Supervised injecting centres
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7431.100 (Published 09 January 2004) Cite this as: BMJ 2004;328:100All rapid responses
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Sir: By definition pragmatism is doing what is practically possible.
Leeds is not in the middle of the Kalahari desert, on a lifeboat or under
seige. Pragmatism would therefore dictate the safest approach possible.
Competing interests:
None declared
Competing interests: No competing interests
Sir:
The first safe injecting facility opened 1986 in Bern, Switzerland.
The first English presentation on this project could be heard at the
first “International Conference on the Reduction of Drug Related
Harm” in Liverpool 1990. The first publication on safe injecting
facilities in English appeared in the book on the high lights of this
conference in 1992 (1). In the same year followed an Australian
publication (2). Presentations in English could be seen and heard
at International Conferences on AIDS (1991 & 1996), International
Conferences on the Reduction of Drug Related Harm, and others.
An attempt to publish some of the scientific results failed due to the
obstacles set up by the reviewers, despite a large support of well
renowned scientists in Switzerland and abroad.
Heroin prescription in Switzerland started only in 1994. The
accompanying debate was separate and different from that of the
safe injecting facilities, despite some parallels in intention (3).
Meanwhile, a pilgrimage of hundreds of visitors of different
backgrounds (select committees, fieldworkers etc.) started already
in the 1980ies and lead to the implementation of similar projects in
a number of countries, first of all in Germany. Generally, visitors
could be persuaded by what they could see, the conceptual
framework and the intentions, and the existing data, with the
exception of some malevolent Americans, who could not detect
any evidence in favour of such an approach. National government
in Germany, forced by the practice, even enacted a special
national law that supports safe injecting facilities.
New South Wales chose to implement a safe injecting facility by
means of a scientific evaluation. However, the problems were not
less, as science in this field has to deal with a number of
shortcomings. First of all, it is impossible to form a proper control
group, an exigency for any interventional study. As a
consequence, the results of the final report are being
“scientifically” questioned, and the further existence of the facility is
depending on the political will, as if no research had been
conducted.
In this short overview two different cultural point of view become
clear: the postmodernist European and the modernist Anglo-
Saxon. Continental European societies take a critical position in
relation to science. Decisions on accepting or not safe injecting
facilities as part of a general drug policy does not primarily depend
on scientific results. It seems that they understand that scientific
results depend largely on the invested money in a certain field,
and that the decision on investment is a political one (4). The
Anglo-Saxon world takes a modernist position (with the exception
of Canada). Science is seen as independent and societal progress
seems to rely purely on scientific evidence. So far the denial of
existence proved to be very effective (already 15 years!) and
science was not forced to happen, but finally the scientific debate
is launched. The next step, as seen in Australia, is the questioning
of the results and the conclusions. And despite the view that
science is universal, the same debate will probably start de novo
in each country. This just underlines that the interpretation of
“scientific” results remains a cultural domain and is not
independent, as claimed by “scientists”.
Reference List
1. Haemmig RB. The streetcorner agency with shooting room
('Fixerstuebli'). In O'Hare PA, Newcombe R, Matthews A, Bunning
EC, Drucker E, eds. The reduction of drug-related harm, pp 181-5.
London & New York: Routledge, 1992.
2. Haemmig R. Overseas Experience: Switzerland. In Fox RW,
Matthews I, eds. Drugs Policy. Fact, fiction and the future, pp 206-
9. Annandale NSW: Federation Press, 1992.
3. Haemmig RB. Harm reduction in Bern: from outreach to heroin
maintenance. Bull.N.Y.Acad.Med. 1995; 72:371-9.
4. Lyotard JF. The postmodern condition: a report on knowledge.
Minneapolis, MN: University of Minnesota Press, 1999.
