Sydney’s Medically Supervised Injecting Centre: Your Questions Answered

Wherever there are people injecting in public, there is a need for a safer injecting facility (SIF). In my opinion.

SIFs are subject to an unnecessary amount of controversy and should ultimately just be seen as an extension of needle and syringe programmes, which we have been providing since the 80’s. So, put simply – we are providing people with sterile injecting equipment to use illicit drugs, surely we should therefore be providing a sterile environment in which to use them?

Perhaps this may seem like a step too far for some. We may not like it, but the reality is that people inject drugs in public places. So if it feels wrong to you to consider providing this service, I invite you to please keep an open mind as you read through these questions and to ask yourself this – ‘If I had a family member who was injecting drugs, what kind of environment would I prefer they did it in?’

I had the privilege of spending two whole weeks in Sydney’s Medically Supervised Injecting Centre (MSIC) while the service was fully operational and I interacted with the clients and staff on a daily basis. Armed with your questions from the Survey, I met with key people and below are your answers (in my own words rather than formal references) which I have tried to keep brief so as not to be too onerous a read.

The list of key papers are provided at the bottom of the page should you wish to do some further reading, many thanks to Allison Salmon of the MSIC for pointing me in the right direction with these and to Dr Marianne Jauncey for checking I had my facts right!

I hope you will find this useful, please do not hesitate to contact me should you require further clarification on any of the points. Meanwhile, I’m off to talk to everyone I can regarding the benefit of SIFs and get on with writing up my report 🙂

Here it is, please click on the link for the full document! – Sydney’s MSIC – your questions answered

JAUNCEY, M., TREVAN, A. P. & SULOVSKY, R. P. 2010. Expecting the unexpected: Intravenous insulin at Sydney’s medically supervised injecting centre. MJA, 192, 477.

JAUNCEY, M., VAN BEEK, I., AM., S. & MAHER, L. 2011. Bipartisan support for Australia’s supervised injecting facility: a decade in the making. MJA, 195, 264.

KIMBER, J., DOLAN, K., VAN BEEK, I., HEDRICH, D. & ZURHOLD, H. 2003. Drug consumption facilities: an update since 2000. Drug and Alcohol Review, 22, 227-233.

KIMBER, J., HICKMAN, M., DEGENHARDT, L., COULSON, T. & VAN BEEK, I. 2008a. Estimating the size and dynamics of an injecting drug user population and implications for health service coverage: comparison of indirect prevalence estimation methods. Addiction, 103, 1604-1613.

KIMBER, J., MATTICK, R. P., KALDOR, J., VAN BEEK, I., GILMOUR, S. & RANCE, J. A. 2008b. Process and predictors of drug treatment referral and referral uptake at the Sydney Medically Supervised Injecting Centre. Drug and Alcohol Review, 27, 602-612.

MAHER, L. & SALMON, A. M. 2007. Supervised injecting facilities: how much evidence is enough? Drug and Alcohol Review, 26, 351-353.

SALMON AM, T. H.-H., KIMBER J, KALDOR JM, MAHER L. 2007. Five years on: what are the community perceptions of drug-related public amenity following the establishment of the Sydney Medically Supervised Injecting Centre? . International Journal of Drug Policy 18.

SALMON, A. M., VAN BEEK, I., AMIN, J., KALDOR, J. & MAHER, L. 2010. The impact of a supervised injecting facility on ambulance call-outs in Sydney, Australia. Addiction, 105, 676-683.

THEIN, H.-H., KIMBER, J., MAHER, L., MACDONALD, M. & KALDOR, J. 2005. Public opinion towards supervised injecting centres and the Sydney Medically Supervised Injecting Centre. International Journal of Drug Policy, 16, 275-280.

VAN BEEK, I. 2003. The Sydney Medically Supervised Injecting Centre: a clinical model. Journal of Drug Issues, 33, 625-638.

VAN BEEK, I., KIMBER, J., DAKIN, A. & GILMOUR, S. 2004. The Sydney Medically Supervised Injecting Centre: reducing harm associated with heroin overdose. Critical Public Health, 14, 391-406.

MARSHALL, B. D., MILLOY, M. J., WOOD, E., MONTANER, J. S. & KERR, T. 2011. Reduction in overdose mortality after the opening of North America’s first medically supervised safer injecting facility: a retrospective population-based study. Lancet, 377, 1429-37.

