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A cost-benefit/cost-effectiveness analysis of an unsanctioned supervised smoking facility in the Downtown… Jozaghi, Ehsan; Vancouver Area Network of Drug Users Nov 13, 2014

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RESEARCHA cost-benefit/cost-effectierinneUs[1-4]. In British Columbia, the daily usage of crack cocainewithin the general population is higher than that in anyexperience multiple health problems [5], and are less likelyto access social and health services [15].Jozaghi Harm Reduction Journal 2014, 11:30http://www.harmreductionjournal.com/content/11/1/30infection is ambiguous. Some researchers have suggestedBurnaby, British Columbia V5A 1S6, CanadaFull list of author information is available at the end of the articleother provinces within Canada [5]. This is a pressing prob-lem in Vancouver, where daily crack use, within a cohortof injection drug users, increased from 7.4% in 1996 to42.6% in 2005 [6]. Among drug users in Vancouver’sDowntown Eastside (DTES), the rate of crack use hasbeen reported to be as high as 86.6% [7]. The use of crackResearch conducted upon a cohort of crack-userpopulation in Vancouver’s DTES revealed that partici-pants had reported 80% sharing rate as it is related totheir drug smoking paraphernalia [16,17]. Studies haveshown a higher-than-average prevalence of human im-munodeficiency virus (HIV), hepatitis C virus (HCV),and tuberculosis in users of crack cocaine who report noinjection drug use [17]. However, the evidence of the rela-tionship between non-injecting drug use and HIV/HCVCorrespondence: eja2@sfu.ca1School of Criminology, Simon Fraser University, 8888 University Drive,costs incurred for health-care services as a direct consequence of not having such a program in Vancouver, Canada.Methods: The data pertaining to the attendance at the SSF was gathered in 2012–2013 by VANDU. By relying onthis data, a mathematical model was employed to estimate the number of HCV infections prevented by the formerfacility in Vancouver’s Downtown Eastside (DTES).Results: The DTES SSF’s benefit-cost ratio was conservatively estimated at 12.1:1 due to its low operating cost. Thestudy used 70% and 90% initial pipe-sharing rates for sensitivity analysis. At 80% sharing rate, the marginal HCVcases prevented were determined to be 55 cases. Moreover, at 80% sharing rate, the marginal cost-effectivenessratio ranges from $1,705 to $97,203. The results from both the baseline and sensitivity analysis demonstrated that theestablishment of the SSF by VANDU on average had annually saved CAD$1.8 million dollars in taxpayer’s money.Conclusions: Funding SSFs in Vancouver is an efficient and effective use of financial resources in the public healthdomain; therefore, Vancouver Coastal Health should actively participate in their establishment in order to reduce HCVand other blood-borne infections such as HIV within the non-injecting drug users.Keywords: Supervised smoking facility, Crack, VANDU, Hepatitis C, Downtown EastsideBackgroundSmoking crack cocaine is not only on the rise in theCanadian municipalities, but it is also often neglected byhealth officials—especially so when compared to similarinner-city health problems such as injection drug useis associated with several other risks when compared tothe tendencies displayed by other drug-using populations.For example, crack users are more likely to have unstablehousing [8], be involved in sex work [9], participate inrisky behavior [10-12], engage in criminal activity [13,14],unsanctioned supervisedDowntown Eastside of VaEhsan Jozaghi1 and Vancouver Area Network of Drug UsAbstractBackground: Smoking crack involves the risk of transmittcurrent study determines whether the formerly unsanctiograssroot organization, Vancouver Area Network of Drug© 2014 Jozaghi; licensee BioMed Central Ltd.Commons Attribution License (http://creativecreproduction in any medium, provided the orDedication waiver (http://creativecommons.orunless otherwise stated.Open Accessveness analysis of ansmoking facility in thencouver, Canadas2g diseases such as HIV and hepatitis C (HCV). Thed supervised smoking facility (SSF)—operated by