"Respondents were asked about past-year use of illegal drugs including cocaine or crack, ecstasy, speed or methamphetamines, hallucinogens and heroin. This section excludes cannabis.

"Past-year use of at least one of five illegal drugs was 3% (987,000), an increase from 2% (678,000) compared to 2015, and 2% (458,000) compared to 2013. This increase is associated with an increase in the use of cocaine, compared to 2015 and 2013.

"Overall, prevalence of past-year use of these illegal drugs was higher among males (5% or 719,000) than females (2% or 268,000). There was an increase in past-year use of illegal drugs for both males and females, compared to 2015 (5% vs. 3% and 2% vs. 1% respectively).

"Past-year use of at least one of five illegal drugs was higher among youth aged 15 to 19 (4% or 81,000) and young adults aged 20 to 24 (10% or 241,000) than among adults aged 25 and older (3% or 665,000).

"While past-year illegal drug use remained low, there was an increase in the prevalence of use of cocaine; 2% (730,000) of Canadians reported using cocaine, an increase from 1% (353,000) compared to 2015, and 1% (259,000) compared to 2013. Cocaine use among adults aged 25 and older was 2% in 2017, an increase from 1% in 2015, and 1% in 2013. There was no change in the prevalence of use of hallucinogens (1% or 443,000), or ecstasy (1% or 271,000). The prevalence of heroin, speed/methamphetamine or salvia use was not reportable due to small sample size.

"Past-year use was more prevalent among males than females for cocaine (4% males vs. 1% females) and hallucinogens (2% males vs. 1% females)."

"Provincial prevalence of past-year cannabis use ranged from 8.5% in New Brunswick to 13.8% in British Columbia. There were no year-to-year changes in provincial rates of cannabis use. Each province’s past-year cannabis prevalence was compared with the average prevalence for the nine remaining provinces. Of these, only British Columbia shows higher than average prevalence."

"Cannabis, which includes marijuana, hash and hash oil, has the highest prevalence of use after alcohol.

"In 2018-19, 18% of students in grades 7 to 12 (approximately 374,000) reported using cannabis in the year preceding the survey, unchanged from 2016-17. Past-12-month use of cannabis by both males and females was 18%, unchanged from the previous cycle. Students in grades 7 to 9 reported an increase in the use of cannabis (7%, approximately 73,000) compared to 6% in 2016-17, whereas cannabis use among students in grades 10-12 remained unchanged at 29%.

"The results of the 2018-19 survey showed that grade 7 to 12 students were on average 14.3 years old when they first used cannabis, unchanged from the previous cycle.

"Grade 7 to 12 students were asked about their methods of cannabis consumption. Among students who used cannabis, smoking (e.g., a joint, bong, etc.) was the most common method (76%, approximately 356,000), a decrease from 2016-17 (80%). The next most popular methods of cannabis consumption included consumption of edibles (an increase from 34% in 2016-17 to 45%, approximately 209,000), vaporizing/vaping (an increase from 30% to 42%, approximately 191,000), and dabbing (an increase from 22% to 28%, approximately 125,000). Drinking cannabis was the least reported method of consumption among students (15%, approximately 67,000), unchanged from 2016-17. Approximately 26% of students who used cannabis (approximately 115,000) also reported using another method, unchanged from 2016-17."

"Eight of the nine provinces with student drug use surveys ask about daily or almost daily use of cannabis in the past month. Overall, 2.2–5.3% of students report smoking cannabis every day or almost every day in the past 30 days (Table 31 and Figure 31). In four of the eight provinces, the prevalence of daily or almost daily cannabis use was significantly greater among males than females (Table 32 and Figure 32). When examined by grade, the same pattern as noted in all previous indicators emerges. In Grade 7, very few students report daily use - so few that most estimates for Grade 7 students are suppressed. In Grade 12, however, 3.3–10.0% of students report using cannabis daily or almost every day (Table 33 and Figure 33)."

