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The facilities provide sterile injection equipment, information about drugs and basic health care, treatment referrals, and access to medical staff. Some offer counseling, hygienic and other services of use to itinerant and impoverished individuals. Most programs prohibit the sale or purchase of illegal drugs. Many require identification cards. Some restrict access to local residents and apply other admission criteria, such as they have to be injection drug users, but generally in Europe they don't exclude addicts who consume by other means. |
The facilities provide sterile injection equipment, information about drugs and basic health care, treatment referrals, and access to medical staff. Some offer counseling, hygienic and other services of use to itinerant and impoverished individuals. Most programs prohibit the sale or purchase of illegal drugs. Many require identification cards. Some restrict access to local residents and apply other admission criteria, such as they have to be injection drug users, but generally in Europe they don't exclude addicts who consume by other means. |
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Evaluations<ref name=vanexp /><ref name=emcdda /> generally find them successful in reducing injection-related risks and harms, including vein damage, overdose and transmission of disease. They also appear to be successful in reducing public order problems associated with illicit drug use, including improper syringe disposal and publicly visible illegal drug use. |
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== Operating facilities == |
== Operating facilities == |
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As of the beginning of 2009 there where 92 facilities operating in 61 cities, including 30 cities in the Netherlands, 16 cities in Germany and 8 cities in Swizerland.<ref name=emcdda /> In Europe, most operate as part of local social services. Although the facilities in Norway, Canada and Australia are scientific pilot projects operating under special law. |
As of the beginning of 2009 there where 92 facilities operating in 61 cities, including 30 cities in the Netherlands, 16 cities in Germany and 8 cities in Swizerland.<ref name=emcdda /> In Europe, most operate as part of local social services. Although the facilities in Norway, Canada and Australia are scientific pilot projects operating under special law. |
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==Evaluations== |
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In the late 1990s there were a number of studies available on consumption rooms in Germany, Switzerland and the Netherlands. “The reviews concluded that the rooms contributed to improved public and client health and reductions in public nuisance but stressed the limitations of the evidence and called for further and more comprehensive evaluation studies into the impact of such services.” <ref>EMCDDA{{cite web |url= http://www.emcdda.europa.eu/attachements.cfm/att_2944_EN_consumption_rooms_report.pdf |title= European report on drug consumption rooms |accessdate=2010-04-28}} 2004 p 27</ref> To that end, the two non-European injecting facilities, Australia’s Sydney Medically Supervised Injecting Centre (MSIC) and Canada’s Vancouver Insite Supervised Injection Site have been more rigorously evaluated. <ref>Davies G. {{cite web |url= http://www.globaldrugpolicy.org/1/3/2.php |title=A Critical Evaluation of the Effects of Safe Injection Facilities |accessdate=2010-01-09}} </ref> |
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The NSW Government has provided extensive funding for ongoing evaluations of the Sydney MSIC, with a formal comprehensive evaluation produced in 2003, 18 months after the centre was opened. Other later evaluations studied various aspects of the operation - service provision (2005), community attitudes (2006), referral and client health (2007) and a fourth (2007) service operation and overdose related events.<ref>{{cite web |url=http://www.sydneymsic.com/Bginfo.htm |year= 2008 |title=MSIC Evaluations |accessdate=2010-01-09}}</ref> |
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In 2003 and 2006 a drug prevention advocacy group, Drug Free Australia, completed analyses of the Sydney MSIC 2003 evaluation and other evaluations.<ref>{{cite web |url=http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Booklet.pdf |year= 2008 |title=The Case for Closure |publisher= Drug Free Australia |accessdate=2010-01-09}}</ref> The Drug Free Australia team included an epidemiologist, an addiction medicine practitioner, social researchers and a senior welfare practitioner. Three of these analysts were well-published authors of research papers in 20 different peer-reviewed medical journals. They released their findings to the media and to politicians, leading to a robust debate in Australia regarding the effectiveness of aspects of the Sydney MSIC. <ref>{{cite web |url=http://www.parliament.nsw.gov.au/Prod/parlment/hansart.nsf/V3Key/LC20070626035 |title=NSW Upper House Hansard |publisher=Hansard |accessdate=2010-05-30}}26 June 2007</ref><ref>{{cite web |url=http://opiateaddictionrx.blogspot.com/2007/05/safe-injection-sites-substantively-and.html |title=Piers Akerman – Daily Telegraph |accessdate=2010-05-30}}Daily Telegraph 3 May 2007</ref><ref>{{cite web |url=http://www.abc.net.au/rn/linguafranca/stories/2007/1920440.htm |
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|title=Graeme Turner on the Rhetoric of Alan Jones |
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|accessdate=2010-05-30}}12 May 2007</ref> |
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The Vancouver Insite facility was evaluated during the first three years of its operation by researchers from the BC Center for Excellence in HIV/AIDS with published and some unpublished reports available. In March 2008 a Final Report of the Expert Advisory Committee appointed by the Canadian Ministry of Health was released, evaluating the performance of the Vancouver Insite against its stated objectives. |