theers (VANDU) for the last few years—costs less than theThis is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andiginal work is properly credited. The Creative Commons Public Domaing/publicdomain/zero/1.0/) applies to the data made available in this article,Jozaghi Harm Reduction Journal 2014, 11:30 Page 2 of 8http://www.harmreductionjournal.com/content/11/1/30that non-injecting drug users (NIDUs) are often in-volved in unsafe sexual behavior [18] and that HCVtransmission in NIDUs is associated with tattooing [19].Some researchers have stirred up a controversy in sug-gesting that NIDUs are essentially injecting drug users(IDUs) who have failed to report their route of trans-mission accurately [20].Nevertheless, research conducted on NIDUs suggeststhat infectious diseases may have been transmitted bythe sharing of crack pipes [21,22]. In fact, most users areoblivious to the risks involved in sharing drug tools [21].Some researchers postulate that HIV and HCV transmis-sion can be accounted for by the high prevalence of orallesions in crack smokers. Some of these include sores,blisters, and cuts on their lips and oral cavities—causedbecause of the mouth and lips coming in contact withhot glass, hot smoke, and the sharp edges of glass pipestems or metal pipe stems [21]. The lack of knowledgewith respect to transmittable diseases further engendersand reinforces the reckless exchange of drug equipment.In fact, a study demonstrated that 2% of crack pipestested positive for HCV [23].Scientific evaluation of Insite, North America’s firstand only supervised injection facility, showed that it hassuccessfully reduced needle sharing and overdose deathwhile concurrently improving service uptake and publicorder within the DTES [24-26]. Despite the improve-ment of conditions in the DTES after the opening ofInsite, Vancouver is still riddled with concerns regardingpublic health and order related to drug use, includingcrack and crystal methamphetamine [27,28]. Accordingly,the region’s health authority has shown some interest inapplying for an exemption under the Controlled and Sub-stance Act of the Criminal Code of Canada to open a su-pervised smoking facility (SSF) in the DTES. However, theconcept of a government-sanctioned SSF is somewhatcontroversial, particularly because the potential impactand benefits of such a facility are unknown.Therefore, the present research was conducted to deter-mine whether a case could be made for the establishmentof SSFs in the DTES of Vancouver. Specifically, the currentstudy analyzed the cost-benefits and cost-effectiveness ofthe only SSF in Canada, operated by Vancouver AreaNetwork of Drug Users (VANDU) without a license fora few years. The SSF mentioned above was located inVANDU’s front office in the DTES, along East HastingsStreet. VANDU has over 800 volunteers, 1,300 activemembers [29], and a Board of Directors composed ofcurrent and former users. See Figure 1 for the locationof VANDU in the DTES.In December of 2013, VANDU was forced to shutdown the SSF under the direction of their fundingagency, the Vancouver Coastal Health. Using mathemat-ical modelling with conservative parameter estimates,this analysis estimated the number of HCV infectionsprevented as a result of SSF. The savings from illnessesavoided were compared to the operational cost of a SSF.The analysis was eventually extended to consider theimpact of opening additional SSFs in the DTES.MethodsBackgroundVANDU operates on an annual budget of CAD$200,000funded through Vancouver Coastal Health. One of theirvarious programs included the operation of an unsanc-tioned SSF. The smoking room was operated by peersand was accessible to one person at a time. There wouldbe an unusually big lineup to use the room that con-tained a fan. Within VANDU, NIDUs would generally beprovided with a ‘safer crack use kit’ that contained thefollowing: mouth pieces, wooden push sticks, screens, al-cohol swaps, and heat-resistant and shatter-proof glasspipes which minimized chances of injury to the users’lips and mouth. See Figure 2 for materials contained inthe ‘safer crack use kit’ provided at VANDU.Moreover, VANDU’s SSF provided a clean and safe en-vironment