Establishing Safe Injecting Rooms in Australia: Attitutes of Injecting Drug Users

Abstract:

Objective: To investigate the attitudes of injecting drug users (IDUs) towards the establishment of safe injecting rooms (SIRs) in Melbourne, Australia.

Methods: Multi-site convenience sampling at Needle and Syringe Exchange Programs (NSEPs) within six Melbourne suburbs. Four hundred current IDUs were recruited directly through NSEP and participant snowballing. Respondents completed either a semi-structured interview, anonymous self-report questionnaire, face-to-face interview or participated in a focus group. Participants were asked to report on their knowledge and attitudes about SIR, their experiences and concerns as participants of street-based illicit drug markets, and their willingness to use SIRs if established.

Results: Participants (91%) were knowledgeable about the SIR issue and thought such a strategy had potential to address both personal and wider community harms associated with public injecting. Most (77%) indicated they would be willing to use a SIR if established in Melbourne. Gender, lifetime non-fatal overdose episodes and frequency of heroin use were all significantly related to a person's willingness to use SIRs. A significant number also reported a preference for injecting at their own place of residence due to concerns regarding privacy, safety and police presence within street-based market places.

Conclusions: This study has Identified a number of important issues relating to the likely demand and uptake of SIRs that should be addressed when considering the feasibility of establishing SIRs within Australia.

Introduction

Safe injecting rooms (also known as safe injecting facilities, safe houses, injecting rooms or safety clinics) are legally sanctioned, indoor facilities where injecting drug use occurs under the supervision of medically trained personnel, and in safe and sterile conditions with access to a full range of sterile injecting equipment. Government-sanctioned safe injecting rooms (SIRs) have operated in some cities within the Netherlands, Switzerland and Germany since the mid-1980s, and are typically housed within integrated centres which also incorporate cafes, counselling facilities, primary medical care services and opportunities for referral to appropriate services (drug treatment, material aid services, advocacy, etc). (1)

It is difficult to assess the precise impact of European SIRs as there have been few impact evaluation studies, and those studies which do exist have not been published in English. However, SIR proponents claim the main benefits of such facilities relate to their potential to help reduce some of the harms associated with injecting drug use, such as the incidence of fatal and non-fatal heroin overdose, blood-borne virus transmission (hepatitis C and B, and HIV), and the prevalence and impact of street-based injecting. (1, 2)

To date, no government-sanctioned SIRs have been established in Australia, however, this option is under active consideration due to emerging evidence of a range of persistent health harms associated with in-jecting drug use, including: increasing rates of fatal and non-fatal heroin overdose, (3, 4) high levels of unsafe injecting behaviour placing people at risk of blood-borne virus transmis-sion, (5) and continuing high rates of hepatitis C virus transmission. (6) Recent studies have also reported on community harms (concerns about unsafely disposed of used injecting equipment, risk of violence, public nuisance, loss of trade, and a sense of fear and dis-placement surrounding the use of public amenities) associated with the proliferation of street-based injecting drug use in some jurisdictions. (7-9)

It is encouraging that the issue of SIR suitability for the Australian setting is being debated at all levels of government, (1, 10) within the general press (11) and at the community level. (12) However, this debate has largely proceeded without direct consultation with the SIR target group -- injecting drug users (IDUs). One important issue which needs to be addressed is the question of likely demand and uptake for such facilities if established. Related to this is the issue of how IDUs perceive such a strategy, and what attitudes and opinions this group may contribute to this important debate.

Methods

The present study consisted of two complementary components. The first, conducted by Turning Point Alcohol and Drug Centre, was an adjunct to the annual Illicit Drug Reporting System (IDRS) study, (8) which occurred during August-October 1998. A total of 293 current IDUs were recruited from Needle and Syringe Exchange Programs (NSEPs) in the Melbourne suburbs of St Kilda, Glenroy, Footscray, Frankston, Dandenong and Fitzroy. Convenience sampling was facilitated through the distribution of recruitment flyers and snowballing (participants informing their network about the study). Participants completed a semi-structured interview which included questions about socio-demographic details, drug use history, recent overdose history as well as questions about their knowledge of SIRs and willingness to use such facilities if established.

