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Supervised injection facilities in Canada: past, present, and future Kerr, Thomas; Mitra, Sanjana; Kennedy, Mary C; McNeil, Ryan May 18, 2017

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REVIEW Open AccessSupervised injection facilities in Canada:past, present, and futureThomas Kerr1,2* , Sanjana Mitra3, Mary Clare Kennedy1,4 and Ryan McNeil1,2AbstractCanada has long contended with harms arising from injection drug use. In response to epidemics of HIV infectionand overdose in Vancouver in the mid-1990s, a range of actors advocated for the creation of supervised injectionfacilities (SIFs), and after several unsanctioned SIFs operated briefly and closed, Canada’s first sanctioned SIF openedin 2003. However, while a large body of evidence highlights the successes of this SIF in reducing the health andsocial harms associated with injection drug use, extraordinary efforts were needed to preserve it, and continuedactivism by local people who inject drugs (PWID) and healthcare providers was needed to promote further innovationand address gaps in SIF service delivery. A growing acceptance of SIFs and increasing concern about overdose havesince prompted a rapid escalation in efforts to establish SIFs in cities across Canada. While much progress has beenmade in that regard, there is a pressing need to create a more enabling environment for SIFs through amendment offederal legislation. Further innovation in SIF programming should also be encouraged through the creation ofSIFs that accommodate assisted injecting, the inhalation of drugs. As well, peer-run, mobile, and hospital-basedSIFs also constitute next steps needed to optimize the impact of this form of harm reduction intervention.Keywords: Supervised injection facilities in CanadaBackgroundCanada has long contended with health-related and socialharms associated with injection drug use. In response,municipalities throughout the country have implementeda range of harm reduction policies and programs. How-ever, support for harm reduction approaches in Canadahas been mixed and contested in various arenas, includingin the country’s highest court [1].In the mid-late 1990s, drug-related harms peaked inthe city of Vancouver. With an annual incidence of HIVinfection of 19% among local people who inject drugs(PWID), and over 300 fatal overdoses occurring in theprovince of British Columbia, Vancouver’s health author-ity declared a public health emergency [2]. A series ofevents and actions that followed eventually led to theopening of Canada’s first unsanctioned and sanctionedsupervised injection facilities (SIFs) [3]. As in other SIFsinternationally, PWID can inject pre-obtained drugsunder nurse supervision at Vancouver’s sanctioned SIFs,as well as access sterile injection equipment, receiveemergency overdose response and referrals to a range ofinternal and external programs [4]. Since this time, ef-forts to establish SIFs have persisted, numerous studieshave demonstrated the health and social benefits of SIFs,innovations in SIF delivery have occurred, and new SIFsare now being implemented throughout the country.Herein, we review the experience with SIFs in Canada,with a focus on the past, present, and future.SIFs in Vancouver: early historyIn response to the provincial overdose crisis, in 1994,the Provincial Chief Coroner of British Columbia formeda task group that produced the “Cain Report” [3].Among their recommendations was that Vancouver ex-plore SIFs given the experience with these facilities inEurope [3]. However, no immediate plans were initiatedby local health authorities to implement SIFs.In the wake of the Cain Report, interest in SIFs grewin Vancouver, particularly among local PWID. In 1995, apeer-led group, IV Feed, opened and operated an un-sanctioned drug user-run SIF known as the Back Alley* Correspondence: uhri-tk@cfenet.ubc.ca1British Columbia Centre on Substance Use, St. Paul’s Hospital, 608-1081Burrard Street, Vancouver, B.C. V6Z 1Y6, Canada2Department of Medicine, University of British Columbia, St. Paul’s Hospital,608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Kerr et al. Harm Reduction Journal  (2017) 14:28 DOI 10.1186/s12954-017-0154-1with the support of local activists Ann Livingston andBud Osborn [5]. Sign-in sheets collected at the site indi-cated that the Back Alley SIF accommodated over 100PWID each night, and accounts suggest that local streetnurses visited the site to provide support [5]. Althoughsome PWID reported having been referred to the IVFeed site by police officers, the site was closed by policeafter approximately 1 year of operation [5].Efforts to establish SIFs in Vancouver were further bol-stered in 2000–2001 when the City of Vancouver releasedits Four Pillar Drug Strategy, which was based on policymodels from Western Europe attempting to balance pre-vention, enforcement, treatment, and harm reduction [6].Included in the strategy was a call for two SIFs. AlthoughCity Council endorsed the strategy in 2001 [5], the chal-lenge remained that the