within which one could use pre-obtained illicitdrugs, get medical attention in the event of an over-dose, and obtain access or referral to primary healthcare when required. This study was approved by SimonFraser University Research Ethics Board (study number:2013 s0058). VANDU’s Executive Board also approved thestudy since it corresponded with its philosophy and thedemand that all projects directly involve its members.ModelFor this analysis, it was necessary to calculate the effectsof both providing clean equipment as well as that ofadopting safer smoking behaviors. Along the lines of re-search conducted on the economic impact of a needleexchange program in Edmonton, Alberta, Canada, thisstudy uses a mathematical model to estimate the num-ber of HCV infections that could be prevented throughthe establishment of a SSF [30]. The number of newHIV infections avoided, A, is calculated as follows:A ¼ INsd 1− 1−qtð Þm½ ;where m is the number of sharing partners when pipesare shared, t is the probability of HCV transmission whenusing an HCV-infected pipe, s is the rate of pipe sharing, Iis the proportion of NIDU population that is HCV nega-tive, N is the number of pipes in circulation, d is the per-centage of pipes not cleaned before use, and q is theproportion of the NIDU population that is HCV positive.Initially, this study was meant to use a few other math-ematical models such as those of Kaplan and O’Keefe [31],Lurie and Drucker [32], Gold et al. [33], Laufer [34], andJozaghi Harm Reduction Journal 2014, 11:30 Page 3 of 8http://www.harmreductionjournal.com/content/11/1/30Pinkerton [35,36]. However, due to lack of data, such asthe rate of HIV transmission from a single pipe and therate of secondary transmission, this analysis had to rely onthe Jacobs et al. [30] model. However, the model employedin the current study has previously been adopted by fourdifferent studies [37-40], which have found that thismodel is the best choice for predicting actual and po-tential cases of HIV and HCV in a Canadian setting.Moreover, the model employed in this study has suc-cessfully produced estimates of HIV and HCV caseswithin the IDU population—similar to known datawidely cited in peer-reviewed reports.Additionally, this study also uses behavior change in-corporated by previous costing studies conducted onFigure 1 Map of the DTES.supervised injection facilities [37-41] because of the em-pirical evidence it provides [24,35,41,42]. Although pre-vious costing studies often go wrong when it comes tousing caution and employing an odd ratio of 0.60, thisstudy uses the point estimate of 0.30 used by previousstudies [37-42] and estimated by Kerr et al. [24]. Thedata collected by VANDU during 2012–2013 pertains tothe number of visits per month to the SSF.Variables and parametersMedical and scientific literatures were used in cases whenVancouver-specific data was not available. Where estimatesdiffered, this study used the lower bound, so all estimatesremain conservative. The concept of behavioral change inJozaghi Harm Reduction Journal 2014, 11:30 Page 4 of 8http://www.harmreductionjournal.com/content/11/1/30the NIDU population was adopted based on the behav-ioral changes related to IDU needle-sharing behavior out-side of the SIF in Vancouver. Kerr et al. [24] and Bravoet al. [43] found that IDUs who relied upon SIFs were alsoable to reduce their needle-sharing activities outside of thefacility up to a significant extent. Table 1 provides the esti-mates and variables used in the model (please note thatpercentages need to be converted to fractions when im-puting the variables in the model).Consequently, it was presumed that NIDUs that vis-ited the unsanctioned SSF were less likely to share theirpipes with others outside of the facility. Furthermore, ifa second SFF was established, the behavioral change onpipe sharing would occur only if new NIDUs became usersof SSF [28]. On the contrary, if the SSF was frequented bythe current users, thereby restricting its use to currentFigure 2 Content materials of a ‘safer crack use kit’ providedat VANDU.users simply indulging in some additional smoking, no fur-ther behavioral changes can be assumed. Accordingly, be-havioral