Supervised injecting centres
http://www.100md.com
《英国医生杂志》
1 Centre for Research in Primary Care, Leeds, LS2 9PL, 2 North East Leeds Primary Care Trust, Leeds LS6 2HF
Correspondence to: N M J Wright n.wright@leeds.ac.uk
The case for piloting supervised injecting centres in the United Kingdom is strong
Medically supervised injecting centres are "legally sanctioned and supervised facilities designed to reduce the health and public order problems associated with illegal injection drug use."1 Their purpose is to enable the consumption of pre-obtained drugs under hygienic, low risk conditions (box).1 They differ from illegal "shooting galleries," where users pay to inject on site.2 Worldwide, medically supervised injecting centres (also referred to as health rooms, supervised injecting rooms, drug consumption rooms, and safer injecting rooms or facilities) are receiving renewed attention. In 2001, the first medically supervised injecting centre in recent times was opened in Sydney, Australia. By 2002, there were 16 centres in five German cities,3 over 20 in the Netherlands, and some in Switzerland and Spain.4
The UK Home Affairs Select Committee recently recommended "that an evaluated pilot programme of safe injecting houses for heroin users is established without delay and that if this is successful, the programme is extended across the country."5 However, the Home Secretary rejected this recommendation, stating that medically supervised injecting centres would be supported only as part of a heroin prescribing programme.5 We argue that this decision should be overturned.
Supervised injecting centres enable the use of pre-obtained drugs under hygenic, low risk conditions
Credit: SHANEY BALCOMBE/NEWSPIX
Functions of medically supervised injecting centres
Enable safe oversight by nursing staff of self injection of street drugs in an explicitly clinical setting. Does not entitle staff to help drug users inject drugs
Open from morning to late evening to accommodate drug users who inject up to three times a day
Full range of resuscitation equipment (including intramuscular naloxone) is available to nursing staff
Ideally should form part of wider health promotion activities such as needle exchange, safer injecting advice, and training to prevent overdoses
Alert users to other treatment services
Ongoing liaison with local business, housing, and police services
Benefits of medically supervised injecting centres
The only comprehensive evaluation of a medically supervised injecting centre was conducted during the 18 month trial of the Sydney centre.6 Staff intervened in 329 overdoses over one year with an estimate of at least four lives saved a year. There was no increase in reported hepatitis B or C infections in the area that the medically supervised injecting centre served despite an increase elsewhere in Sydney.
The report described a decreased frequency of injecting related problems among clients. Half the centre's clients reported that their injecting practices had become less risky since using the centre. Furthermore, clients were more likely than other injectors to report that they had started treatment for their drug use; 11% of clients were referred to treatment for drug dependence. An economic evaluation of deaths averted by intervention of the medically supervised injecting centre showed that costs were comparable to those of other widely accepted public health measures.
The centre also had benefits for the local community. Residents and business respondents reported fewer sightings of public injection and syringes discarded in public places, and syringe counts in the vicinity of the centre were lower after it opened than before. In addition, there was no evidence of an increased number of theft and robbery incidents in the area. Acceptance of the medically supervised injecting centre increased among both businesses and residents over the study period.
Little evaluative work has been conducted into supervised injection facilities in other countries. In Hanover, however, 98% of users of the medically supervised injecting centre did not encounter any negative experience with local residents and 94% reported no negative police encounters.7 Research from Frankfurt showed that a drug user who overdoses on the street is 10 times more likely to stay in hospital for one night than a drug user who overdoses in a medically supervised injecting centre.8 In addition, no one has died from heroin overdose in any medically supervised injecting centre. Therefore, establishing such centres in the United Kingdom is likely to reduce the number of drug related deaths.
