Safe Injection Facilities: Should Victoria Have a SIF Pilot-Trial?

The drug problem is one of the most complex issues facing society today. There is no simple or single answer to this issue. Illicit drug use affects all communities and every level of society.

One of the principal reasons for looking closely at the experience of Safe Injecting Facilities overseas,(1) which has pertinence to the Australian context, is in their perceived ability to substantially curtail the incidence of death from overdose in the injecting illicit-drug-using community.

Across Victoria there were 125 deaths from heroin in the 12 months to June 30, 1997(2) and many health workers are concerned that Hepatitis C has the potential to be of epidemic proportions.

There are no quick-fix solutions, and anyone who thinks they have all the answers to these problems is deluding themselves, or intentionally engaging in misinformation.

It has been continually stated that the only way forward in the development of drug policy is for decision makers to have an "open mind" when examining possible strategies to address this burgeoning problem.

It is unfortunate that many options and possible alternative approaches have been consigned to the too-hard-basket because implementation of these measures is seen as politically unpalatable.

In terms of the urgency of canvassing and assessing a range of alternative strategies to the escalating drug problem this country is facing, it has been universally acknowledged that past policies and practices have had little efficacy in substantially countering this problem, and in particular the increasing prevalence of illicit drug use.

Revisiting past policies or maintaining the status quo, is in fact a retrograde step and an admission of failure. Prohibition and the resurrection of the law-and-order approach to the drug problem, has been shown to be ineffective and a waste of police and community resources.

Politicians and other decision makers in society, if they are honest about tackling the complex problem of increasing illicit drug use, need to canvass and examine in a bipartisan way, a range of alternatives, even where these may be perceived as being "radical".

The Public Debate

While there will be many obstacles to the establishment of a trial for a Safe Injecting Facility, the public has shown an increasing preparedness to discuss and explore new programs and strategies to tackle the problems that it is currently facing.

The pilot-program to set up a Safe Injecting Facility would proceed on the basis of a medical and scientific experiment with stringent evaluation and monitoring procedures based on the collection of detailed data.

As has been argued in other discussion papers that have looked at this issue, if a pilot program is set up, then in order for this to be successful it is better that this is done in a number of sites rather than being concentrated in one municipality. This would curtail problems with one area being singled out as a perceived magnet for drug users. The actual number of sites would be the subject of further analysis.

Specific problems in the Springvale area

Many of the drug problems in Springvale and the surrounding area relate to the community's perception of the problem, its "visibility", rather than a statistical analysis of levels of increased drug activity.

While this perception is not based on hard statistical data, the community's concern is wide and strongly felt and has had its expression in a number of forums and other public meetings that have been held to look specifically at the drug issue.

One of the main concerns continually expressed by residents and workers in the Springvale area has to do with "environmental pollution", and in particular the prevalence of inappropriately discarded needles being found in public places and on private property.

There is concern about needle-stick injury and some residents have said that finding needles in the street, schools and public places has led to a growing sense of anxiety in the community.

Another correlative concern has been the so called "nuisance factor" brought about by what is seen as increased drug activity in the main shopping precinct. This has included anti-social behaviour associated with increased drug activity, as well as shooting up and overdosing in public.

These factors have affected residents, businesses and schools, with increasing reports of people finding alternate shopping venues, and schools in the area worried about declining enrolments which threaten their long-term viability.

Unless these and associated problems are significantly addressed, they will have a major impact on the long-term future of Springvale and its surrounding area.

Springvale Community Health Centre's support for needle exchange services

Springvale Community Health Centre, in accordance with the State Government's central philosophy of harm minimisation in drug policy, fully supports the provision of needle- exchange services as a core component in reducing the spread of blood-borne viruses such as HIV/AIDS and hepatitis in the injecting drug-user and wider community.

In accordance with this, up until recently SCHC was a secondary provider needle-exchange service which was auspiced by the Dandenong Hospital-AIDS Prevention and Support Unit.

The service at SCHC was provided through the SHACK youth support unit, and since closing the in-house needle-exchange service component of its operation, has reverted to its initial core purpose of providing "at risk" youth in the area with a wide range of integrated support services. The new needle-exchange service is now run as an outreach program, which promotes links with the integrated services provided by SHACK staff.

Anomalies in legislation and practices concerning needle-exchange services

A central anomaly in the current policy regarding needle-exchange services is that while Federal and State Governments support programs where sterile needles and syringes are given out to injecting drug users, those same users are often forced into unhygienic environments (in the case of Springvale this can be toilet blocks, alleyways or behind business premises) in order to inject.

Another major concern relates to fear of police apprehending needle-exchange clients. Even though it is a formal part of Victoria Police policy not to have a significant presence in or near needle-exchange services, the reality is that in terms of Springvale this is sometimes overlooked, and this seems to be especially the case by police who are temporarily recruited from outside areas.

