Pubdate: Fri, 11 May 2001
Source: International Herald-Tribune (France)
Copyright: International Herald Tribune 2001
Heroin addicts in this city's most notorious drug den, an area called King's Cross, used to rent rooms for 15 to 30 minutes at a time in shooting galleries, cheap hotels that sometimes also sold drugs and syringes.
The police cracked down five years ago. It did not end the problem, but simply moved it into parks and back streets where, to the aggravation of residents, syringes were left tossed on sidewalks or discarded under trees. Overdoses, in fact, have been on the rise.
The government, desperate to improve the situation and after months of legal challenges, this week allowed a former pinball hall in the heart of King's Cross to open as Australia's first legal and medically supervised injecting center.
Advocates like the Reverend Ray Richmond, of the nearby Wayside Chapel, said he hoped the center would ''meet some of the users' needs, but also meet the needs of the community.''
But advocates are cautious in describing the center's mission and the ills that it will not or cannot cure, like drug-related crime, and even the drug use itself.
''The main purpose of the injecting center is a harm-minimization measure, '' explained the Reverend Harry Herbert, executive director of Uniting Care, the church-affiliated group that is operating the center, which is paid for by the government.
''Some of our supporters tend to overemphasize what the center will achieve,'' he added. ''If they set the bar too high, we'll never climb over that.''
Though new to Australia, medically supervised injecting centers are not a new idea in other parts of the world. Over the past decade, 45 have been set up in Europe, including in Germany, Switzerland and the Netherlands. In Frankfurt, deaths from overdose fell by one quarter in the three years after that city's program started.
The purpose of such centers is primarily to provide a safe place for addicts to inject drugs. Australian research has found more than 80 percent of those who shoot up in public would prefer to use a supervised center. And, according to an independent survey last year, 71 percent of people who live and work in King's Cross support the center there.
The center opened Sunday night, and according to its medical director, Dr. Ingrid van Beek, eight addicts used it during the first shift. Within a month or so, the center will be open for a pair of four-hour shifts daily.
Inside the building, which has a security guard, visitors enter a reception room that looks like a doctor's office. Users must be at least 18 years old and provide medical staff with information about themselves and their drug taking before being registered. The center will be restricted to those registered, and no one drunk or pregnant will be allowed to inject drugs.
A second area inside resembles an examining room, with stainless-steel countertops and sterile equipment. Specially trained nurses will hand out needles and swabs to users who will sit at one of eight booths, which offer privacy, but also allow staff members to monitor activity. The center has oxygen supplies and other materials required in case of an overdose.
In a separate lounge with an adjoining counseling room, staff will be able to offer information about treatment and social services, like housing assistance.
The center's presence, which was first authorized in legislation passed by the state legislature in 1999, has been opposed by local businesses. The King's Cross Chamber of Commerce and Tourism, which failed in a lawsuit to stop the center from opening, says it is already harming business.
The legislation that permitted the center to open also requires an independent panel to evaluate its effects regularly, as critics fear the center will only increase the flow of drugs to the area and exacerbate associated problems.
''It's going to be a disaster,'' said Malcolm Duncan, the chamber's senior vice president. ''We can only see things getting worse.''
Pubdate: Sun, 13 May 2001
Source: Australian Broadcasting Corporation (Australia Web)
Copyright: 2001 Australian Broadcasting Corporation
The New South Wales Opposition says the Government must immediately put in place regulations governing the operation of Australia's first legal heroin injecting room.
The medically supervised centre is run by the Uniting Church and opened in Kings Cross last week despite complaints from local businesses and the New South Wales Opposition.
The Opposition's police spokesman, Andrew Tink, says there are no regulations on how the centre is operated and no rules of conduct for people using the injecting room.
He says the Government must immediately rectify the situation.
"It provides greater certainty for police, for everybody involved in the operation of the centre and the public many of whom are opposed to this centre in the first place," he said.
"At the very least they have the right to know through regulations what the conduct in the centre is to be, what the rules are to be."
A spokesman for the Government says there is no need for the regulations, because the operation of the injecting room is covered by the license held by the Uniting Church.
