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Medically Supervised Injecting Centres - A Good Idea or Not?

Monday, 11 July 2011  | Alan Gijsbers

The debate on safe injecting facilities is an interesting example of a debate between two groups of Christians about a secular service within a secular environment.  It also well illustrates David Hume’s famous maxim, “Reason is the slave of the emotions.” 

Injecting rooms were first started in The Netherlands in the 1970’s by St Paul’s church Rotterdam.  In response to the squalor in which people were injecting addictive agents in the streets and laneways, they decided to set up clean injecting facilities which would provide a safe and humane environment in which those marginalised in society by their addiction could inject their drugs in a supportive non-judgmental way, hopefully building bridges which would eventually lead to recovery. 

The only Medically Supervised Injecting Centre (MSIC) in Australia was set up by the NSW state government in response to the 1997 Royal Commission into the NSW Police Service.  Justice James Wood said, “To shrink from the provision of safe, sanitary premises where users can safely inject is somewhat short sighted.”  A joint parliamentary committee into Safe Injecting Rooms recommended in 1998 that such a facility should be set up.  Subsequently the 1999 NSW Drug Summit recommended that a trial injecting facility should be set up.  Initially such a centre was to be run by the Sisters of Charity Health Service (who run the two St Vincent’s Hospitals in Sydney and Melbourne) but when they withdrew on the advice of the Vatican, the NSW Government invited the Uniting Church of Australia to apply for a license to run this service.  They started in May 2001, for a trial period of 18 months.  Subsequently this trial has been extended for three further periods until finally in October 2010 the NSW parliament passed legislation allowing the MSIC to continue operation.  During this trial time the Uniting Church’s Board for Social Responsibility published a theological perspective in March 2000 and the experimental phase has been independently evaluated by five different bodies up until 2010.  The MSIC website gives access to all these reports.  Over 50 professional bodies support their work, including the Royal Australasian College of Physicians, the Royal Australian and New Zealand College of Psychiatrists, the Baptist Inner City Ministries, the Australasian College of Emergency Medicine, the AMA in NSW and bodies like that.    

Over and against this impressive array of experts and political persuasion is a very active group of people called Drug Free Australia who have vigorously challenged the findings of the MSIC.  They have published their own reports and continued to debate the MSIC claims on the Internet.  Thus the Wikipedia entry on Supervised Injecting Sites contains within it a debate between supporters of injecting facilities and Drug Free Australia (DFA).  The debate is somewhat more pointed in the talk page to this site.  DFA’s first evaluation was published in 2003 and the latest in 2010.  Readers can judge for themselves whether DFA on the one hand is the little boy who declared that the Emperor had no clothes, perhaps the minority true prophet over and against the multitude of false prophets, or on the other hand whether in their passion to ban injecting rooms they have distorted the benefits and cost-effectiveness declared by a number of independent evaluators.   

In Victoria, safe injecting facilities were supported by both Kennett Liberal and Bracks Labor governments two elections ago, but they have been strongly opposed by the current Baillieu Liberal government, on very little grounds other than, “We do not endorse such activities in Victoria.”This  in spite of a positive review of the benefits of a safe injecting facility published in October 2009 by the Centre for Population Health, Burnet Institute, commissioned by the Yarra Drug & Health Forum, and endorsed by the Yarra City Council.   

We have yet to see whether the new Liberal/National Government in Victoria with its “tough on drugs” approach will be more successful than the more liberal attitude to injecting facilities in NSW.   

It is unfortunate that when a debate is heavily polarised, it is likely that the protagonists will lose perspective.   Safe injecting facilities make sense from a harm minimisation perspective, where a clean, medically supervised facility may well save people from overdose and the dissemination of infections.  However by themselves they are no more than a bandaid on the broader issues of addiction.   

The first comment is why should clean facilities by used to inject dirty unsafe street drugs?  Why not supply clean medications in such facilities?  This of course would horrify DFA and we would be accused of supporting addictions rather than eradicating addictions.  The Australian Capital Territory was at the forefront of some good work evaluating the benefits of medically supervised heroin facilities before John Howard stepped in and banned such an approach, when he came into power in 1996.  However there is considerable international experience to demonstrate the worthwhileness of heroin injecting facilities. 

The second comment is that so much attention has been paid to heroin, and other opioids (which increase the risk of overdose and death) that there is not much attention paid to the very different profile of injecting psychostimulants (amphetamines such as speed and ice, and cocaine).  Here the danger is not so much overdose and death as the risks of infection and the possibility of psychosis with excessive use – issue which are much more difficult to control and manage.   

The third comment is to ask, if MSICs are such a good idea, how can one centre in King’s Cross service the whole of Sydney, or how can one centre in Richmond serve the whole of Melbourne?  How many centres would serve the population adequately?  How much would they cost and how would a service like this feed into the rest of the services required to provide a comprehensive addiction service, rather than just an injecting room?   

The last comment is to ask what happens when users are sick of using and want to try and stop?  If they want to stop injecting heroin, there are two broad options.  One is to pursue substitution pharmacotherapy with methadone and buprenorphine, and the other is to risk abstinence with its attendant dangers of relapse and overdose.  Protagonists of this latter drug-free approach are currently trialling depot injections of naltrexone.  They have support from some Members of Parliament who complain that “drug industry elites” are muddying the debate on the value of such a move.  They claim these drug industry elites have biased the evidence base to support a single ideology and prevented those advocating abstinence from being properly heard.  On the other hand those like me working in the field and prescribing substitution pharmacotherapy are concerned that untrialled medications are being offered before they are properly evaluated.  It is early days yet, but as the naltrexone implant story is becoming clearer, there may be growing support for that strategy.  It is still true however that the current best evidence is substitution pharmacotherapy.  It is safer and has better outcomes than the naltrexone implant story.  However the pendulum may well swing in the next few years.  Hopefully that will be the province of science rather than that of the ideologies of both sides.      

Associate Professor Alan Gijsbers
is Head of Addiction Service Medicine, Royal Melbourne Hospital; Medical Director of Substance Withdrawal Service, The Melbourne Clinic; President of ISCAST and a former National Chairman  of the Christian Medical and Dental Fellowship of Australia. 



July 12, 2011, 2:12PM
Thanks Alan for a well-informed and informative piece. It seems to me that theologically Jesus' radical middle way in Mt 19 provides a way forward. He responds to the Pharisees request trying to justify an anything goes approach to divorce - legalise it on all grounds e.g. she burnt the toast, I've seen someone better looking etc cf legalising drugs and stresses, in order to protect the victims, i.e. women, and reduce the harm to them, that God's original purpose in Creation was one man one wife for life but Moses permitted (for purposes of harm minimisation) divorce because of their hardness of heart. This is neither libertinism nor legalism (just say no). It maintains the ideal but has a retrieval ethic (Michael Hill) to minimise harm in a fallen world.
Alan Gijsbers
July 21, 2011, 10:02AM
Thanks Gordon. It seems though that your story might imply that the less than ideal is a novel situation. As I read the Old Testament (and especially the stories of Abraham, Isaac, Jacob and Joseph) that God usually works through the messy everyday of troubled humans with all the less than ideal compromises that that brings. The rest of God's grappling with his people would support that view as would the behaviour of the Son of God and his mixing with tax collectors, sinners, outcasts etc. Harm minimisation seems a frequent reality rather than an occasional exception!

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