Added to this are the problems associated with the self administration laws. While it is not illegal to carry a syringe, having traces of an illicit drug within a syringe is illegal.

As in other states of Australia, the self administration laws are seen by many as working against the principles of harm minimisation in drug policy, and because of this a number of states are currently reviewing this legislation.

Anecdotal evidence as well as comments from staff working in the needle-exchange service at the SCHC, confirm the view that injecting drug users will often get rid of needles immediately after administering drugs because of fear of being charged by the police.

This has been exacerbated by the fact that the needle-exchange is now an outreach service, one part of which operates as a mobile exchange or "foot-patrol". People working on the mobile service have claimed that police have apprehended clients who have obtained sterile syringes once the "foot-patrols" have moved on. This is a highly unsatisfactory situation that should be rectified through legislation.

Overseas support for safe drug injecting environments

In terms of the overseas experience, there have been a range of terms and labels to describe the provision of an environment or facility where injecting drug users can administer drugs in safe and hygienic surroundings.

Safe Injecting Facilities, or what have amongst other things been called "Safe Injecting Rooms" or "Safe Houses", have operated successfully in a number of overseas countries for several years.

A good overview of SIF's and there success overseas is given by Kate Dolan from the National Drug and Research Centre in a recent edition of Connexions. (In terms of this discussion paper it is worth quoting from this article in detail.)

Under the heading "The Swiss Experiment" she states that: "Injecting rooms, sanctioned by the government and funded either by government or non-government organisations, have been operating in Switzerland since 1985. Centres now operate in Bern, Basel and Zurich and are available to people aged 16 and over."(3)

In summarising the main benefits of SIF's she states: "They aim to reduce deaths from drug overdose, to reduce the spread of infections from the shared use of injecting equipment, and to reduce the public nuisance associated with drug injecting in streets and parks."(4)

Other points she makes are:

• The typical injecting room is discreetly located within a large centre which includes a cafe, counselling room and clinic for primary medical care.
• The rooms where injecting occurs are small and quite sterile. They contain several tables at which clients sit to prepare and inject their drugs.
• Injecting paraphernalia such as needles and syringes, a candle, sterile water and spoons are placed at each position at the tables. Paper towels, cotton pads, bandaids and rubbish bins are available.
• Clients generally stay in the injecting room for about 15 to 20 minutes to inject with a maximum of 6 - 10 people at any time.
• Clients prepare only their own drugs in the injecting room. Staff are not permitted to help them inject.
• One staff member is present in the injecting rooms at all times, rotating hourly. All staff are trained to resuscitate clients if they overdose, with one staff member assigned prime responsibility on each shift.
• Doctors are employed on a sessional basis and visit the centre for a few hours a week.
• Some centres have direct phone lines to police and ambulance services.
• Approximately 100 clients visit each centre every day. In Zurich over a 12 month period, there were an estimated 68,000 injections, 3000 abscesses treated, 22 clients resuscitated and 10 calls for an ambulance to attend.
• The main reasons given for attending injecting rooms in 1995 were to inject in peace, to obtain free injecting equipment, and because medical attention was available.(5)

In summary, Dolan says: "Injecting rooms have been well tolerated in their communities with benefits clearly outweighing costs"...and that "Injecting rooms are now well established in Switzerland, but only seem to be needed in particular circumstances and in certain locations."(7)

Support for Safe Injecting Facilities within Australia

It is not the intention of this discussion paper to canvass all the possible objections to the concept of SIF's, but rather to examine some of the arguments that have been put forward both within Victoria and throughout Australia as to why they should at least be considered as one of the array of possible alternatives to current drug policies and programs.

The Wood Royal Commission in NSW has come out with one of the strongest statements in support of safe injecting environments in the Australian context.

In its final Report it states: "There are...good reasons for the existence of approved injecting rooms in high risk locations, as:

• it is fanciful to think that drug addicts can be prevented from obtaining and using prohibited drugs;
• the risk of the spread of infectious diseases demands that sterile syringes and needles be made readily available to the population of injecting drug users;
• used syringes and needles need to be disposed of safely;
• such an environment reduces the incidence of theft and violent assaults on drug users;
• injecting drug users, very many of whom want help, can be targeted for education and encouraged to seek treatment for their addiction and associated medical problems; and
• in the event of an overdose, staff are available to contact the Ambulance Service and, if suitably trained, to administer preliminary first aid.(8)

The Report states that the health and public safety benefits outweigh the policy considerations against condoning otherwise unlawful behaviour, and "for these reasons, the Commission favours the establishment of premises approved for this purpose and invites consideration of an amendment of the Drug Misuse and Trafficking Act to provide for the same."(10)