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The drug prevention advocacy group, Real Women of Canada has called for the closure of the Vancouver Insite facility, citing the evaluation by the Expert Advisory Committee and pointing to what is, in their view, a failure to achieve significant outcomes by Insite.<ref>Real Women of Canada {{cite web |url= http://www.realwomenca.com/alerts.htm |title=THE VANCOUVER DRUG INJECTION SITE MUST BE SHUT DOWN|accessdate=2010-01-09}}</ref> |
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====Client Characteristics and Utilization==== |
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The first 2003 Evaluation of the Sydney MSIC found that it had “made service contact with its target population”, <ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p xvi</ref> with 9,778 visitors to the Centre for a total of 391,170 injections between 2001 and 2007, where clients averaged 14 years of illicit drug use and where 51% were heroin injectors and 35% had experienced an overdose previously. <ref>NCHECR, {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Sydney Medically Supervised Injecting Centre Evaluation Report No. 4 |accessdate=2010-01-09}} 2007 pp 14-17</ref> |
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The Drug Free Australia 2003 analysis found that clients were averaging only one in every of their 35 injections in the room, evidencing low utilization rates in light of the ever-present risk of fatal overdose to each heroin user.<ref>{{cite web |url=http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Booklet.pdf |year= 2008 |title=The Case for Closure |publisher= Drug Free Australia |accessdate=2010-01-09}} 2007</ref><ref>Drug Free Australia {{cite web |url=http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Detailed_Research.pdf |title= The Case for Closure - Detailed Evidence |publisher= Drug Free Australia |accessdate=2010-01-09}} 2007 p 12</ref> With injector safety the most prominent rationale for the establishment of injecting rooms, the analysis questioned such low utilization rates in light of the room’s purpose. It is noted that the Sydney MSIC has capacity for 330 injections per day,<ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p 38</ref> but in 2007 was averaging 212 injections per day. <ref>NCHECR, {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Sydney Medically Supervised Injecting Centre Evaluation Report No. 4 |accessdate=2010-01-09}} 2007 p 7</ref> Low utilization rates indicate, in Drug Free Australia’s view, that Sydney clients were injecting at least 34 out of 35 injections in unsafe situations - at home, at a friend's place or squat, at a dealer's home, on the street, in a car, in a public toilet or in an illegal shooting gallery, while the injecting room was underutilized. |
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The Expert Advisory Committee for Insite<ref>see Research Conclusions and Limitations - 1. INSITE Utilization and User Characteristics {{cite web |url= http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php#insite |title=Final Report of the Vancouver Insite Expert Advisory Committee |accessdate=2010-04-19}} 2008</ref> cited 8,000 people who had visited INSITE, with 18% accounting for 80% of all visits to INSITE, less than 10% using the site for all injections, a median number of 8 visits across all clientele, and 600 visits per day, of which 80% were to inject, showing that the facility was near capacity. Two surveys of approximately 1,000 users established some key user characteristics – clients averaged 15 years of drug use, 51% injected heroin and 32% cocaine, 87% were infected with Hepatitis C virus and 17% with HIV, 20% were homeless with numerous others living in single resident rooms, 80% had been incarcerated, 21% were using methadone and 59% reported a non-fatal overdose during their lifetime. |
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European consumption rooms cater moreso to users older than 30 years, mainly with problematic heroin and cocaine habits. Various studies have documented an ageing population of clients over time. Whereas in 1990, in one study, 50% of clients were 25 years or younger, by 2001 the percentage was 15%. Clients across European consumption rooms are characterized by heavy injecting drug use, a continuous use of illicit drugs and deriving from a poorer demographic. German studies found that between 19% and 27% of clients were from unstable accommodation. In the injecting rooms near Madrid 42% of the marginalized target group were homeless, while the number was 60% for the Can Tunis area of Barcelona. In a German study 15% of clients had never accessed addiction treatment of any kind.<ref>Hedrich, D {{cite web |url=http://www.emcdda.europa.eu/attachements.cfm/att_2944_EN_consumption_rooms_report.pdf |title=A Report on European Consumption Rooms|accessdate=2010-05-28}} EMCDDA 2004 pp 31-33</ref> |
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Client utilization in the European situation is more difficult to analyze. Studies on sites in Frankfurt and Zurich found that clients used facilities 5 times a week<ref>EMCDDA{{cite web |url= http://www.emcdda.europa.eu/attachements.cfm/att_2944_EN_consumption_rooms_report.pdf |title= European report on drug consumption rooms |accessdate=2010-04-28}} 2004 pp 35,6</ref> and in Rotterdam 6 times a week and twice in the previous 24 hours.<ref>EMCDDA{{cite web |url= http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowAbstract&ArtikelNr=000068807&Ausgabe=228974&ProduktNr=224233 |title=Drug Consumption Rooms in Rotterdam: An Explorative Description |accessdate=2010-04-28}}</ref> A study of clients in Frankfurt in 1997 found that 63% claimed to be daily visitors, while in another surveyed non-random sample from 18 German consumption rooms, 84% claimed use of the facility at least once weekly, with 51% claiming at least once per day utilization.<ref> Hedrich, D {{cite web |url=http://www.emcdda.europa.eu/attachements.cfm/att_2944_EN_consumption_rooms_report.pdf |title=A Report on European Consumption Rooms|accessdate=2010-05-28}} EMCDDA 2004 p 35</ref> Critics have asserted that sufficient information is not available on the injecting habits of these clients to judge their prevalence of supervised injection, where, for instance, one or two injections in the consumption room for 5 days weekly may still represent a small percentage of injections for a heavily dependent user injecting 10 times per day. <ref>Davies G. {{cite web |url= http://www.globaldrugpolicy.org/1/3/2.php |title=A Critical Evaluation of the Effects of Safe Injection Facilities|accessdate=2010-01-09}} Journal of Global Drug Policy and Practice Vol. 2 Iss. 1</ref> |