The second study component was conducted at the Western Region AIDS and Prevention program and primary needle exchange (WRAP) in Footscray during September-October 1998. One-hundred and seven current IDUs were recruited for participation in either face-to-face interview (n=7), focus group discussion (n=22) or self-completion of an anonymous self-report questionnaire (n=78). Recruitment was facilitated through project flyers posted at the WRAP site. Participants were asked to report on basic demographic details, current and preferred locations of injecting, experiences as participants of street-based illicit drug markets and preferred features of SIRs if established.

Data analysis

Survey data collected within the Turning Point and WRAP components was analysed via descriptive statistics. A bivariate analysis of factors related to willingness to utilise SIRs was conducted for Turning Point survey data. Chi-squared and t-test analyses were performed using SPSS for Windows version 8.0. Focus group data from the study's WRAP component was analysed via a simple consensus-driven exploration of themes reported by participants. (13)

Results

Soclo-demographic details

Most participants of the Turning Point component of the study were male (61%), with an age range of 16-52 years (mean 27, SD 7.7). Sixty-six per cent of participants were unemployed and the mean years of education completed was 10.6 (SD 1.7). Forty-four per cent had either completed or were enrolled in tertiary level study at the time of interview. Thirty-three per cent reported a previous history of incarceration, and 32% of people were involved in treatment for drug-related issues. The WRAP sample was also mostly male (66%), and aged between 15 and over 45 years. Other socio-demographic details were not collected from this sample.

Locations of injecting drug use

Participants of the study's WRAP component reported that they injected drugs within a range of both private and public locations. The majority (60%) indicated that they most often injected drugs within their own homes. However, these people reported that they also injected in public locations such as: parks (13%); public toilets (12%); cars (11%); laneways (9%); car parks (8%); and disused or abandoned buildings (7%).

WRAP participants expressed concerns regarding injecting in public locations. The main concerns reported were related to: the presence of inappropriately discarded used syringes in public areas (65%); the risk of hepatitis C infection (62%); police presence (54%); risk of heroin overdose (53%); lack of safety and privacy (50%); risk of being seen by members of the general public (47%); and a lack of opportunities for cleanliness and hygiene during street-based or public injecting (38%).

Knowledge about SIRs

When asked to describe their understanding of SIRs, 91% of participants of the Turning Point survey readily identified the main components of SIR facilities as defined by the European model. The most commonly reported features were: safety and security; clean and sterile environment for injecting; absence of police presence; supervision of injecting processes by suitably trained staff who may provide assistance to clients in the case of overdose on the premises; opportunities for access to sterile injecting equipment; and safe disposal of used injecting equipment.

Willingness to use SIR

Seventy-seven per cent of the Turning Point sample indicated that they would be willing to use a SIR if established in Melbourne. Further analyses revealed that a number of factors were related to a person's willingness to use SIR. Those people who were willing to use a SIR had experienced significantly more nonfatal overdoses in their lifetime (mean=2.44, SD=5.33), compared to those who were unwilling (mean=0.75, SD=1.29), t (281)=6.36, p<0.05. Males (83%) were more likely than females (68%) to be willing to use SIRs (X(x) [1, n=283]=8.71, p<0.01). Finally, those people who were willing to use a SIR had used heroin on more days within the past six months (mean=118.63, SD=65.17) than those who were unwilling (mean=93.43, SD=72.83), t (281)=7.01, p<0.01. A person's age, experience of overdose in the past 12 months and main source of heroin supply were not related to their willingness to use SIR.

Reasons given by the Turning Point survey respondents for their willingness to use a SIR related to concerns which they held regarding both personal and community harms associated with streetbased injecting. These included: the desire for safety and privacy while injecting drugs (37%); the desire to keep injecting off the street and out of public areas (27%); the opportunity to be free from police pressure (27%); a greater capacity to safely dispose of used injecting equipment (15%); the presence of trained staff to assist in the event of overdose (11%); and the chance to inject in a clean and hygienic environment (10%).