Enns, E. A., Zaric, G. S., Strike, C. J., Jairam, J. A., Kolla, G., and Bayoumi, A. M. (2015) Potential cost-effectiveness of supervised injection facilities in Toronto and Ottawa, Canada. Addiction

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Results of the Opinion Survey on Drug Consumption Rooms (DCRs) for Scotland

Many thanks again to everyone who contributed their opinions for this survey, the results of which I present to you below.

Whilst I am far from an academic, I do recognise that there are several limitations to this survey so I am not suggesting it is a full representation of the Scottish population. The survey was only live for two weeks online via Survey Monkey and was not actively directed at or necessarily available to people who use drugs, which is obviously something that will be prioritised and researched in due course. The purpose at this stage was to gain a quick snapshot of opinions and questions to help inform and lead my project by adding to the discussion with stakeholders in Scotland and staff from Sydney’s Medically Supervised Injecting Centre (MSIC).

There were 428 responses, which I was very happy with! But it should be noted that the questions could be skipped so not all 428 people answered fully.

The majority of respondents were working in the voluntary sector (39%) followed by health services (20%) with the remainder being government, police, prison service, social care and peers/volunteers. Those who marked ‘other’ included people who use drugs and a broad range of other backgrounds and disciplines.

23% of respondents were from Greater Glasgow and Clyde, followed by Lothian (16%). The only health board areas not represented were Orkney and Western Isles. People from out with Scotland also responded and made up around 8%.

74% of people were supportive of MSICs/DCRs, with 19% being unsure and 7% not in support.

The following themes presented from those in support and the text in brackets highlights some of the comments made (in no particular order)

  • Safety – for users (sterile and hygienic environment) and the community
  • Reducing drug-related deaths (staff on hand to respond to overdoses)
  • Reduce sharing of injecting equipment (less blood borne virus (BBV) transmission)
  • Cost saving (less ambulance call-outs and BBV treatment)
  • Engagement in services
  • Education and information
  • Reduce medical problems (BBVs, wounds, early identification of bacterial infections)
  • Reduce discarded injecting equipment (less needle litter)
  • Reduce public injecting
  • Promote recovery
  • Reduce stigma
  • Evidence

One respondent said the following;

“Having used the one in Sydney when I was still using I saw first hand the effectiveness of the service. I was treated with dignity and respect and was able to use in a safe, monitored environment. Without it I would have had to resort to riskier behaviour. Talking with other addicts in the Kings Cross area they confirmed drug deaths in the area had fallen. Here in Scotland a facility like this would save lives and give moments for brief interventions which may lead someone to seek further support for their addiction issues.”

There were 84 responses from those felt unsure or not in support of a MSIC/DCR which have been grouped or noted below (in no particular order)

  • Lack of understanding about such a service (this was the main response in this section)
  • Lack of resources
  • Encourages drug use
  • Negative policing
  • Impact on children
  • Doesn’t aid recovery
  • Drug users congregating around the service
  • Needs large scale population to be viable
  • Effect on nurses/staff

66% of people felt Greater Glasgow and Clyde was most in need of a MSIC/DCR, followed by Lothian (8%). The only health board area to receive no response was Western Isles and 77% of people would be supportive of an MSIC/DCR in their own health board area.

There were 71 comments on why people did not support this in their own area (or were unsure), which centred around –

  • Lack of understanding
  • Rural nature
  • Cost

When asked what type of services people would like to see offered, all of the following received more than 80% from the choices provided –

  • A safer injecting environment
  • A safer environment where drugs could be injected and inhaled
  • Wound care
  • BBV testing/vaccinations
  • Access to drug treatment
  • Take-home naloxone
  • Mental health services
  • Links to mutual aid

BBV treatment and social interventions received 79% and 78% respectively.

There were 55 ‘other’ responses which included many other services, an example of some are listed below –

  • Non-judgemental staff
  • Heroin-assisted treatment
  • Dental services
  • Sexual health testing/treatment

One respondent stated the following –

“The DCR needs to be able to process people fairly quickly to deal with demand. The priority has to be immediate safer injecting. It shouldn’t replicate services available elsewhere but provide a unique service.”