"The reported prevalence of drugs (other than alcohol and cannabis) such as cocaine or heroin among students is relatively rare. That said, provinces routinely measure use of these substances. British Columbia, Alberta, Manitoba, and Ontario estimates are for lifetime use. Atlantic provinces, Québec and the YSS [Youth Smoking Survey] ask about use in the past 12 months. Therefore, the two sets of prevalence estimates are presented separately in different tables. In addition to the different time frames used in the survey questions, there is also considerable variation in the terminology used in referring to these drugs as noted where appropriate in the tables below.
"All the surveys ask about ecstasy. Estimates for ecstasy use range from 3.4–7.2% reporting past-12-month use
and 4.4–7.1% reporting lifetime use (Tables 43 and 44). Following ecstasy, inhalants are second overall in reported
use with estimates ranging from 2.6–4.4% for past-year use and 2.2–3.8% for lifetime use. However, not all surveys ask about use of inhalants; some ask about ‘solvents’ or ‘glue’. These differences in terminology result in different prevalence estimates (Tables 45 and 46). Estimates for steroid use range from 1.4–1.7% for past-12-month use and 1.2–1.4% for lifetime use (Tables 47 and 48). Estimates for lifetime heroin use in British Columbia, Alberta, Manitoba and Ontario range from 0.8–1.3% (Table 49). Atlantic Canada does not ask students about heroin use. The YSS asks about past-12-month use of heroin [1.3% (1.0, 1.6)]."

"Among those who used cannabis, 17.7% (representing about 420,000 Canadians or 1.6% of the Canadian population aged 15 years and older) reported doing so for medical purposes. Prevalence of use for medical purposes was similar between male and female cannabis users (17.3% versus 18.4%, respectively), while more than one in five (21.8%) cannabis users aged 25 years and older reported using it for medical purposes, representing 1.5% of all adults in this age group. The percentage of youth who used cannabis for medical purposes is not reportable.
"Half (49.7%) of those who used cannabis for medical purposes did so mainly for chronic pain caused by conditions such as arthritis, back pain and migraines, while the remaining 50.3% used cannabis primarily for one of a variety of conditions that included insomnia, depression and anxiety. These numbers do not in any way measure or reflect enrolment in the federal Medical Marijuana Access Program."

"In 2012, 78.4% of Canadians reported drinking alcohol in the past year, a rate similar to that reported in 2011 (78.0%). There was, however, a decrease in past-year alcohol use among youth 15 to 24 years of age compared to CAS in 2004, from 82.9% to 70.0% in 2012. Similar to previous years, in 2012, a higher percentage of males than females reported past-year alcohol use (82.7% versus 74.4%, respectively) while the prevalence of past-year drinking among adults aged 25 years and older (80.0%) was higher than among youth (70.0%).
"Provincial rates of current drinking ranged from 72.3% in Nova Scotia to 82.1% in Quebec. Each province’s past-year alcohol prevalence was compared with the average for the nine remaining provinces. Three provinces had lower than average prevalence (Nova Scotia, New Brunswick (73.8%) and Prince Edward Island (74.0%)) while the prevalence of past-year alcohol use in Quebec was higher than average. Prevalence of past-year alcohol use since 2011 was unchanged for all provinces."

"In 2009, Canadian law enforcement seized a total of 34,391 kilograms (kg) of marihuana and 1,845,734 marihuana plants. These figures, which have remained relatively unchanged from 2008 and coupled with steady street prices in 2009, indicated an apparently stable marihuana market. As in 2008, the majority of marihuana seized was domestically produced, yet the drug continued to be imported from Jamaica, the United States, the Netherlands, and Thailand."

