Supervised Injecting Facilities: Do They Work?

TheMelbourneReview, 06 February 2012, by Robert Power

It’s just over a decade since supervised injecting facilities were last seriously considered (and then rejected) as an option for Victoria. But the debate – and, more significantly, the evidence – has moved on from the days of the Bracks government. A considered and dispassionate review of this harm-reduction option is now the way forward.

Supervised injecting facilities (also known as drug consumption rooms) have been with us for 20 years, providing clean and safe places for people to inject. There are more than 75 around the world, mainly in Europe, Scandinavia and North America, but there’s just one in Australia, in Sydney’s Kings Cross.

The evidence from those facilities points to three main conclusions: the facilities reap benefits for individual and public health; they render improvements in public amenity and community well-being; and they need to be part of a broader harm-reduction response.

The facilities attract the most marginalised and stigmatised people who inject drugs: the homeless, sex workers, former prisoners, frequent injectors, and poly-drug users. Of Sydney’s clients, three-quarters had never previously been in contact with a drug agency, and these are the ones most likely to be engaged in high-risk activities, such as needle sharing. For them, life on the street is unhygienic and often dangerous, leaving them vulnerable and liable to injecting drugs in dirty, rushed conditions, where overdoses, needle sharing and injuries linked to poor injecting techniques are everyday realities.

Evidence from across the globe shows that supervised injecting facilities can ameliorate these problems. Sydney’s has attracted more than 12,000 vulnerable clients in nine years and supervised more than half a million injections – injections that took place off the streets, away from the public, with safe disposal of injecting material.

An unpublished analysis of a Burnet Institute study found that two-thirds of injectors in Melbourne last injected in a public place, mainly in cars, streets, parks and in the stairwells of public buildings. This is not only inappropriate for the person injecting, but also bad for the local population, raising concerns about discarded needles and general security and safety.

Overdose is another problem for people who use drugs on the street. The Sydney facility has dealt with 3,500 cases of overdose, with no fatalities. Indeed, no overdose fatalities have been recorded at any supervised injecting facility anywhere in the world.

Aside from the personal and familial tragedies averted, there are significant economic savings from thousands less overdose cases for ambulances and hospital emergency rooms; if we factor in the primary healthcare these facilities offer, alongside problems deflected through teaching injecting techniques, then the economic benefits and returns on investment are even greater.

Some European facilities have ‘contact cafes’ where drug users can relax with staff and peers, receiving health promotion, counselling and providing opportunity for staff to develop much needed trust. A fifth of Sydney’s clients were referred to health and social services, including drug treatment.

Contrary to some public perception, the Sydney and Vancouver evaluations showed that drug dealing, drug-acquisition crime and rates of new drug injectors have not increased in their environs. Indeed, many facilities reported reduced crime and the closure of illegal ‘shooting galleries’ in the surrounding areas. This improves local communities, with less visible signs of drug use, notably public injecting and discarded needles.

So where to for Melbourne and Victoria? First and foremost we need to be guided by the evidence. We must accept that some Victorians will continue to use illicit drugs and a small proportion of these people will inject. However, some may wish to stop using drugs and these facilities, through their own staff efforts and referral networks, can help.

The Centre for Research Excellence into Injecting Drug Use, based at Burnet Institute, last year approved funding for further research to be conducted in 2012 into the feasibility and need for a supervised injecting facility in North Richmond. This research will be conducted in consultation with the Yarra Drug and Health Forum (YDHF), who commissioned Burnet’s first feasibility study. Greg Denham, the Executive Officer for YDHF, says that from his experience working in the North Richmond area, most of the community supports the introduction of an injecting facility.

“I have spoken to numerous people living and working in the North Richmond area and have not met one person opposed to the idea.

“The majority of people in the community want to try something that reduces the visible impact of injecting drug use, and I believe that the evidence in Sydney shows that an injecting facility will help.

“We anticipate that such a facility will reduce visible public injecting and ‘nuisance’ type behaviour and improve significantly the public amenity. No one wants to see people shooting up and needles and syringes left in parks and streets,” he said.

The project will take up to four months with researchers collecting and analysing data from organisations such as ambulance services, primary health care facilities, local government and contractors and drug and alcohol treatment agencies.

Further data will be collected through observation of drug use, injecting and disposal practices in the area and there will be a review of the existing public health responses to public injecting. If the data supports the introduction of a supervised injecting facility, a model will be developed as part of the project.

The head of Burnet Institute’s Alcohol and Other Drugs group Professor Paul Dietze says there is clear evidence worldwide that safe injecting facilities are effective in reducing drug related harms. What we now need to ascertain is the benefit (or otherwise) in locating a facility in North Richmond and determine how to successfully implement the program in the community.

“It might not be the case that a supervised injecting facility is required, but we do know these facilities are valuable in high drug use areas. We just need to find out the needs of the various people involved, the people using drugs, retailers, police and the wider community in the area so clear recommendations can be made to council or State Government to make a response,” said Professor Dietze.

“If this needs analysis recommends that a supervised injecting facility is the way forward, we then need to determine what that facility might look like, how it will operate.

“Research indicates that, overall, the community is supportive of harm reduction interventions of this sort,” he added.

Harm reduction is based on a hierarchy of needs that equally well supports efforts towards abstinence alongside other public health goals. But for those who continue to use drugs, for whatever reason, we need to offer comprehensive harm reduction services to keep them healthy and protect society from drug-related harm.

For supervised injecting facilities to function effectively there needs to be community and political support, engagement and collaboration with healthcare services and other agencies. The rooms need to be in places where drug users congregate and may be integrated into existing services, such as needle and syringe programs, or even as mobile units.

And supervised injecting rooms must be adequately funded, but not at the expense of other vital harm reduction services.

Key Findings

In 2009, Burnet Institute was commissioned by the Yarra Drug and Health Forum to undertake research into the viability of supervised injecting facilities for Melbourne. The key findings of that report (see presentation below), generated through a review of published and unpublished literature and key expert consultation are highlighted below.

Supervised Injecting Facilities improve:

• Individual and public health
• Public amenity
• Comprehensive harm reduction

Melbourne currently has:

• Prominence of public injecting
• High rates of hepatitis C amongst injecting drug users
• High occurrence of serious and potentially serious injecting-related injuries and disease amongst injecting drug users
• High numbers of fatal and non-fatal overdoses occurring in public places
• Community concern around publicly discarded injecting equipment

Approaches to supervised injecting facilities require:

• Political and community support
• Strong relationships with other service providers such as local government, community and welfare services are essential
• Police relationships are particularly important
• Strong supporters and champions are needed in government
• Community understanding of the role and purpose of a Safe Injecting Facility built through education and participation
• Focus on rigorous evaluation
• Explore impact on public health via overdose and disease prevention
• Calculate cost savings to health and emergency services
• Review acceptability by target group and access to, and utilisation of, the service
• Monitor provision of referrals to drug treatment
• A range of accessible services
• Employment of a range of workers including nurses and social workers
• Provide fixed site and outreach services
• Locate SIF near existing drug markets
• Provide an integrated range of health and welfare services
• Provide spaces in which client engagement for referral and other assistance can occur.

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