change is only accounted for in the second facility.Table 1 Sources for variables used in mathematicalmodellingVariable Value SourceRate of pipe sharing (s) 80.0% Ivsins et al. [44]Number of pipes incirculation (N)90,000 VANDU [45], Mui [46]Percentage of pipesnot cleaned (d)33.0% Scheinmann et al. [47]Number of sharing partners (m) 6.30 Gyarmathy and Neaigus [48]Proportion of crack users whoare HCV negative (I)83.0% Fischer et al. [49]Proportion of crack users whoare HCV positive (q)17.0% Fischer et al. [49]Probability of HCV infectionfrom single crack pipe (t)2.00% Fischer et al. [23],Gilbert et al. [50]Furthermore, since there was no estimated number ofcrack users in the DTES of Vancouver, this number wascalculated based on the percentage of drug users (con-servatively estimated to be around 5,000 in the DTES[51-53]) who have smoked crack. The total number ofdrug users was reported by DeBeck et al. [7] to be 86.6%(5,000 drug users × 0.866 use crack = 4,330 crack usersin the DTES). This number was subsequently multipliedby the number of subjects who smoked crack per day—estimated to be around ten per day [54,55] (4,330 × 10 ×365 days =15,804,500 smoking per year).The number of those indulging in smoking per yearwas multiplied by the percentage of pipe sharing in theDowntown Eastside (15,804,500 smoking per year × 0.80sharing = 12,643,600 shared crack smoking events). Thetotal visits to the SSF during 2012–2013 year were deter-mined to be 23,120 per year with the average visit of1,843 per month. Consequently, 17,696 smoking incidentswere not shared as a result of having an unsanctioned SSFoperating in the DTES (23,120 × 0.8 sharing =17,696smoking events that were not shared). This number wasadded to the behavioral change odd ratio and laterdeducted from the total shared crack pipe events inthe DTES.The medical cost of new HCV casesHCV infection among people who use drugs is a seriouspressing concern in Canada and the United States[56,57]. HCV infections could lead to multiple healthproblems such as cirrhosis, liver failure, hepatocellularcarcinoma, and even death [58]. Accordingly, 50% of pa-tients achieve sustained virological success to treatment[59]. Pegylated interferon, in combination with ribavirin,is the standard course of treatment for HCV-infected pa-tients [57]. The range of treatment for HCV patients isdetermined based on the genotype: ‘a 48-week course isrecommended for genotypes 1 and 4, whereas a 24-weekcourse is recommended for genotypes 2 and 3’ [57], p.1016. Accordingly, the cost of treatment varies accordingto genotype and seriousness of infections.On an average, savings from HCV range from $20,000per completed course of treatment per patient [60],to $30,000 [61], and to more than $69,188 [58]. Thisstudy uses a conservative figure of CAD$35,143 (2012US Dollars = 33,856), as reported in [62] and utilized incosting studies of a potential SIF in Montreal [39] andOttawa [40]. The conservative figure used in this studyessentially disregards the cost of the complications aris-ing from HCV in hepatocellular carcinoma, liver failure,and liver transplant cases.Cost of SSFIn order to estimate the cost of operating a potentialSSF, it was important to calculate the operating cost ofTable 2 The cumulative cost-effectiveness and cost-benefit of SSF in Vancouver using Jacobs et al.’s [30] modelVariables Annual cost of operation ($) Sharing rate (%) # of HCV averted Cost-effectiveness ratio HCV ($) Cost-benefit ratio HCVPost SSF 97,203 69 57 1,705 20.6(78, 60) (65, 50) (1,495, 1,944) (23.5, 18.1)Two SSF 194,406 59 109 1,784 19.7(67, 52) (121, 93) (1,607, 2,090) (21.9, 16.8)Three SSF 291,609 58 110 2,651 13.3(67, 52) (121, 94) (2,410, 3,102) (14.6, 11.3)Four SSF 388,812 58 111 3,503 10(67, 52) (122, 94) (3,187, 4,136) (11, 8.5)Five SSF 486,015 58 112 4,339 8.1(67, 52) (123, 95) (3,951, 5,116) (8.9, 6.9)Six SSF 583,218 57 113 5,161 6.8(66, 52) (124, 95) (4,703, 6,139) (7.5, 5.7)Seven SSF 680,421 57 114 5,969 5.96)shJozaghi Harm Reduction Journal 2014, 11:30 Page 5 of 8http://www.harmreductionjournal.com/content/11/1/30the existing SSF in the DTES. The former facility oper-ated from Monday to Friday from 10–7 