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====Client Referral==== |
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Evaluators of the Sydney MSIC found that over a six year period “staff provided 44,082 other occasions of service (113 per 1,000 visits) including drug and alcohol information (approximately 5,000 occasions)”, advice on drug and alcohol treatment on more than 3,000 occasions, 21,000 occasions where staff had provided vein care and safer injecting advice, with a total of 6,243 referrals to other services where 45% of referrals were to treatment.<ref>NCHECR, {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Sydney Medically Supervised Injecting Centre Evaluation Report No. 4 |accessdate=2010-01-09}} 2007 p 7</ref> Of the 2,801 referrals to treatment 947 were to detox and 336 to abstinence-based rehabilitation or therapy. The evaluators asserted that the MSIC was thereby evidenced as a gateway for treatment. <ref>NCHECR, {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Sydney Medically Supervised Injecting Centre Evaluation Report No. 4 |accessdate=2010-01-09}} 2007 p 21</ref> |
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The Expert Advisory Committee found that Insite had referred clients such that it had contributed to an increased use of detoxification services and increased engagement in treatment. Insite had encouraged users to seek counseling. Funding has been supplied by the Canadian government for detoxification rooms above Insite. <ref>see {{cite web |url= http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php#insite |title=Final Report of the Vancouver Insite Expert Advisory Committee |accessdate=2010-04-19}} 2008</ref> |
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====Impact on Public Nuisance==== |
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“The Sydney MSIC client survey conducted in 2005, found that public injecting (defined as injecting in a street, park, public toilet or car), which is a high risk practice with both health and public amenity impacts, was reported as the main alternative to injecting at the MSIC by 78% of clients. 49% of clients indicated resort to public injection if the MSIC was not available on the day of registration with the MSIC. From this, the evaluators calculated a total 191,673 public injections averted by the centre.<ref>NCHECR, {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Sydney Medically Supervised Injecting Centre Evaluation Report No. 4 |accessdate=2010-01-09}} 2007 p 21</ref> |
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Public amenity can be further improved by reduced numbers of publicly disposed needles and syringes. Data from the Sydney MSIC’s 2003 report indicated reductions in needles and syringe counts and resident and business-operator sightings of injections in public places decreased marginally but could not be certain that there was any effect by the MSIC beyond the heroin drought which had commenced some months prior to the opening of the MSIC. <ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p 125</ref> The Drug Free Australia analysis pointed to the needle, syringe and public sighting decreases being almost exactly equivalent to the 20% decreases in the number of needles distributed from local pharmacies, needle exchanges and the MSIC, thereby indicating no clear impact by the MSIC. <ref>{{cite web |url=http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Detailed_Research.pdf |year= 2008 |title=The Case for Closure - Detailed Evidence |publisher= Drug Free Australia |accessdate=2010-01-09}}p 32</ref> |
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Observations before and after the opening of Insite indicated a reduction in public injecting. <ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p xvi</ref> |
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====Impact on blood-borne viruses==== |
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The evaluators of the Sydney MSIC found that it “had not increased blood-borne virus transmission” <ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p xvi</ref> with the data more specifically showing no improvement re HIV infection incidence, no improvement in Hep B infections, <ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 pp 71,2</ref> either worse or no improvement (depending on the suburb studied) in new Hep C notifications,<ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p 80</ref> no improvement in reuse of others' syringes and injecting equipment, no improvement in tests taken for HIV and Hep C and initial improvement in tests taken for Hep B but worsening again in 2002. <ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 pp 91-8</ref> |
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The Expert Advisory Committee for Vancouver’s Insite found that journal studies with mathematical modeling by researchers from self-reports of users generated a wide range of estimates for HIV cases averted, but they were not convinced that the assumptions were valid. |
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====Impact on community levels of overdose==== |