He says the Government has the power to revoke the license at any time, but there is no pressing need to do so at this stage.
He says the Government believes the Uniting Church is more than able to operate the facility.
Date: Wed, 22 Aug 2001 08:15:38 EDT
Subject: Fwd: UPDATE A tale of two cities - injecting rooms in Munster and Sydney.
To all (with apologies if this is a duplicate)
Andrew's summary of the experience on opposite sides of the world, in Sydney and in Muenster, is thought-provoking, especially to Americans. In sum, both cities noted a fair number of "takers" of the availability of the facility, lots of overdoses were treated (presumably at least some of these individuals would be dead now if not for this treatment), no apparent disruptions in the neighborhood were reported, and quite a high number (in absolute terms - sounds like about 80 per month) were made in Sydney to treatment. Regarding the latter experience, NYC ambulatory detox program 30 years ago noted a similarly unexpected result among addicts who could have gone directly to a long-term treatment program, drug-free or MMTP, but did not do so, opting instead for a 10-14 day maximum ambulatory methadone taper - and then (about one-third!) did accept the offer to be referred by the detox staff. Anyway - it sounds like we have (again) evidence that addicts will voluntarily seek services that we know save lives, for minimal expense, without an apparent downside for the local community - and in the process facilitate access to long-term care. So the question is: why do I find it so unthinkable to propose such a measure in NYC? Why can I find it equally improbable to launch such an initiative in Hoboken, or Des Moines or rural Kentucky or in the Barrio of LA? Conceivably, the answer is that I lack imagination and the crusading spirit needed to try. Or . . . ? Seems to at least deserve serious open discussion. NY Academy of Medicine has sponsored meetings on heroin dispensing, office-based methadone treatment and other fairly far-out notions. Maybe this is another topic around which NYAM should convene a conference so that then international epxerience can be reported, and publicized, and serve to motivate serious consideration in america and other places where it hasn't been tried. Thoughts? Robert Newman
FROM ANDREW BYRNE, AUSTRALIA
At the same time as the Medically Supervised Injecting Centre (MSIC) in Sydney was opening, a similar endeavour was happening in Munster, Germany (pop. 300,000). Their 3 month figures (see web site below) show about 3000 attendances, remarkably similar to the number reported by Dr Ingrid VanBeek relating to the Australian 3 month experience. And almost 2000 were in the most recent month, showing that the service is becoming more popular with drug users.
Although the German centre was only open for about 6 hours on weekdays, it still attracted about the same number of users (8 clients per hour compared with the Australian average of 7 per hour by my calculations). The Sydney centre is open 8 hours every day, including weekends, from noon to 4pm and from 6pm to 10pm (last registration 9.30pm).
In a busy tourist district such as Kings Cross it is hard to imaging such small numbers seriously upsetting the local amenity. Indeed, double or triple this number would still be barely perceptible amongst the busy passing crowds. Also, every registration is potentially another drug user who no longer uses public places both to use their drug of choice and to 'recuperate' from its effects. The mean time spent in the Sydney centre is apparently about 20 minutes. While congregating could occur before and after the MSIC opening hours, these have not been reported as far as I am aware.
Both Sydney and Munster services reported comparable numbers of patients needing medical assistance with about 35 overdoses in each. Nearly all were treated without resorting to Narcan (naloxone) reversal. Both had significant numbers needing medical treatment such as dressings, vein care, etc (over 1000 in Sydney over 3 months). The Munster centre had primary care available on- site while the Sydney service used local public and GP services as appropriate. In Sydney, remarkably, there were 250 discrete referrals for formal dependency treatment such as detox, buprenorphine or methadone.