pm. On week-ends, the facility would operate from 4–7 pm. The staffsupervising the unsanctioned SSF were mostly volunteersthat were provided with a small stipend, collectivelyamounting to CAD$47,203 per year. The total cost of therent and the safe crack kit is estimated to be CAD$50,000.Altogether, the operating cost of the facility is estimated tobe CAD$97,203.ResultsThe model used here [26] predicted the number of new(66, 52) (124, 9The numbers in parentheses represent the results of the sensitivity analysis (90%HCV cases prevented based on the pipe-sharing rate. Thisincluded the impact of behavioral changes in pipe sharingTable 3 The marginal cost-effectiveness and cost-benefit of SVariables Annual cost of operation ($) Sharing rate (%) # of HCVPost SSF 97,203 69 57(78, 60) (65, 50)Two SSF 97,203 59 52(67, 52) (56, 43)Three SSF 97,203 58 1(67, 52) (1, 1)Four SSF 97,203 58 1(67, 52) (1, 0.5)Five SSF 97,203 58 1(67, 52) (1, 0.5)Six SSF 97,203 57 1(66, 52) (1, 0.5)Seven SSF 97,203 57 1(66, 52) (1, 0.5)The numbers in parentheses represent the results of the sensitivity analysis (90% shoutside of the SSF. The behavioral change, according toTables 2 and 3, was only considered twice—once for thefirst SSF and once for the second SSF—based on a conser-vative odd ratio that falls within the limit specified by [31].As expected, the results presented in Tables 2 and 3show that expanding SSFs would decrease HCV cases.The model predicts 57–114 cases for HCV with themarginal range being much smaller at 1–57 for HCV.This range disparity, as outlined in Tables 2 and 3,translates into substantial differences between the cu-mulative estimates and the marginal estimates. For ex-ample, according to Table 2, the benefit-cost ratio(5,487, 7,088) (6.4, 5)aring rate, 70% sharing rate).ranges from 5.9 to 20.6 and the cost-effectiveness valueranges from $1,705 to $5,969 (cost per lifetime treatment).SF in Vancouver using Jacobs et al.’s [30] modelaverted Cost-effectiveness ratio HCV ($) Cost-benefit ratio HCV1,705 20.6(1,495, 1,944) (23.5, 18.1)3,739 18.8(1,736, 2,261) (20.2,15.5)97,203 0.4(97,203, 97,203) (0.4, 0.4)97,203 0.4(97,203, 194,406) (0.4, 0.2)97,203 0.4(97,203, 194,406) (0.4, 0.2)97,203 0.4(97,203, 194,406) (0.4, 0.2)97,203 0.4(97,203, 194,406) (0.4, 0.2)aring rate, 70% sharing rate).Jozaghi Harm Reduction Journal 2014, 11:30 Page 6 of 8http://www.harmreductionjournal.com/content/11/1/30In contrast, the marginal estimates of SSF expansion trans-late into a much smaller return. This is particularly true withrespect to its benefit-cost and cost-effectiveness ratio; for in-stance, the marginal benefit-cost ratio varies from 20.6 to0.4. The marginal cost-effectiveness value for HCV rangesfrom $1,705 to $97,203 (cost per lifetime treatment). Fur-thermore, Table 3 shows that both cumulative benefit-costand cost-effectiveness ratios dwindle after the second SSF.Finally, a sensitivity analysis was conducted for themodels employed. The sensitivity analysis pertained tosimulating different pipe-sharing rates (see Tables 2 and 3).Similar to costing studies in Vancouver [37,38], Montreal[39], and Ottawa [40] that used different needle-sharingrates, the current analysis used 70% and 90% initialpipe-sharing rates. Convincingly, the results from boththe baseline and sensitivity analysis demonstrate thatthe establishment of an SSF by VANDU had saved tax-payer money.DiscussionThe current analyses assessed whether the former SSF,operated by VANDU in the DTES, would have had a netpositive fiscal impact on the Canadian society andwhether or not this policy initiative would save publichealth-care funds by averting new HCV infections.Moreover, the optimal number of SSFs was assessed basedon marginal cost-effectiveness and benefit-to-cost ratios.The results presented here suggest that closing the onlyunsanctioned SSF in Vancouver was a policy failure thathas potentially resulted in the spread of HCV within thedrug-user population. In fact, establishing more SSFs inVancouver’s DTES would be a beneficial and fiscally re-sponsible in addition to the publically funded health-caresystem. Based on the marginal counts, it should be notedthat although expansion