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Over a six year period the Sydney MSIC managed 2,106 overdose-related events with not one fatality<ref>NCHECR, {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Sydney Medically Supervised Injecting Centre Evaluation Report No. 4 |accessdate=2010-01-09}} 2007 p 7</ref> while Vancouver’s Insite had managed 336 overdose events in 2007 with not a single fatality. |
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The 2003 evaluators of the Sydney MSIC found it had made “no detectable change in heroin overdoses at the community level”, <ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p xvi</ref> with no improvement in ambulance overdose attendances in the area, no improvement in ambulance overdose attendance during hours the injecting room was open and no improvement in overdose presentations at hospital emergency wards. <ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 pp 60-62</ref> |
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Research by injecting room evaluators in 2007 presented statistical evidence that there had been later reductions in ambulance callouts during injecting room hours,<ref>{{Cite journal |last1= Salmon |first1= Allison |last2= Van Beek |first2= Ingrid |last3= Amin |first3= Janaki |last4=Kaldor |first4= John |last5= Maher |first5= Lisa | author = Allison M. Salmon, Ingrid van Beek, Janaki Amin, John Kaldor & Lisa Maher | year = 2010 | month = February | title = The impact of a supervised injecting facility on ambulance call-outs in Sydney, Australia | journal = Addiction | volume = 105 | issue = 4 | pages = 676–683| DOI = 10.1111/j.1360-0443.2009.02837.x | url =http://www3.interscience.wiley.com/journal/123278060/abstract?CRETRY=1&SRETRY=0 |pmid=20148794 }}</ref><ref name="pmid18172151">{{cite journal |
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| last1 = Beletsky |first1= Leo |last2= Davis |first2= Corey S |last3= Anderson |first3= Evan |last4= Burris |first4= Scott |
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| title = The law (and politics) of safe injection facilities in the United States |
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| journal = American Journal of Public Health |
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| volume = 98 |
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| issue = 2 |
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| pages = 231–7 |
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| year = 2008 |
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| month = February |
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| pmid = 18172151 |
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| pmc = 2376869 |
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| doi = 10.2105/AJPH.2006.103747 |
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| url = http://www.ajph.org/cgi/pmidlookup?view=long&pmid=18172151 |
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}}</ref><ref name="pmid17689337">{{cite journal |
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| last1 = Kerr |first1= Thomas |last2= Kimber |first2= Jo |last3= Rhodes |first3= Tim |
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| title = Drug use settings: an emerging focus for research and intervention |
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| journal = The International Journal on Drug Policy |
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| volume = 18 |
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| issue = 1 |
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| pages = 1–4 |
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| year = 2007 |
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| month = January |
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| pmid = 17689337 |
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| doi = 10.1016/j.drugpo.2006.12.016 |
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| url = http://linkinghub.elsevier.com/retrieve/pii/S0955-3959(06)00262-3 |
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}}</ref> but failed to make any mention of the introduction of sniffer dog policing, introduced to the drug hot-spots around the injecting room a year after it opened.<ref>{{cite web |url=http://www.abc.net.au/news/newsitems/200205/s558480.htm|title=Police to crack down on Kings Cross drug trade |accessdate=2010-01-09}} 2003</ref> |
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Increases in the number of fatal overdoses in Vancouver since the introduction of Insite have made it difficult to assess its impact on overdoses at the community level. <ref>Mangham C. {{cite web |url= http://www.globaldrugpolicy.org/1/2/2.php |title=A Critique of Canada’s INSITE Injection Site and its Parent Philosophy: Implications and Recommendations for Policy Planning |accessdate=2010-01-09}}</ref> Vancouver’s overdoses increased from 50 in 2003 to 77 in 2005. <ref>Real Women of Canada {{cite web |url= http://www.realwomenca.com/alerts.htm |title=THE VANCOUVER DRUG INJECTION SITE MUST BE SHUT DOWN|accessdate=2010-01-09}}</ref> |
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====Site experience of overdose==== |
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While overdoses are managed on-site at Vancouver, Sydney and the facility near Madrid, German consumption rooms are forced to call an ambulance due to naloxone being administered only by doctors. A study of German consumption rooms indicated that an ambulance was called in 71% of emergencies and naloxone administered in 59% of cases. The facilities in Sydney and Frankfurt indicate 2.2-8.4% of emergencies resulting in hospitalization.<ref> Hedrich, D {{cite web |url=http://www.emcdda.europa.eu/attachements.cfm/att_2944_EN_consumption_rooms_report.pdf |title=A Report on European Consumption Rooms|accessdate=2010-05-28}} EMCDDA 2004 p 46</ref> |
