BMJ  2004;328:102-103 (10 January), doi:10.1136/bmj.328.7431.102

Commentary

Supervised fixing rooms, supervised injectable maintenance clinics—understanding the difference

¹ National Addiction Centre, King's College London, London SE5 8AF, ² London WC1R 4HD

Harm reduction policies and practices (where anything goes, if it actually reduces harm) have fundamentally altered our approach to the drugs problem. Two innovations were recently considered by the Home Affairs Select Committee—supervised injecting centres and supervised injectable maintenance clinics—but with unhelpful confusion between the two.¹ They have different target populations, potential benefits, and legal obstacles.

Supervised injecting centres (also known as supervised drug consumption rooms or fixing rooms) are essentially public access facilities, perhaps the injecting drug user's equivalent of a pub or bar, where the injection of unknown drugs by unknown persons should be safer by virtue of supervision and consequent speed of response in the event of overdose.² The target population is all injecting drug misusers—regardless of whether or not they are dependent or wish to change their drug taking habits. Perhaps providing this safer haven may lead some to seek treatment. But this is not the primary objective of the facility. Drug users bring their own chosen substances from the black market pharmacopoeia and choose their degree of intoxication and technique of administration. Workers within the facility may seek to influence their choice of drugs, dose, and technique—but it would be counterproductive to have rules that drive injecting drug misusers out of the facility. The supervised injecting centre is not for treatment of individual addictions—it is a public health facility.

The supervised injectable maintenance clinic may initially seem similar, but is profoundly different in concept, operation, and target population. It is usually considered only for the most entrenched heroin addict who has failed to benefit from first line treatment.^{3 4}

The attendee is a known patient, receiving treatment from their doctor, and self administering the prescribed injectable maintenance (for example, injectable heroin or injectable methadone) supervised by the nurse or other worker within the clinic—a comfortable fit within the concept of individual treatment. Randomised clinical trials of such injectable heroin maintenance have recently been conducted.⁴ The only drugs are those prescribed by the doctor, albeit in consultation with the patient, and the doctor is also responsible for the dose and route of administration, notwithstanding that the patients themselves administer their drugs. Such treatment for the most severe heroin addicts would be a tertiary service. It would certainly not be open to attendees on an impromptu basis.

These two different proposals pose different organisational and legal challenges. For the open access supervised injecting centre, there are major operational issues. Should the attendee be prohibited from choosing certain drug mixtures, doses, or sites of injecting considered too dangerous—for example, injecting barbiturates or temazepam, or ground-up tablets of methadone, Diconal (dipipanone/cyclizine) or Ritalin (methylphenidate), or injecting dangerous doses, or injecting in femoral or neck veins? Would there be a lower age limit? When deaths occur (inevitable, eventually), where will medicolegal liability lie? Both action and inaction may leave the doctor and organisation liable. And what of charges (already made) of aiding and abetting, and even fostering more frequent and more excessive drug use? When dealing occurs (inevitable, to some extent), will agencies and staff be open to prosecution, as with the imprisoned staff from Wintercomfort day centre?^{5 6} These obstacles may not be insuperable, but they cannot just be ignored.

For the supervised injectable maintenance clinics, there are major scientific questions about their worth, but the operational issues are simpler. The doctor prescribes treatment to a patient, with self administration supervised by the nurse. The extent and limits of liability are clear. There will be challenges with initial dose assessment, around patients with failing venous access, and with security, but the medicolegal context is clear.

Both proposals deserve serious consideration—but separately. Claims of "harm reduction" must be tested for both innovations. It is just not good enough to have good intentions; new approaches must be studied to establish whether they truly reduce harm,⁵ and then either rejected as well intentioned bad ideas or, if successful, robustly supported. The United Kingdom is the only country with a substantial history of injectable opiate maintenance treatment; if finite resources force choices, the priority is a clear scientific answer to the worth of supervised injectable maintenance clinics.

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Competing interests: JS chaired the working group preparing guidelines on injectable opiate maintenance treatment for the National Treatment Agency and Department of Health (2002/3) and has recently been awarded a research grant for randomised trial of injectable versus oral opiate maintenance treatment.

References

1. Select Committee on Home Affairs. Third report. May 2002. www.parliament.the-stationery-office.co.uk/pa/cm200102/cmselect/cmhaff/318/31802.htm (accessed 30 Dec 2003).
2. Van Beek I. The Sydney medically supervised injecting centre: a clinical model. J Drug Issues 2003;22: 625-38.
3. Zador D. Injectable opiate maintenance in the UK: is it good clinical practice? Addiction 2001;96: 547-53.[Medline]
4. Van den Brink W, Hendriks V, Blanken P, Koeter M, van Zweiten B, van Ree J. Medical prescription of heroin to treatment resistant heroin addicts: two randomised controlled trials. BMJ 2003;327: 310-5.[Abstract/Free Full Text]
5. Burrell I, Norton C. Living agony of prison life for charity worker jailed for allowing homeless to deal in drugs. Independent 2000 January 20.
6. Court of Appeal (Criminal Division). R v Brock and Wyner [ 2001] Cr.App.R.3.

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