"In 2009, an abundant supply of Canadian-produced MDMA continued to meet domestic consumption requirements, as well as provide significant quantities for international markets.⁴⁰ Domestic prices for MDMA remained at the record low levels from 2008, while purity levels of the drug remained high, or even may have increased. The nature or extent of MDMA production in Canada appeared to be unaffected by the significant shortage in the supply of MDP2P, that reportedly impacted European markets. In Europe, the shortage resulted in a decline in Ecstasy seizures and in the number of seizures of laboratories, storage, and dump sites related to large-scale MDMA production.
"Cross-border MDMA smuggling from Canada to the United States, the primary foreign market for Canadian-produced MDMA, significantly increased from 2008. As in previous years, smuggling activity at or between ports of entry (POEs) was reported in the provinces of British Columbia, Ontario, and Quebec.⁴¹ For example, a record amount of 2.6 million dosage unit equivalents confirmed as MDMA were seized in the Pacific region in 2009. However, there was also smuggling activity across the Canada-U.S. border in other provinces, such as Manitoba.⁴²"

"Seventeen percent (17%) of inmates reported recently injecting drugs. A substantial proportion of these inmates increased their risk of acquiring a blood-borne infection (BBI) by using someone else’s used injecting equipment (see Table 4 for gender-specific estimates). Of those who recently injected drugs, 37% of inmates reported sharing a needle with a person with a positive or unknown BBI status and 42% reported using someone else’s works after they had used them. Additionally, men were more likely than women to report using someone else’s used needle, 55% vs. 41%, ?2 (1, n=438) = 6.22, p < 0.05 and sharing works with a person with a positive or unknown BBI status, 33% vs. 23%, ?2 (1, n=397) = 4.40, p < 0.05."

"Overall, 87% of inmates who recently injected drugs in a penitentiary reported opiates as one of their three most used drugs. Although the number of inmates who reported injecting only non-opiate drugs was small, comparisons between this group and opiate users suggests that injecting opiates may be associated with the use of someone else’s used equipment (see Table 9). Inmates who recently injected opiates were more likely, than those who recently injected non-opiates, to use someone else’s used needle, 81% vs. 48%, ?2 (1, n=251) = 13.92, p < 0.05, and works, 59% vs. 36%, ?2 (1, n=236) = 3.98, p < 0.05."

"Although estimates of the number of new HIV infections are uncertain, the number of new infections in 2011 was estimated at 3,175 (range between 2,250 and 4,100) which was about the same as or slightly fewer than the estimate in 2008 (3,335; range of 2,370 to 4,300) (Table 2, Figure 2). In terms of exposure category, MSM continued to comprise the greatest proportion (46.6%) of new infections in 2011, which was slightly higher than the proportion they comprised in 2008 (44.1%). In 2011, the proportion of new infections among IDU was lower than in 2008 (13.7% compared to 16.9%). The proportion of new infections attributed to the heterosexual/non-endemic and heterosexual/endemic exposure categories were about the same in 2011 compared to 2008 (20.3% vs 20.1% and 16.9% vs 16.2%, respectively) (Figure 3)."

"We detected no reduction in druguse frequency or drug price in response to a large-scale police crackdown on drug users in Vancouver's DTES. The evidence that drugs became more difficult to obtain was consistent with reports of displacement of drug dealers and was supported by the significantly higher rates of reporting that police presence had affected where drugs were used, including changes in neighbourhood and increases in use in public places. These observations were validated by examination of needle-exchange statistics.

"Our findings are consistent with those showing that demand for illicit drugs enables the illicit drug market to adapt to and overcome enforcement-related constraints. Although evidence suggested that police presence made it more difficult to obtain drugs, this appeared to be explained by displacement of drug dealers."

"Diacetylmorphine was found to be a dominant strategy over methadone maintenance treatment in each time horizon studied (Table 2). Over a lifetime horizon, people in the methadone cohort lived 14.54 years on average following entry into the model, spending 8.79 years (60% of their remaining life) in treatment and 5.52 years in relapse. They accumulated 7.46 discounted QALYs and generated a societal cost of $1.14 million. People in the diacetylmorphine cohort lived 15.45 years on average, spending 10.41 years (67% of their remaining life) in treatment (2.34 years of which was in post-diacetylmorphine methadone treatment) and 4.05 years in relapse. They accumulated 7.92 discounted QALYs and generated a societal cost of $1.10 million. Based on these findings in the baseline model, over a lifetime horizon the provision of diacetylmorphine in the hypothetical cohort provided greater incremental health benefits and reduced the total costs to society compared with methadone maintenance treatment."