One of the most comprehensive investigations into the drug problem in Victoria has been conducted by the Premier's Drug Advisory Council. The Chairman of this Council, Professor David Penington, in discussing the various approaches to the problem of drug abuse has been quoted as saying that: "The two strands of a policy to minimise the harm of drugs were reducing drug supply through policing, and helping addicts through programs, including controlled trials and safe 'shooting galleries'." (The Age 16/9/97)

Another recent newspaper article also highlighted support for the concept of safe injecting environments from a number of local councils across Australia. The article under the heading "Mayors back local shooting gallery trials" says "local government leaders in South Australia and Queensland have backed a trial of legal heroin shooting galleries" and that "a national survey of mayors...has shown that shooting galleries are on the agenda of other local authorities." (The Australian, 10-9-97)

The City of Greater Dandenong, in a report on the issue of "Safety Clinics" and their potential to reduce the number of inappropriately discarded syringes and needles being found in locations throughout the municipality, gave support to the concept of safe injecting environments.

The report recommends that: "Council support the Harm Minimisation philosophy and that Safety Clinics are a harm reduction strategy which seem to have had success internationally. It recommends that Council write to the State and Federal Governments requesting that the Government pursue at the Commonwealth level a clinical trial of a Safety Clinic in an appropriate location."(11)

The Report defines Safety Clinics as "legally sanctioned facilities where injecting occurs under medical supervision" and states that "Safety Clinics would also offer counselling and referral, education about vein care and information on safer drug use."(12)

How would a SIF address the specific problems in Springvale?

It is envisaged that a properly operating pilot-trial of a Safe Injecting Facility in Springvale and other nominated locations would substantially decrease the incidence of inappropriately-discarded needles in the respective municipalities.

Because of the time frame users are able to be in the facility (overseas experience suggests that this should be no more than one hour), there would be a greater potential to "engage" users and link them to a range of integrated support services, which would include counselling and rehabilitation programs.

In the case of Springvale, this "linkage" would be to the SHACK, Springvale Community Health Centre's youth support facility. The SHACK will continue to provide a range of integrated services to young people in the area who are perceived to be "at risk".

It is envisaged that as part of the clinical trial, needles and syringes would not be taken away from the SIF, and this policy would further reduce the incidence of inappropriately discarded needles and syringes being found in public places.

(The number of inappropriately discarded syringes will not be entirely eliminated as pharmacies which act as a dispensing services only, account for 43% of syringes and needles ordered within the City of Greater Dandenong which are used by illicit drug users within a one year period.)(13)

Locating a SIF in a discrete environment, in for instance an industrial part of the municipality similar to the provision for legal brothels, would reduce the "visibility" of the so-called "nuisance factor" from the Springvale central business district, main shopping strip, parks, schools and other public places.

What would be involved in the setting up of a SIF in Springvale?

It is important to emphasise that in terms of this discussion paper the proposed clinical-trial for a Safe Injecting Facility is very different to the premises set in place for the ACT Heroin Trial. A SIF is not a substitute for or another version of the ACT Heroin Trial, they are completely separate and different concepts.

There has been a lot of confusion over these two issues, and this had been fuelled in part by recent media reports.

A clinical-trial for a Safe Injecting Facility, has entirely different objectives and intended outcomes to those proposed in the ACT Heroin Trial. A SIF, it needs to be stated clearly, is NOT a Heroin Trial.

A SIF would not be involved in the dispensing of drugs. It would be a legally-operating facility that has no involvement in the promotion of illicit drug taking and would implement procedures to ban dealing of drugs in or near the premises.

It is an essential premise of SIF's that they are set up to provide a safe and hygienic environment for injecting drug users to carry out their activities in controlled and discrete surroundings rather than in public places.

One of the strongest arguments in favour of trialing SIF'S is their potential to save lives through reduction in deaths caused by overdose. They would also provide a venue to reinforce messages about safe injecting practices and the danger of sharing needles.

There would be provision of medical support services and first-aid training in overdose procedures, treatment of abscesses as well as a range of related medical factors for staff within the SIF environment.

While, for the sake of convenience, the term Safe Injecting Facility in relation to this proposal is generally meant to mean some type of building, the term can also be broadened to include a room, a safe place, part of a building or it has even been suggested in preliminary discussions on this issue, that this could be in the mobile form of a bus.

At this stage the idea of what a SIF provides is probably more important than precise delineations of what this environment would be physically situated in.

How much is it anticipated a clinical trial of a SIF would cost?

It has been estimated that the annual cost of running a SIF in Switzerland has been about $300,000 per centre.(14) In terms of the Australian context, while this figure can be used as a rough guide, the fact that what is being proposed is a trial or pilot program will ultimately affect determination of costs. (This of course would need considerable negotiation between all relevant parties.)