The last part of the survey asked people ‘what questions would you like addressed from Sydney’s experience of their MSIC? (opened in 2001)’ – and there were 188 responses! I did, however, manage to condense this down to a more manageable 40 questions which will form the content of my next blog.

If you would like to look at the survey in more detail I have attached the charts in the form of a powerpoint here and the full survey results with all comments here.

I hope you have found this useful and I look forward to sharing the answers to your questions next time 🙂

‘No Act of Kindness, No Matter How Small, Is Ever Wasted’ – a few thoughts from my 2 weeks in Sydney’s MSIC

What an incredible two weeks in Sydney. I honestly don’t know where to start when trying to sum it up so I’m just going to start typing and see where it goes.

I was based in the MSIC and spent my days there between 9:30am and 6pm, apart from when I was out to meet with the following people;

  • Rosie Gilliver and colleagues, Kirketon Road Centre (it’s worth a look at the huge range of services they provide here)
  • Frank Hansen, former NSW Police Superintendent involved in establishing MSIC (who also very kindly took me on a day trip to Manly with his partner!)
  • Superintendent Tony Crandell, formerly in command of Kings Cross area and the recently retired Supt Pat Paroz
    Tony (left) and Pat, awesome attitudes re. harm reduction
  • Dr Sarah Larney and colleagues, National Drug and Alcohol Research Centre
  • David McGrath, former public servant and political mastermind
  • Graham Long, Pastor and CEO of The Wayside Chapel and colleagues
    Meeting with Wayside Chapel staff :)
    Meeting with Wayside Chapel staff 🙂
  • Deborah Zador and Stephen Ward, Justice Health
  • Staff from the Lord Mayor’s office
  • Colette McGrath, former Clinical Service Manager of the MSIC
  • His Honour Judge, Peter Zahra
  • Roy Bishop and Alex Greenwich, MP

This list doesn’t include the internal MSIC meetings with Marianne Jauncey (Medical Director), the staff team, management, consumer group, community consultation, Allison Salmon (research lead) and the many informal conversations with staff on the floor. Just a few then?! Every single person was so accommodating, happy to share information on the service and I have been provided with more data than you can shake a stick at. (I’ve never used that phrase before, I don’t understand it, it seemed appropriate) Also a special thanks to Allison for all my in-flight reading!

The staff really made me feel like part of the team and I will miss them along with all the clients, many of whom I began to get to know quite well. I looked back through some of the client comment books from 2001 when the service first opened and it was heartwarming to read about how people felt. The thing that struck me the most, asides from the clear feelings of safety and the obvious life-saving element, was that people really appreciated a friendly face and just being treated like a human being in a world where they are denied this the majority of the time. I’m not going to lie and say it doesn’t make me feel a bit emotional thinking about that and I thought about it a lot at nights when I was back in my nice, cosy apartment and most of the MSIC clients were sleeping rough. We should never forget how the smallest acts of kindness can make such a difference to some people’s lives. So when I saw this message on a thank you card it seemed quite fitting to give to the clients, along with a load of cakes and chocolate!

no-act-of-kindness-no-matter-how-small-is-ever-wasted-aesop

I took the opportunity during my last week to ask people about why they come to the MSIC and everyone I asked was happy to write down their thoughts. I am grateful to them for sharing this with me. Here’s an example from someone who has been in the Kings Cross area for many years and remembers clearly the situation before the MSIC opened –

“Since the centre has opened, I no longer have to look over my shoulder for police, shopkeepers, passers-by etc wondering if I am going to be arrested, moved along or jumped on by fellow users. I enjoy the safety, cleanliness, provision of clean equipment and staff with the proper training in case anyone drops. As far as I know there hasn’t been a death (*in the MSIC) since it has opened. The other benefits are the chill out area (free tea and coffee) and the introduction to other services such as housing, detoxing, methadone programs etc. Also the surrounding areas are a lot more cleaner, back st, doorways etc…”

I have several more comments on the service, from workers also, that I plan to include in my official report that I will get started on soon.

Those of you who contributed to the opinion survey on DCRs for Scotland will remember you were asked what questions you would like to know from Sydney’s MSIC – well you had over 130 of them! So I managed to condense them all in to a more manageable 40 questions and basically interviewed Marianne Jauncey for 2 hours (she got me back by forcing me to eat vegemite and taking photos of the torturous experience). Your questions were invaluable and certainly covered all of the key points, so thanks again for your help with that – I’m sure you’ll be impressed by the answers.