City did not have responsibilityfor implementing health programs, as provinces areresponsible for healthcare administration in Canada. Still,the Four Pillar Strategy served to further ignite publicdialog and education about drug-related harm and the po-tential of SIFs as one part of a larger strategy.Around the same time, a number of public eventsfocused on drug use led to increased interest in SIFs.These events included visits from European officials withexperience with SIFs [5] and prompted one group,known as the Harm Reduction Action Society, todevelop a full proposal for a pilot SIF [7]. This groupincluded a range of stakeholders, including local PWID,activists, healthcare professionals, researchers, and fam-ilies of people who use drugs. SIFs soon after became anissue during a municipal election, with every partystating that they would implement SIFs if elected. LarryCampbell, a former Royal Canadian Mounted PoliceOfficer, was elected mayor in 2002 and promised toestablish a SIF within a month of being elected [8].However, prior to a SIF being opened, a large policecrackdown was initiated in Vancouver’s DowntownEastside (DTES). In response, local activists and PWIDopened an unsanctioned SIF to protest the crackdownand delays in opening a SIF [9]. The “327 Carrall StreetSIF” operated for 184 days, during which time the SIFvolunteers supervised over 3000 injections [10]. This SIF,like many of the other unsanctioned SIFs before it, waseventually closed due to pressure from local police andpolicy makers [10].In 2002, another important development occurredwhen nurses working at the Dr. Peter Centre begansupervising injections [11]. The Dr. Peter Centre oper-ates a day program and a residence for people livingwith HIV/AIDS. These activities of the Dr. Peter Centrewere eventually made public following a series of consul-tations with the provincial professional nursing associ-ation, the Registered Nursing Association of BritishColumbia (RNABC) [11]. Representatives from RNABCinformed the Dr. Peter Centre nurses that, in the opin-ion of the association, the supervision of injections fellwithin the scope of acceptable nursing practice even ifthose injections were of illegal substances [11]. TheRNABC also went one step further and indicated thatthe supervision of injections in a setting like the Dr.Peter Centre was part of the nurses’ ethical obligationsgiven the potential harms that could arise from unsuper-vised injections [11].Insite: Canada’s first sanctioned SIFIn September 2003, Canada’s first legally sanctioned SIFopened. This came about after a Vancouver-based non-government organization, the Portland Hotel Society(PHS), quietly built a SIF within a boarded up and seem-ingly vacant building, and then one day announced pub-licly that the SIF had been built [3]. Eventually, theregional health authority agreed to work with the PHSto open the SIF, although it is unclear how long this mayhave taken if the PHS had not taken the rather extraor-dinary measure of building the physical site in secret.Health Canada had released its SIF guideline documentshortly before this development, which set out how indi-vidual municipalities could obtain an exemption from thefederal Health Minister to legally establish a SIF [3, 5].This document laid out numerous conditions and re-quired site visits by Health Canada officials, but eventuallyInsite opened with federal approval of an exemptionunder Section 56 of the Controlled Drugs and SubstancesAct granted by the federal Health Minister. The site in-cludes 13 spaces for injecting and is usually open 18 h aday from 10 am to 4 am [12], although some experiment-ing with 24 h of operation has been undertaken.Insite was opened under the condition that it operateas a scientific pilot and be rigorously evaluated. This wasdeemed essential, especially given the limited peer-reviewed data specific to SIFs in Europe. The evaluationquickly showed that Insite was meeting its objectives ofreducing public disorder [13], infectious disease trans-mission [14, 15], and overdose [16] and was successfullyreferring individuals to a range of external programs, in-cluding detoxification and addiction treatment programs[17, 18]. Further, the evidence indicated that Insite wasnot resulting in increases in crime or promoting initi-ation into injecting [19, 20], and Insite was found to becost-effective [15, 21]. To date, over 40 peer-reviewedstudies have been published which speak to the manybenefits and lack of negative impacts of this site.Despite the success of Insite, the facility came underfire from many sides. Importantly, in 2006, in the finalyear of the three-year pilot study of Insite, Canadaelected a new Conservative government, which was pub-licly vocal in its opposition to harm reduction and Insitein particular [22]. Coinciding with this, a number ofKerr et al. Harm Reduction Journal  (2017) 14:28 Page 2 of 9groups in Canada and internationally, including theDrug Free America Foundation, The Drug PreventionNetwork of Canada, and Drug Free Australia, began pol-iticizing and