"The present study determined participants’ satisfaction with received treatments in the first North American RCT [Randomized Controlled Trial] to provide injectable diacetylmorphine or hydromorphone compared to oral methadone for the treatment of long-term, treatment resistant, opioiddependency. At 3 and 12 months, participants were satisfied with the treatment received during the study period, although satisfaction was greater for those randomized to receive injectable treatments. At 3 months, participants who reported that the program met their needs were more likely to be retained at 12 months. To our knowledge this is the first study to assess treatment satisfaction among participants receiving supervised injectable diacetylmorphine or hydromorphone.

"Regardless of the outcome of the randomization, participants in the trial were highly satisfied with the treatment received. This follows previous studies which have consistently found that patients tend to report high levels of treatment satisfaction, including community health services [45], services for mental health [13], addiction [46], and opioid dependence [20]."

Harm Reduction

"At the time of the survey, 7% of all inmates reported being on MMTP. An additional 9% of all inmates reported not being on the program but previously trying to get on it at CSC. The remaining 84% of inmates reported never trying to join the program (63%), never using drugs (20%), and no longer needing the program (<1%).
"Participation in MMTP was associated with drug use in penitentiaries. Of inmates who were on MMTP, 60% reported not using opiates recently in a penitentiary; however, 40% did (see Table 10). Similarly, of those who were not on CSC’s MMTP but had tried to get on the program, almost equal proportions reported no drug use in a penitentiary (45%) and recent opiate use a penitentiary (44%). Conversely, the majority of inmates who never tried to get on MMTP at CSC reported no recent opiate use in a penitentiary (87%) and a minority (12%) reported recent opiate use in a penitentiary."

"In the present analysis we found that overdose events were not uncommon at the Vancouver safer injection facility. During an 18-month period, 285 individuals accounted for 336 overdose events, yielding an overdose rate of 1.33 (95% CI: 0.0–3.6) overdoses per 1000 injections. Heroin was involved in approximately 70% of all overdoses, and opiates considered together were involved in 88%of overdoses. It is notable, however, that approximately one-third of overdoses involved stimulants. The most common indicators of overdose were depressed respiration, limp body, face turning blue, and a failure to respond to pain stimulus. The majority of overdoses were successfully managed in the SIF, with the most common overdose interventions undertaken by SIF staff involving the administration of oxygen, a call for ambulance support, and the administration of naloxone hydrochloride via injection. Among a randomly selected sample of SIF users, factors associated with time to overdose at the SIF included fewer years injecting, daily heroin use, and having a history of overdose. None of the overdose events occurring at the SIF resulted in a fatality."

"Among IDU [Injection Drug Users] who attended Vancouver’s supervised injecting facility, regular use of the SIF and having contact with counselors at the SIF were associated with entry into addiction treatment, and enrollment in addiction treatment programs was positively associated with injection cessation. Although SIF in other settings have been evaluated based on wide range of outcomes (Dolan et al., 2000; Kimber et al., 2003; MSIC Evaluation Committee, 2003), our study is the first to consider the potential role of SIF in supporting injection cessation. While our study is unique, our findings build on previous international analyses demonstrating a link between SIF attendance and entry into detoxification programs (Wood et al., 2006; Wood et al., 2007a; Kimber et al., 2008).