What will some of the major barriers be to this trial?

Extensive community consultation would be a crucial pre-requisite before a clinical-trial of a SIF could be set in place.

As well as this, overseas experience suggests that it is highly appropriate and conducive to a higher level of successful outcomes, that injecting drug users are part of that consultative process.

A representative from the NSW Users and AIDS Association (NUAA), Annie Madden, has highlighted the need for this type of consultative process. "Drug users are best placed to identify their own needs and issues. As with needle and syringe exchange programs, they are also likely to provide us with the answers to the difficult issues in relation to injecting rooms, such as how they should operate, where they should be based, who should staff them, what services should be offered and, most importantly, how we ensure that they are attractive and safe places for drug users."(15)

Legal issues relating to a trial for a Safe Injecting Facility

There are significant legal issues which need to be addressed in setting up a trial of this nature.

The City of Greater Dandenong Report on "Safety Clinics" states that: "In 1995, the Redfern Legal Centre in New South Wales, prepared a submission to the NSW Government on the issue of injecting rooms (Safety Clinics). The laws against self administration and possession of small quantities of drugs were highlighted as barriers to these.

The Redfern Legal Centre gave three options for consideration:

• If the proposal was initially on a trial basis, to introduce a rider to existing legislation providing, in effect, a temporary suspension of enforcement of the law for the specific purpose of the trial. This should include the exact location of the trial and a time frame.
• A second option would be to instruct the police to keep away from the facilities. This is an unacceptable solution, leaving police open to charges of corruption.
• The third option is to repeal laws altogether, but this was seen to be highly unlikely at present and would take several years to achieve.(16)

Evaluation procedures for a clinical trial of a SIF

There would need to be extensive scientific evaluation and monitoring procedures set in place for a trial of this nature, and this could be an extension of the type of data already collected by needle exchange services within the City of Greater Dandenong.

In terms of the data collected on injecting rooms in Switzerland, this has included monitoring the number of needles and syringes distributed and returned, as well as the number of injections, overdoses, abscesses and the number of times an ambulance has been called.

The exact details of evaluation and monitoring procedures for a trial of a Safe Injecting Facility within the Springvale and other nominated areas, would form part of a more detailed submission if this proposal is favourably responded to.

Overseas experience of Safe Injecting Facilities has shown that they provide a real opportunity to gather important data on a range of issues relating to illicit drug use and that they have had a significant impact on morbidity and mortality rates for injecting drug users.

Notes

1. Some drug experts have argued that the term "Safer Injecting Facility" should be used, as no form of injecting is safe.
2. Herald-Sun (8-10-97).
3. Dolan, K. "The Swiss Experiment": Connexions Dec. 1996/Jan. 1997. p.10.
4. Dolan, p.10.
5. Dolan, p.10.
6. Dolan, p.10.
7. Dolan, p.10.
8. Wood Royal Commission Final Report, p. 226.
9. Wood, p. 226.
10. Wood, p. 226.
11. City of Greater Dandenong Council Report on "Safety Clinics", 22 September, 1997, p. 79.
12. City of Greater Dandenong Report, p.78.
13. City of Greater Dandenong Report, p.90.
14. Dolan, K. Final Report on Injecting Rooms in Switzerland (National Drug and Alcohol Research Centre) p.2.
15. Connexions December 1996/January 1997, p.7. 
16. City of Greater Dandenong Report, p.88.

Eddie Micallef is a member of the Victorian Drugs and Crime Prevention Committee. This is a bipartisan committee that has examined and evaluated a range of drug programs and strategies both within Australia and overseas.

Mr Micallef is also a member of the Springvale Drug Strategies and Assessment Committee (the local drug action group) and a member of its after-hours sports program sub-committee. The aim of this sub-committee it to target "at risk" young people in the hours after school through involvement in a range of sporting activities.

He has been the President of the Springvale Community Health Centre from its inception in 1984 until it was incorporated into the Southern Region Health Network at the end of 1997. During his term as President of the SCHC, he oversaw the introduction of the Shack youth support centre for young people "at risk", the setting up of a secondary needle-exchange program and its recent transformation into an outreach service.

Mr Micallef has participated in numerous forums, seminars and public meetings that have looked at the drug problem in areas like Springvale, and has hosted visits by international experts that have addressed public meetings on specific drug issues and in particular assessment of alternate drug strategies.

While standing down from the position of President of the Springvale Community Health Centre in December of 1997, he has continued to have input into the Health Centre as a member of its Reference Committee.

Many of the points made in this discussion paper are the result of assessment and synthesis of current research both within Australia and overseas on the issue of Safe Injecting Facilities. More generally, many points made are the result of extensive discussion and liaison with key drug agencies in the City of Greater Dandenong as well as members of the Springvale Community Health Centre board of management.