Safe injection site leads to detox

This article reports on a letter to the editor run in yesterday's New England Journal of Medicine about a study of the safe injection site in Vancouver. The main findings reported in the letter were: 1) 18% of the study subjects entered a detox program during the follow-up period; 2) More frequent use of the site and having contact with an addiction counselor at the site were associated with entering detox. The median follow-up period was 344 days.

I've got a few thoughts.

First, why is 18% good? What's the natural rate of opiate addicts seeking detox? If I was operating a needle exchange or injection site (I know, hard to imagine. Don't worry, it won't happen this week.), would I be satisfied with 18% entering detox? I think I'd be pretty disappointed.

Second, I'm not sure why it's surprising that more frequent use of the site and contact with an addiction counselor were associated with entering detox. Wouldn't more frequent use of an injection site be an indication of concern about one's health, and wouldn't you expect this to be associated with entering detox? It's worth noting that subjects had to be repeat users of the site to be selected for the study. Same thing with seeing the addiction counselor. Also, the study got this information by looking at admissions records of detoxes in the city, not by following-up on referrals from the injection site. So, we don't even know if the detox admission is related to an intervention or referral from the injection site.

I don't doubt that, under the right circumstances, something like this could be an effective outreach to get difficult to engage people into treatment and recovery. However, this seems like case of the "subtle bigotry of low expectations." Maybe it's related to the fact that the researchers are primarily interested in HIV/AIDS. I don't want to put words in their mouths, but their expectations of addicts may be low and maybe any effects other and HIV transmission reductions are seen as a bonus rather than an expectation or prerequisite for success.