"A postulated benefit of SIF is that, by providing a sanctioned space for illicit drug use, a hidden population of IDU can be drawn into a healthcare setting so that service delivery can be improved. The present study provides additional evidence that SIF appear to promote utilization of addiction services and builds on past evaluations to demonstrate that, through this mechanism, they may also lead to increased injecting cessation. While these findings are encouraging, it is concerning that Aboriginal participants were less likely to enter addiction treatment. This finding is consistent with prior reports (Wood et al., 2005a; Wood et al., 2007b), and highlights the need for innovative and culturally appropriate addiction treatment services developed with full consultation with Aboriginal people who use drugs."

Economics

"Measured in terms of the burden on services such as health care and law enforcement, and the loss of productivity in the workplace or at home resulting from premature death and disability, the overall social cost of substance abuse in Canada in 2002 was estimated to be $39.8 billion. This estimate is broken down into four major categories in Figure 1. This overall estimate represents a cost of $1,267 to every man, woman and child in Canada, as indicated according to substance in Figure 2.
"Tobacco accounted for about $17 billion or 42.7% of that total estimate, alcohol accounted for about $14.6 billion (36.6%) and illegal drugs for about $8.2 billion (20.7%) (see Table 2).
"Productivity losses amounted to $24.3 billion or 61% of the total, while health care costs were $8.8 billion (22.1%). The third highest contributor to total substance-related costs was law enforcement with a cost of $5.4 billion or 13.6% of the total."

Laws & Policies

"The National Anti-Drug Strategy is a horizontal initiative of 12 federal departments and agencies, led by the Department of Justice, with new and reoriented funding4 covering activities over a five-year period from 2007/08 to 2011/12. The goal of the Strategy is to contribute to safer and healthier communities through coordinated efforts to prevent use, treat dependency, and reduce production and distribution of illicit drugs. Illicit drugs are defined in the Controlled Drugs and Substances Act (CDSA) to include opiates, cocaine and cannabis-related substances (including marihuana) as well as synthetic drugs such as ecstasy and methamphetamine. The Strategy encompasses three action plans: Prevention, Treatment and Enforcement:
"• The objectives of the Prevention Action Plan are to prevent youth from using illicit drugs by enhancing their awareness and understanding of the harmful social and health effects of illicit drug use; and to develop and implement community-based interventions and initiatives to prevent illicit drug use.
"• The objective of the Treatment Action Plan is to support effective treatment and rehabilitation systems and services by developing and implementing innovative and collaborative approaches.
"• The objective of the Enforcement Action Plan is to contribute to the disruption of illicit drug operations in a safe manner, particularly targeting criminal organizations.
"The Strategy‘s action plans are expected to contribute to a reduction in the supply of, and demand for, illicit drugs, which ultimately contributes to safer and healthier communities."

"Our analyses suggest that public perceptions of the relative seriousness of substance abuse problems are incongruent with the actual costs they impose on Canadian society. In particular, the total social costs associated with alcohol are more than twice those for all other illicit drugs in 2002, yet the public consistently rated the overall seriousness of illicit drugs as higher at the national, provincial and local levels in the Canadian Addiction Survey (2004). Interpreting these findings it is possible to suggest that perceptions of the seriousness of illicit drugs are relatively amplified while perceptions of the seriousness of problems associated with alcohol are relatively attenuated in Canadian society."

The Canadian government in 2001 established regulations to expand the use of marijuana as a medicine. According to an editorial in the Canadian Medical Association Journal, "The new regulations promise more transparency in the review of applications to grow or possess medicinal marijuana, a broader definition of medical necessity, and greater latitude for physicians in determining the needs of individual patients."