Controversies
Despite such impressive outcomes over a relatively short follow up, controversy remains over medically supervised injecting centres. The United Nations International Narcotics Control Board views the centres as violating international drug conventions.9 Others believe that such an approach turns a legitimate war on international illegal drug trafficking into a "war on drug users" with a negative effect on population health.10 However, the strength of the centres is that they bring unsafe injecting practice into the open in a safe, structured clinical environment and integrate it with other harm reduction services such as needle exchange programmes.
Current policies regarding staff endorsement of injecting are pragmatic and credible in that staff are acting illegally only if they physically help a user to inject. Trained staff are able to offer safer injecting advice, which includes helping users move away from injecting. We believe that such a clinical approach is not condoning or promoting drug use. Indeed, similar arguments were used against needle exchange programmes in the 1980s.11 However, such programmes are now part of accepted best practice and have demonstrably improved public health.12
The argument that medically supervised injecting centres promote drug use and related harm is not supported by the evidence. Whereas drug related death rates significantly increased throughout Europe during 1985-95, they fell in both the Netherlands and Switzerland, where medically supervised injecting centres were operational.13 We would not claim that the fall was due solely to the presence of medically supervised injecting centres. Rather, that a comprehensive policy on health promotion with outcomes to reduce harm does in fact reduce mortality without increasing the prevalence of drug use.14 For policy to be effective it needs to be integrated into service provision, of which medically supervised injecting centres are one important aspect of a range of harm reduction initiatives. We would argue that medically supervised injecting centres are not a panacea for drug related deaths but a proxy marker of a policy commitment to a broad based health promotion framework for working with drug users.
UK position
The Home Office has endorsed prescribable heroin centres rather than medically supervised injecting centres as the basis for future policy. We believe that neither is a panacea and that holistic provision should include both methods. Prescribable heroin is most appropriate for long term heroin addicts who have not responded to traditional treatment.15 However, such users are different from the patient group targeted by a medically supervised injecting centre—people who are socially excluded and homeless. It is these vulnerable individuals who are least likely to access treatment services and most likely to inject unsafely in public places. In the Sydney evaluation report, the most common reason given for not using the medically supervised injecting centre was injecting in the privacy of their own home.6
Summary points
Medically supervised injecting centres have been established in several countries
Evidence suggests they reduce the risk of harm to drug users
By reducing injection on the street they also reduce the risk to the general population
A pilot project should be set up in the United Kingdom
By targeting homeless, drug using populations, medically supervised injecting centres also have the potential to resolve the current conflict for housing professionals working with homeless drug users. Current legislation places a responsibility on housing providers (for example, staff working in homeless hostels) to remove residents who inject illicit drugs on their premises.16 This means that, currently, services providing care for homeless populations are able to dispense clean needles to drug users yet have a statutory responsibility to prevent injection in their services (whether housing, health, or social care services). Medically supervised injecting centres can help resolve this paradox and improve public health by minimising the risk of drug users injecting unsafely in public places.
Contributors and sources: NMJW has extensive experience working with homeless drug users who engage in risky injecting practice in public places. He has visited safe injecting centres in Australia, the Netherlands, and Germany. CNET performed the search for the paper.
Competing interests: None declared.
References
Consumption Rooms as a Professional Service in Addictions Health: International Conference for the development of guidelines. Guidelines for the operation and use of consumption rooms. 1999. www.adf.org.au/injectingrooms/guidelines.pdf (accessed 11 Nov 2003).
Carlson RG. Shooting galleries, dope houses, and injection doctors: examining the social ecology of HIV risk behaviors among drug injectors in Dayton, Ohio. Hum Organ 2000;59(3): 325.
Stoever H. Consumption rooms—a middle ground between health and public order concerns. J Drug Iss 2002;32: 597-606.
European Monitoring Centre for Drugs and Drug Addiction. Annual report on the state of the drugs problem in the European Union and Norway. Luxembourg: EMCDDA, 2002.
Government reply to the third report from the Home Affairs Committee: The Government's Drugs Policy: Is It Working? Session 2001-2002 HC 318. 2002. London, HMSO.