Apart from the immediate task of saving people from overdose deaths, the injecting room concept may have major benefits in other areas such as education and treatment referrals. The fears of some regarding mischief, loitering or increased drug dealing have just not eventuated.
comments by Dr Andrew Byrne, General Practitioner, Drug and Alcohol,
75 Redfern Street, Redfern, New South Wales, 2016, Australia
Tel (61 - 2) 9319 5524 Fax 9318 0631
Pubdate: Tue, 21 Aug 2001
Source: Canadian Medical Association Journal (Canada)
Copyright: 2001 Canadian Medical Association
Details: http://www.mapinc.org/media/754 Authors: E. Wood, M.W. Tyndall, P.M. Spittal, K. Li, T. Kerr, R.S. Hogg, J.S.G. Montaner, M.V. O'Shaughnessy, M.T. Schechter
Bookmarks: http://www.mapinc.org/hr.htm (Harm Reduction)
http://www.mapinc.org/find?137 (Needle Exchange)
http://www.mapinc.org/find?142 (Safe Injecting Rooms)
Items related to the Vancouver plan and the Vancouver Sun's series 'Searching For Solutions - Fix On The Downtown Eastside' http://www.mapinc.org/thefix.htm
In several European countries safer injecting rooms have reduced the public disorder and health-related problems of injection drug use. We explored factors associated with needle-sharing practices that could potentially be alleviated by the availability of safer injecting rooms in Canada.
The Vancouver Injection Drug User Study is a prospective cohort study of injection drug users (IDUs) that began in 1996. The analyses reported here were restricted to the 776 participants who reported actively injecting drugs in the 6 months before the most recent follow-up visit, during the period January 1999 to October 2000. Needle sharing was defined as either borrowing or lending a used needle in the 6-month period.
Overall, 214 (27.6%) of the participants reported sharing needles during the 6 months before follow-up; 106 (13.7%) injected drugs in public, and 581 (74.9%) reported injecting alone at least once. Variables independently associated with needle sharing in a multivariate analysis included difficulty getting sterile needles (adjusted odds ratio [OR] 2.7, 95% confidence interval [CI] 1.8-4.1), requiring help to inject drugs (adjusted OR 2.0, 95% CI 1.4-2.8), needle reuse (adjusted OR 1.8, 95% CI 1.3-2.6), frequent cocaine injection (adjusted OR 1.6, 95% CI 1.1-2.3) and frequent heroin injection (adjusted OR 1.5, 95% CI 1.04-2.1). Conversely, HIV-positive participants were less likely to share needles (adjusted OR 0.5, 95% CI 0.4-0.8), although 20.2% of the HIV-positive IDUs still reported sharing needles.
Despite the availability of a large needle-exchange program and targeted law enforcement efforts in Vancouver, needle sharing remains an alarmingly common practice in our cohort. We identified a number of risk behaviours -- difficulty getting sterile needles, needle sharing and reuse, injection of drugs in public and injecting alone (one of the main contributing causes of overdosing) -- that may be alleviated by the establishment of supervised safer injecting rooms.
The incidence of fatal overdoses and the emergence of the HIV epidemic among injection drug users (IDUs) have led to wider recognition that illicit drug use is a public health problem. Public health initiatives aimed at preventing overdoses and disease transmission among IDUs are referred to as harm reduction.  In addition to prevention, harm reduction aims to protect drug users by enabling them to inject safely until they can be helped off drugs.  A cornerstone of harm reduction is making sterile needles available through needle-exchange programs and other means.  Although needle exchange is accepted as a public health intervention in many cities in Canada, the apparent tolerance of drug use associated with it has made needle exchange controversial in some smaller Canadian settings and in many countries around the world.  Nevertheless, overwhelming evidence indicates that needle-exchange programs can substantially reduce HIV risk behaviour and the transmission of bloodborne infections, including HIV. [5,6,7,8] However, such programs have not been sufficient to prevent HIV epidemics in all settings. This is true of Vancouver's Downtown Eastside, where an HIV epidemic, characterized by a peak annual incidence rate of 18%, was documented in 1997 despite the presence of a needle-exchange program.  The inability of the program to prevent this epidemic was later attributed to specific local factors, including a high prevalence of cocaine injection. 