Competing interests:
Responsible medical
doctor of a safe injecting
facility since 1986
Competing interests: No competing interests
Dear Editor,
With continuing high rates of drug related deaths in the UK, the BMJ
is right to again give prominence to the issue. The report by Wright and
Tompkins [ref 1] clearly demonstrates that there are new and promising
ways to address the current UK epidemic of overdose deaths from street
drugs, including medically supervised injecting facilities. Overseas
experience with injecting centres over 15 years has been uniformly
positive. Over one million injections occur each year in such centres
where deaths and serious complications almost unknown. Nearly all such
injections would otherwise take place in less savoury and thus less safe
environs. Such services also bring large number of addicts into contact
with health care workers, some for the fist time.
It is thus disappointing that in their following commentary [ref 2],
rather than unequivocally supporting such moves, Strang and Fortson raise
the canard of the differences between prescribed heroin for dependency and
injecting facilities (which they pejoratively call ‘fixing rooms’).
As a leading dependency expert, Strang knows the reassuring reports
of such centres in Europe, Australia and, most recently, Canada. The
concept has worked effectively elsewhere [ref 3], including apparently
unofficial experience in London. Strang and Fortson give no realistic
alternative strategy for the UK’s high rates of overdose, HIV and
hepatitis C.
These authors compare injecting centres to pubs, adding to the
confusion they are trying to address. Licensed premises, like Swiss
heroin prescription trials, supply the patrons’ drug of choice in a safe
environment, while injecting centres only provide the supervised
environment for consumption of illicit drugs. Injecting centres are
perhaps more like patrolled beaches where people do risky, even foolhardy
things, while professional life-guards move into action if needed in a non
-judgemental manner.
Strang and co-author cannot know how insensitive their petty
reservations on injecting rooms must sound to grieving relatives when
every one of these English overdose deaths is potentially preventable.
They appear to suggest that simple safety measures may cause people to
take greater risks ‘en masse’, despite presenting no evidence for this
extraordinary interpretation. Their parenthetical dismissal of ‘harm
reduction’ in the first sentence belies its being the foundation of good
medical and public health practice since the time of Hippocrates. It is
also official government health policy in some countries and has been
credited with preventing HIV infection from penetrating the drug using
population in Australia and Hong Kong.
Yours faithfully,
Andrew Byrne ..
References:
[1] Wright NMJ, Tompkins CNE. Supervised injecting centres. BMJ
(2004) 328:100-102
[2] Strang J, Fortson R. Supervised fixing rooms, supervised
injectable maintenance clinics—understanding the difference. BMJ (2004)
328:102-103
[3] Burton, B. Supervised drug injecting room trial considered a
success. BMJ (2003) 327:122
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
The idea of setting up supervised injecting centres requires a
paradigm shift in our medical thinking. None the less it is an idea worthy
of further research and I would welcome pilot projects in the UK.
For a sub-group of patients who are otherwise not engaged by
conventional medical services it allows for contact with skilled
professionals.
We must not make the mistake of shunning an idea simply because we
find it difficult to reconcile with our traditional medical culture.
Yours sincerely,
Iain B Craighead
Competing interests:
None declared
Competing interests: No competing interests
Sir,
Wright and Tompkins have well summarised the many apparent benefits
of medically supervised injecting centres while Strang and Fortson have
rightly emphasised that heroin-assisted treatment is a very different
approach with quite distinct objectives and techniques.
However, these approaches have much in common. Both still require far
more evaluation before firm conclusions can be drawn about the nature and
extent of benefits, costs and cost-effectiveness. Yet, at this stage, both
seem promising approaches though only required in unusual circumstances.
Supervised injecting centres appear to be only required in proximity to
some major illicit drug markets while heroin-assisted treatment appears to
only need consideration in a small minority of treatment refractory,
severely dependent, heroin users.
Both approaches have been severely criticised by the International
Narcotics Control Board which claims that they infringe the international
drug treaties (1961, 1971, 1988). However internal legal documents of the
United Nations International Drug Control Programme indicate that these
interventions do not infringe these or any other international treaties.
