Commentary on Enns <i>et al.</i> (2016): Supervised injection facilities as a cost‐effective intervention

The authors build upon evidence for expanded access to supervised injection facilities (SIFs) based on a growing body of cost-effectiveness literature that evaluates estimable costs and costs avoided from infectious diseases. Future directions for economic evaluations of SIFs should seek to examine broader SIF benefits and costs that encompass increased access to addiction treatment and other key health and social outcomes. Injection drug use is associated with a range of costly harms. In addition to direct health-care costs associated with blood-borne infections and overdose, the societal burden attributable to injection drug use is much broader 1. Decreased public order due to street-level drug use, the drug economy and associated costly interventions involving the criminal justice system all contribute to further costly harms and lost productivity 2. In this issue of Addiction, Enns et al. report on a cost-effectiveness analysis undertaken to determine the optimal number of supervised infection facilities (SIFs) in two Canadian cities, Toronto and Ottawa 3. Overall, the study demonstrates that three SIFs in Toronto and two in Ottawa would be cost-effective at a threshold of $50 000 quality-adjusted life-years based on a wide variety of assumptions, including a 50% reduction in needle sharing and fixed operating costs of less than $2.0 million annually. Importantly, establishing no facility was unlikely to be the most cost-effective option in either city. Of note, the authors' findings were based narrowly on direct health-care costs attributable to HIV- and hepatitis C virus (HCV)-transmitted infections and build upon past research, which has found that SIFs reduce HIV and HCV risk behaviours, in particular syringe-sharing during injection 4. In their study, the main health-care cost savings and health benefits of SIFs were attributable to averted HCV infections. While the paper by Enns and colleagues is a welcome addition to the literature, this and past cost-effectiveness work 5-8 has suffered from not accounting for other benefits of SIFs, which is probably explained by the fact that some SIF impacts are difficult to monetize for the purposes of health economic evaluation. For instance, past research has suggested that SIFs do much more than simply reduce HIV risk behavior. Other key findings from previous studies of SIFs include reductions in public injection drug use and improvements in public order 9. The opening of Vancouver's SIF was also associated with reduced fatal overdoses in the close vicinity of the facility, suggesting that SIFs are effective interventions to reduce community overdose mortality 10. SIFs have been associated with increased uptake and more rapid entry into detoxification programs and opioid agonist treatment, behaviors themselves associated with reduced drug-related harm 11, 12, allaying concerns that SIFs may lessen the likelihood of people who inject drugs (PWID) accessing addiction treatment services. Enns et al. also build upon past cost–benefit and cost-effectiveness research from the Vancouver SIF that demonstrated cost savings and years of life gained with implementation of SIFs 5-8. Despite the limitations of the current paper and past economic evaluations that focus largely upon estimable costs and costs avoided due to narrow impacts, primarily infectious diseases and overdose, the authors build upon a growing body of evidence for expanded access to SIFs. Among the best ways to prevent HIV and HCV infection is through addiction treatment 13, 14. The common ambivalence to engage in addiction treatment among PWID is well recognized. However, there remains limited exploration of the particular role that engagement through harm reduction programs plays in motivating PWID to enter addiction treatment. A wealth of practical experience and limited study suggests that harm reduction programs may enhance motivation to seek addiction treatment 15. Rigorous evaluation in this area could help to address ongoing controversies of the benefits of SIFs and lend further estimates that could be included in future cost-effectiveness work focused not so narrowly on infectious diseases that encompass broader beneficial impacts of these programs. None. This research was undertaken, in part, thanks to funding from the Canada Research Chairs program through a Tier 1 Canada Research Chair in Inner City Medicine which supports E.W.

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