"In 2006, the province of Alberta passed the Drug Endangered Child Act,¹⁷ which authorized the state (child welfare authorities or the police) to seize children from drugproducing homes, even if based on suspicion alone.¹⁸ Often these children, and even the parents, might not know about the drugs. More troubling is that there may not even be illicit substances present, but rather the chemicals used to create such substances, and this may be deemed sufficient for apprehension of the children. To add to the equation, the Motherisk Laboratory at the Hospital for Sick Children receives hair samples to be analyzed for drugs of abuse from thousands of parents implicated in child-protection matters each year from across the country, and they are analyzed for drugs of abuse. Based on consultations with child protection workers or the respective authorities, children are rarely removed from drug-using parents’ care until substantial evidence of child safety issues is built. Among our cohort of children presented here, however, the majority of the parents were not known to be using illicit substances themselves and, on the basis of our clinical assessments, appear to be able to parent their children adequately. It is not likely that the production of drugs, particularly marijuana, hinders effective parenting much more than actual drug use, yet the differences in the ways these cases are handled suggest that police and child protection agencies perceive the former to be of greater concern with respect to child safety than the latter."

"Public health oriented regulation has much potential to reduce the health, social and fiscal harms associated with all psychoactive substances.
"In addition, public health oriented regulation is supportive of Canadians human rights as established by the pre-eminence of the Charter of Rights and Freedoms 7 i.e. the “right to life, liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice.” (section 7), “subject only to such reasonable limits prescribed by law as can be demonstrably justified in a free and democratic society” (section 1)."

"Our analysis showed that the implementation of a province-wide centralized prescription network was associated with large, immediate and sustained reductions in filled prescriptions for opioid analgesics and benzodiazepines deemed inappropriate by our definition. These findings provide empirical evidence that centralized prescription networks can reduce inappropriate prescribing and dispensing of prescriptions by offering health care professionals real-time access to prescription data. Physicians did not have access to PharmaNet when it was first introduced; consequently, the reductions observed in our study likely reflect the availability of real-time prescription information to front-line pharmacists."

"The North American Opiate Medication Initiative (NAOMI) is a carefully controlled (clinical trial) that will test whether medically prescribed heroin can successfully attract and retain street-heroin users who have not benefited from previous repeated attempts at methadone maintenance and abstinence programs.

"The NAOMI study will enroll 470 participants at three sites in Vancouver, Montreal and Toronto. The Toronto and Montreal sites are expected to begin recruitment this spring.

"Each site will enroll about 157 participants. About half of these volunteers will be assigned to receive pharmaceutical-grade heroin (the experimental group) and half will receive methadone (the control group). The prescribed heroin will be self-administered under careful medical supervision within a specially designed clinic. Those in the heroin group will be treated for 12 months then transitioned, over three months, into either methadone-maintenance therapy or another treatment program. The researchers expect a 6-9 month recruitment period, so that the total time to complete the study will be 21 to 24 months."

CONCLUSIONS
"1. Heroin-assisted therapy proved to be a safe and highly effective treatment for people with chronic, treatment-refractory heroin addiction. Marked improvements were observed including decreased use of illicit “street” heroin, decreased criminal activity, decreased money spent on drugs, and improved physical and psychological health.
"2. The NAOMI trial attracted the most chronic and marginalized heroin users who were outside the treatment system and continued to use heroin despite numerous previous treatment attempts. Both heroin-assisted therapy and optimized methadone maintenance treatment achieved high retention rates and remarkable response rates in this difficult-to-treat group.
"3. Contrary to pre-existing concerns, the treatment clinics appeared to have no negative impacts on the surrounding neighbourhoods.
"4. Participants on hydromorphone did not distinguish this drug from heroin. Moreover, hydromorphone appeared to be equally effective as heroin although the study was not designed to test this conclusively. If this were proven to be true, hydromorphone-assisted therapy could offer legal, political and logistical advantages over heroin and could be made more widely available."

"The Study to Assess Longer-term Opioid Medication Effectiveness (SALOME) is a clinical study that tests alternative treatments for people with chronic heroin addiction who are not benefiting sufficiently from available treatments such as oral methadone.

"SALOME compared two medications – diacetylmorphine, the active ingredient of heroin, and hydromorphone (HDM), a legal, licensed pain medication.