misrepresenting the evidence generatedfrom the evaluation of Insite [22, 23]. This culminated inDrug Free Australia submitting a complaint to the re-searchers’ university alleging the team had engaged inacademic misconduct and falsified data. An arms-lengthinvestigation was undertaken, and the complaint wasquickly dismissed as having no merit [24].Eventually, the PHS and two local drug users (DeanWilson and Shelly Tomic) took the federal government tothe Supreme Court of British Columbia in an effort toprevent the closure of Insite [25]. The Supreme Courtjudge ruled in support of the continued operation ofInsite, recognized it as a health service, and noted that itwould be unconstitutional to deny PWID access to thislife saving service [25]. The federal government appealed,and the appeal court judges also ruled in favor of thecontinued operation of Insite [26]. Again, the federal gov-ernment appealed to the Supreme Court of Canada [27].The PHS and local PWID leading the case were supportedby a range of intervenors, including the Canadian MedicalAssociation, the Canadian Association of Nurses, and theCanadian Public Health Association [27]. The SupremeCourt justices ruled 9–0 in favor of the continued oper-ation of Insite and in their decision stated:“The Minister’s failure to grant [an exemption] toInsite…contravened the principles of fundamentaljustice…Insite has been proven to save lives with nodiscernable negative impact on the public safety andhealth objectives of Canada…(p. 139)” [27]The federal government was then granted 1 year to re-vise its policies to allow for the legal operation of SIFs inCanada. The government responded with a new bill (BillC-2), which made opening a SIF more difficult than be-fore, listing 26 conditions that had to be met before aSIF could be opened [28]. Among them, municipalitieshad to have local community support and the support oflocal police. This led many, including the CanadianMedical Association, to criticize the new bill [28], al-though the majority government was able to pass it.While Insite has continued to operate, local evidencesuggests that there is much unmet need for SIF servicesin Vancouver. Although reliable estimates of the size ofthe PWID population in Vancouver are lacking at thistime, several indicators point to the need for further SIFsin this setting. For example, it has been estimated thatbetween 30 and 40 PWID leave Insite each day withoutaccessing the injecting room due to long wait times [29].Other research has pointed to distance as a primary bar-rier to accessing Insite [30]. Further, it has been shownthat some individuals avoid the block where Insite islocated due to past experiences of violence in the imme-diate vicinity [31].SIFs in Montreal, Toronto, Ottawa, and VictoriaGiven the ongoing problems with injection drug usethroughout Canada and the experience with Insite, anumber of other municipalities across Canada beganundertaking SIF feasibility research and developing plansfor establishing SIFs; included were the cities of Montreal,Toronto, Ottawa, and Victoria [32–36]. Consistent withwork done elsewhere, SIF feasibility research suggestedthat local PWID would use a SIF, although work done inToronto suggested that, because the population of PWIDwas spread throughout the city, a greater number ofsmaller SIFs should be implemented [33]. Further, a costeffectiveness analysis recommended that three SIFs beestablished in Toronto and two be established in Ottawa[37]. A qualitative evaluation of key stakeholder opinionsin Toronto and Ottawa also identified opposition to orconcern about SIFs [38]. Specifically, seven reasons forambivalence were identified, including: “lack knowledge ofevidence about SIFs; concern that SIF goals are too nar-row…; uncertainty that the community drug problem islarge enough to warrant a SIF(s); the need to know moreabout the “right” places to locate a SIF(s) to avoid dam-aging communities or businesses; worry that a SIF(s)will renew problems that existed prior to gentrification;concern that resources for drug use prevention andtreatment efforts will be diverted to pay for a SIF(s);and concern that SIF implementation must includeevaluation, community consultation, and an explicitcommitment to discontinue a SIF(s) in the event of ad-verse outcomes” [38]. Police in Toronto also expressedconcerns regarding SIFs [39]. However, follow-up researchdemonstrated that public opinion regarding SIFs increasedover time [32]. As well in Ottawa and Toronto, emphasiswas placed on creating integrated supervised injecting ser-vices, where PWID could access additional programs andsupports [33]. Still, with a Conservative government inpower, no sustained efforts were made to create a SIF inthese settings.Drug user activismDespite the lack of an enabling environment for SIFs inCanada following the election of a Conservative govern-ment, a drug user organization in Vancouver continued toaddress gaps in service delivery and promote innovationin SIF programming. First, recognizing that the sanctionedSIF did not accommodate