As in many other settings, a primary response to the HIV epidemic was to increase targeted law enforcement efforts in the Downtown Eastside so that greater numbers of police officers could patrol the neighbourhood's alleys and other areas where drug use is concentrated.  Currently in Canada the vast majority of resources aimed at preventing the harms of drugs are now allocated to policing. In British Columbia, 82% of the total direct costs associated with illicit drug use are accounted for by law enforcement.  Despite the resources provided to law enforcement, the incidence of hepatitis C and HIV infection in Vancouver's Downtown Eastside indicate that a substantial number of IDUs continue to share needles.  Furthermore, the region continues to experience an epidemic of overdoses, 312 occurring on average each year since 1996. 
A harm reduction intervention that has been highly effective elsewhere is safer injecting rooms, which are legally sanctioned and supervised facilities where IDUs can inject pre-obtained illicit drugs. Within these facilities, IDUs are provided access to health care and other services as well as sterile injecting equipment. [15,16] Although safer injecting rooms have not been established in North America, over 45 of them now operate in about a dozen European cites, and a facility has recently opened in Australia.  The reported benefits of these facilities include improved health and social functioning of clients, reductions in public disorder (e.g., drug injection, intoxication and discarding of needles in public), reductions in overdoses and reductions in risk behaviours for disease transmission. [15,16,17,18,19]
Several cities in Canada, including Vancouver,  are considering scientific evaluations of safer injecting rooms. These proposals have met resistance from community groups expressing fear that the drug epidemic in Canada is such that the European experience is unlikely to be replicated here. [21,22] Therefore, we conducted analyses to examine factors associated with needle sharing among Vancouver IDUs and to evaluate whether any of these factors could potentially be alleviated by the establishment of safer injecting rooms.
Beginning in May 1996 people who had injected illicit drugs in the previous month were recruited into the Vancouver Injection Drug User Study. In brief, over 1400 subjects were recruited through self-referral and street outreach efforts. Eligible subjects were those who had injected illicit drugs at least once in the previous month, resided in the Greater Vancouver area and provided written informed consent. At baseline and semi-annually, subjects provided blood samples and completed an interviewer-administered questionnaire. The questionnaire was designed to elicit demographic data and information about drug use, HIV risk behaviours and drug treatment.
For our analyses, we included baseline data and data from the most recent follow-up questionnaire available (administered during January 1999 to October 2000). Demographic characteristics such as age, sex and ethnic background were derived from the baseline questionnaire. To evaluate current drug injection practices, information such as drug use and health-related characteristics such as HIV status were obtained from the most recent follow-up questionnaire.
We chose needle sharing as the dependent variable because this behaviour has been shown to have the highest risk of HIV transmission among IDUs. Needle sharing was defined as either the lending or borrowing of a used needle in the 6 months before the follow-up visit. We did not restrict our analyses to needle sharing with either casual or intimate partners, because we have recently shown that both risk behaviours are associated with HIV seroconversion among IDUs in Vancouver.  People who had not injected drugs in the 6 months before the most recent follow-up visit were excluded from our analyses, because we sought to evaluate predictors of needle sharing among people who were actively injecting drugs. We also examined, and report on briefly in this article, the proportion of IDUs who reported sharing needles as defined above in the cohort during the prior 5 follow-up visits.
Univariate and multivariate analyses were performed to determine factors associated with current needle sharing practices. Sociodemographic and behavioural characteristics considered in the analyses included age, sex, ethnic background, education level, HIV status, and self-report at baseline of ever having had a diagnosis of mental illness. We also considered information on the receipt of methadone treatment, being refused drug treatment, being refused sterile needles at pharmacies and requiring help injecting.
Characteristics of drug use considered in our analyses included difficulty getting sterile needles, frequency of cocaine and heroin injection, average use of needles (once v. more than once), nonfatal overdoses, injection in public, safety of needle disposal and frequency of injecting alone. As we have done previously, [9,10] frequent cocaine or heroin use was defined as injection of the drug once or more daily. Safe needle disposal was defined as the placement of needles in a "safe place" or a sharps container or the return of needles to the needle-exchange program. To evaluate the effect of police activities on drug use, we considered the number of subjects who reported that police activities affected their source of drugs.
