT IS advancing legislation to allow for the creation of supervised injection facilities (SIFs), where drug users can legally inject drugs in a medically-supervised centre.

Naturally, the debate around this proposal has intensified, and on TV3′s Tonight With Vincent Browne last week, there was a robust back-and-forth between Catherine Byrne, the minister in charge of the plan, and Dublin City councillor Mannix Flynn, who is opposed to it.

There were a few very noteworthy factual claims, so we’ve broken this into three parts.

On Saturday, we examined Minister of State Byrne’s claim that, contrary to widespread contention, there are 787 detox beds in Ireland.

Last night, we checked Mannix Flynn’s claim that SIFs do not reduce drug-related crime.

And tonight, we’re taking a look at his claim that SIFs do not reduce drug-related deaths.

(Send your FactCheck requests to factcheck@thejournal.ie, tweet @TJ_FactCheck, or send us a DM).

What was said: You can watch a short video with an excerpt of the debate, below. But our focus here is on this statement:

Across the globe, the statistics are really clear in relation to these particular centres – they don’t reduce crime, they don’t reduce deaths.

Claim: Supervised injection facilities don’t reduce deaths

THE FACTS

Inside a supervised injection facility in Athens, Greece. Source: AP/Press Association Images

Before we start, it should be noted that the Councillor is referring here to drug-related crime and drug-related deaths.

Europe

1. A major 2004 review by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) calculated that the availability of SIFs (or “consumption rooms”) in Germany prevented at least 10 overdose deaths per year (pg 53).

2. The EMCDDA review (pg 52) also quoted previous research (written in German and commissioned by the German Ministry of Health) which had tracked overdose deaths in four German cities, and concluded:

…The work of consumption rooms is statistically significantly related to the reduction of drug-related deaths. (Emphasis added).

The review added (pg 55):

…The fact that no overdose-related death has yet occurred at these facilities despite the fact that millions of drug consumptions have been supervised and thousands of emergencies have been treated shows that they provide a high level of safety from overdose-death for those who use them. (Emphasis added).

Canada

3. After the opening of an SIF in Vancouver in 2003, a 2008 study analysed overdose incidents, potentially fatal overdoses and overdose deaths between 2004 and 2008.

It estimated that the existence of the Vancouver SIF had prevented between 2 and 12 deaths per year.

4.2011 study tracked the rate of fatal overdoses in the 32 months before the centre was opened and the 27 months after it was opened (2003-2005), both within a 500-metre radius of the centre, and in the rest of the city.

It found that within the immediate vicinity of the centre, the rate of overdose deaths fell by 35% in the first two years of the centre’s operation, while it fell by just 9.3% in the rest of the city.

This suggests that the centre played a role in a significant reduction in fatal overdoses.

5.2008 study estimated that the Vancouver centre had prevented around three deaths and 35 HIV infections per year.

6. However, the 2008 review of the Vancouver SIF, commissioned by Canada’s Department of Health, challenged the validity of the assumptions that this estimate was based on.

The government’s Expert Advisory Committee also added, in relation to HIV:

There is no direct evidence that the INSITE service impacted rates of blood-born diseases or injection related infections in the target population. (Emphasis added).
However, there is evidence that the service had a positive impact on needle sharing and other risk behaviours

Australia

Heroin Havens Inside the Medically Supervised Injecting Centre in Sydney. Source: Rick Rycroft/PA Images

After the establishment of an SIF in Sydney in 2001, the New South Wales government ordered a series of follow-up reviews into its operations.

7. The first major review, in 2003, found (pg 47):

It is likely that the early intervention provided by the supervised setting of the MSIC [medically-supervised injection centre] reduced the morbidity [non-fatal harm] and mortality [deaths] that would have otherwise been associated with these drug overdoses had they occurred elsewhere. (Emphasis added).

There was a significant reduction in overdose deaths in the vicinity of the SIF in early 2001, but this reduction was mirrored in the wider neighbourhood, and in the state of New South Wales at large.

It appears to have been associated with a nationwide heroin shortage at that time, rather than the opening of the SIF, and the authors added:

There was no evidence that the operation of the [SIF] affected the number of heroin overdose deaths in the [area surrounding the SIF].

8. A follow-up review in 2005 (pg 23) concluded that:

It is not possible to state which specific overdose incidents at the Sydney [SIF] would have resulted in an ambulance call out or significant mortality and morbidity [death and injury] had they occurred elsewhere.
However, it is likely that a substantial proportion of overdoses managed at the Sydney [SIF] would otherwise have occurred in public. (Emphasis added).

9. A further follow-up in 2007 (pg 25) tracked overdose-related ambulance call outs in the area surrounding the SIF, and in the rest of the state of New South Wales, in the three years before, and five years after its opening.

It found that while there was a 60% decline in overdose-related ambulance call outs in the rest of New South Wales, after the opening of the SIF, that reduction was 80% in the postcode immediately surrounding the SIF.

This would seem to suggest that the opening of the SIF had some positive impact in overdose-related hospitalisation, in the immediate vicinity of the centre.

The report also found that there was a 70% decline in overdose deaths in the vicinity of the SIF, after it was opened, but that this decline was mirrored in the rest of New South Wales as well.

10. In 2008, the advisory firm SAHA International published a cost-benefit analysis of the Sydney SIF.

It estimated that the availability of the SIF prevented 25 overdose deaths per year (pg 18).

The report reached this estimate by calculating the number of injections at the SIF in 2007 (76,532).

It then took the actual rate of overdose observed at the SIF (0.54% of injections) and estimated a higher rate of overdose, in the absence of the SIF (0.654%) – due to the clean needles, dosage advice, and help with “vein care” provided at the SIF.

This yields an estimated 496 overdoses per year. It should be noted here that no overdose at the Sydney SIF has ever been fatal.

