North America’s first supervised injection facility (SIF) was established in Vancouver, Canada, in 2003. Although evaluation research has documented reductions in risk behavior among SIF users, there has been limited examination of the influence of operational features on injection drug users’ access to these facilities. We conducted an ethnographic study that included observational research within the SIF, 50 in-depth individual interviews with SIF users, and analysis of the regulatory frameworks governing the SIF. The government-granted exemption allowing the facility to operate legally imposes key operating regulations, as well as a cap on capacity, which results in significant wait times to enter the injecting room. Regulations that prohibit practices that are common in the local drug culture also negatively affect SIF utilization. Restructuring policies that shape the operation of the SIF could enhance access to the facility and permit SIF services to better accommodate local drug use practices.
Aceijas, C., & Rhodes T. ( 2007). Global estimates of prevalence of HCV infection among injecting drug users. International Journal of Drug Policy , 18(5), 352-358. doi:10.1016/ j.drugpo.2007.04.004
2.
Aceijas, C., Stimson, G.V., Hickman, M., & Rhodes, T. ( 2004). Global overview of injecting drug use and HIV infection among injecting drug users. AIDS, 18(17), 2295-2303. Retrieved from http://journals.lww.com/aidsonline/Fulltext/2004/11190/Global_overview_of_injecting_drug_use_and_HIV.10.aspx
3.
Blankenship, K., Bray, S.J., & Merson, M. ( 2000). Structural interventions in public health. AIDS, 14, S11-S21. Retrieved from http://journals.lww.com/aidsonline/Fulltext/2000/06001/Structural_interventions_in_public_health.3.aspx]
4.
Bourgois, P. ( 1998). The moral economies of homeless heroin addicts: Confronting ethnography, HIV risk, and everyday violence in San Francisco shooting encampments . Substance Use & Misuse, 33(11), 2323-2351. doi:10.3109/10826089809056260
5.
Bourgois, P. ( 2000). "Disciplining addictions": The bio-politics of methadone and heroin in the United States. Culture, Medicine and Psychiatry , 24, 165-195. doi:10.1023/A:1005574918294
6.
Bourgois, P., & Bruneau, J. ( 2000). Needle exchange, HIV infection, and the politics of science: Confronting Canada’s cocaine injection epidemic with participant observation . Medical Anthropology Quarterly, 18, 325-350. doi:10.108 0/01459740.2000.9966161
7.
Bourgois, P., Prince, B., & Moss, A. ( 2004). The everyday violence of hepatitis C among young women who inject drugs in San Francisco. Human Organization, 63(3), 253-264. Retrieved from http:// sfaa.metapress.com/openurl.asp?genre=article&issn=0018-7259&volume=63&issue=3&spage=253
8.
Broadhead, R.S., Kerr, T.H., Grund, J.-P., & Altice, F.L. ( 2002). Safer injection facilities in North America: Their place in public policy and health initiatives. Journal of Drug Issues , 32(1), 329-355. Retrieved from http://www.2.criminology.fsu.edu/~jdi/32n1.htm
9.
Burris, S., Blankenship, K., Donoghoe, M., Sherman, S., Vernick, J.S., Case, P., . . . Koester, S. ( 2004). Addressing the "risk environment" for injection drug users: The mysterious case of the missing cop. Milbank Quarterly , 82, 125-156. doi:10.1111/j.0887-378X.2004.00304.x
10.
Carlson, R.G. ( 2000). Shooting galleries, dope houses, and injection doctors: Examining the social ecology of risk behavior among drug injectors in Dayton, Ohio. Human Organization, 59(3), 325-332. Retrieved from http://sfaa.metapress.com/link.asp?id=w483t11p717473k6
11.
Corneil, T.A., Kuyper, L.M., Shoveller, J., Hogg, R.S., Li, K., Spittal, P.M., . . . Wood, E. ( 2006). Unstable housing, associated risk behaviour, and increased risk for HIV infection among injection drug users. Health & Place, 12(1), 79-85. doi:10.1016/j.healthplace.2004.10.004
12.