Statistical analyses were used to compare IDUs who shared needles and those who did not share needles in the 6 months before the most recent follow-up visit. Categorical explanatory variables were analyzed using Pearson's c2 test, and continuous variables were analyzed using the Wilcoxon rank-sum test. All variables that were statistically significant at the 0.05 cutoff point were considered in a logistic regression analysis. All reported p values are two-sided.
Since the study's inception, 124 participants have died (28 of HIV/AIDS, 41 of an overdose and 55 of other causes). A total of 962 participants responded to at least 1 questionnaire during the period January 1999 to October 2000 and were therefore eligible for our study. Compared with the 351 participants who did not come in for the most recent follow-up, those included in our study were more likely to be female (p = 0.001), Aboriginal (p = 0.001), HIV-positive at last follow-up (p = 0.001), older (p ( 0.001) and have a high school education (p = 0.006). No significant differences were found between the groups with regard to difficulty acquiring clean needles (p = 0.30), frequency of cocaine injection (p = 0.72) or heroin injection (p = 0.93), or need for help injecting (p = 0.84). Of the 962 participants eligible for our study, 776 (80.7%) reported injecting drugs in the 6 months before the most recent follow-up visit and were therefore included in our analyses; 562 (72.4%) reported not sharing needles and 214 (27.6%) reported sharing needles in that 6-month period. The proportions of active IDUs who reported needle sharing at the 4 follow-up visits before the study period were 31.2%, 22.7%, 23.5% and 25.5% respectively. Of the 247 HIV-positive IDUs, 20.2% reported sharing needles in the 6 months before the most recent follow-up visit. Of the 776 IDUs in our study, 106 (13.7%) injected drugs in public, and 581 (74.9%) injected alone at least once.
The results of the univariate analysis of sociodemographic and health-related characteristics are shown in Table 1. Being refused sterile needles at pharmacies (odds ratio [OR] 2.0) and requiring help to inject drugs (OR 1.9) were positively associated with sharing needles. Although not achieving statistical significance, having a diagnosis of mental illness was associated with sharing needles (OR 1.4, p = 0.07). Alternatively, being older (OR 0.97 per year of age [95% CI 0.95-0.99]; data not shown), and being HIV positive (OR 0.6) were inversely associated with needle sharing. We found no evidence that ethnic background, education level, sex, receipt of methadone treatment or being refused drug addiction treatment were associated with needle sharing.
The results of the univariate analysis of drug use and behavioural characteristics are shown in Table 2. Factors positively associated with needle sharing were difficulty getting sterile needles (OR 3.1), frequent cocaine injection (OR 1.6), frequent heroin injection (OR 1.8), use of needles more than once on average (OR 2.0), nonfatal overdose (OR 1.7) and reporting that police activities had affected the source of drugs (OR 1.9). We found no evidence that injection in public, unsafe needle disposal or injecting alone were associated with needle sharing.
The variables that were found to be independently associated with needle sharing in the stepwise logistic regression analyses are listed in Table 3. Difficulty getting sterile needles (adjusted OR 2.7), requiring help to inject drugs (adjusted OR 2.0), frequent cocaine injection (adjusted OR 1.6), frequent heroin injection (adjusted OR 1.5) and use of needles more than once on average (adjusted OR 1.8) were all positively associated with needle sharing. HIV-positive status was inversely associated with needle sharing (adjusted OR 0.5). Interpretation Despite targeted police efforts and a large needle-exchange program in Vancouver's Downtown Eastside, 27.6% of the IDUs included in our study reported sharing needles, and 9.7% had had a nonfatal overdose in the 6 months before the most recent follow-up visit. Having difficulty getting sterile needles, needing help injecting, reusing needles, and frequent cocaine and heroin injection were all associated with needle sharing.
Several of our findings suggest that barriers to sterile needle use persist despite the presence of a large needle-exchange program.  Although expanding the program would likely help to reduce needle sharing further, several risk factors remained independently associated with needle sharing after adjustment for difficulty getting needles. Furthermore, 19.1% of the participants included in our study shared needles even though they did not report having difficulty getting sterile needles. All of these factors suggest that expansion of the needle-exchange program alone will not be sufficient to eliminate this risk.