Both approaches continue to attract increasing interest in new
countries. A supervised injecting centre has recently commenced operation
in Vancouver, Canada where a research proposal to evaluate heroin assisted
treatment was rated one of the top applications in a fiercely competitive
national general medical research funding round.
Strang and Fortson emphasise appropriately the need for more data to
determine the return on investment in these interventions. Even more
urgently needed is data to determine the return on investment in supply
control measures. These appear to have limited effectiveness, are very
costly and cause considerable collateral damage. Opponents of harm
reduction go to inordinate lengths to obstruct even scientific research to
evaluate the costs and benefits of supervised injecting centres and heroin
-assisted treatment. Perhaps they do so because of a fear that rigorous
evaluation will one day be demanded for supply control measures.
It is now undeniable after many decades that global drug prohibition
has failed to deliver the desired benefits. Under these circumstances,
doctors and medical researchers must continue with efforts to find more
effective ways of dealing with the problems caused by drugs and current
drug policy. Ultimately, drugs must once again be considered primarily a
health and social issue and no longer just a criminal justice concern.
Competing interests:
None declared
Competing interests: No competing interests
I read with interest the article on supervised injecting rooms by
Wright and Tomkins (1) and the commentary on that article by Strang and
Fortson (2) in the BMJ of 10.01.04. The article by Wright and Tompkins did
not disagree with the idea of supervised injectable maintenance clinics
but put the case for supervised injecting centres. The Home Affairs Select
Committee had recommended both but the Home Secretary has rejected
supervised injecting centres. This begs the question of why the Home
Secretary is allowed to make such decisions!
Strang and Fortson in their commentary are critical of the idea of
supervised injecting rooms. Their apparent preference for supervised
injecting rooms may be associated with competition for resources and
control over those resources. Strang and Fortson’s final remark “ …if
finite resources force choices, the priority is a clear scientific answer
to the worth of supervised injectable maintenance clinics.” supports this
point of view.
The type of language used in Strang and Fortson’s commentary
unsettles me. Sadly prejudice is rampant in Society‘s perceptions of
psychiatric disorders in general and drug problems in particular. These
prejudices are widely shared within the medical profession including those
of us involved in the treatment of the addictions. An American colleagues
(3) has used the acronym SPAM, S=stigma, P=prejudice, A=and, M=
misunderstanding, to facilitate analysis of our professional activities.
Contemporary Bio-medical Ethics speaks of Autonomy, Non-malificence,
Beneficence and Justice as the principles underlying our clinical conduct
in these matters. Autonomy emphasises the patient right fully to
participate in decisions about their treatment, to be able to give
informed consent and to be treated with dignity.
Strang and Fortson’s Commentary falls at the first fence. They speak
in the title of their commentary of supervised fixing rooms rather than
supervised injecting centres. The use of the argot of the street is to
denigrate Wright and Tomkins’s serious discussion and is a sign of our
prejudices against drug users. It lowers the level of argument, which
makes it difficult to take Strang and Fortson’s commentary seriously.
Strang and Fortson describe supervised injecting centres as “perhaps the
drug user’s equivalent of a pub or bar”. As a pub and bar user I do not
see these supervised injecting centres as having anything to do with bars
or pubs. This remark appears to be intended as a smear on supervised
injecting centres and is unworthy of the authors of the commentary. In the
commentary we meet phrases such that supervised injectable maintenance
clinics are “ usually considered only for the most entrenched heroin
addict who has failed to benefit from first-line treatment.” The words
‘entrenched’, ‘heroin addict’ and ‘failed to benefit’ in this context are
stigmatising terms, whether or not they are widely used. Entrenched is a
moralising concept not a clinical term. Our patients are not heroin
addicts but are patients dependent on heroin. Our patients have not
‘failed to benefit’, rather treatments have failed to benefit.
(Surely as good a case can be made for supervised injectable
maintenance to be offered first to those only recently addicted to
heroin).
The commentary has a sub-text of the control of drug users and the
resources available to treat them. This as if the Home Office owns these
drug users: what price Autonomy?