With Marianne, post interview 😉
So it was an emotional, eye opening, hugely beneficial and sometimes hilarious experience (who knew that taking your false teeth out to scratch your arm was an effective strategy to deal with an itch?) and I cannot thank the staff enough!

I’m now very privileged to be in Perth at the APSAD conference where I’m delivering an overdose workshop and a presentation on the Scottish Naloxone Programme, which will be followed by a few days off to catch up with some Scottish friends who live here before returning home!

So for now, thanks for following my trip and I’ll get back to you soon with the survey results and your questions answered!

What an awesome bunch, I’d quite happily return to work here!

First Impressions: Day One in Sydney’s Medically Supervised Injecting Centre

It’s almost 10am as I leave my apartment and I’m so excited for the day ahead. I know that the centre is only five minutes away from where I’m staying but, despite looking at the shop numbers as I walk along Darlinghurst Road, I completely miss it and have to turn back. I think to myself that this is a sign of how discreet the service is rather than an indicator of me being directionally challenged.

There’s a security guard standing outside and he’s very friendly as I mention to him that I’m here to meet with Julie, Nursing Unit Manager, (who is also Scottish) while he opens the door for me. The reception area has a few people arriving to use the centre and I’m only there a minute before Julie comes to greet me. We head upstairs to the staff offices and I’m made to feel very welcome while I meet more of the staff and we discuss my plans for the 2 weeks that I’m here. I realise I’m going to be in a very privileged position to get full access to all the goings on in the centre and I’m truly grateful for the opportunity.

It’s decided I may as well get straight downstairs into ‘Stage 2’ to see what happens. This is the injecting stage and I sit with the staff behind the counter with all the sterile injecting equipment to see how it all works. It’s not long before it becomes very busy and it takes me a while to pick up the local lingo when people come over to the counter asking for ‘fits’ (1ml syringes and needles as a whole unit) and tips (needles). The following things are provided in any quantity requested;

  • 1ml fits
  • Syringes (3ml, 5ml and 10ml)
  • A range of different sized needles (plus small quantities of butterfly ones if needed)
  • Normal filters and wheel filters
  • Swabs
  • Water
  • Tourniquets
  • Spoons (plastic or metal)
  • Cotton wool
  • Band Aids (or ‘plasters’ if you’re Scottish)
  • Citric (normally used with Fentanyl as the heroin here does not require it)

Once people collect their equipment they head to one of the 16 stations in the 8 booths (booths can be shared but only if the two people have entered the centre together with that intention). Remember that people are still required to bring their own drugs – the centre does not provide them!

   The first thing I’ve noticed is how the staff clearly have good relationships with their clients (or ‘guests’ as stated by one staff member which I really liked) and how comfortable people seemed to be within the centre. It is obvious that this service has developed into a slick, streamline process with everyone playing their part to make it as safe an environment as possible. As soon as someone has finished at their station they move through to ‘Stage 3’ and the staff quickly clean the booth ready for the next guests. This soon becomes one of my jobs and I’m happy to be helping out.


  

The next thing I help with is the fantastic computer system to process clients through the stages. This lets us see how many people are waiting in stage one and remain in stage 3, client details such as when they have last used (highlighting increased risk of overdose if it has been more than a few days), which drugs they have with them to inject and any recent ‘drops’ (overdoses) they have experienced in the centre. I start getting to grips with logging the station numbers, processing clients through the system and dealing with some of the equipment requests and I’m surprised at how comfortable people seem to be with a new face which I put down to the ethos of the centre and the fact that those attending it don’t appear to feel judged in any way.

But things can’t run this smoothly all the time and it’s not long before someone overdoses.

The person concerned has injected heroin and becomes heavily intoxicated very quickly. He wanders around before slumping down to the floor and the staff respond immediately by checking his oxygen saturations (which were very low) and support him through to the clinical room and onto the bed while he is still responsive. He soon requires oxygen therapy and is monitored regularly. I lose track of time but from memory I’d say he is there around half an hour or so before he comes around, gets up, is alert and off to find his bike. This type of thing has become routine for the staff, although it doesn’t happen every day, and I am incredibly impressed by how it was dealt with.

