Full text of DOI:10.1111/j.1467-842X.2002.tb00365.x

Policy – Practice Gaps
Brief Report
The Sydney Medically Supervised Injecting Centre:
a controversial public health measure
Abstract
Cate Kelly and Katherine M. Conigrave
Faculty of Medicine, University of Sydney, New South Wales
Background: Injecting drug use remains a
major public health concern, particularly
because of opiate overdose and
transmission of blood-borne viruses.
Sydney ’s Medically Supervised Injecting
Centre (MSIC) opened on a trial basis in
May 2001 in an effort to reduce the harms
of drug use. In this report, we provide a
brief overview of the reported public health
impact of supervising injecting facilities
n estimated 2% of the Australian publications on the function and public
adult population has at some stage
health impact of SIFs. Bibliographies of
1
A
injected illicit drugs. In 2000 there publications were perused for additional
were 725 deaths attributed to opioids in references. The Medical Director of the
Australia, 90% of which were in the 15-44 Sydney MSIC, Dr Ingrid van Beek, was
2
years age group. These figures are from the
f irst year of the ‘heroin drought’ and
represent 38% fewer deaths than in the
interviewed.
(SIFs) and review the history and early
process evaluations of the Sydney Centre.
Methods: Medline, Internet searches and
perusal of bibliographies of articles were
used to identify key English language
publications on SIFs.These were
previous year. We have yet to see whether Results
the reduction will be maintained. Hepatitis
European experience of
C incidence remains high despite public supervised injecting facilities
education and needle syringe programs.
There are now more than 45 supervised
There are 16,000 new cases of hepatitis C in injecting rooms in Europe, including centres
Australia each year and 90% of these are in The Netherlands, Switzerland, Germany
and Spain.5-7 The first opened in The
Against the background of marked Netherlands in the 1970s and centres have
increases in opiate-related deaths and high operated continuously in Switzerland since
supplemented by interview with the Medical
Director of Sydney MSIC, Dr Ingrid van
Beek.
linked to injecting drug use.3
Discussion and conclusions: It is difficult
to be certain of the public health impact of
SIFs but evidence from overseas and
Sydney ’s early process evaluations provide
promise that they may make a positive
contribution to health.
incidence of blood-borne viral infections, and the mid 1980s. Staff trained in resuscitation
in response to concerns over drug-related supervise all injections and clean injecting
crime and the emergence of illicit ‘shooting
galleries’, the 1997Wood Royal Commission
into the NSW Police Service proposed
equipment is available. In most centres staff
do not help with injecting but provide
(
Aust N Z J Public Health 2002;26: 552-4)
5
education on injecting techniques. In
opening a ‘safe injecting facility’ on a trial
overdoses, oxygen is administered, and if
4
basis. Similar facilities have been proposed breathing does not improve an ambulance is
in Melbourne and Canberra, but only in
called. Naloxone (the specific opiate
7
NSW has a centre opened. In this report we antagonist) is not used in most SIFs. Many
provide a brief overview of reports on the SIFs provide a range of other services such
operation and public health impact of as medical care, counselling and subsidised
supervised injecting facilities (SIFs) overseas food. The increased contact between health
and report on the history and results of early professionals and drug users aims to facilitate
process evaluation of Sydney’s Medically access to medical and other treatment
Supervised Injecting Centre (MSIC). The services for this hard-to-reach population.
aim of this report is not to provide an
It is difficult to accurately assess the
exhaustive review, but to guide the reader to benefits arising out of SIFs, as they have
key publications and issues.
generally been instituted as part of a range
6
,8
of public health measures. There have been
Methods
no reports of overdose deaths in any of the
6
Medline and Internet searches were SIFs and data suggest that public drug use
6
,9
employed to identify English-language
has declined in cities with these centres.
Correspondence to:
Submitted: April 2002
Katherine Conigrave, Drug Health Services, Royal Prince Alfred Hospital, Missenden Road,
Camperdown, NSW 2050.Fax: (02) 9515 8970; e-mail: katec@med.usyd.edu.au
Revision requested: June 2002
Accepted: September 2002
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Policy – Practice Gaps
The Sydney Medically Supervised Injecting Centre
Frankfurt, Germany first established a SIF in 1992 and currently
has four facilities. There has been a significant decrease in fatal
overdoses in that city from 147 in 1991 to 22 in 199710 and this
decline was significantly greater than in the rest of Germany.11 In
Switzerland, drug-related deaths fell from a peak in 419 in 1992
to 209 in 1998.12 Clients using SIFs report reductions in needle
a residential area. It is within 100 metres of 50% of drug over-
doses that ambulances were called to in Kings Cross in 1999. An
independent poll of local Kings Cross residents in 1998 showed a
surprising 76% supported making “available places where drug
users can inject”.18
A licence was granted to the UnitingCare in October 2000 for
operation of the Medically Supervised Injecting Centre (MSIC).
In March 2001, the Kings Cross Chamber of Commerce launched
legal proceedings against the licensing authorities, but these were
unsuccessful in preventing the MSIC’s opening.