Medically Supervised Injecting Centre Evaluation Committee. Final report on the evaluation report of the Sydney medically supervised centre. Sydney: MSIC Evaluation Committee, 2003.
Jacob J, Rottman J, Stoever H. Entstehung und Praxis eines Gesundheitsraumangebotes für Drogenkonsmierende. Abschlu?bericht der einj?hrigen Evaluation des `drop-in Fixpunkt,' Hannover. Oldenburg: Bibliotheks und Informationssystem der Universitat Oldenburg, 1999.
Integrative Drogenhilfe. Jahresbericht 1996. Frankfurt, Integrative Drogenhilfe, 1997.
Yamey G. UN condemns Australian plans for "safe injecting rooms". BMJ 2000;320: 667.
Buchanan J, Young L. The war on drugs—a war on drug users? Drugs: Educ Prev Policy 2000;7: 409-22.
Glantz LH, Mariner WK. Needle exchange programs and the law—time for a change. Am J Public Health 1996;86: 1077-8.
Taylor A, Goldberg D, Hutchinson S, Cameron S, Gore SM, McMenamin J, et al. Prevalence of hepatitis C virus infection among injecting drug users in Glasgow 1990-1996: are current harm reduction strategies working? J Infect 2000;40: 176-83.
De Jong W, Weber U. The professional acceptance of drug use: a closer look at drug consumption rooms in the Netherlands, Germany and Switzerland. Int J Drug Policy 1999;10: 99-108.
Van Ameijden EJ, Coutinho RA. Large decline in injecting drug use in Amsterdam, 1986-1998: explanatory mechanisms and determinants of injecting transitions. J Epidemiol Community Health 2001;55: 356-63.
National Treatment Agency. Injectable heroin (and injectable methadone): potential roles in drug treatment (executive summary). www.nta.nhs.uk/publications/prescribing/heroin.htm (accessed 11 Nov 2003).
KFx. Section 8. www.ixion.demon.co.uk/section8.htm (accessed 24 Nov 2003).(Nat M J Wright, general p)
Correspondence to: N M J Wright n.wright@leeds.ac.uk
The case for piloting supervised injecting centres in the United Kingdom is strong
Medically supervised injecting centres are "legally sanctioned and supervised facilities designed to reduce the health and public order problems associated with illegal injection drug use."1 Their purpose is to enable the consumption of pre-obtained drugs under hygienic, low risk conditions (box).1 They differ from illegal "shooting galleries," where users pay to inject on site.2 Worldwide, medically supervised injecting centres (also referred to as health rooms, supervised injecting rooms, drug consumption rooms, and safer injecting rooms or facilities) are receiving renewed attention. In 2001, the first medically supervised injecting centre in recent times was opened in Sydney, Australia. By 2002, there were 16 centres in five German cities,3 over 20 in the Netherlands, and some in Switzerland and Spain.4
The UK Home Affairs Select Committee recently recommended "that an evaluated pilot programme of safe injecting houses for heroin users is established without delay and that if this is successful, the programme is extended across the country."5 However, the Home Secretary rejected this recommendation, stating that medically supervised injecting centres would be supported only as part of a heroin prescribing programme.5 We argue that this decision should be overturned.
Supervised injecting centres enable the use of pre-obtained drugs under hygenic, low risk conditions
Credit: SHANEY BALCOMBE/NEWSPIX
Functions of medically supervised injecting centres
Enable safe oversight by nursing staff of self injection of street drugs in an explicitly clinical setting. Does not entitle staff to help drug users inject drugs
Open from morning to late evening to accommodate drug users who inject up to three times a day
Full range of resuscitation equipment (including intramuscular naloxone) is available to nursing staff
Ideally should form part of wider health promotion activities such as needle exchange, safer injecting advice, and training to prevent overdoses
Alert users to other treatment services
Ongoing liaison with local business, housing, and police services
Benefits of medically supervised injecting centres
The only comprehensive evaluation of a medically supervised injecting centre was conducted during the 18 month trial of the Sydney centre.6 Staff intervened in 329 overdoses over one year with an estimate of at least four lives saved a year. There was no increase in reported hepatitis B or C infections in the area that the medically supervised injecting centre served despite an increase elsewhere in Sydney.