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A survey of consumption rooms in the Netherlands, Germany and Switzerland found overdose rates ranging from 1 overdose per 10,000 injections to 36 overdoses per 10,000 injections. <ref>Davies G. {{cite web |url= http://www.globaldrugpolicy.org/1/3/2.php |title=A Critical Evaluation of the Effects of Safe Injection Facilities|accessdate=2010-01-09}} </ref> Vancouver’s Insite yielded 13 overdoses per 10,000 injections shortly after commencement, <ref>Kerr T, Tyndall MW, Lai C, Montaner JSG, Wood E. {{cite web |url=http://www.harmreduction.org/downloads/Kerr_Overdose_IJDP.pdf |year= 2008 |title=Drug-related overdoses within a medically |
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supervised safer injection facility |accessdate=2010-05-01}}</ref> but in 2009 had more than doubled to 27 per 10,000.<ref> see {{cite web |url=http://supervisedinjection.vch.ca/research/supporting_research/ |year= 2009 |title=User Statisitics |accessdate=2010-05-01}}</ref> but in 2009 had more than doubled to 27 per 10,000.<ref>Insite {{cite web |url=http://supervisedinjection.vch.ca/research/supporting_research/ |year= 2009 |title=Insite User Statisitics |accessdate=2010-05-01}}</ref> The Sydney MSIC recorded overdose rates of 72 overdoses per 10,000 injections covering all drugs used in the centre, <ref>Davies G. {{cite web |url= http://www.globaldrugpolicy.org/1/3/2.php |title=A Critical Evaluation of the Effects of Safe Injection Facilities|accessdate=2010-01-09}} </ref> but 96 overdoses per 10,000 injections for those using heroin. <ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p 24</ref> Commenting on the high overdose rates in the Sydney MSIC, the evaluators suggested that, |
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: “In this study of the Sydney injecting room there were 9.2 (sic) heroin overdoses per 1000 heroin injections in the centre. This rate of overdose is higher than amongst heroin injectors generally. The injecting room clients seem to have been a high-risk group with a higher rate of heroin injections than others not using the injection room facilities. They were more often injecting on the streets and they appear to have taken greater risks and used more heroin whilst in the injecting room. <ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p 59</ref> |
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The Drug Free Australia analysis of the Sydney MSIC 2003 evaluation found overdose levels in the MSIC 36 times higher than on the surrounding streets of Kings Cross.<ref>{{cite web |url=http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Detailed_Research.pdf |year= 2008 |title=The Case for Closure - Detailed Evidence |publisher= Drug Free Australia |accessdate=2010-01-09}}p 14</ref> The Drug Free Australia calculations used only the data published in the MSIC’s 2003 evaluation document, and used precisely the same assumptions utilized by the MSIC evaluators. Drug Free Australia has expressed concern that the evaluators, in using injecting room overdose data to calculate quite incorrect 'lives saved' estimates, failed to examine the extent to which overdoses were over-represented in the injecting room against data they had gathered on overdose rates in the Kings Cross area. |
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The Sydney MSIC has subsequently argued that the 2003 evaluators overestimated the number of injecting drug users in the Kings Cross area,<ref>E-mail from MSIC staffer Bernadette Keeffe sent to Drug Free Australia, posted on ADCA’s Drugtalk bulletin board 26 July 2006 1.30 PM</ref> thereby inflating the overdose ratio between injections in the injecting room as compared to the streets outside. Their lower estimate of only 605 heroin injectors being in Kings Cross on any given day, rather than the 2,000 per day estimated by the evaluators,<ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p 58</ref> reduces injecting room overdoses to 11 times higher than street levels of overdose, but Drug Free Australia noted that this lower daily estimate failed to be cognizant of the fact that the injecting room’s 2003 evaluation data showed 860 registered clients living within walking distance of the injecting room,<ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p 17</ref> with this group representing just 23% of the room’s total clientele. |
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Against other measures the Sydney MSIC’s overdose rate is highly disproportionate. Estimates of the number of dependent heroin users in Australia completed for the year 1997,<ref>Hall W, Ross J, Lynskey M, Law M, Degenhardt L {{cite web |url= http://www.mja.com.au/public/issues/173_10_201100/hall/hall.html |title=How many dependent heroin users are there in Australia? |accessdate=2010-05-01}} MJA 2000; 173: 528-531</ref> compared with estimates of the number of total non-fatal and fatal overdoses in Australia for 1997/98<ref>Warner-Smith M, Lynskey M, Darke S, Hall W |
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{{cite web |url=http://www.ancd.org.au/images/PDF/Researchpapers/rp1_heroin_overdose.pdf |title=Heroin overdose: prevalence, correlates, consequences and interventions |
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|accessdate=2010-05-01}} p 12</ref> yields a rate of 2 overdoses for every 10,000 injections against the MSIC’s rate of 96 overdoses for every 10,000 injections. A review of the MSIC registration surveys recording each client’s previous overdose histories<ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p 16</ref> reveals that MSIC clients’ previous overdose history were less prone to overdose than various other previously studied heroin injector cohorts in Australia.<ref name="Drug Free Australia">{{cite web |url=http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Detailed_Research.pdf |year= 2008 |title=The Case for Closure - Detailed Evidence |publisher= Drug Free Australia |accessdate=2010-01-09}}p 55</ref> |
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====Calculations of Lives Saved==== |