people who need assistancewith injections due to federal regulations, the VancouverArea Network of Drug Users (VANDU) began operating aSIF within their offices where people could get manual as-sistance with injections [40]. An evaluation of thisKerr et al. Harm Reduction Journal  (2017) 14:28 Page 3 of 9program indicated that VANDU reshaped the social,structural, and spatial contexts of assisted injection prac-tices in a manner that minimized HIV and other healthrisks, while allowing people who require help injecting toescape drug scene violence [40]. Second, VANDU also op-erated a safer smoking room for crack users, given thatindividuals who smoked crack remained vulnerable to ar-rest and violence when consuming drugs in public [41].An evaluation of the program demonstrated how a highdemand for the safer smoking room was driven by theneed to minimize exposure to policing, drug scene vio-lence, and stigma [41]. Further, the program was found tofoster harm reduction practices by reshaping the social-structural context of crack smoking and reduced the po-tential for health harms [41]. The VANDU supervisedconsumption services were closed after operating for ap-proximately 3 years following a threat from the localhealth authority to rescind the organization’s funding [42].A changing political landscapeIn October 2015, Canadians elected a new Liberal govern-ment under the leadership of Justin Trudeau, whose gov-ernment had publicly expressed support for SIFs [43].Within only a few months of taking office, Health Canadagranted a legal exemption to the Dr. Peter Centre [44],after almost 14 years of operation without an exemption.With the change in the political landscape, various muni-cipalities began planning to open SIFs.The election of the Liberal government coincided withthe emergence of opioid overdose epidemics in manyplaces in Canada. This in turn prompted calls for thefederal government to amend Bill C-2, which outlinedthe various conditions that needed to be met in order toopen a SIF [45]. After much lobbying, the governmentintroduced a new bill, Bill C-37, to replace Bill C-2 [46].The new bill replaces the 26 conditions with five condi-tions, including: demonstration of the need for such asite to exist, demonstration of appropriate consultationof the community, presentation of evidence on whetherthe site will impact crime in the community, demonstra-tion that regulatory systems are in place, and provisionof evidence that appropriate resources are in place [47].New SIF feasibility work and planningWith a new government in place that expressed supportfor SIFs, and given the emergence of the opioid overdoseepidemic, a number of municipalities began developingplans to establish SIFs, and several initiated SIF feasibil-ity research. Montreal quickly moved forward with plansto open three SIFs, and in February 2017 obtained ap-proval from the federal government to do so [48]. Pollsindicated that public support for SIFs in Montreal washigh, and all levels of government were supportive [49].Plans to open a mobile SIF have also been discussed inMontreal [49]. As well, the City of Vancouver has soughtfederal approval for several additional SIFs, including awomen- only SIF, which is expected to open in 2017[50]. Other cities with advanced plans to open SIFsincluded Victoria (one site) [51], Toronto (three sites)[52], Ottawa (one site) [53], Surrey (two sites) [54], andEdmonton (four sites, including a hospital-based site)[55]. However, support for SIFs has varied considerablyin these settings. In Ottawa, the mayor and police offi-cials have expressed strong opposition to SIFs, making anumber of statements inconsistent with the availableevidence, including the suggestion that SIFs increasecrime [56, 57]. In Victoria, citizen groups have opposedsyringe exchange and other harm reduction programs,and have expressed opposition to SIFs [58]. In Kelownaand Kamloops, public opposition to SIFs, in particularby local business associations [59], appears to haveprompted the local health authority to opt for a mobilerather than fixed SIF in each of these municipalities, asgaining acceptance for any specific permanent locationfor fixed SIFs proved too difficult [60].A number of other jurisdictions in Canada also beganconducting SIF feasibility research in the wake of thechange in the federal government. These included small,mid, and more remote municipalities, including inLondon and Thunder Bay [61–63]. Consistent with re-sults generated elsewhere, these studies found high ratesof willingness to use a SIF among local PWID, includingamong those at high risk for drug-related harms, as wellas high levels of key stakeholder support [64]. Discus-sions about SIF feasibility research and establishing SIFshave occurred in other cities, including Hamilton, Chilli-wack, Calgary, and Saskatoon [61, 65–67].The fentanyl overdose crisis—overdose prevention sitesAlthough a number of settings in Canada have been con-tending with opioid overdose epidemics for some time,the emergence of illicitly manufactured fentanyl—apowerful