6
sharing. Despite initial concerns, local residents have found SIFs
an acceptable alternative to frequent public injecting, 10,13
The process of establishing a SIF in Sydney
Following the Wood Royal Commission, the Parliament of NSW
set up a Joint Select Committee to advise on the costs and benefits
of a SIF. This committee received submissions and visited overseas
facilities. Ultimately, in spite of a body of expert opinion favouring
a SIF on a trial basis, the committee recommended against it. In
the weeks leading up to the 1999 NSW Drug Summit, the Wayside
Chapel, a parish of the Uniting Church in Kings Cross, Sydney,
pre-emptively and publicly opened a SIF out of concern over the
number of overdose deaths in the area. This service was closed by
the police, but legal proceedings against the responsible minister
were dropped.
Operation of the Sydney Medically Supervised
Injecting Centre
Sydney’s MSIC opened its doors on 6 May 2001.19,20 It operates
eight hours a day and is staffed by a medical director, nurses,
counsellors and a security guard. It is not available for use by
intoxicated clients, pregnant women, persons in custody of a child
and those aged less than 18. Clients can only inject once per visit.
Unlike most European centres, naloxone can be administered by
staff in cases of overdose if administration of oxygen is insufficient.
If breathing does not then respond an ambulance is called.While
staff are prohibited from assisting with injecting, a rubber arm is
available for instruction.
Among the 172 recommendations of the 1999 Drug Summit
was a statement that:
The Government should not veto proposals from non-government
organisations fo r a tightly controlled trial of medically supervised
injecting rooms in defined areas where there is a high prevalence
of street dealing in illicit drugs, where those proposals incorporate
options for primary health care, counselling and referral for
The evaluation of the SIF is being conducted by a consortium
commissioned by the NSW Government. This includes the
National Drug and Alcohol Research Centre, the National Centre
in HIV Epidemiology and Clinical Research, members of the
Faculty of Medicine at the University of New South Wales, and
the NSW Bureau of Crime Statistics.To date, one-month and six-
month process evaluations have been released.19,20 During its first
six months of operation, 1,503 clients registered at the MSIC and
11,237 visits were made for injection.20 The number of visits
increased markedly from 187 in May to 588 in October 2001.The
most common drugs injected were cocaine (47%) and heroin
14
treatment …
Difficulties encountered in establishing
a SIF in Kings Cross
15
Later in 1999 the Drug Misuse andTraffickingAct 1985 was
amended to allow the operation of licensed SIFs. Possession and
self-administration of small quantities of illicit drugs would not
be illegal when occurring in a licensed SIF. These changes do not
protect anyone supplying illicit drugs in SIFs. Subsequently, in
(
45%).20 As well as supervising injections, staff provided 2,000
episodes of advice on injecting and vein care, and 1,000 episodes
of psychosocial services, such as counselling or advice on
accommodation. More than 200 referrals were made to drug
treatment services, and more than 200 for general medical or dental
care.20 Fifty heroin-related overdoses were treated, with eight of
2
000 the Federal Government and the International Narcotics
Control Board (INCB) suggested the SIF would be in breach of
Australia ’s international treaty obligations.16 However, it was
determined that a SIF did not contravene these conventions in a
study situation and while proscribed drugs were not provided. It
is less clear whether an ongoing SIF would constitute a breach,
but in aiming to decrease the harms associated with injecting drug
use, the SIF abides by the treaty’s goal. To date, the UN has not
acted against those European countries in which SIFs exist.
Numerous challenges delayed the opening of the injecting centre,
including intervention from the Vatican when a Catholic
organisation (the Sisters of Charity Health Service) was going to
participate in its operation. The Uniting Church then offered to
operate the centre. Kings Cross was chosen as the site for the SIF
20
these requiring naloxone. In addition, there were 28 incidents of
cocaine-related toxicity and five benzodiazepine overdoses.
Discussion and conclusions
An evaluation of the public health benefit of the MSIC faces
the challenge of differentiating the impact of the supervised
injecting room from the impact of other control, prevention and
treatment measures directed at the harms of drug use, and from
local, national and international fluxes in drug supply and use.8
We also know that not all injectors will use a SIF.21 Nonetheless,
overseas experience and early process evaluations suggest that such
a service may make a positive contribution to health. The NSW
Government has announced its intention to extend the operation
because it is an area of frequent public injecting and the site of
one-fifth of all NSW overdose deaths.17 In addition, illegal
4
‘
shooting galleries’ were known to operate in that suburb. The
selected site is readily accessible by public transport and is not in
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Kelly and Conigrave
Brief Report
9
1
.
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with interest the final assessment of this potentially important but
controversial public health measure.
0. Joint Select Committee into Safe Injecting Rooms. Report on the Establish-
ment or Trial of Safe Injecting Rooms. Sydney(NSW): Parliament of NSW;
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1
1
1
Acknowledgements
We would like to thank Dr Ingrid van Beek for her invaluable
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the Medical Prescription of Narcotics. Bern(Switzerland): Swiss Federal
Office of Public Health; 1999.
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13. Drug Policy Expert Committee. Heroin: Facing the Issues. Melbourne(VIC):
Victorian Government; 1999.
1
4. NSW Drug Summit 1999: Government Plan of Action. Sydney(NSW):
Parliament of NSW; 1999.
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