DeBeck, K., Small, W., Wood, E., Li, K., Montaner, J., & Kerr, T. ( 2008). Public injecting among a cohort of injecting drug users in Vancouver, Canada. Journal of Epidemiology and Community Health, 63, 81-86. doi:10.1136/ jech.2007.069013
13.
Elliott, R., Malkin, I., & Gold, J. ( 2002). Establishing safe injection facilities in Canada: Legal and ethical issues. Toronto, ON, Canada: Canadian HIV/AIDS Legal Network. Retrieved from http://www.aidslaw.ca/publications/interfaces/downloadFile.php?ref=776
14.
Fairbairn, N., Wood, E., Small, W., Stoltz, J.A., Li, K., & Kerr, T. ( 2006). Risk profile of individuals who provide assistance with illicit drug injections. Drug & Alcohol Dependence, 82(1), 41-46. doi:10.1016/j.drugalcdep.2005.08.007
15.
Fischer, B., Turnbull, S., Poland, B., & Haydon, E. ( 2004). Drug use, risk and urban order: Examining supervised injection sites (SIS) as ‘governmentality.’International Journal of Drug Policy, 15, 357-365. doi:10.1016/j.drugpo .2004.04.002
16.
Fry, C.L. ( 2002). Injecting drug user attitudes towards rules for supervised injecting rooms: Implications for uptake. International Journal of Drug Policy, 13, 471-476. doi:10.1016/ S0955-3959(02)00076-2
17.
Fry, C.L. ( 2003). Safer injecting facilities in Vancouver: Considering issues beyond potential use. Canadian Medical Association Journal, 169(8), 777-778. Retrieved from http://www.cmaj.ca/cgi/content/full/169/8/777
18.
Grund, J.P., Friedman, S.R., Stern, L.S., Jose, B., Neaigus, A., Curtis, R., & Des Jarlais, D.C. (1996). Syringe-mediated drug sharing among injecting drug users: Patterns, social context and implications for transmission of blood-borne pathogens. Social Science & Medicine, 42(5), 691-703. doi:10.1016/0277-9536(95)00193-X
19.
Hall, N. ( 2010, January 15). B.C. court rules Vancouver’s Insite safe injection site can stay open. Vancouver Sun. Retrieved from http://www.vancouversun.com/news/court+rules+Vancouver+Insite+safe+injection+site+stay+open/2446233/story.html
20.
Health Canada. (2002). Application for an exemption under Section 56 of the Controlled Drugs and Substances Act for a scientific purpose for a pilot supervised injection site. Ottawa, ON, Canada: Office of Drug Strategy and Controlled Substances Programme. Retrieved from http://www.cdnaids.ca/web/mailouts.nsf/1937f4d80b2408c685256aaa0055ae02/da6097909fcbc99c85256ccd005daaae/$FILE/SIS%20guidance%20jan2nd.rtf
21.
Hedrich, D. ( 2004). European report on drug consumption rooms. Luxembourg: Office for Official Publications of the European Communities. Retrieved from http://www.emcdda.europa.eu/attachements.cfm/att_2944_EN_consumption_rooms_report.pdf
22.
Higgs, P., Yohannes, K., Hellard, M., & Maher, L. ( 2009). Factors influencing a self-limiting HIV outbreak among ethnic Vietnamese injecting drug users in Melbourne, Australia. Qualitative Health Research, 19, 1690-1701. doi:10.1177/1049732309352470
23.
Howell, M. ( 2009, November 4). Organization eyes second supervised injection site. Vancouver Courier. Retrieved from http://www.vancourier.com/health/Organization+eyes+second+supervised+injection+site/2896947/story.html
24.
Jürgens, R., Csete, J., Amon, J.J., Baral, S., & Beyrer, C. ( 2010). People who use drugs, HIV, and human rights. Lancet, 376(9739), 475-485. doi:10.1016/S0140-6736(10)60830-6
25.