I find this commentary a most disturbing document.
Dr. David Marjot. Consultant Psychiatrist. 16, Walton Lane. Weybridge,
Surrey. KT13 8NF.
Postmaster@marjotdj.demon.co.uk
1. Wright NMJ., Tomkins CNE. 2004. Supervised injecting centres. BMJ.
328: 100-101
2. Strang J., Fortson R. 2004. Commentary: Supervised fixing rooms,
supervised injectable maintenance clinics – understanding the difference.
BMJ. 328: 102
3. Dr. Charlton Erikson. 2001. A(ddiction) T(reatment) F(orum). #Winter
2001. Page12 http://www.atforum.com
Competing interests:
None declared
Competing interests: No competing interests
Both this paper,and Dr Stranng's related piece, are hughly relevant
to those of us working with homeless drug users.
Despite an abundance of accessible services in Leeds, frequently we
are made aware of individuals who are severely socially isolated,
apparently reluctant to make contact with agencies who might expect a
committment to change. Life on the streets can induce an apathy which
becomes difficult to shift without long-term, low level support.Behaviour
which is high risk, both for the individual and for society, is common,
with discarded injecting paraphernalia being a big problem in our city
centres. Most of these drug users are not the "most severe heroin addicts"
requiring the "tertiary services" which Dr Strang describes. They are low
level users, nonetheless engaging in dangerous injecting practices.Some
may never have sought help, others have had difficulty in engaging with
mainstream services.
I would welcome a further assessment of the proposal to provide safer
injecting rooms for these most vulnerable drug users. The issues of
improved access to services, better public safety and a reduction in fatal
drug overdose all seem worth exploring. My hunch is that nothing would
change very quickly; but to expose excluded street dwellers to a service
where few demands were made, but where a chance to build relationships of
trust and respect over a prolonged period was afforded, would be likely to
have a long term postive effect. This is not "halfway safety" - it is a
pragmatic approach to a group of problems which are not being addressed at
present.
Dr Strang believes that the priority should be to explore the
possibility of providing injection facilities for those prescribed heroin.
As far as I am aware, injectable heroin on prescription is not indicated
for pre-contemplative users. This initiative would therefore target a
smaller group of users, already receiving tertiary services. A greater
number would benefit, and a greater public health benfit be accrued, if
the focus was on the other end of the spectrum: excluded homless users
currently posing a huge risk to themselves and our communities.
Competing interests:
None declared
Competing interests: No competing interests
Sir
In this otherwise excellent piece, Nat Wright mistakenly says the
following regarding use of controlled drugs on premises and attributes
this to myself
"Current legislation places a responsibility on housing pro-
viders (for example,staff working in homeless hostels)
to remove residents who inject illicit drugs on their
premises."
In fact, and as I have made clear in the publication cited and
numerous others, the opposite is in fact true. The current legislation
does not place such a responsibility on housing providers although many
think, mistakenly, that it does.
While the Government introduced legislation (s.38 of the Criminal
Justice and Police Act 2001) to impose such an obligation, a decision was
reached last year not to implement the amended legislation, so as to avoid
having a negative impact on housing providers and other drug
professionals.
The current state of play is that many housing providers do house
ongoing users and do allow them to inject on site. It is not helpful that
the BMJ misrepresents the legal position so badly, and I would hope that a
full clarification is provided in a subsequent issue.
Yours Faithfully,
Kevin Flemen
KFx
Competing interests:
Kevin Flemen is a freelance trainer with a specialist interest in housing drug users
Competing interests: No competing interests
Sir: The danger of giving the impression to those who are doing
something inherently unsafe, injecting unknown substances, that what they
are doing is now safe or "safer" might well outweigh any benefits in lives
saved by this practice. The Syndey experience, where over eighteen months
four lives appear to have been saved, does not tell us whether the risk
taking increased as a result of perceived safety increases thus abolishing
any apparent benefit.