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The conclusion of the Sydney MSIC evaluators was that “a small number of opioid overdoses managed at the MSIC might have been fatal had they occurred elsewhere”, calculating that the centre had saved 4 lives per annum during the evaluation period. <ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 pp 58,9</ref> Estimates were directly calculated from the 329 heroin overdose interventions in the centre. |
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Drug Free Australia cites two statistics together which demonstrate that the Sydney MSIC cannot statistically claim to save even one life per year. The first is that 1% of dependent heroin users die from fatal overdose each year in Australia. The second is that a dependent heroin user averages ‘at least’ three injections per day according to the MSIC 2003 evaluation’s researchers. Taking these two statistics together, it is clear that the injecting room would need to host 300 injections per day (ie enough heroin injections for 100 heroin addicts injecting 3 times daily) before they could claim they had saved the life of the one (1%) of those 100 who would have died annually. But the injecting room averages just half that number with 156 heroin injections per day. Drug Free Australia has shown that the 2003 MSIC evaluators failed to factor the vastly elevated number of overdoses in the centre into their calculations of lives saved.<ref>Drug Free Australia {{cite web |url= http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Detailed_Research.pdf |title=The Case for Closure: Detailed Evidence |accessdate=2010-01-09}} p 26ff</ref> |
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While the Expert Advisory Committee for Vancouver’s Insite recognized that there were no overdose deaths amongst the 336 overdoses in the facility in 2007, their mathematical modeling, calculating between 400 and 500 injections per day at Insite, but for which they advised some caution regarding validity, suggested that INSITE saves about one life per year via its intervention in overdoses. |
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====Increases in Crime==== |
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The Sydney MSIC was judged by its evaluators to have caused no increase in crime<ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p xvi</ref> and not to have caused a ‘honey-pot effect’ of drawing users and drug dealers to the Kings Cross area.<ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p 204</ref> The Drug Free Australia analysis pointed to data within the report clearly demonstrating that drug-related loitering and drug dealing worsened at the station entrance 25 metres opposite the MSIC<ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 pp 146,7</ref> and at the rear door of the centre.<ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 pp 140</ref> |
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Testimony of ex-clients reported to the NSW Legislative Council<ref>NSW Parliament Hansard {{cite web |url=http://www.parliament.nsw.gov.au/Prod/parlment/hanstrans.nsf/V3ByKey/LC20070626 |title=Rev Dr Gordon Moyes Injecting Room Hansard |accessdate=2010-01-09}} 26 June 2007</ref> alleged that the extremely high overdose rates were due to clients experimenting with poly-drug cocktails and higher doses of heroin in the knowledge that staff were present to ensure their safety. The 2003 evaluation explanation for high overdose rates citing greater amounts of heroin used <ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p p 62,63</ref> has been cited by Drug Free Australia as cause for concern. |
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Observations before and after the opening of Insite indicated no increases in drug dealing or petty crime in the area. There was no evidence that the facility influenced drug use in the community, but concerns that Insite ‘sends the wrong message’ to non-users could not be addressed from existing data.<ref>see Executive Summary of {{cite web |url= http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php#insite |title=Final Report of the Vancouver Insite Expert Advisory Committee |accessdate=2010-04-19}} 2008</ref> Critics have noted that no observed increases in petty crime may likely be due to more than 60 extra police assigned to a 5 block area surrounding Insite soon after the facility was opened. <ref>Mangham C. {{cite web |url= http://www.globaldrugpolicy.org/1/2/2.php |title=A Critique of Canada’s INSITE Injection Site and its Parent Philosophy: Implications and Recommendations for Policy Planning |accessdate=2010-01-09}}</ref> The European experience has been mixed. <ref>see Sections A7 to A9 of Appendix B {{cite web |url= http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php#insite |title=Final Report of the Vancouver Insite Expert Advisory Committee |accessdate=2010-04-19}} 2008</ref> |
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====Community support==== |
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The Sydney MSIC has enjoyed the support of the surrounding Kings Cross community, with the 2005 evaluation indicating 73% of residents supportive of its presence and 68% of business operators. <ref>NCHECR {{cite web |url= http://www.nchecr.unsw.edu.au/NCHECRweb.nsf/resources/Interim_eval_Rep1/$file/IntRep2SurveyMSICJul06.pdf |title=Interim Evaluation Report No 2: Evaluation of Community Attitudes towards the Sydney MSIC, March 2006. |accessdate=2010-01-09}} p 3</ref> |
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The Expert Advisory Committee for Vancouver’s Insite found that health professionals, local police, the local community and the general public have positive or neutral views of the service, with opposition decreasing over time. <ref>see Executive Summary of {{cite web |url= http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php#insite |title=Final Report of the Vancouver Insite Expert Advisory Committee |accessdate=2010-04-19}} 2008</ref> |