Kerr, T., Fairbairn, N., Tyndall, M., Marsh, D., Li, K., Montaner, J., & Wood, E. ( 2007). Factors associated with non-fatal overdose among a cohort of polysubstance-using injection drug users. Drug and Alcohol Dependence, 87(1), 39-45. doi:10.1016/j.drugalcdep.2006.07.009
26.
Kerr, T., Oleson, M., Tyndall, M.W., Montaner, J., & Wood, E. ( 2005). A description of a peer-run supervised injection site for injection drug users. Journal of Urban Health, 82(2), 267-275. doi:10.1093/jurban/jti050
27.
Kerr, T., Tyndall, M.W., Li, K., Montaner, J., & Wood, E. ( 2005). Safer injection facility use and syringe sharing in injection drug users. Lancet, 366, 316-318. doi:10.1016/ S0140-6736(05)66475-6
28.
Kerr, T., Wood, E., Palepu, A., Small, D., & Tyndall, M.W. ( 2003). The potential use of safer injection facilities among injection drug users in Vancouver’s Downtown Eastside. Canadian Medical Association Journal, 169(8), 1-5. doi:10.1503/cmaj.1040774
29.
Kerr, T.H., Wood, E., Palepu, A., Wilson, D., Schechter, M.T., & Tyndall, M.W. ( 2003). Responding to explosive HIV epidemics driven by frequent cocaine injection: Is there a role for safer injecting facilities?Journal of Drug Issues, 33(3), 579-608. Retrieved from http://www.2.criminology.fsu.edu/~jdi/33n3.htm
30.
Kimber, J., Dolan, K., van Beek, I., Hedrich, D., & Zurhold, H. ( 2003). Drug consumption facilities: An update since 2000. Drug & Alcohol Review, 22(2), 227-33. doi:10.1080 /095952301000116951
31.
Kimber, J., Dolan, K., & Wodak, A. ( 2005). Survey of drug consumption rooms: Service delivery and perceived health and amenity impact. Drug and Alcohol Review , 24, 21-24. doi:10.1080/09595230500125047
32.
Koester, S., Booth, R.E., & Zhang, Y. ( 1996). The prevalence of additional injection-related HIV risk behaviors among injection drug users. Journal of Acquired Immune Deficiency Syndromes, 12(2), 202-207. Retrieved from http://journals.lww.com/jaids/Fulltext/1996/06010/The_Prevalence_of_Additional_Injection_Related_HIV.15.aspx
33.
Koester, S., Glanz, J., & Baron, A. ( 2005). Drug sharing among heroin networks: Implications for HIV and hepatitis B and C prevention. AIDS and Behavior, 9, 27-39. doi:10.1007/ s10461-005-1679-y
34.
Kral, A.H., Bluthenthal, R.N., Erringer, E.A., Lorvick, J., & Edlin, B.R. ( 1999). Risk factors among IDUs who give injections to or receive injections from other drug users. Addiction, 94, 675-683. doi:10.1046/j.1360-0443.1999.9456755.x
35.
Li, X., Sun, H., Marsh, D.C., & Anis, A.H. ( 2007). Impact of welfare cheque issue days on a service for those intoxicated in public. Harm Reduction Journal, 26(4), 12. Retrieved from http://www.harmreductionjournal.com/content/4/1/12
36.
Lloyd-Smith, E., Rachlis, B.S., Tobin, D., Stone, D., Li, K., Small, W., . . . Kerr, T. ( 2010). Assisted injection in outdoor venues: An observational study of risks and implications for service delivery and harm reduction programming . Harm Reduction Journal, 7, 6. Retrieved from http://www.harmreductionjournal.com/content/7/1/6
37.
Mathers, B.M., Degenhardt, L., Ali, H., Wiessing, L., Hickman, M., Mattick, R.P., . . . 2009 Reference Group to the UN on HIV and Injecting Drug Use. (2010). HIV prevention, treatment, and care services for people who inject drugs: A systematic review of global, regional, and national coverage. Lancet, 375(9719), 1014-1028. doi:10.1016/ S0140-6736(10)60232-2
38.