Several conditions, such as lack of experience or physical disability, may place IDUs in need of help with injections. The high prevalence of assisted injection has been documented in other settings,  although the strong association with HIV risk behaviour has not been previously established to our knowledge. Again, adequate availability of sterile needles will probably not be sufficient to mitigate this risk behaviour.
We also found that subjects who were HIV-positive were half as likely as HIV-negative IDUs to share needles. This suggests a benefit of HIV testing and counselling in this community.  However, despite substantial outreach services offering testing and counselling to IDUs in Vancouver, only 15.0% of the participants in our study had ever had an HIV test before recruitment into the study (unpublished data).
Another major problem associated with injection drug use is death from overdose. In Canada, British Columbia has the highest number of such deaths per capita, with about 4.7 per 100 000 population annually, and in several recent years illicit drugs have been the leading cause of death among adults 30 to 49 years of age. [12,14] Although needle-exchange programs have been associated with reductions in overdoses, 26 overdoses continue to occur all too frequently among IDUs.
Several of the variables we examined highlight the public disorder problems associated with injection drug use. For instance, in the 6 months before the most recent follow-up visit 13.7% of the participants in our study reported injecting drugs in public and 45.6% reported that they did not always practise safe needle disposal.
We found a positive association between police activities and needle sharing. Although further study of this association is required, the potentially negative consequences of policing efforts on HIV risk behaviour, such as creating fear of possessing needles, have been reported elsewhere. [27,28]
Our study has several limitations. Compared with the IDUs included in our study, those who did not come in for the most recent follow-up had a number of characteristics (e.g., younger and more likely to be HIV negative) that may make them more likely to be involved in needle sharing. Furthermore, it has been shown previously that IDUs may substantially underreport HIV risk behaviour and that HIV testing and counselling that accompany cohort studies such as ours may reduce risk behaviour over time. [29,30] Therefore, we may have underestimated the extent of needle sharing among IDUs.
In summary, our data demonstrate a continued health crisis among IDUs. Furthermore, the proportion of IDUs who reported needle sharing did not decrease over the past 5 follow-up visits, despite the presence of a large needle-exchange program and targeted law enforcement efforts.
Meanwhile, in several European cities, the risk factors we identified have proven amenable to improvement through the establishment of safer injecting rooms as part of comprehensive harm reduction strategies. Increases in HIV testing and counselling, health and social functioning, and drug addiction treatment have occurred among clients of safer injecting rooms in these cities. [15,16,31] Conversely, the incidence of HIV risk behaviour including needle sharing, hospital admissions, improper needle disposal, drug injection in public places and death from overdose have all decreased. [15,16,31,32] In fact, there has not been a fatal overdose in a safer injecting room since their establishment in the mid-1980's.  In the present study we did not evaluate safer injecting rooms per se. We have merely identified risk factors among IDUs that have proven amenable to improvement through the availability of such facilities in other settings. [15,16,31,32] Given the high prevalence of HIV risk behaviours, overdoses and other health-related concerns that persist in Vancouver, it is crucial to evaluate whether the European experience with safer injecting rooms can be replicated in Canada.
Competing Interests None declared.
Contributors Mr. Wood and Dr. Schechter were the principal authors and were involved in all aspects of the study. Drs. Tyndall, Spittal, Hogg, Montaner and O'Shaughnessy were involved in the original concept and design of the study and in revising the manuscript. Mr. Kerr prepared much of the background material and literature review on safer injecting rooms and was involved in revising the manuscript. Ms. Li was involved in data collection, statistical analyses, and drafting and revising the manuscript.
Acknowledgments We thank Bonnie Devlin, Caitlin Johnston, Robin Brooks, Suzy Coulter, Steve Kain, Guillermo Fernandez, John Charette, Will Small and Nancy Laliberte for their research and administrative assistance. We also thank all of the participants in the Vancouver Injection Drug User Study.
The study was supported by the US National Institutes of Health (grant no. RO1 DA11591). Mr. Wood is supported by the Canadian Institutes for Health Research and the British Columbia Health Research Foundation. Dr. Schechter holds a tier I Canada Research Chair in HIV/AIDS and Urban Population Health.
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