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Drug Free Australia has expressed concern that supporters, staff and various NSW politicians continually has represented each overdose intervention in the centre to the Australian media as a life saved, when such an equation was clearly false.<ref>{{cite web |url=http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Booklet.pdf |year= 2008 |title=The Case for Closure |publisher= Drug Free Australia |accessdate=2010-01-09}} p 2</ref> |
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====Cost effectiveness==== |
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The cost of running Insite per annum is $3,000,000 Canadian. Mathematical modeling showed cost to benefit ratios of one dollar spent ranging from 0.97 to 2.90 in benefit. However the Expert Advisory Committee expressed reservation about the certainty of Insite’s cost effectiveness until proper longitudinal studies had been undertaken. Mathematical models for HIV transmissions foregone had not been locally validated and mathematical modeling from lives saved by the facility had not been validated.<ref>see {{cite web |url= http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php#insite |title=Final Report of the Vancouver Insite Expert Advisory Committee |accessdate=2010-04-19}} 2008</ref> The Sydney MSIC cost upwards of $2.7 million Australian per annum in 2007.<ref>NCHECR, {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Sydney Medically Supervised Injecting Centre Evaluation Report No. 4 |accessdate=2010-01-09}} 2007 p 35</ref> Drug Free Australia has asserted that in 2003 the cost of running the Sydney MSIC equated to 400 NSW government-funded rehabilitation places<ref>Drug Free Australia {{cite web |url= http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Detailed_Research.pdf |title=The Case for Closure: Detailed Evidence |accessdate=2010-01-09}} p 39</ref> while the Health Minister for the Canadian Government, Tony Clements, has stated that the money for Insite would be better spent on treatment for clients. <ref>Clement, T. {{cite web |url= http://www2.parl.gc.ca/housechamberbusiness/ChamberPublicationIndexSearch.aspx?arpist=s&arpit=vancouver+insite&arpidf=2006/01/01&arpidt=2010/05/31&arpid=True&arpij=False&arpice=False&arpicl=&ps=Parl0Ses0&arpisb=Publication&arpirpp=100&arpibs=False&Language=E&Mode=1&Parl=39&Ses=1&arpicid=3535078&arpicpd=3537184#Para1130935 |
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|title=Canadian Parliament Hansard |accessdate=2010-05-31}}2 June 2008</ref> |
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==See also== |
==See also== |
Revision as of 00:24, 4 June 2010
Supervised Injection Sites (SIS)[1] (also known as Safe Injection Site[1] Safer Injection Facility (SIF), Drug Consumption Facility (DCF)[2] or Medically Supervised Injection Center (MSIC)[3]) are legally sanctioned and medically supervised facilities designed to addressed to reduce nuisance from public drug use and provide a hygienic and stress-free environment for illicit drug users when consuming drugs, mostly injecting drug use.[2]
Part of a Harm reduction approach towards drug problems, they have come under considerable criticism as it "condones illicit drug use and drug trafficking and runs counter to the provisions of the international drug control treaties."[4]
General information
The facilities provide sterile injection equipment, information about drugs and basic health care, treatment referrals, and access to medical staff. Some offer counseling, hygienic and other services of use to itinerant and impoverished individuals. Most programs prohibit the sale or purchase of illegal drugs. Many require identification cards. Some restrict access to local residents and apply other admission criteria, such as they have to be injection drug users, but generally in Europe they don't exclude addicts who consume by other means.
Operating facilities
What disparagingly is called "shooting galleries" have existed for a long time, there where illicit for-profit galleries in New York during 1980s and in Sydney (Australia) during the 1990s. What differs these from the legally sanctioned is the care they provide. While the operators of the facilities New York and Sydney (Australia) they had little regard for the health of their clients, modern supervised injection facilities are a professionally staffed health and welfare service.[5]
The first professionally staffed service where drug injection was accepted emerged in the Netherlands during the first years of the 1970s as part of the "alternative youth service" provided by the St Paul's church in Rotterdam. At its peak it had two centers that combined an informal meeting place with a drop-in center providing basic health care, food and laundering service. One of the centers also was also a pioneer in providing needle-exchange. The purpose was to improve the psychosocial function and heath of its clients. The centers received some support from law enforcement and local government officials, although where not officially sanctioned until 1996.[5]
The first legally sanctioned drug consumption facility was set up in Berne 1986 and further legal facilities was emerging other cities in Swizerland Germany and the Netherlands during the 1990s.[2][5] In the first decade of 2000, facilities opened in Spain, Luxembourg, Norway, Canada and Australia.[2]
The Sydney Medically Supervised Injecting Centre (MSIC) opened in May, 2001, in Kings Cross, Sydney.[6] It was set up as a recommendation of the Wood Royal Commission to combat street crime in the area and reduce police corruption.[7]
The Canadian Insite commenced operation in 2003. As well as public order and improving health, the major difference between the supervised injecting centres and the unsupervised European model is the more clinical nature of the service. Oxygen and Naloxone are administered in the case of opioid and heroin overdose.[6]
As of the beginning of 2009 there where 92 facilities operating in 61 cities, including 30 cities in the Netherlands, 16 cities in Germany and 8 cities in Swizerland.[2] In Europe, most operate as part of local social services. Although the facilities in Norway, Canada and Australia are scientific pilot projects operating under special law.