opioid that has been found in more commonlyinjected drugs such as heroin—has made the situationworse [68]. For example, the province of British Columbiasaw 922 illicit drug overdose deaths in 2016, a 78% in-crease over 2015, with a growing number of overdosesinvolving fentanyl [69]. This situation prompted the gov-ernment of British Columbia to declare a public healthemergency [69].In Vancouver’s DTES, in response to the rapidly in-creasing number of deaths, local activists including AnnLivingston and Sarah Blythe erected a tent with tableswhere people could sit and inject or smoke drugs undersupervision and receive emergency overdose response asneeded [70]. During this time, line ups at the local sanc-tioned SIF became long and the program was unable tomeet demand. The so-called “pop-up safe injection site”Kerr et al. Harm Reduction Journal  (2017) 14:28 Page 4 of 9was tolerated by local health officials and police, and intime, other pop-up SIFs started to emerge in other settingsin the province, including in Nanaimo [71]. This low-threshold SIF model, while not providing the level of orintensity of support offered at Insite, was well-utilized,and many overdoses were reversed at this site [72].After calls on the federal government to declare anemergency failed, the Health Minister of British Columbiainstructed various regional health authorities to open whathave become known as “overdose prevention sites” (OPSs)[73]. At these sites, PWID are provided with sterile equip-ment for injection in a closed indoor setting, and staff(unusually non-nursing staff ) provides emergency re-sponse in the event of overdose. The motivation for mak-ing a distinction between SIFs and OPSs may reflectsubtle differences in service design, as well as the ongoingneed for federal approval to open a sanctioned SIF andfrustration with the time it takes to acquire such approval.Within a couple of days, three new OPSs opened in theDTES, including one in the office of VANDU, which con-stituted the first sanctioned peer-run model in Canada[74, 75]. These OPSs differ from Insite in several ways.Importantly, the sites are designed primarily to preventoverdoses, do not employ nurses, and offer a lower levelof clinical intervention around safer injecting practice andother issues (e.g., diagnosis and treatment of soft tissue in-fections). The OPSs are also simpler in physical layout,often as a result of their rapid integration into existingspaces rather than implementation within purpose-builtfacilities. However, sterile injecting supplies are provided,injections are supervised, and naloxone is administered inthe event of overdose. As the overdose epidemic contin-ued to rage on, more OPSs opened in Vancouver andthroughout the rest of the province, including in Victoria[76]. At this time, there are approximately 18 OPSs oper-ating in the province of British Columbia [73]. The City ofVancouver has also sought federal approval for a women-only SIF, which is expected to open in 2017 [50].DiscussionEfforts to establish SIFs in Canada have persisted sincethe mid-1990s and were undertaken primarily in re-sponse to under-addressed epidemics of HIV infectionand overdose [5]. Although a sanctioned SIF opened in2003 [77], the value of SIFs remained contested, leavingCanada’s lone SIF in perpetual pilot status for over adecade. Continued activism by local PWID and nursesled to further innovations in SIF programming [11, 40],changes in the federal government created a more en-abling environment, and numerous municipalities havesince moved towards opening SIFs. Although progresshas been made towards making SIFs a component withinthe continuum of services offered to PWID, these sitesremain difficult to establish, and opportunities to extendthis model and promote innovation have been missed.The opening of Canada’s first sanctioned SIF resultedfrom the actions taken by a diverse group of communityactors (e.g., activists, researchers, health care profes-sionals), including targeted and sustained civil disobedi-ence by PWID and their allies [3, 5]. This experience isconsistent with the establishment of harm reduction pro-gramming elsewhere in Canada and internationally, as in-jection drug-using populations and other communityactors have circumvented bureaucratic and legal processesto implement innovative programs to reduce social suffer-ing among injection drug-using populations [78–80] Suchcommunity organizing and drug user activism proved fur-ther necessary to sustain Insite when its operator (PHSCommunity Services) and two persons who inject drugs(Dean Wilson, Shelly Tomic) preemptively sued to keepthe facility open after the then-Conservative federal gov-ernment appeared positioned to withhold annual exemp-tions for the facility. As noted, along with the extensiveresearch evidence, this was critical to the ruling that en-abled continued operation of Insite.Despite this landmark ruling, political opposition con-tinues to be the most significant barrier to the expansionof SIFs in Canada [22] Although provinces are respon-sible for the