   

The centre continues to be a hive of activity for a while until it finally settles down a bit. And then there’s another ‘drop’.

This time the person has also used heroin but reportedly had benzodiazepines the night before (people are asked at stage one what they have used in the past 24 hours). He becomes unresponsive almost immediately and he is supported to the floor where oxygen is administered instantly. He is still breathing and his saturations are stable with the oxygen therapy but it takes some time for him to be responsive enough to assist him on to a chair. He is made comfortable and continues to receive oxygen beyond the time I go for a break almost an hour later. Thankfully he too made a full recovery.

Other guests showed real compassion and concern for their peers during these incidents and it was nice to see this from them as well as the respectful staff.

For the rest of the afternoon I get to watch the video produced by the MSIC that shows some of the history of the centre and how it functions. It’s emotive and powerful. I’m also grateful for some time with Clinical Services Manager, Miranda, who spends a lot of time with me answering many of the questions raised from the Opinion Survey on DCRs for Scotland.

During my time upstairs in the office there are several more overdoses in Stage 2 and there is a feeling that the heroin must be of a higher purity (which allows the staff to warn clients before they use of the increased risk). None of the overdoses required naloxone as they were all successfully reversed with oxygen only due to the prompt action of the staff.

Without the MSIC there may well have been several overdose fatalities in Kings Cross today.

I leave with a feeling that’s hard to describe, it’s like a sense of pride and huge respect for what has been achieved here. It makes me think of those in Scotland who would benefit so greatly from a service like this and those who have died having not had the time to consider making changes in their lives.

So my first impressions of Sydney’s MSIC? Lifesaving.

Reflecting on my time in Melbourne

I’m sitting in Melbourne Airport awaiting my flight to Kuala Lumpur for the International Harm Reduction Conference and I’m reflecting on my time in Melbourne.

I arrived here just over a week ago and have had a whirlwind of a time which has included some bizarre experiences on trams and in taxis (which I may mention later), meeting some amazing people and an insight into some of the good harm reduction work taking place but also some of the barriers which can make delivery or engagement in these services fairly complicated.

This was my schedule;

Thursday (late pm) – arrive in apartment in St Kilda booked through Air BnB, which I would definitely use again when travelling.

Friday – negotiate the public transport system to visit Harm Reduction Victoria

 
Saturday and Sunday – socialising thanks to Paul Dietze (activities included the random taxi event, a dinner party, a scenic trip up the Yarra Valley, a winery and some kangaroo spotting)

Monday – Keynote presentation at the CREIDU Colloquium

 
Tuesday – Visit to the Salvation Army Crisis Services in St Kilda 

   
Wednesday – Meeting with Justice Health to discuss naloxone-on-release from prisons and an evening meeting with John Ryan, CEO of the Penington Institute (which included the bizarre tram experience on the journey home)

  

Thursday – Meeting with the staff team at Uniting Care ReGen followed by a Harm Reduction Café 

 

Friday – Probably the most insightful experience of the week into the lives of people who use drugs. I spent the day with Craig Harvey of Barwon Health who took me on a tour to show me how they deliver naloxone in Geelong and then to North Richmond where public injecting is prevalent and I’ll talk more about this in a moment.

All of the meetings have been extremely useful and have given me different perspectives on the picture here so I am most grateful for the time people took to speak to me and make me feel welcome here. These are some of the main things I’d like to pick up on;

Naloxone

There is a real will among the sector to provide take-home naloxone (THN) and some excellent examples of this with individual workers doing a supreme job in getting naloxone to those who need it (Jane Dicka from HRVic is a prime example), but good will is not enough and some of the legalities and systems make it much more restrictive than is necessary.

People providing naloxone are required to have each individual prescription signed by a doctor so there is no equivalent Patient Group Direction supply taking place like we have in Scotland. This therefore relies on creativity among workers and is often successful due to good relationships rather than by design.

As you can imagine it means that there is not always the opportunity to provide people with THN immediately and often requires workers tracking people down or seeing people at a later date to provide it. Barwon Health has a free phone number for people to contact Craig for THN which is an excellent idea to try to engage more people.