McKnight, I., Maas, B., Wood, E., Tyndall, M.W., Small, W., Lai, C., . . . Kerr T. ( 2007). Factors associated with public injecting among users of Vancouver’s supervised injection facility. American Journal of Drug and Alcohol Abuse, 33(2), 319-325. doi:10.1080/00952990601175102
39.
Milloy, M.J., Kerr, T., Tyndall, M., Montaner, J., & Wood, E. ( 2008). Estimated drug overdose deaths averted by North America’s first medically-supervised safer injection facility. PLoS One, 3(10), e3351. doi:10.1371/journal.pone.0003351
40.
Minister of Justice. (1996). Controlled drugs and substances act. Ottawa, ON, Canada: Government of Canada.
41.
Ministry of Public Safety and Solicitor General. ( 2008). BC coroners service illicit drug deaths 1997 to 2007 . Retrieved from http://www.pssg.gov.bc.ca/coroners/publications/docs/stats-illicitdrugdeaths-1997-2007.pdf
42.
Moore, D. ( 2004). Governing street-based injecting drug users: A critique of heroin overdose prevention in Australia. Social Science and Medicine, 59(7), 1547-1557. doi:10.1016/j.socscimed.2004.01.029
43.
Moore, D. ( 2005). Key moments in the ethnography of drug-related harm: Reality checks for policy makers? In T. R. Stockwell, P. Gruenewald, J. Toumbourou, & W. Loxley (Eds.), Preventing harmful substance use: The evidence base for policy and practice (pp. 433-442). Chichester, UK: Wiley & Sons.
44.
Moore, D. ( 2009). ‘Workers,’ ‘clients’ and the struggle over needs: Understanding encounters between service providers and injecting drug users in an Australian city. Social Science & Medicine, 68, 1161-1168. doi:10.1016/j.socscimed.2008.12.015
45.
Murphy, S., & Waldorf, D. ( 1991). Kickin’ down to the street doc: Shooting galleries in the San Francisco Bay Area. Contemporary Drug Problems , 18, 9-29. Retrieved from http:// www.heinonline.org/HOL/Page?page=9&handle=hein.jour nals%2Fcondp18&collection=journals
46.
Neale, J. ( 1999). Drug users’ views of substitute prescribing conditions . International Journal of Drug Policy, 10(3), 247-258. doi:10.1016/S0955-3959(99)00016-X
47.
Needle, R.H., Coyle, S., Cesari, H., Trotter, R., Clatts, M., Koester, S., . . . Williams, M. ( 1998). HIV risk behaviors associated with the injection process: Multiperson use of drug injection equipment and paraphernalia in injection drug user networks. Substance Use & Misuse, 33(12), 2403-2423. doi:10.3109/10826089809059332
48.
O’Connell, J.M., Kerr, T., Li, K., Tyndall, M.W., Hogg, R.S., Montaner, J., & Wood, E. ( 2005). Requiring help injecting independently predicts incident HIV infection among injection drug users. Journal of Acquired Immune Deficiency Syndrome, 40, 83-88. doi:10.1097/01. qai.0000157006.28535.mL
49.
O’Shaughnessy, M., Hogg, R., Strathdee, S., & Montaner, J. ( 2009). Deadly public policy: The inadvertent facilitation of an HIV outbreak among IDUs in Vancouver, Canada. 5th International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention. Capetown, South Africa, July, 2009. Retrieved from http://www.ias2009.org/pag/Abstracts.aspx?AID=2658
50.
Pearshouse. R., & Elliott, R. ( 2007). A helping hand: Legal issues related to assisted injection at supervised injection facilities. Toronto, ON, Canada: Canadian HIV/AIDS Legal Network .
51.
Petrar, S., Kerr, T., Tyndall, M.W., Zhang, R., Montaner, J.S., & Wood, E. ( 2007). Injection drug users’ perceptions regarding use of a medically supervised safer injecting facility. Addictive Behaviors, 32(5), 1088-1093. doi:10.1016/j. addbeh.2006.07.013
52.
