Law and Order: Medically Supervised Injecting Centres

Medically supervised injecting centres (MSICs) are an exemption from the standard practices of law and order: instead of policing drug users, these facilities allow people to bring illegal drugs to dedicated, clean settings where they can legally inject themselves and receive medical care if required. Essentially, drugs like heroin and ice can be used in a safer environment often integrated with other health and welfare services. These centres aim to improve public health and amenity outcomes, but are criticised for facilitating drug use.

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Australia’s MSICs have been controversial since their inception. The first local MSIC opened in Kings Cross, Sydney in 2001, following a Vatican intervention to withdraw nuns and the arrest of a Reverend for opening a short-lived unsanctioned injecting facility (1,2). Local businesses and residents feared a nearby “safe haven for drug users” would accelerate rampant and disruptive public drug use and threatened last-minute legal action (3). The centre is still in operation and has now supervised more than one million injections without a single overdose fatality (1,4). Medical director Dr Marianne Jauncey explained how the Kings Cross centre saves lives in a discussion with the ABC this year (5).

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Yet before Australia’s second MSIC opened in Richmond, Melbourne in 2018, commentators continued to decry the proposition as accepting and passively encouraging drug use. Nationals MP Emma Kealy announced, "It sends the wrong message to our kids and effectively says we've given up on preventing drug use” (6). With consultation ongoing to establish a third Australian MSIC in the Melbourne city centre, it’s valuable to detangle the misconceptions around the effects of MSICs on communities and their value as public health tools.

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 Much controversy around Australia’s MSICs centres on three concerns: the number of overdoses occurring on premises, the attraction of drug addicts to the areas, and the drain on public health resources. Examining the data collected by public health scientists demonstrates that these concerns are unfounded and supports the continued consideration of MSICs as effective public health interventions.

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WHAT EFFECT DO MSICS HAVE ON OVERDOSES?

It’s critical to understand that MSICs are proposed for areas with heavy drug use, particularly use in public settings and causing medical emergencies like overdoses. At the turn of the millennium, the streets of Kings Cross were a major site of public drug use, overdoses, and ambulance callouts (7). In
2000, one spate of thirty-five Sydney overdoses, four fatal, occurred in a single twenty-four hour period (3). At the time, 10% of all drug overdoses in Australia occurred in Kings Cross (3). In response, the Kings Cross MSIC opened in 2001 following decades of mounting evidence in Europe. European drug injection centres had been operating since the 1970s, with growing official support through the 1990s in countries like the Netherlands, Switzerland, and Germany (2). Evaluations reported successful reductions in public nuisance, improved service access, and declining overdose deaths (2). Switzerland demonstrated annual overdose deaths halved in four years and a tenfold reduced chance of hospital admission in MSIC overdoses compared to overdoses on the streets (2,3).

Similarly, the Richmond MSIC opened in 2018 as a response to the highest heroin death toll in sixteen years and record ice deaths in 2016, with the major drug market in Richmond considered the “epicentre of Melbourne’s heroin crisis” (8). It could be easy to criticise the overdoses occurring on the MSIC premises, but these overdoses predated the MSICs and prompted their opening after other strategies failed to address the crisis.

As public health interventions, MSICs are most effective in areas with high densities of public drug use, like Kings Cross and Richmond, which is why these sites were chosen to house MSICs (7). A systematic review of studies covering a range of MSIC facilities, including Kings Cross, concluded that all facilities had a significant reduction in overdose deaths in their local area (9). Ambulance callouts for overdoses near Kings Cross decreased by 68% within six years of opening (9).

In Richmond, emergency medical attendances to drug overdoses near the MSIC have decreased significantly. Only 30 of the 2657 overdoses treated at the MSIC in its first eighteen months led to ambulance attendance and there has been a 25% decrease in naloxone administration, a treatment for opioid overdose, by ambulances in the one kilometre radius of the MSIC (10). The impact of drug overdoses in these areas has been greatly mediated by the presence of the MSICs. In 2017, the Kings Cross MSIC celebrated one million injections with zero fatal overdoses (1). The lack of a single overdose death at these facilities despite the number of overdoses should be considered a mark of
commendation (1,5,10,11).

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DO MSICS ATTRACT DRUG USERS TO THE AREA?

A second concern is that MSICs attract drug addicts to the area in which they are situated. However, this misattribution of causality arises because MSICs are purposefully located in areas with pre- existing drug markets. Major drug markets create local hotspots of public injection as many drug users inject immediately to reduce withdrawal and avoid police attention (7). These areas of high public drug use became candidates for the establishment of MSICs because drug users already
frequented the area.

Before the MSIC opened, over 90% of ambulances attendances for overdoses in Kings Cross were within a 300 metre radius of the proposed MSIC location. The area was chosen for an MSIC because
of the existing disruption caused by public drug use and overdose. Improving public amenity, such as decreasing encounters with discarded needles, drug injection and overdose, is one of the most important goals of MSICs (2,11). Despite initial outrage in Kings Cross, support for the centre among local businesses increased to 70% in 2005, and local perceptions were positive (11,12). Monitoring of the area found no increase in drug-related crime, dealing or loitering after the Kings Cross MSIC opened (11).