Drug workers are not supported organisationally to administer naloxone in an emergency while they are on duty. This is incredible. If they were off duty they would be covered by a Good Samaritan Law. So for example, if an outreach worker who delivers naloxone training comes across someone who has overdosed they are required to call a ‘code blue’ to their organisation and a doctor will come running to wherever they are (assuming it’s nearby) to administer it. Or, in many cases, the naloxone will be administered by a peer whilst the worker (who probably trained said peer) watches on. This is very frustrating for all concerned and I would suggest requires immediate attention to resolve this issue.

THN is provided as 0.4mg mini-jets so five syringes are supplied at a time incase multiple doses are required. There are pros and cons to this. One of the problems is the sheer bulk of equipment to be carried around and the fact that needles need to be provided separately. I do really like the fact that the provision of face-masks for rescue breathing is the norm.  

There is no naloxone-on-release for people leaving prisons in Victoria but the discussions are happening and certainly it appeared from my meeting that this would be introduced. Hopefully they won’t wait too long since this is such a high risk population at increased risk of overdose when liberated.

A very exciting development for naloxone in Australia is the expected rescheduling to Schedule 3, which is the equivalent of a Pharmacy Medicine in the UK and essentially means that it will be available from a pharmacist over the counter. If there are no problems, this will come in to force from 1st February 2016. This will make it much more accessible but there are many questions to be answered, particularly regarding cost.

Costs for pharmacotherapy and injecting equipment for ‘consumers’! *shrieks in horror*

I have to say this was one unexpected shock for me – that people who are prescribed opiate replacement therapy (ORT) are required to pay a pharmacy dispensing and administration fee of around $5 for each dose. Talk about putting people off accessing treatment! This can be a real problem for some, particularly those with very little income. There are instances where people starting ORT have previous debts with the pharmacy and are required to pay this off and a start up fee prior to receiving their prescription, resulting in delays or inability to proceed. There are programmes in some services to assist and support with initial payments but these are not permanent solutions and not available to everyone.

Most needle and syringe programmes (NSPs) also charge for equipment apart from a select few who will fund this provision through their individual services. Not all NSPs will have suitably trained staff providing the equipment so the potential for using that brief interaction as an opportunity for advice or interventions is limited.  

The provision of sharps disposal units across the City is to be admired. Every public toilet had them, including the airport toilets, and they were also situated on the streets, which I spotted wherever I was walking around.  

Engagement and retention in treatment (pharmacotherapy)

Let’s ignore the cost issue for a moment. Most of the prescribing of ORT is by doctors/GPs, which differs from Scotland since the majority of prescribing is via doctors (mostly psychiatrists) attached to Community Addiction Teams. This seems to provide better retention on ORT as people are very unlikely to be discharged for non-compliance with the service’s expectations (ie. no illicit drug use or missing appointments) and I was extremely impressed by some services that were able to start people on ORT on the day that they present and others who were generally within the week. There was recognition that this was not the case in all areas due to some of the rural locations and problems logistically.

Language

Rather than ‘drug and alcohol’ services, people in Melbourne referred to ‘alcohol and other drug’ (AOD) services which is much more appropriate as it gives more emphasis to the fact that alcohol is indeed a drug.

During my time here meeting with numerous people, not once did I hear anyone refer to substance ‘misuse’, drug ‘abuse’, ‘addicts’ or any other such terms which add a level of judgment, stigma and discrimination that we say we work to avoid. I think language is incredibly important in the AOD sector and we should ensure we use people first language at all times. While I’m on the subject, ‘dirty’ and ‘clean’ is not acceptable when talking about urine testing. Positive and negative will suffice. I also prefer to talk about sterile rather than clean injecting equipment but I know that’s not so much of an issue for some.

So on my last day after a morning with Craig Harvey highlighting the logistical nightmare (but not impossible task) of providing naloxone, which he goes out of his way to do, we head over to North Richmond where Kacey takes us out and about to get a first hand feel for what goes on in the area (first hand for me anyway, Craig used to work in this service so is well aware of the challenges).   

   
She introduces us to one of the naloxone peer trainers (who has been trained by Harm reduction Victoria) and he tells us that he has used naloxone to reverse more than 30 overdoses successfully. Having lost many friends to overdose he has now made it his mission to keep watch over his local area and takes pride in the fact that since he has been equipped with THN, no one in his area has died. The work he does is incredible and I have no doubt that he is an inspiration to his peers although he recognises that it can be emotionally draining and that there is a lot of pressure, since he will be called on any time of the day or night to respond. His dedication reminded me of many of the peer trainers in Scotland who have volunteered their own time and those who have administered naloxone on numerous occasions. We discussed the difference between the way that staff are supported with regular supervision (formally and informally) and that peers often don’t have access to the same level of support. It’s important we look after the people who are doing a lot of the looking after!  