Pitfield, T.H.M.J. ( 2008). PHS Community Services Society v. Attorney General of Canada, 2008 BCSC 661. The Supreme Court of British Columbia .
53.
Rhodes, T. ( 2002). The ‘risk environment’: A framework for understanding and reducing drug-related harm. International Journal of Drug Policy, 13, 85-94. doi:10.1016/S0955-3959(02)00007-5
54.
Rhodes, T., Kimber, J., Small, W., Fitzgerald, J., Kerr, T., Hickman, M., & Holloway, G. ( 2006). Public injecting and the need for ‘safer environment interventions’ in the reduction of drug-related harm. Addiction, 101, 1384-1393. doi:10.1111/ j.1360-0443.2006.01556.x
55.
Rhodes,T., Singer, M., Bourgois, P., Friedman, S., & Strathdee, S. ( 2005). The social structural production of HIV risk among injecting drug users. Social Science and Medicine, 61, 1026-1044. doi:10.1016/j.socscimed.2004.12.024
56.
Riddell, C., & Riddell, R. ( 2006). Welfare checks, drug consumption, and health: Evidence from Vancouver injection drug users. Journal of Human Resources , 41(1), 138-161. Retrieved from http://www.ssc.wisc.edu/jhr/2006ab/riddell1.htm
57.
Simmonds, L., & Coomber, R. ( 2009). Injecting drug users: A stigmatised and stigmatising population. International Journal of Drug Policy, 20(2), 121-130. doi:10.1016/j. drugpo.2007.09.002
58.
Small, D. ( 2008). Fighting addiction’s death row: British Columbia supreme court justice Ian Pitfield shows a measure of legal courage. Harm Reduction Journal, 5, 31. Retrieved from http://www.harmreductionjournal.com/content/5/1/31
59.
Small, W., Rhodes, T., Wood, E., & Kerr, T. ( 2007). Public injection settings in Vancouver: Physical environment, social context and risk. International Journal of Drug Policy , 18, 27-36. doi:10.1016/j.drugpo.2006.11.019
60.
Spittal, P.M., Craib, K.J., Wood, E., Laliberté, N., Li, K., Tyndall, M.W., . . . Schechter, M.T. (2002). Risk factors for elevated HIV incidence rates among female injection drug users in Vancouver. Canadian Medical Association Journal, 166(7), 894-899. Retrieved from http://www.cmaj.ca/cgi/content/abstract/166/7/894
61.
Strathdee, S.A., Patrick, D.M., Currie, S.L., Cornelisse, P.G., Rekart, M.L., Montaner, J.S., . . . O’Shaughnessy, M.V. (1997). Needle exchange is not enough: Lessons from the Vancouver injecting drug use study. AIDS, 11(8), F59-F65. Retrieved from http://journals.lww.com/aidsonline/Fulltext/1997/08000/Needle_exchange_is_not_enough__lessons_from_the.1.aspx
62.
Tyndall, M.W., Craib, K.J., Currie, S., Li, K., O’Shaughnessy, M.V., & Schechter, M.T. (2001). Impact of HIV infection on mortality in a cohort of injection drug users. Journal of Acquired Immune Deficiency Syndromes, 28(4), 351-357. Retrieved from http://journals.lww.com/jaids/Fulltext/2001/12010/Impactof_HIV_Infection_on_Mortality_in_a_Cohort.8.aspx
63.
Tyndall, M.W., Currie, S., Spittal, P., Li, K., Wood, E., O’Shaughnessy, M.V., & Schechter, M.T. (2003). Intensive injection cocaine use as the primary risk factor in the Vancouver HIV-1 epidemic. AIDS, 17(6), 887-893. Retrieved from http://journals.lww.com/aidsonline/Fulltext/2003/04110/Intensive_injection_cocaine_use_as_the_primary.14.aspx
64.
Tyndall, M.W., Kerr, T., Zhang, R., King, E., Montaner, J., & Wood, E. ( 2006). Attendance, drug use patterns, and referrals made from North America’s first supervised injection facility. Drug & Alcohol Dependence, 83, 193-198. doi:10.1016/j .drugalcdep.2005.11.011
65.