The report described a decreased frequency of injecting related problems among clients. Half the centre's clients reported that their injecting practices had become less risky since using the centre. Furthermore, clients were more likely than other injectors to report that they had started treatment for their drug use; 11% of clients were referred to treatment for drug dependence. An economic evaluation of deaths averted by intervention of the medically supervised injecting centre showed that costs were comparable to those of other widely accepted public health measures.
The centre also had benefits for the local community. Residents and business respondents reported fewer sightings of public injection and syringes discarded in public places, and syringe counts in the vicinity of the centre were lower after it opened than before. In addition, there was no evidence of an increased number of theft and robbery incidents in the area. Acceptance of the medically supervised injecting centre increased among both businesses and residents over the study period.
Little evaluative work has been conducted into supervised injection facilities in other countries. In Hanover, however, 98% of users of the medically supervised injecting centre did not encounter any negative experience with local residents and 94% reported no negative police encounters.7 Research from Frankfurt showed that a drug user who overdoses on the street is 10 times more likely to stay in hospital for one night than a drug user who overdoses in a medically supervised injecting centre.8 In addition, no one has died from heroin overdose in any medically supervised injecting centre. Therefore, establishing such centres in the United Kingdom is likely to reduce the number of drug related deaths.
Controversies
Despite such impressive outcomes over a relatively short follow up, controversy remains over medically supervised injecting centres. The United Nations International Narcotics Control Board views the centres as violating international drug conventions.9 Others believe that such an approach turns a legitimate war on international illegal drug trafficking into a "war on drug users" with a negative effect on population health.10 However, the strength of the centres is that they bring unsafe injecting practice into the open in a safe, structured clinical environment and integrate it with other harm reduction services such as needle exchange programmes.
Current policies regarding staff endorsement of injecting are pragmatic and credible in that staff are acting illegally only if they physically help a user to inject. Trained staff are able to offer safer injecting advice, which includes helping users move away from injecting. We believe that such a clinical approach is not condoning or promoting drug use. Indeed, similar arguments were used against needle exchange programmes in the 1980s.11 However, such programmes are now part of accepted best practice and have demonstrably improved public health.12
The argument that medically supervised injecting centres promote drug use and related harm is not supported by the evidence. Whereas drug related death rates significantly increased throughout Europe during 1985-95, they fell in both the Netherlands and Switzerland, where medically supervised injecting centres were operational.13 We would not claim that the fall was due solely to the presence of medically supervised injecting centres. Rather, that a comprehensive policy on health promotion with outcomes to reduce harm does in fact reduce mortality without increasing the prevalence of drug use.14 For policy to be effective it needs to be integrated into service provision, of which medically supervised injecting centres are one important aspect of a range of harm reduction initiatives. We would argue that medically supervised injecting centres are not a panacea for drug related deaths but a proxy marker of a policy commitment to a broad based health promotion framework for working with drug users.