Twenty-three per cent of Turning Point participants reported that they would not use a SIR if established. The main reasons related to: a preference to inject at home (48%); concerns regarding the degree of privacy within such facilities (34%); concerns about police presence and activities in the immediate vicinity (13%); and the fact that some people did not access or inject drugs within street-based illicit drug market places (11%).

The majority of WRAP survey respondents (74%) indicated that, if given a choice, they would prefer to inject within their own home. Other preferred locations included: within a SIR (31%); at a friend's home (8%); and in a car (4%). The reported desirable features of people's preferred location of use were: safety, privacy, comfort and security (83%); the absence of police (78%); and the cleanliness of the environment (63%). Female participants of the WRAP focus groups were especially concerned about their privacy and safety as participants of street-based illicit drug markets, and expressed reluctance to inject in public areas unless in the company of others. This group, as well as younger participants (71%), reported feeling especially vulnerable and prone to violence and 'stand-over tactics' (threats made to gain access to money and/or drugs) in these contexts.

Desired SIR features In the Australian setting

WRAP survey respondents identified a number of features which they believed were important for SIRs, if established in the Australian context. These were: needle exchange facilities (76%); flexible hours of operation (74%); confidentiality for clients (63%); accessibility for all ages (58%); adequate staffing and supervision (48%); capacity for assistance in the case of overdose (59%); capacity to provide information and establish appropriate referral links to treatment and other services (47%); and proximity to public transport (36%). WRAP focus group participants also indicated that a SIR would not necessarily attract people who did not currently access drugs from the area in which it was established. Similarly, 11% of the Turning Point sample reported that they would be most likely to use a SIR if it were located conveniently in relation to their supply source.

Asked to indicate their preferences for possible SIR sites such as existing NSEPs, at a stand alone site, at a hospital or at a medical centre - the majority of the WRAP sample (76%) indicated that they would prefer SlRs to be established within existing NSEPs. Others (18%) suggested that SIRs could be established either within or close to hospitals or medical centres.

Discussion

The majority of Turning Point study participants who indicated that they would be willing to use SIRs if established in Melbourne, supported the perceived potential of SIRs to address the personal and community harms associated with street-based injecting. Many IDUs are not only concerned about the harms which they themselves are exposed to when injecting in public spaces, but also the resultant harms to which fellow members of the community may be exposed. This finding indicates that IDUs are an important target group to be consulted when exploring strategies to address the public health impact of injecting drug use

Turning Point study participants who were willing to use SIRs were more likely to be male, have experienced more non-fatal heroin overdoses and used heroin more frequently in the past six months compared to those people were not willing to use SIRs. This is an important target group for harm minimisation strategies such as SIRs, which aim to reduce the incidence of fatal and non-fatal heroin overdose. The finding that this group would be willing to use SIRs is particularly encouraging.

A number of findings from this study have important implications for the likely rates of SIR demand and uptake if established in Australia:

• A significant minority of participants of the Turning Point survey reported that they would not be willing to use SIRs. The major reasons given were a preference to inject at home and concerns regarding privacy within such facilities.
• The majority of participants of the WRAP component of this study indicated that they would prefer to inject in their own home. Reasons given included feeling safe and secure within the home setting: the absence of police presence and pressure; and the greater capacity for cleanliness and hygiene when injecting at home.
• Female participants of WRAP focus groups expressed concerns about their safety as participants of street-based illicit drug markets, and were also less likely than male participants to express willingness to use SIRs.
• WRAP study respondents predicted that SIR would not necessarily be inundated with people who did not currently access or use injectable drugs within the area in which such facilities were established. Respondents were adamant that IDUs would not travel long distances to other street-based illicit drug market places just to use a SIR. This is a particularly relevant issue for Melbourne, given evidence of the existence of multiple and geographically distinct street-based heroin markets. (8) Further, this raises the question of how best to approach the trialling and/or establishment of SIRs within jurisdictions such as Melbourne where street-based injecting drug use is not restricted to one or two localities.