Tyndall, M.W., Wood, E., Zhang, R., Lai, C., Montaner, J.S., & Kerr, T. ( 2006). HIV seroprevalence among participants at a supervised injection facility in Vancouver, Canada: Implications for prevention, care and treatment. Harm Reduction Journal, 8, 36. doi:10.1186/1477-7517-3-36
66.
van Beek, I. ( 2003). The Sydney Medically Supervised Injecting Centre: A clinical model. Journal of Drug Issues, 3, 625-638. Retrieved from http://www.2.criminology.fsu.edu/~jdi/33n3.htm
67.
van der Poel, A., Bargendregt, C., & van de Mheen, D. (2003). Drug consumption rooms in Rotterdam: An explorative description. European Addiction Research, 9, 94-100. doi:10.1159/000068807
68.
Wood, E., & Kerr, T. ( 2006). What do you do when you hit rock bottom? Responding to drugs in the city of Vancouver. International Journal of Drug Policy, 17(2), 55-60. doi:10.1016/j. drugpo.2005.12.007
69.
Wood, E., Kerr, T., & Montaner, J.S. (2007). HIV treatment, injection drug use, and illicit drug policies. Lancet, 370(9581), 8-10. doi:10.1016/S0140-6736(07)61025-3
70.
Wood, E., Kerr, T., Small, W., Li, K., Marsh, D.C., Montaner, J.S., & Tyndall, M.W. ( 2004). Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users. Canadian Medical Association Journal, 171(7), 731-4. doi:10.1503/cmaj.1040774
71.
Wood, E., Kerr, T., Tyndall, M.W., & Montaner, J.S. (2008). The Canadian government’s treatment of scientific process and evidence: Inside the evaluation of North America’s first supervised injecting facility. International Journal of Drug Policy, 19(3), 220-225. doi:10.1016/j.drugpo.2007.11.001
72.
Wood, E., Spittal, P.M., Kerr, T., Small, W., Tyndall, M.W., O’Shaughnessy, M.V., & Schechter, M.T. (2003). Requiring help injecting as a risk factor for HIV infection in the Vancouver epidemic: Implications for HIV prevention. Canadian Journal of Public Health, 94(5), 355-9. Retrieved from http://journal.cpha.ca/index.php/cjph/article/download/425/425
73.
Wood, E., Tyndall, M.W., Li, K., Lloyd-Smith, E., Small, W., Montaner, J.S.G., & Kerr, T. ( 2005). Do supervised injecting facilities attract higher-risk injection drug users?American Journal of Preventive Medicine , 29(2), 126-130. doi:10.1016/j.amepre.2005.04.011
74.
Wood, E., Tyndall, M.W., Stoltz, J., Small, W., Zhang, R., O’Connell, J., . . . Kerr, T. ( 2005). Safer injecting education for HIV prevention in a medically supervised safer injecting facility. International Journal of Drug Policy, 16, 281-284. doi:10.1016/j.drugpo.2005.07.004
75.
Wood, E., Tyndall, M.W., Zhang, R., Stoltz, J., Lai, C., Montaner, J.S., & Kerr, T. ( 2006). Attendance at supervised injecting facilities and use of detoxification services. New England Journal of Medicine , 354(23), 2512-2514. doi:10.1056/NEJMc052939
76.
Wood, E., Tyndall, M., Zhengou, Q., Zhang, R., Montaner, J., & Kerr, T. ( 2006). Service uptake and characteristics of injection drug users utilizing North America’s first medically supervised safer injecting facility. American Journal of Public Health, 96(5), 770-773. doi:10.2105/AJPH.2004.057828
77.
Wood, E., Werb, D., Kazatchkine, M., Kerr, T., Hankins, C., Gorna, R., . . . Montaner, J. ( 2010). Vienna declaration: A call for evidence-based drug policies . Lancet, 76(9738), 310-312. doi:10.1016/S0140-6736(10)60958-0