Furthermore, is it illogical or unethical to
provide a bit of safety to a population who can be provided with optimum
safety through the supply of both injection facilities and safe injectable
material? Are there any analogous situations in other branches of
medicine? Would, for instance, a surgeon amputate a gangrenous leg at the
ankle or a GP give half the known effective dose of an antibiotic? Both
of these interventions have the potential to help 'a bit' but equally the
potential to do harm. Would the treating physician go along with these
interventions even if they were the patients' choices or would they, on a
risk benefit analysis, do nothing? All or nothing arguments are often
wrong and narrow minded but occaionally the only logical response.
Competing interests:
None declared
Competing interests: No competing interests
Medically Supervised Injecting Centres - Moving the Debate Forward
In considering the electronic responses to our paper (1) on
supervised injecting centres we wish to make the following comments. The
response by Kevin Flemen draws attention to how the law is far from clear
in terms of the responsibilities it places upon housing providers (2). Our
paper could have more clearly reflected the current situation by stating
“Current proposed legislation places a responsibility upon housing
providers (for example staff working in homeless hostels) to remove
residents who inject illicit drugs on their premises.” Kevin Flemen
through the KFx website has produced an informative document (3). This is
a better representation of the current legal position. To quote, “Under
the proposals could a housing provider tolerate people to inject heroin in
their rooms in hostels? As the amended section 8(d) is not in force, the
answer to this is a cautious “yes”. You would need to ensure that such use
did not put other residents at risk of harm or nuisance. This would be a
breach of your organisation’s health and safety policy, and a breach of
your duty of care to other residents. If the activity started to cause
nuisance to the public, you would run the risk that the police would seek
a closure order. However, there would be scope for the organisation to
seek other routes to resolve the problem other than facing closure.
Will the same thing apply if we know supply of controlled drugs is taking
place? No. Legally you must still do everything that you reasonably can to
stop supply taking place. If you do not, you could face prosecution under
Section 8 (b) and a closure order if the premises were associated with
nuisance or serious disorder” (3).
In the wider debate on supervised injecting centres we welcome the
post-modernist European approach as described by Robert Haemmig (4). The
limitations of comparing two different interventions in widely differing
and constantly fluid social contexts is a fundamental premise of the post-
modern research paradigm. Such paradigms acknowledge the huge gains made
by biomedical research in evaluating interventions to prevent disease.
However they also challenge us to acknowledge the limitations of such
rationalist positivism when evaluating wider health promotion activity.
The excellent MSIC evaluation report in estimating lives saved by the MSIC
acknowledged its limitations due to the effect of the shifting social
context of the heroin drought (5). Therefore scientific inquiry will often
bring increased clarity upon which policy and practice decisions can
reasonably be made. However such decisions will need to be subject to
regular review in the light of fresh evidence as in some domains a final
definitive scientific answer is simply not possible.
References
(1) Wright NMJ, Tompkins CNE. Supervised Injecting Centres. British
Medical Journal 2004; 328:100-102.
(2) Flemen K. Misinterpretation of Law affecting Housing Providers.
http://bmj.bmjjournals.com/cgi/eletters/328/7431/100. 2004. Accessed 9-1-
2004.
(3) Managing Drugs on Premises: Working within Section 8 of the
Misuse of Drugs Act 1971 and Section 1 of the Antisocial Behaviour Act
2003.
http://www.ixion.demon.co.uk/Managing%20Drugs%20on%20Premises%202004.pdf.
2004. Accessed 16-1-2004.
(4) Haemmig R. Safe Injecting Facilities and Culture.
http://bmj.bmjjournals.com/cgi/eletters/328/7431/100. 2004. Accessed 27-1-
2004.
(5) Medically Supervised Injecting Centre Evaluation Committee. Final
Report on the Evaluation Report of the Sydney Medically Supervised
Injecting Centre. 2003. Sydney, MSIC Evaluation Committee.
Competing interests:
None declared
Competing interests: No competing interests