Previous research, commissioned by the National Drug and Alcohol Research Centre in Australia (pg 9), conservatively estimated that 5% of overdoses are fatal, in Australia.

It gave an alternative estimate of 10% (pg 30), but the SAHA review used the lower estimate.

Five percent of 496 is 24.8 – which is the source of the estimate that 25 overdose deaths per year are prevented by the availability of the SIF.

If we take the actual overdose rate at the SIF (0.54%, rather than the inflated estimate of 0.654%), we get 412 overdoses per year.

If 5% of those ended in death, that’s still close to 21 overdose deaths per year that could reasonably be estimated to have been prevented at the Sydney SIF.

And if we take an even lower estimated overdose fatality rate of 2%, presented elsewhere, this still yields 8 deaths per year which the availability of the Sydney SIF could reasonably be estimated to have prevented.

11. After the Sydney scheme was extended, a major 2011 review by the auditing firm KPMG pointed out that between 2001 and 2010, there had been 3,426 overdoses at the SIF, without any deaths. The report added (pg ix):

It is reasonable to assume that a proportion of these overdose-related events managed at the [SIF] would have led to overdose injury or overdose death had they occurred in another location (public place or a private dwelling) that did not have accessible medical supervision and intervention. (Emphasis added).

Discussion

Greece Drug Declaration A staff member holds a drug preparation kit at a supervised injection facility in Athens, Greece. Source: AP/Press Association Images

12. In response to our request for evidence, Mannix Flynn provided a summary of what we presume to be research published by Drug Free Australia, a group opposed to SIFs there.

(FactCheck asked Mannix Flynn to clarify the source of his evidence, but he did not do so).

It contained material related mainly to the uptake by drug users of the SIF in Sydney, the continued injection of drugs outside the SIF, and the rate of overdose in the centre.

The only piece of evidence relating specifically to drug-related deaths was this claim:

…The [SIF] could not claim to statistically save even one life per annum against an ongoing expenditure of $2.7 million in 2007.

To complicate matters slightly, the Drug Free Australia report is itself an evaluation of the 2011 KPMG review we discussed in the section above.

In brief, it argues that the KPMG review exaggerates the number of lives likely prevented by the availability of the Sydney SIF.

It argues for using the methodology employed in the EMCDDA review we addressed earlier, which assumed that a heroin user in Germany injects around twice or three times a day, and that two out of every 100 users will die of an overdose in a given year.

This means that two injections out of 100,000 will lead to a fatal overdose.

Drug Free Australia then applied this method to the figures for the Sydney SIF, where there were around 485,000 opiate (heroin) injections between 2001 and 2010.

They assumed a mortality rate of 1.095% – meaning one out of every 109,500 heroin injections will lead to a fatal overdose. Since there were 485,000 opiate injections at the SIF, this means an estimated 4.4 deaths were prevented over the course of nine years.

The first thing to say here is that, as evidence in support of the claim that SIFs “don’t reduce deaths”, this is clearly not helpful, since it still concludes that some lives were saved by the SIF.

Secondly, this method of figuring out how many injections lead to fatal overdose is contradicted by the findings of the 2008 SAHA International report, which had the benefit of using the actual number of overdoses observed at the SIF in a one-year period (2007).

We know that in 2007, there were 76,352 injections and 412 overdoses. That’s one overdose for every 185 injections. If only 2% of those overdoses is fatal, that’s 8.24 fatal overdoses – or one fatal overdose for every 9,266 injections.

The Drug Free Australia critique is based on an assumption that one out of every 109,500 heroin injections leads to a fatal overdose – which places the rate of fatal overdose 11 times lower.

This is a significant discrepancy, and resolving it is beyond the scope of this fact check.

For our purposes, it suffices to note that the evidence (apparently) cited by Mannix Flynn does not support his claim. It concludes that the Sydney SIF prevented 4.4 deaths over nine years.

Since Flynn’s claim was that SIFs don’t reduce deaths, this evidence is not helpful in supporting that claim.

Conclusion

Dublin City Councillor Mannix Flynn. Source: TV3.ie

In examining research from Europe, Australia and Canada – involving 12 pieces of evidence – we uncovered a clear pattern in support the conclusion that the setting up of supervised injection facilities does help reduce the number of drug-related deaths.

Some of the research used statistical models to quantify the number of deaths prevented, with estimates varying, and some methodology open to dispute.

Other research relied, to a certain extent, on common sense.

The fact is that, according to the research we examined, nobody has ever died of an overdose in any of the dozens of SIFs worldwide, despite millions of injections (mostly of heroin), over a period of around 25 years.

And this fact appears not to be an anomaly, or beyond explanation. The centres involve the provision of clean syringes and trained injection advice, and are specifically designed to provide medical supervision and treatment in the immediate aftermath of an overdose.

Furthermore, FactCheck did not find any evidence showing that SIFs do not bring with them a decline in drug-related deaths, nor any evidence even suggesting that they lead to an increase in such deaths.

Mannix Flynn’s claim was that supervised injection facilities “don’t reduce deaths”.

The best evidence available clearly shows that they do – however you precisely measure those deaths, and whether or not you believe they represent a good return on the cost of setting up and maintaining the centres.

We rate his claim FALSE. As our verdicts guide explains, this means: “The claim is inaccurate”.

This is the second time we’ve fact-checked a claim by Mannix Flynn. Previously, we gave him a verdict of Mostly TRUE. You can read his FactCheck File here.

Source: TheJournal.ie/YouTube

TheJournal.ie’s FactCheck is a signatory to the International Fact-Checking Network’s Code of Principles. You can read it here.

For information on how FactCheck works, what the verdicts mean, and how you can take part, check out our Reader’s Guide here.

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About the author:

Dan MacGuill

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