   
Public injecting and overdoses are frequent in this area, discarded needles require daily collection and tragically there are many drug-related deaths amidst what is often a very chaotic and unpredictable environment.  

  It’s clear to me that many of these problems would be much more manageable or avoidable with a supervised injecting facility, particularly so that overdoses could be promptly managed rather than finding people dead in the adjacent car park where they were hidden. It appears there’s a long way to go… 

 I’m in complete admiration of Kacey, the awesome work she does (which can be pretty hard core) and the positive relationships she harnesses with the people she looks out for. All services need a Craig and a Kacey!  

So I have some top tips for Scotland;

  1. Provide personal protective equipment (a face-mask for rescue breathing) along with every naloxone kit. If we’re encouraging people to provide supported ventilation we should be giving them the protective equipment to do it with. They’re not expensive.
  2. Sharps disposal units should be more widely available where public injecting exists. Most places then.
  3. Stop removing people from ORT by trying harder to retain them in treatment when they require it rather than discharging them. People are much safer when on ORT, this is not a secret.
  4. Aim to provide people with ORT on the day they present. Quick prescribing is more likely to engage people.
  5. Have more low-threshold services and drop-in clinics to fit the needs of the people who require services.
  6. Stop talking about substance ‘misuse’. Substance ‘use’ is fine. Take more time to consider how language in this sector can inadvertently contribute to stigma and discrimination.
  7. More assertive outreach to reach those who are hard to engage, not hard to find.

Thank you and well done if you’ve reached this point. I’m now on the plane and going to have to go due to the person in front of me having a serious case of selfish seat recline which is threatening the life of my laptop.

Oh…you wanted to know about my bizarre experiences? Ok, quickly –

There was the taxi driver who got me talking about drugs and overdose prevention who decided to call his wife and get me to speak to her to give her advice re her brother who was using a risky combination of opiates and alcohol. After this intervention he dropped me off at the wrong address in the middle of nowhere. Cheers.

Then there was the person with mental health problems on the tram who was becoming increasingly agitated so moved to sit beside me as he ‘felt safe with me and I was a kind person’. He talked to me for the duration of his journey about his 46 days with Arnold Schwarzenegger and what all the lines meant on his palms, including one that was a missile, much to the horror of our fellow passengers. He was lovely, I hope he’s ok.

Never a dull moment! Bye for now 🙂  

Considering New Approaches to Reduce Drug-Related Deaths with the Minister for Community Safety and Legal Affairs

Today, thanks to the Drugs Policy Unit, I am meeting with Paul Wheelhouse, Minister for Community Safety and Legal Affairs who has been briefed regarding my agenda.


I’ve now met the Minister a few times in relation to naloxone and I first experienced his support for the programme when I was working for the Borders Addiction Service and he spoke out against the comments from John Lamont (Conservative MSP) who claimed that distributing naloxone encouraged drug use…

“John Lamont’s comments on Naloxone use are utterly ill-informed, irresponsible and an insult to the highly-respected medical professionals in NHS Borders and indeed the team at Borders Addiction Services which is one of the highest-performing services in Scotland”

When he then took up post as Minister I was relieved we had someone who saw the value in saving the lives of people who use drugs and we met at Scottish Drugs Forum to discuss the programme and he commented that it was good to hear “straight from the Horsburgh’s mouth” – a statement for which I was mocked by my colleagues.

He also recently attended the National Forum on Drug-Related Deaths where he heard the forum’s thoughts on what needs to be done to reduce drug-related deaths, including the strong support for drug consumption rooms (DCRs).

So I arrive at Holyrood and there are film crews and crowds all over the place – alas, they have not heard the Minister is talking to me about DCRs but instead Labour leader Jeremy Corben has stolen my moment. I’m accompanied by Michael Crook from the Drugs Policy Unit and we are shown up to his office where the Minister’s private secretary also joins us.