UK position
The Home Office has endorsed prescribable heroin centres rather than medically supervised injecting centres as the basis for future policy. We believe that neither is a panacea and that holistic provision should include both methods. Prescribable heroin is most appropriate for long term heroin addicts who have not responded to traditional treatment.15 However, such users are different from the patient group targeted by a medically supervised injecting centre—people who are socially excluded and homeless. It is these vulnerable individuals who are least likely to access treatment services and most likely to inject unsafely in public places. In the Sydney evaluation report, the most common reason given for not using the medically supervised injecting centre was injecting in the privacy of their own home.6
Summary points
Medically supervised injecting centres have been established in several countries
Evidence suggests they reduce the risk of harm to drug users
By reducing injection on the street they also reduce the risk to the general population
A pilot project should be set up in the United Kingdom
By targeting homeless, drug using populations, medically supervised injecting centres also have the potential to resolve the current conflict for housing professionals working with homeless drug users. Current legislation places a responsibility on housing providers (for example, staff working in homeless hostels) to remove residents who inject illicit drugs on their premises.16 This means that, currently, services providing care for homeless populations are able to dispense clean needles to drug users yet have a statutory responsibility to prevent injection in their services (whether housing, health, or social care services). Medically supervised injecting centres can help resolve this paradox and improve public health by minimising the risk of drug users injecting unsafely in public places.
Contributors and sources: NMJW has extensive experience working with homeless drug users who engage in risky injecting practice in public places. He has visited safe injecting centres in Australia, the Netherlands, and Germany. CNET performed the search for the paper.
Competing interests: None declared.
References
Consumption Rooms as a Professional Service in Addictions Health: International Conference for the development of guidelines. Guidelines for the operation and use of consumption rooms. 1999. www.adf.org.au/injectingrooms/guidelines.pdf (accessed 11 Nov 2003).
Carlson RG. Shooting galleries, dope houses, and injection doctors: examining the social ecology of HIV risk behaviors among drug injectors in Dayton, Ohio. Hum Organ 2000;59(3): 325.
Stoever H. Consumption rooms—a middle ground between health and public order concerns. J Drug Iss 2002;32: 597-606.
European Monitoring Centre for Drugs and Drug Addiction. Annual report on the state of the drugs problem in the European Union and Norway. Luxembourg: EMCDDA, 2002.
Government reply to the third report from the Home Affairs Committee: The Government's Drugs Policy: Is It Working? Session 2001-2002 HC 318. 2002. London, HMSO.
Medically Supervised Injecting Centre Evaluation Committee. Final report on the evaluation report of the Sydney medically supervised centre. Sydney: MSIC Evaluation Committee, 2003.
Jacob J, Rottman J, Stoever H. Entstehung und Praxis eines Gesundheitsraumangebotes für Drogenkonsmierende. Abschlu?bericht der einj?hrigen Evaluation des `drop-in Fixpunkt,' Hannover. Oldenburg: Bibliotheks und Informationssystem der Universitat Oldenburg, 1999.
Integrative Drogenhilfe. Jahresbericht 1996. Frankfurt, Integrative Drogenhilfe, 1997.
Yamey G. UN condemns Australian plans for "safe injecting rooms". BMJ 2000;320: 667.
Buchanan J, Young L. The war on drugs—a war on drug users? Drugs: Educ Prev Policy 2000;7: 409-22.
Glantz LH, Mariner WK. Needle exchange programs and the law—time for a change. Am J Public Health 1996;86: 1077-8.
Taylor A, Goldberg D, Hutchinson S, Cameron S, Gore SM, McMenamin J, et al. Prevalence of hepatitis C virus infection among injecting drug users in Glasgow 1990-1996: are current harm reduction strategies working? J Infect 2000;40: 176-83.
De Jong W, Weber U. The professional acceptance of drug use: a closer look at drug consumption rooms in the Netherlands, Germany and Switzerland. Int J Drug Policy 1999;10: 99-108.
Van Ameijden EJ, Coutinho RA. Large decline in injecting drug use in Amsterdam, 1986-1998: explanatory mechanisms and determinants of injecting transitions. J Epidemiol Community Health 2001;55: 356-63.
National Treatment Agency. Injectable heroin (and injectable methadone): potential roles in drug treatment (executive summary). www.nta.nhs.uk/publications/prescribing/heroin.htm (accessed 11 Nov 2003).
KFx. Section 8. www.ixion.demon.co.uk/section8.htm (accessed 24 Nov 2003).(Nat M J Wright, general p)