administration of health care in Canada, therequirement that SIFs receive exemptions to federal druglaws has subjugated local efforts to implement these crit-ical health services to the whims of municipal, provin-cial, and federal politicians, as successive governmentshave varied in their positions on SIFs, and the require-ment of local support has at times been difficult to ob-tain. The previous Conservative federal government(2006–2015) opposed their operation and defied thespirit of the Supreme Court of Canada ruling by passingnew legislation that erected considerable barriers to theirexpansion, including the requirement of approval bylocal police. The more recently elected Liberal govern-ment (2015–present) has signaled support for the expan-sion of SIFs and since introduced new legislationrepealing some of the more burdensome requirementsof the previous legislation, which has prompted citiesacross Canada to more aggressively pursue establishingSIFs [46]. However, under this new legislation, the fed-eral government will maintain responsibility for theapproval of new facilities and there remains a need todemonstrate a lack of impact on crime [19], thus con-tinuing to subject the expansion of these critical healthservices to political processes.It is unclear why so many bureaucratic requirements(e.g., police approval) must still be met to implementSIFs, and why health officials cannot simply implementSIFs where there is a demonstrated need without obtain-ing support from other stakeholders [28]. This in partKerr et al. Harm Reduction Journal  (2017) 14:28 Page 5 of 9reflects a longstanding over-emphasis on enforcement-based approaches despite pronouncements by federalpoliticians that drug use should be regarded first andforemost as a health issue [81, 82]. The internal incon-sistency between such official statements, policies, andactions represent an unfortunate and unnecessary bar-rier to the expansion of SIFs as Canada grapples with anopioid overdose crisis. Although British Columbia hasrapidly implemented low-threshold SIFs under the labelof “overdose prevention sites” in response to a publichealth emergency [73], these actions could be inter-preted to contravene federal drug laws. Specifically, anexemption from the federal Minister of Health is re-quired to operate a health service where people consumeillicit drugs. Further legislative changes are needed toaddress the internal inconsistencies of the current legis-lation and more fully equip health officials with the toolsto rapidly implement and scale-up supervised injectionfacilities in response to localized overdose and infectiousdisease outbreaks.Along with changes to approval processes under fed-eral legislation, there remains a need to revisit the oper-ating procedures of supervised injection facilities toensure their optimization for injection drug-using pop-ulations, particularly highly vulnerable sub-populations.Most notably, under the parameters of federal druglaws and guidelines, sanctioned SIFs are unable to ac-commodate people who require manual assistance withinjections. Previous research has shown that up to onethird of PWID in Vancouver report requiring assistancewith injections, including a disproportionate number ofwomen [83], and that requiring assistance with injec-tions increases vulnerability to HIV infection, overdose,and violence [84–86]. However, as demonstrated by thepeer-run and unsanctioned SIF operated by VANDU,assisted injections administered in a regulated settingand in accordance with harm reduction practices canreduce these risks [40]. A further opportunity to alignSIFs with the needs of drug-using populations wouldinvolve the addition of safer smoking rooms (SSRs) soas to accommodate individuals who inhale drugs, suchas crack, methamphetamine, and heroin. While theseinterventions exist in some European settings and havebeen well accepted by those who inhale drugs, there areno sanctioned SSRs in Canada at this time [87], despitepast feasibility research showing that a majority ofcrack smokers would be willing to use them [88]. Re-forms are urgently needed to facilitate the integrationof assisted injection and safer smoking interventionsinto SIFs and reduce challenges in access to these facil-ities stemming from gender, disability, and polysub-stance use.Furthermore, current gaps in coverage of supervisedinjection facilities point to the need to extend thisevidence-based intervention into new settings andconsider new approaches. For example, there is agrowing body of literature regarding the challengesassociated with in-hospital drug use, as well ascurrent abstinence-focused hospital policies in drivingdischarges from hospital against medical advice [89].Previous feasibility research has demonstrated a highwillingness to use hospital-based supervised injectionfacilities among PWID [90], while qualitative researchin a 24-h palliative and supportive care program withsupervised consumption services demonstrated howthis approach improves retention in care and mini-mizes drug-related risks [91]. While Edmonton