beyond the second SSF locationmay not provide the same economic return as the cumula-tive estimates, it may still be considered cost-effectivegiven that the cumulative result was cost-effective beyondthe seventh potential location.Though not outlined in this analysis, there are severalother benefits of opening a SSF that may add to theexisting financial benefits of a SSF. One such benefit isthe lowering of the risk of overdose, particularly forthose smoking heroin and methamphetamine [63]. InBritish Columbia alone, 14 deaths have been attributedto heroin smoking [27]. Given the medical supervisionof NIDUs, SSF has the potential to mitigate the risk ofoverdose deaths.Another benefit of opening a SSF is the potential to in-crease detoxification and reduce risk behavior througheducation. Research indicates that NIDUs will changetheir risk behavior when provided with appropriate edu-cation and treated with care [27]. Moreover, IDUs thatregularly use the Vancouver’s Insite are more likely toinitiate and maintain addiction treatment [4]. By visitinga SSF, people who use drugs may utilize various servicessuch as mental health, counselling, and detoxification.Furthermore, SSFs can be expected to reduce publicdrug use in the same way that Vancouver’s Insite hasbeen able to reduce public drug-use behavior of IDUs.In summary, not only on the use of crack among drugusers is on the rise but also the sharing of crack pipehas been increasing at an alarming rate in Vancouver.With recent research demonstrating the significant riskof disease transmission via oral smoking equipment, thecurrent study determined whether the former unsanc-tioned SSF operated by the grassroot organization,VANDU, would cost less than the health-care conse-quences of not having such a program in Vancouver.The results indicated that the former facility not onlysaved taxpayers’ money but also deserved to be ex-panded instead of being forced to shut down. This in-formation and analysis should be useful for policymakers who seek to find practical, cost-effective solu-tions to serious health-care problems in a climate ofscarce public resources.AbbreviationsVANDU: Vancouver Area Network of Drug Users; DTES: Downtown Eastside;SSF: supervised smoking facility; HCV: hepatitis C; IDU: injecting drug user;NIDU: non-injecting drug user; HIV: human immunodeficiency virus.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsVANDU collected the data. EJ conducted the analysis and wrote the results,discussion, conclusion, and the references. Both authors (VANDU executiveboard) read and approved the final version of the paper.AcknowledgementsWe would like to thank Mr. Hugh Lampkin (president of VANDU) for hiscontribution to the study.Author details1School of Criminology, Simon Fraser University, 8888 University Drive,Burnaby, British Columbia V5A 1S6, Canada. 2380 East Hastings Street,Vancouver, British Columbia V6A 1P4, Canada.Received: 4 July 2014 Accepted: 3 November 2014Published: 13 November 2014References1. Werb D, DeBeck K, Kerr T, Li K, Montaner J, Wood E: Modelling crackcocaine use trends over 10 years in a Canadian setting. Drug Alcohol Rev2010, 29:271–277.2. Haydon E, Fischer B: Crack use as a public health problem in Canada callfor an evaluation of ‘safer crack use kits’. Can J Public Health 2005,96:185–188.3. Fischer B, Manzoni P, Rehm J: Comparing injecting and non-injecting illicitopioid users in a multisite Canadian sample (OPICAN cohort). Eur AddictRes 2006, 12:230–239.4. 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Smith C: Baffling brain ailment hits heroin smokers, The Georgia Straight; 2004.http://www.straight.com/news/baffling-brain-ailment-hits-heroin-smokers.doi:10.1186/1477-7517-11-30Cite this article as: Jozaghi: A cost-benefit/cost-effectiveness analysis ofan unsanctioned supervised smoking facility in the Downtown Eastsideof Vancouver, Canada. Harm Reduction Journal 2014 11:30.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionJozaghi Harm Reduction Journal 2014, 11:30 Page 8 of 8http://www.harmreductionjournal.com/content/11/1/30Submit your manuscript at www.biomedcentral.com/submit

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