The evidence is in, and Victorians must decide how best to use it.
Lotte believes Sydney's supervised injecting room saved her life. "I've overdosed before, when I was living rough . . . was lucky, my mate called the ambos and they brought me round." She'd injected in a hurry, in a car, concerned that police were close by. The heroin was too strong and she passed out.
Now she attends the Sydney facility, where she can take her drugs in a secure environment, with medically trained staff close by. "They give us clean needles and teach us safe ways to inject. They talk to us like people, not junkies, tell us where we can get help for other stuff. If I hadn't gone there, I'd be dead on the streets, I know I would." She talks about trying to get off heroin, but hasn't made it yet. "I know when I'm ready they'll help me out."
A decade has passed since supervised injecting places 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. It is now timely for a considered and dispassionate review of this harm reduction option. Supervised injecting rooms have been around for 20 years, providing clean and safe places for drug users to inject. Of the 76 around the world, mainly in Europe, Scandinavia and North America, there's just one in Australia, in Sydney's Kings Cross.
The evidence 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 drug users: 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 rooms 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.
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 injector, but also bad for the local population, raising concerns about discarded needles and general security and safety.
Overdose is a huge risk to drug users on the street, as Lotte's experience shows. The Sydney facility has dealt with 3500 cases of overdose, with no fatalities. Indeed, no overdose fatalities have been recorded at any supervised injecting room anywhere in the world. Aside from the personal and familial tragedies averted, there are cost savings from thousands less overdose cases for ambulances and emergency rooms.
If we factor in the primary healthcare these facilities offer, alongside problems deflected through teaching injecting techniques, then the cost benefits and returns on investment increase.
Some European facilities have "contact cafes" where drug users can relax with staff and peers, receiving health promotion, counselling and much-needed trust building. A fifth of Sydney's clients were referred to health and social services, including drug treatment.
What of concerns over a "honey-pot" effect? 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 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 smaller proportion will inject. Some may wish to stop using drugs, and these facilities, through their own staff efforts and referral networks, can help.
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 stumble and fall, we need to offer comprehensive harm reduction services to keep them healthy and protect society from drug-related harm.
For supervised injecting rooms 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-exchange 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. In short, the evidence is there. It's now over to Victorians to decide how to use it.
Professor Robert Power is principal for disease prevention at the Burnet Institute.
Sydney Morning Herald
June 22, 2010