Supervised injecting centre marks 21 years

The controversial Sydney facility has managed a million injections and 11,000 overdoses without a single death.

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Australia’s first medically supervised injecting centre has proven its critics wrong time and time again. So why aren’t there more?

Operated by Uniting – the business branch of the Uniting Church – the Kings Cross centre is one of just two supervised injecting sites in the country.

Now in its 21st year of operation, it was originally established in response to the 1990s heroin epidemic that hit Sydney, causing a sharp increase in overdose death and blood-borne virus transmission.

The current medical director of the medically supervised injecting centre, Dr Marianne Jauncey, was working as a drug and alcohol doctor at the Kirketon Road Centre in Kings Cross during that era.

“The streets were just awash with drugs, everywhere you looked and went there were people using drugs, suffering the impact of drugs, selling drugs – it was very in-your-face,” says Dr Jauncey, who didn’t start working at the supervised injecting centre until 2008.

“In 1999, which was the year that there were the most heroin deaths in Australia, the highest concentration was in and around the streets of Kings Cross.”

Dr Jauncey says the late 90s were a steep learning curve.

“I’ve done electives as a medical student in places like Africa and Northeast Arnhem Land, where you expect to see really significant pathology,” she tells The Medical Republic.

“Whereas suddenly I was working in downtown Darlinghurst and I’d see somebody walk in with a haemoglobin of 7 and go, ‘no, I don’t really feel like going to hospital’.”

At the peak of the epidemic, Dr Jauncey says it wasn’t unusual for patients to come see her at the Kirketon Road Centre for clean injecting equipment, only to overdose in the nearby public toilet.

“I knew that my job was to provide the community with clean injecting equipment, I knew that Australia had this incredible record for preventing an epidemic of HIV,” she says.

“And yet when I was one of the people fishing out somebody that had overdosed in our toilet … [I would get] very indignant.”

Now, the public health clinician recognises that her anger came from fear and a certain amount of ignorance.

A simple question from a colleague after a bathroom overdose incident was what set Dr Jauncey on her harm-reduction advocacy journey.  

“One of the nurses came up to me very quietly and said, ‘where else did you think they’d go?’, and I realised I’d never thought about it before,” says Dr Jauncey.

“And I think that’s the point – we don’t think about it, it’s out of sight out of mind because it’s not our problem any more.

“But it is our problem [as doctors] when people are injecting in public and dying.”

Initial criticism of the medically supervised injecting centre focussed on the idea that it would draw more illicit drug users to the area; this was proven false within the first few years of operation.

While on paper and in news reports it may have looked as though the odds were stacked against the clinic, Dr Jauncey says that in reality there was a swell of grassroots support.

“The King’s Cross Chamber of Commerce was particularly determined, I think, to close the centre in the early days and ended up going bankrupt in their attempt,” she says.

The clinic was independently evaluated for a full 10 years, and the injecting centre team were able to show, over time, that the majority of businesses and residents consistently supported the ongoing operation of the service.

“Sometimes there’s a smaller number of voices, but they’re quite loud, quite shrill and heard quite well, and that can warp the public perception a little bit,” Dr Jauncey says.

Data from the clinic is certainly impressive.

Since 2001, there have been over a million supervised injections by 18,000 registered clients of the service, according to a recent MJA perspective piece.

Among these there were around 11,000 overdoses.

The clinic has never seen a single fatality, even as progressively stronger drugs like fentanyl made their way on to the market.

“In 2014–15 there was a marked increase in pharmaceutical fentanyl injections at the [medically supervised injecting centre] associated with increased overdoses,” the MJA authors, Dr Jauncey among them, say.

“Each fentanyl overdose was managed onsite and none required hospital transfer.”

In 2009, there was an incident where five clients unknowingly injected insulin.

“Early identification of the symptoms resulted in all but one client being managed onsite,” the authors say.

“The one client transferred to hospital was subsequently released without complication.”

The Kings Cross clinic hasn’t just prevented 11,000 overdose deaths over its two decades of operation, but also provided 20,500 formal referrals to health and social services.

“Put simply, when a safer place to inject drugs is provided, the associated short-term harms are greatly reduced,” say MJA authors.

“The longer-term harms are also reduced with increased access to services, including drug treatment, hepatitis C care and smoking cessation.”