This is also supported by more recent findings in 2017, that alongside improving local amenity and reducing ambulance callouts, the Kings Cross MSIC did not draw dealers and addicts to the area in a
‘honey pot’ effect (6). This was corroborated by a systematic analysis which found no increase in drug-related violence and crime related to MSICs in Sydney and Vancouver across the results of four studies (9). The same review concluded that MSICs do not promote drug use, crime, drug trafficking, or increase new drug users (9).

Likewise, demand for the Richmond MSIC was created by the existing Richmond drug market and disruption to the community, with 46 of 49 local stakeholders found to support a proposed MSIC in a 2017 consultation (11). Alongside harm minimisation, one submission highlighted the “significant toll on health workers and members of the local community who have to deal with the aftermath of overdoses and for children to see people in public in such a terrible state” as motivating their support for establishing a Richmond MSIC (11).

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Since opening, concern that additional people would travel to use the centre was abated by findings that travel distance was a major reason for not attending the MSIC and residential information collected from Richmond MSIC users (10). Regarding public amenity, an evaluation found mixed results in its eighteen months of operation, with reduced sightings of public injections and incidents at the neighbouring school, but decreased perception of safety and community support for the MSIC (10). It remains to be seen how this trend develops with continued operation of the centre.

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DO MSICS DRAIN PUBLIC HEALTH RESOURCES?

While the primary goal of MSICs is to reduce the harms associated with overdose and public drug injection, MSICs have broader public impact through integration with complementary social and medical services. People who inject drugs are subject to associated harms, ranging from increased risks of blood-borne diseases (HIV, HBV, HCV) and psychiatric disorders to homelessness, crime, and prostitution (2,10). This socially marginalised group often lacks adequate access to healthcare, despite the significantly increased risks of harm and death (9). 

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Analysis of the Vancouver MSIC found the streamlined and preventative healthcare provided to drug users was quantifiably more effective and saved both millions of dollars and 920 years of life over 10 years (9). In 2008, an economic review of the Kings Cross MSIC determined that averted health costs alone made significant savings for the government, and the value of prevented deaths would pay for operating costs more than 30 times (13).

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Furthermore, unprecedented access to drug users can facilitate important research to investigate and validate public health issues and strategies. For example, a 2017 paper analysed the rates and severity of overdoses for illicit and prescription opioids with data from the Sydney MSIC, producing clinically salient research enabled by access to marginalised and vulnerable populations (14).

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Alongside reductions in ambulance callouts and overdose complications which are instead managed at the centre, MSICs can improve the reach and delivery of health and social services for drug users, including blood-borne disease screening, drug treatment and rehabilitation, and mental health counselling (9,10). Engagement with MSICs and integrated services promoted safer injecting practices, health and social service use, and entry to treatment programs. The overall proportion of MSIC-attending drug users in treatment programs was 93%, compared to 61% of first-time attendees at the facility, demonstrating the improved effectiveness of reaching drug users with healthcare programs (15). 

Across seven studies on drug user uptake of MSICs, 75% of drug users reported improvements in their behaviours regarding public amenity and safe injection (9). This effect was particularly strong for marginalised and at-risk attendees, like those who were homeless, Indigenous, had previously overdosed, and others with self-identified need (15). MSICs contribute massively to overall public health strategy, through both direct harm reduction and efficiently increasing access to existing services.

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BEYOND MEDICALLY SUPERVISED INJECTING CENTRES

MSICs in Australia and across the world have been successful in achieving their objectives; reducing drug-associated harms and community exposure to public injection and overdose (9,12). The continued controversy around MSICs despite their established and validated success betrays widespread misunderstanding around the nature of addiction, the effective treatment and harm reduction for drug abuse. 

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In 2017, despite the support of three coronial recommendations and the Australian Medical Association for a Richmond MSIC, MP Tim Smith asked, “Since when did we start rewarding people who break the law, since when did drug users become victims, we need to enforce the law" (6,8). Political discourse that distorts the goals of MSICs and distracts from their established efficacy only serves to stagnate evidence-based action and weaken Australia’s response to damaging drug use.  While MSICs attract stagnating attention and controversy, public health issues around drug addiction and opioid dependency remain unaddressed (16). In Australia, prescription drug abuse causes ten times more overdose deaths than illicit drug abuse, and prescription opioids provides a pathway to the use of illegal opioids, like heroin and fentanyl (14,16). As seen in the 2017 investigation into the prevalence and consequences of opioid overdoses in the Kings Cross MSIC, prescription opioid injection is a significant form of harmful drug use (14). MSICs are a useful and effective tool to combat drug abuse, but are not intended to solve all drug-pertinent problems; they must be incorporated into broader public health and crime strategies (9). 

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Drug abuse is a seriously complicated problem, so it makes sense to have misconceptions around the impacts of MSICs. Effective drug policy needs to consider MSICs as a component of a broader public health strategy and educate the public about responses to drug abuse. It’s critical for communities and decision-makers to stay informed and choose evidence-based strategies to address the public health and amenity goals around drug use.