Commentary on Pinkerton (2010): Drug consumption rooms—time to accept their worth

The idea of providing supervised, hygienic rooms for the consumption of illicit drugs has proved highly contentious. To many, it appears to condone, encourage or at least take a laissez faire approach to injecting drug use. For others, it is an approach that keeps some of the most marginalized and damaged people in society alive. Can economic analyses help in these debates? While much of the recent focus has been upon the well-resourced, medically orientated facilities set up first in Sydney, Australia (the Medically Supervised Injecting Centre, MSIC) and then in Vancouver, Canada (the Insite project), there is great variety in the aims, design and operation of these facilities around the world 1. Such variety carries implications for cost–benefit analyses. The evidence base on the effectiveness of Drug Consumption Rooms (DCRs) has been growing rapidly. There is evidence that DCRs are effective in providing medical care and referring users to treatment, other health and social services and reducing the transmission of blood-borne viruses, public injecting and associated litter; ambulance and police call-outs to overdose incidents and drug-related deaths (e.g. 2, 3). Economic evaluations can be used to put a value on these diverse benefits and, by combining these with costs for situations with and without such facilities, can provide evidence on the cost-effectiveness of DCRs. Prior to this year, we were aware of only two such evaluations 4, 5. However, two further evaluations have been published this year 6, 7, both focusing upon the Insite facility in Vancouver. Indeed, three of the four published evaluations have been of Insite and all three have concluded that the project is saving society more money than it costs society. The perceived need for further economic evidence may reflect the threatening political climate that has surrounded the project since its inception. Pinkerton's evaluation focuses solely upon the project's impact on preventing human immunodeficiency virus (HIV) infections through needle and syringe exchange. Insite provides sterile injecting equipment to each user injecting within the facility but it also operates as a large needle and syringe exchange project, providing clean syringes for users to take away with them. As the number of safe injections occurring within the project is dwarfed by the number of sterile syringes distributed through the exchange, the evaluation effectively sets the benefits of this exchange function against the whole cost of the project. The annual figure of 83.5 prevented HIV infections and the medical savings from preventing these cases (Can$17.6 million) was compared to the annual cost of the project (Can$3 million) and the savings of Can$14.6 million resulted. Sensitivity analyses were then conducted, where the ranges of the parameters were manipulated and the impact on the cost–benefit analysis explored. The savings proved to be largely robust, although quite sensitive to the rate of borrowing syringes. One assumption that was not varied in this analysis was that, of those who have injected with a borrowed syringe in the past 6 months, 30% of their injections will have been with borrowed syringes. The Health Canada survey 8 showed that of the 48 users in Victoria who had shared a used needle/syringe over the previous 6 months, 34 had done so only occasionally or once. This parameter is varied in Andresen & Boyd's study [7] on Insite's ability to prevent both HIV infections and deaths, from HIV and from overdoses. They include an interesting discussion of the rationale for including the value of preventing the premature deaths of drug users, pointing out that, from the viewpoint of cold economic rationalism, preventing the death of a drug user might constitute an increased price to society (in terms of future crime and health costs). However, from a moral standpoint there is clearly ‘worth’ (indeed, many would argue, an imperative) to prevent avoidable deaths—thus, to the extent that a DCR prevents deaths, an economic model should recognize the social benefit of this aspect of its work. In addition to differences already noted, the two studies adopted different estimates of the project costs and the life-time savings associated with preventing an HIV infection. These variations demonstrate the range of decisions that have to be made in evaluating the costs and benefits associated with such a complex project as a DCR. These evaluations have not attempted to include the full range of outcomes outlined above, such as reduced ambulance and police call-outs to overdose events. Such detailed evaluation is clearly required to calculate the full savings associated with DCRs, but are likely to be more important for studies where the aim is to compare the cost-effectiveness of different models of DCRs, which may not only have very different costs but also focus upon achieving different outcomes. Given the positive findings from all four evaluations, all of which employed a partial analysis of the benefits, the evidence is strong that, however calculated, DCRs such as Insite deliver net savings to society. This finding should trump the social and political fears that continue to stymie the development and survival of DCRs around the world. None.

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