In recent years, a flurry of scholarly reports have demonstrated the effectiveness of supervised injection facilities (SIFs) as a strategy to reduce physical and social harms associated with injection drug use. Empirical data on SIFs lagged well behind their scale-up, but SIFs have now been shown to decrease HIV risk behaviors , overdose deaths  and public disorder , and increase uptake of detoxification services . In this issue, Salmon and colleagues  demonstrate dramatic decreases in ambulance attendances at opioid-related overdoses in the period following the opening of the Sydney SIF, a finding that supports program cost-effectiveness . While SIFs remain controversial, there are at least 90 SIFs in 40 cities globally. To this end, SIFs are becoming increasingly viewed as a necessary component of a comprehensive strategy to reduce drug-related harms and facilitate uptake of medical care and drug treatment among street-based drug users [3,7].
A logical extension of SIFs are supervised inhalation rooms (SIRs), intended for individuals who smoke or snort drugs such as crack cocaine, heroin and methamphetamine; yet most supervised drug consumption programs target drug injectors exclusively. In fact, SIRs operate in only a few countries (e.g. Germany, Holland, Switzerland and Spain) [8–11], and none have been evaluated formally.
The rationale for SIRs may be less obvious than that for SIFs, but is no less important. Sharing of crack pipes—particularly among individuals with sores on their lips as a result of burns and cuts—may contribute to infectious disease transmission [12,13]. Inhalation of methamphetamine has been associated independently with human immunodeficiency virus (HIV) infection among female sex workers, even after accounting for injection drug use . A recent laboratory study suggests that methamphetamine accelerates HIV replication . Furthermore, police crackdowns often drive drug users into clandestine spaces (e.g. abandoned buildings, etc.), where their health is placed at risk . Displacement of drug users contributes to their low uptake of public health and social services . Because many drug smokers are stimulant users who are historically very difficult to engage in drug treatment, SIRs represent a pivotal entry-point where they can begin to be reached. In Vancouver, willingness to use an inhalation room was associated independently with working in the sex trade, sharing crack pipes, having crack pipes confiscated by police, smoking crack in public places and having burns from hurried drug consumption . As many cities are witnessing decreasing numbers of drug injectors but increasing numbers of people who smoke/snort drugs , SIRs warrant a close second look.
A powerful case can be made in support of SIRs based upon the personal experience of one of the authors of this commentary (J.R.N.), who helped to coordinate a drug consumption facility in the city of Bilbao, in Spain's Basque region. From the outset, a non-governmental organization (NGO), Munduko Medikuak-Medecins du Monde-Basque Country, strategically involved community stakeholders in the planning process for a drug consumption facility that included rooms for supervised drug injection and inhalation. The NGO met regularly with community leaders, devised a media plan and gathered technical advice from other European cities. The program opened its doors in 2003, supported by funds from regional, national and European institutions, but was restricted initially to a SIF due to ongoing community concerns. After many months of operation without incident, the community's concerns were allayed and the accompanying SIR was opened in 2005. Initially, its space was limited to allow for the simultaneous supervision for four drug smokers, but a year later this was expanded to accommodate six people. All paraphernalia required for personal consumption within a limited duration was provided (e.g. foil, ammonia/sodium bicarbonate, spoon, distilled water).
Interestingly, a different profile of clients emerged among clients of Bilbao's SIR compared to the SIF. The SIR was attended by more women, ethnic minorities and younger users. Heroin consumption predominated in the inhalation room, whereas cocaine was the drug of choice in the injection room. Anecdotally, a progressive increase was observed in the number of users attending the SIR, and some IDUs who first attended the injection room appeared to transition from injection to smoking. These observations were unfortunately not accompanied by systematic data collection, although transitions from injection to non-injection drug use in Spain have been documented concomitant with a comprehensive harm reduction approach . It therefore seems reasonable to hypothesize that co-existence of SIFs and SIRs could promote transitions from injection to non-injection, thereby reducing the risk of blood-borne infections in the community. However, only through systematic data collection in a controlled study setting can such a hypothesis be tested formally. In our view, it is high time to consider the potential role of SIRs in reducing drug-related harm, and to facilitate rigorous evaluations so that drug smokers are not left peering through the two-way mirrors, waiting to inhale.