These findings show that there arc significant numbers of IDUs who, for a variety of reasons, would be unlikely to utilise SIRs if established in this country. This has important implications for the impact that SIRs may have upon drug-related harms in Australia. For example, evidence from studies of heroin overdose fatalities has demonstrated that 33-68% of deaths occur in the home or private environment. (14-16) Similarly, available data on rates of non-fatal overdose show that 45-66% of non-fatal overdose episodes occur within private settings such as the home. (3,17) It is likely therefore that even if SlRs were to be established in Australia, the risk of death from heroin overdose would continue among a significant number of IDUs who prefer to inject in private settings. These findings highlight the importance of being realistic about the potential benefits of SIRs for the Australian setting. The evidence presented in this study suggests that SIRs alone are unlikely to be a panacea for the major health harms associated with injecting drug use. SIRs should be viewed as but one part of an integrated and multifaceted set of initiatives and strategies which seek to reduce the harms associated with injecting drug use.

The study participants' views regarding desirable features of SIRs for the Australian context provide implicit support for an integrated approach to reducing illicit drug related harm. In addition to identifying SIR features with which to address the harms associated with the injecting process itself (provision of sterile injecting equipment, assistance in the case of overdose, sterile injecting environment, disposal facilities, safety and privacy), participants indicated that SIRs should also be responsible for providing a range of educational materials and information, as well as referrals between clients and appropriate drug treatment and other health and welfare services. Further, the majority of WRAP study participants indicated that SIRs would be best established within existing NSEPs. However, this finding should be interpreted with caution, given that this was a sample of primary NSEP clientele.

This study has provided important evidence in relation to issues such as the level of IDU support for SIRs, and the likely rates of demand and uptake for such facilities if established in Australia. In addition, there are a number of other important issues which require further investigation as we continue to explore the feasibility of establishing SIRs in this country. Foremost among these is the issue of comparability between the illicit drug use contexts of Australia and those European countries in which SIRs exist. What type of contextual climate is most conducive to the successful operation of SIRs? An equally important issue relates to the SIRs' impact upon injecting drug use, the community, health harms and drug markets. To what extent can reductions in a variety of personal and community harms associated with injecting drug use within the European context truly be attributed to the establishment of SIRs? Do we have the standard of evidence required for making such conclusions? A third issue which deserves attention is that of community attitudes towards SIRs. How do the communities in which SIRs are located view these facilities? A related question is that of the likely rates of SIR demand and uptake among people from culturally and linguistically diverse backgrounds. How will SIR meet the needs of these groups?

Acknowledgments

The Turning Point Alcohol and Drug Centre component of the study was supported by the Commonwealth Department of Health and Aged Services, as part of the Illicit Drug Reporting System project. The Western Region AIDS and Hepatitis Prevention Program component was supported by the City of Maribyrnong Council. The authors wish to thank Jenny Kelsall, James Dixon, Ian Bell, Fiona Wiltshier, Jane Dicka, Karen Reiter for conducting interviews with study participants. Thanks also to the agencies which assisted with the recruitment of study participants (Western Region AIDS and Hepatitis Prevention Program, Turning Point Alcohol and Drug Centre, Dandenong Hospital AIDS Prevention and Support Unit, St. Kilda Crisis Centre, Southern Hepatitis/HIV/AIDS Resource and Prevention Service, AIDS Prevention & Health Awareness Program). We are grateful to the WRAP study critical reference group (Carlo Campora, Hepatitis C Council; Lynley Dumble, Maribyrnong City Council; Belinda Mawby, Melbourne City Council; Danny Mehan, Consultant; Sabine Obermeier, Western Region AIDS and Hepatitis Prevention Program; Mark Young, AIDS Prevention & Health Awareness Program). Thanks also go to Paul Dietze for commenting on final drafts of this paper.

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