"Studies in Canada and Europe have demonstrated that treatment with diacetylmorphine is more effective than oral methadone for some of the most vulnerable heroin users. HDM has now been shown to be as good as diacetylmorphine and should now become an alternative for those currently not benefitting from methadone and other treatments, and be integrated in the treatment continuum available through licensed doctors."

"Since its inception, Insite has been subject to an independent review by a team of physicians and scientists put in place to provide an 'arm’s length' evaluation of the program. The results of this scientific evaluation have been published in peer-reviewed academic journals and have indicated that Insite has reduced unsafe injection practices, public disorder, overdose deaths and HIV/Hepatitis while increasing uptake of addiction services and detox [8]. To date, there have been over three-dozen peer-reviewed papers evaluating Insite published making it one of the most evaluated healthcare programs in the history of Canada [9-38]. In light of the evidence, the program has garnered widespread support from Canadian physicians, scientists and healthcare professionals."

"The British Columbia Centre for Excellence in HIV/AIDS was commissioned to evaluate Insite. A study published in 2006 showed that there was an increase in uptake of detoxification services and addiction treatment.¹³ Another study published that year showed that Insite did not result in increased relapse among former drug users, nor was it a negative influence on those seeking to stop drug use.¹⁴ Results of studies using mathematical modelling showed that about one death from overdose was averted per year by Insite.¹ A subsequent study estimated 2–12 deaths averted per year.¹⁵ Although these studies did not have sufficient power to detect any difference in incidence of blood-borne infections, Kerr and colleagues did find that Insite users were 70% less likely to report needle-sharing than those who did not use the facility.¹⁶ Before the opening of Insite, those same individuals reported needle-sharing that was on par with cohort averages. As for public order, Wood and colleagues found that there was no increase in crime following the opening of the facility.¹⁷ In fact, there had been statistically significant decreases in vehicle break-ins and theft, as well as decreases in injecting in public places and injection-related litter."

(Reduced Overdose Mortality) "In this population-based analysis, we showed that overdose mortality was reduced after the opening of a SIF [supervised injecting facility]. Reductions in overdose rates were most evident within the close vicinity of the facility—a 35% reduction in mortality was noted within 500 m of the facility after its opening. By contrast, overdose deaths in other areas of the city during the same period declined by only 9%. Consistent with earlier evidence showing that SIFs are not associated with increased drug injecting (panel),38,39 these findings indicate that such facilities are safe and e!ective public-health interventions, and should therefore be considered in settings with a high burden of overdose related to injection drug use."

"In summary, the present study demonstrates that the SIF was associated with increased use of detoxification service use and that residential detoxification was associated with increased rates of methadone use and other forms of addiction treatment. Given the known role of methadone and other forms of addiction treatment in reducing levels of injection drug use, and given that detoxification programme use was associated with reduced injecting at the SIF, our findings imply that the SIF has probably helped to reduce rates of injection drug use among users of the facility."

"In this population-based analysis, we showed that overdose mortality was reduced after the opening of a SIF. Reductions in overdose rates were most evident within the close vicinity of the facility—a 35% reduction in mortality was noted within 500 m of the facility after its opening. By contrast, overdose deaths in other areas of the city during the same period declined by only 9%. Consistent with earlier evidence showing that SIFs are not associated with increased drug injecting (panel),^38,39 these findings indicate that such facilities are safe and effective public-health interventions, and should therefore be considered in settings with a high burden of overdose related to injection drug use.

"In both the primary and sensitivity analyses, we saw no significant reductions in overdose mortality further than 500 m from the SIF. This finding is not surprising, since over 70% of frequent SIF users reported living within four blocks of the facility. Although the facility operates at capacity with over 500 supervised injections per day on average,²³ it is a pilot programme with only 12 injection seats in a neighbourhood with about 5000 injection drug users.⁴⁰ Therefore, and since previous studies have shown that waiting times and travel distance to the facility are barriers to SIF use,⁴¹ larger reductions in community overdose mortality would probably require an expansion of SIF coverage."