I launch into the details of my project but as we don’t have a lot of time the focus is on DCRs. I explain my position, discuss the evidence and provide a run down on the main results from the opinion survey. The Minister shows genuine interest and has lots of relevant questions to ask of the Sydney experience;

  • How did they manage to engage with the local community on this to get their support?
  • What were the opinions and outcomes for local businesses?
  • Did they see a reduction in police and ambulance call outs?

Of course we also discussed the huge benefits to people who inject drugs and he was interested to hear the experience of the person I spoke with who had used the Sydney centre.

I showed him the photos of my recent visit to the public injecting site in Glasgow and he appeared horrified by the conditions in which people were using and we took time to consider the risks this posed.

He stated that taking steps to introduce a DCR in Scotland would pose a political and financial challenge and that it is important to gather as much information about the topic as possible, including the benefits of DCRs, not only to those who use drugs and whose lives could be saved, but also to the broader community. I have no doubt that my time in Sydney will provide such evidence.

I asked specifically about how we can take this forward on my return (I’ve never been too keen on all talk and no action) and I was offered the opportunity to present my findings to other key people in Scottish Government which I gladly accepted and look forward to making the case.

So I leave the meeting (having taken up more time than I’d been allocated) feeling hopeful for positive changes in an area in desperate need for new approaches.

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Should Scotland propose to introduce a supervised injecting facility as a research project? Discussion with Health Protection

I’m heading around the corner from our office in Glasgow to Health Protection Scotland (HPS) at Meridian Court to meet with Professor David Goldberg. David is responsible for the HPS group dealing with Blood Borne Viruses, Sexually Transmitted Infections, Vaccine Preventable Diseases and Respiratory Infections, and Lead on Hepatitis (B and C) and HIV/STI programmes of work.

I haven’t met David before so I’m unsure of his views regarding supervised injecting facilities (SIFs) but I’ve heard from colleagues that he’s interested in supporting the discussions to take this agenda forward.

So we head into one of the meeting rooms and I launch into my spiel about my aspirations for SIFs in Scotland and that perhaps this would be more acceptable to some if introduced as a pilot. David tells me he is personally supportive of SIFs but that this is “not enough” and advises against suggesting a ‘pilot’. He goes on to describe the potential benefits of promoting an ‘evaluation of effectiveness’ by an independent research team which may be seen as more acceptable and would address all of the predictable positive outcomes but also identify any less favourable consequences or effects. He stated he was convinced that a research study would show real benefits and therefore have a strong case to continue following the evaluation period and that this approach may make it easier to push through legal exemptions for the purpose of a ‘study’.

I hadn’t considered the research aspect so I asked hypothetically what the process would be to get the wheels in motion if we were to take this forward;

A steering group would be established with several organisations and international representation and this would be seen as the ‘operational team’. It seems appropriate that Glasgow would be the initial site based on the numbers of people injecting in public, high prevalence of injecting drug users, recent bacterial infection outbreaks (eg. botulism) and increases in new cases of HIV. Funding would be sought from the Scottish Government (and perhaps the local health board area/alcohol and drug partnership) to allow the proposal to go out to tender for potential evaluation teams.

We then got a bit ahead of ourselves and started to consider where the best place would be, what the building might look like and what services would be on offer, with David pointing out that we would want to make the environment warm, welcoming and inviting. He also suggested that we could look to hire a portacabin which could be introduced quickly and designed to include several health services, part of which could be a ‘drop in’ separate to the injection part and accessible to people who use drugs, particularly those who are homeless. I can see his point about how this would be ideal on some levels, but I have a lot of reservations about how prominent this type of building would appear and that people may be reluctant to attend a service that would make them easily identifiable en route, especially to police. It will be interesting to hear the thoughts from Sydney on this matter.

So although this was a fairly brief meeting I felt I’d gained a lot from it and certainly had some other perspectives to consider. We agreed it would be useful to present my findings on my return from Australia and I will get back in touch with David in due course to do so. I hope we’ll work together on this in the future…

I completely understand where he’s coming from with the need to get buy in for SIFs by means of an evaluation but I have to admit that I am already convinced by the international evidence and came across this quote on the International Network of Drug Consumption Rooms website prior to writing this update –

“Research to prove that injecting inside drug consumption rooms is safer than injecting elsewhere, is like needing to prove that jumping from a plane with a parachute is safer than jumping without one.”
Joan Colom I Faran in Viral Hepatitis in Europe, 2014