hassignaled its intention to open a hospital-based SIF,further steps are needed in other cities to extend thisprogramming into hospital settings [55]. To morefully respond to the opioid overdose crisis, there iscause to further explore integrating supervised injec-tion facilities into other settings where PWID com-monly use drugs and experience overdoses and otheradverse outcomes (e.g., emergency and social housing)and complementing fixed-site SIFs with mobile ser-vices to expand geographic coverage and ensure re-sponsiveness to changing drug scene dynamics.Finally, while SIFs have been primarily advanced asa health care service in Canada, the successes ofpeer-run SIFs point to the need to consider de-medicalizing these interventions through direct sup-port for peer-based models. Although several peer-runoverdose prevention sites are currently operating inBritish Columbia as part of the province’s response tothe overdose crisis, federal regulations currently pro-hibit the establishment of peer-run SIFs [40]. Theassumption that SIFs must be operated by health careprofessionals is at odds with previous studies demon-strating the feasibility and acceptability of peer-runsupervised consumption services, and their role in re-ducing drug-related risks and harms. Not only havePWID in some cases expressed a strong preferencefor peer-run SIFs [92], but these have been also foundto be uniquely positioned to extend coverage by en-gaging those who encounter social-structural barriersto accessing sanctioned interventions [40]. Buildingon the successes of these approaches represents oneof the most promising ways to harness peer networksand community expertise to respond to the opioidcrisis. To facilitate the creation and continued func-tioning of peer-run SIFs, amendments to federal lawsshould be made to allow PWID to work in SIFs. Fur-ther, local health authorities should seek to promotethe operation of peer-run SIFs and provide necessaryfinancial support given existing evidence indicatingthat peer-run SIFs extend the reach and coverage ofthese programs [40].Kerr et al. Harm Reduction Journal  (2017) 14:28 Page 6 of 9ConclusionsIn conclusion, our review of Canada’s experience withSIFs demonstrates that although considerable progresshas been made towards integrating this form of inter-vention into the continuum of programs offered toPWID, continued activism, research advocacy, and litiga-tion has been necessary in order to advance thisevidence-based approach in Canada. Presently, increasedacceptance of SIFs as a result of Canada’s overdose crisisand political changes has led to the rapid escalation ofefforts to expand SIFs across the country. Notwithstand-ing the importance of these developments, there remainsa pressing need to amend federal legislation to betterenable the scale-up of these services. Although in manysettings, such as Vancouver, access to a range of servicessuch as SIF and naloxone distribution has increased [93],the ongoing overdose crisis indicates clearly that moremust be done [69]. Further, models that are more respon-sive to the needs of PWUD (e.g., assisted injection ser-vices, peer-run models) should be implemented andevaluated, and SIF programming should be extended intonew settings (e.g., hospital). Only then will Canada betruly maximizing the many opportunities for supervisedinjection facilities to reduce harm and health inequities.AbbreviationsDTES: Downtown Eastside; OPS: Overdose prevention sites; PHS: PortlandHotel Society; PWID: People who inject drugs; RNABC: Registered NursingAssociation of British Columbia; SIFs: Supervised injection facilities; SSRs: Safersmoking rooms; VANDU: Vancouver Area Network of Drug UsersFundingThis work was supported by Canadian Institutes for Health Research FoundationGrant (FDN-148476).Availability of data and materialsNot applicable.Authors’ contributionsTK, SM, and RMcN conducted the review of relevant literature. TK and RMcNcompleted the first draft of the article, while SM and MCK provided feedbackon the draft and contributed new text to the final draft. All authors read andapproved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Consent for publicationNot applicable.Ethics approval and consent to participateNot applicable.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1British Columbia Centre on Substance Use, St. Paul’s Hospital, 608-1081Burrard Street, Vancouver, B.C. V6Z 1Y6, Canada. 2Department of Medicine,University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street,Vancouver, BC V6Z 1Y6, Canada. 3Ontario HIV Treatment Network, 1300Yonge Street, Suite 600, Toronto, ON M4T 1X3, Canada. 4School ofPopulation and Public Health, University of British Columbia, 5804 FairviewAvenue, Vancouver, BC V6T 1Z3, Canada.Received: 20 March 2017 Accepted: 8 May 2017References1. Small D. 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Accessed 12 May 2017.•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Kerr et al. Harm Reduction Journal  (2017) 14:28 Page 9 of 9

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