University of Sydney drug and alcohol researcher Associate Professor Carolyn Day, who holds an honorary position at the injecting centre and was also an author on the MJA piece, says that the actual number of referrals was much higher than 20,500.

“It’s one of those things when you’re very tight in your word limit in a paper – those referrals would grossly underestimate what’s actually happening there,” she tells TMR.

“They’re just the formal referrals that get recorded.”

Often, Professor Day says, staff might give informal referrals to a client or spend a number of hours over multiple visits building a rapport with a client before attempting a formal referral.

“The clinician might have [waited] for the right time to go, ‘okay, now let’s see if we can get you into methadone’ or ‘why don’t you go and see this treatment service up here’,” she says.

“We [do formal referrals] when we really think that the client thinks that they’re ready, because there’s been that work, and a lot of that’s not recorded.”

Published data may tell the story of a successful clinic, but it’s the unmeasurable data that tell the story of a truly groundbreaking service.

“[Overdose prevention and referrals] are the hard numbers, but there’s a lot of soft numbers that tell the story equally as well, we just can’t say exactly what they are.” Professor Day says.

Despite the clinic’s achievements, Dr Jauncey acknowledges that supervised injecting centres are a political hot potato, not least within medical circles.

She has an argument ready for any of her colleagues who may still be irked by the idea.

“I would suggest that every time we’re providing people with clean injection equipment – which, let’s not forget, we’ve been doing for 35-odd years – we’re failing in our duty of care, because we have a law that says, ‘you must now go away and use that equipment that I’ve given you, because the law does not allow me to be present’,” Dr Jauncey says.

“That’s just absolutely crazy.”

Under the current laws, the injecting centre medical director said, doctors are almost required to have a level of enforced naivety.

“How on earth is it okay for a doctor to hand out a clean syringe, knowing that it is for the injection of heroin, methamphetamine or whatever, and talk to that person about the fact that they’re at risk, find out that they’ve just come out of prison, find out that they’ve just come out of rehab and they’re about to relapse, talk to them about harm reduction techniques, talk to them about safe injecting, do not use alone, blah, blah, blah,” she says.

“But when they say, ‘well, I don’t have anywhere else to go and I don’t have anyone else to inject with, can I inject here?’, we say, ‘oh, heavens no’.

“What did we think was going to happen with that equipment?”

The fact that NSW gives out 13 million syringes, but forces people to use that equipment unsupervised, is “morally bankrupt” in Dr Jauncey’s opinion.

“I actually think it’s high time that across NSW, that if the government isn’t going to do something, then I think the medical workforce needs to start acknowledging that we are failing in our duty of care,” she says.

Australia’s only other supervised injection room is in North Richmond, Victoria.

The state has managed a three-year successive decline in overdose deaths after hitting a peak of 543 in 2018.

There have been a number of changes to the illicit drug environment in Victoria over that time; the supervised injecting room opened in 2018, lockdowns saw the introduction of take-home methadone doses in 2020 and 2021 was the first full year in which it was mandatory to check the a real-time prescription monitoring system prior to prescribing and dispensing certain medicines.

Reporting on the declining deaths, the Coroners Court of Victoria largely credited the introduction of SafeScript, which was introduced on a voluntary basis in 2018.

“As noted at the time, there may be many explanations for these findings, but the 2019 and 2020 interruption to the historical increasing trend in overdose deaths is a cautiously positive result,” they say.

“Further to this point … the decreasing trend has continued into 2021, with further declines in the number of overdose deaths involving pharmaceutical drugs monitored by SafeScript as well as pharmaceutical drugs that SafeScript does not presently monitor.”

Nationally, there have been 35,000 drug-induced deaths since 2001.

The Penington Institute’s annual overdose report for 2022, which analysed data from 2020, issued a stark warning: if nothing changes, America’s opioid epidemic will be Australia’s future.

In the first year of the pandemic, the Penington Institute estimates that there were 856 unintentional opioid deaths, representing half of all drug deaths for that year.

This marked a slight decrease on the number of opioid deaths in 2019, but an overall three-fold increase in opioid deaths since 2006.

Heroin still accounts for the most deaths within the drug class – 413 in 2020 – but overdose deaths using pharmaceutical opioids fentanyl, pethidine and tramadol have risen by 1300% since 2006, accounting for 165 deaths in 2020.

MJA 2022, online September 19