Evaluations
In the late 1990s there were a number of studies available on consumption rooms in Germany, Switzerland and the Netherlands. “The reviews concluded that the rooms contributed to improved public and client health and reductions in public nuisance but stressed the limitations of the evidence and called for further and more comprehensive evaluation studies into the impact of such services.” [8] To that end, the two non-European injecting facilities, Australia’s Sydney Medically Supervised Injecting Centre (MSIC) and Canada’s Vancouver Insite Supervised Injection Site have been more rigorously evaluated. [9]
The NSW Government has provided extensive funding for ongoing evaluations of the Sydney MSIC, with a formal comprehensive evaluation produced in 2003, 18 months after the centre was opened. Other later evaluations studied various aspects of the operation - service provision (2005), community attitudes (2006), referral and client health (2007) and a fourth (2007) service operation and overdose related events.[10]
In 2003 and 2006 a drug prevention advocacy group, Drug Free Australia, completed analyses of the Sydney MSIC 2003 evaluation and other evaluations.[11] The Drug Free Australia team included an epidemiologist, an addiction medicine practitioner, social researchers and a senior welfare practitioner. Three of these analysts were well-published authors of research papers in 20 different peer-reviewed medical journals. They released their findings to the media and to politicians, leading to a robust debate in Australia regarding the effectiveness of aspects of the Sydney MSIC. [12][13][14]
The Vancouver Insite facility was evaluated during the first three years of its operation by researchers from the BC Center for Excellence in HIV/AIDS with published and some unpublished reports available. In March 2008 a Final Report of the Expert Advisory Committee appointed by the Canadian Ministry of Health was released, evaluating the performance of the Vancouver Insite against its stated objectives.
The drug prevention advocacy group, Real Women of Canada has called for the closure of the Vancouver Insite facility, citing the evaluation by the Expert Advisory Committee and pointing to what is, in their view, a failure to achieve significant outcomes by Insite.[15]
Client Characteristics and Utilization
The first 2003 Evaluation of the Sydney MSIC found that it had “made service contact with its target population”, [16] with 9,778 visitors to the Centre for a total of 391,170 injections between 2001 and 2007, where clients averaged 14 years of illicit drug use and where 51% were heroin injectors and 35% had experienced an overdose previously. [17]
The Drug Free Australia 2003 analysis found that clients were averaging only one in every of their 35 injections in the room, evidencing low utilization rates in light of the ever-present risk of fatal overdose to each heroin user.[18][19] With injector safety the most prominent rationale for the establishment of injecting rooms, the analysis questioned such low utilization rates in light of the room’s purpose. It is noted that the Sydney MSIC has capacity for 330 injections per day,[20] but in 2007 was averaging 212 injections per day. [21] Low utilization rates indicate, in Drug Free Australia’s view, that Sydney clients were injecting at least 34 out of 35 injections in unsafe situations - at home, at a friend's place or squat, at a dealer's home, on the street, in a car, in a public toilet or in an illegal shooting gallery, while the injecting room was underutilized.
The Expert Advisory Committee for Insite[22] cited 8,000 people who had visited INSITE, with 18% accounting for 80% of all visits to INSITE, less than 10% using the site for all injections, a median number of 8 visits across all clientele, and 600 visits per day, of which 80% were to inject, showing that the facility was near capacity. Two surveys of approximately 1,000 users established some key user characteristics – clients averaged 15 years of drug use, 51% injected heroin and 32% cocaine, 87% were infected with Hepatitis C virus and 17% with HIV, 20% were homeless with numerous others living in single resident rooms, 80% had been incarcerated, 21% were using methadone and 59% reported a non-fatal overdose during their lifetime.
European consumption rooms cater moreso to users older than 30 years, mainly with problematic heroin and cocaine habits. Various studies have documented an ageing population of clients over time. Whereas in 1990, in one study, 50% of clients were 25 years or younger, by 2001 the percentage was 15%. Clients across European consumption rooms are characterized by heavy injecting drug use, a continuous use of illicit drugs and deriving from a poorer demographic. German studies found that between 19% and 27% of clients were from unstable accommodation. In the injecting rooms near Madrid 42% of the marginalized target group were homeless, while the number was 60% for the Can Tunis area of Barcelona. In a German study 15% of clients had never accessed addiction treatment of any kind.[23]
Client utilization in the European situation is more difficult to analyze. Studies on sites in Frankfurt and Zurich found that clients used facilities 5 times a week[24] and in Rotterdam 6 times a week and twice in the previous 24 hours.[25] A study of clients in Frankfurt in 1997 found that 63% claimed to be daily visitors, while in another surveyed non-random sample from 18 German consumption rooms, 84% claimed use of the facility at least once weekly, with 51% claiming at least once per day utilization.[26] Critics have asserted that sufficient information is not available on the injecting habits of these clients to judge their prevalence of supervised injection, where, for instance, one or two injections in the consumption room for 5 days weekly may still represent a small percentage of injections for a heavily dependent user injecting 10 times per day. [27]
Client Referral
Evaluators of the Sydney MSIC found that over a six year period “staff provided 44,082 other occasions of service (113 per 1,000 visits) including drug and alcohol information (approximately 5,000 occasions)”, advice on drug and alcohol treatment on more than 3,000 occasions, 21,000 occasions where staff had provided vein care and safer injecting advice, with a total of 6,243 referrals to other services where 45% of referrals were to treatment.[28] Of the 2,801 referrals to treatment 947 were to detox and 336 to abstinence-based rehabilitation or therapy. The evaluators asserted that the MSIC was thereby evidenced as a gateway for treatment. [29]
The Expert Advisory Committee found that Insite had referred clients such that it had contributed to an increased use of detoxification services and increased engagement in treatment. Insite had encouraged users to seek counseling. Funding has been supplied by the Canadian government for detoxification rooms above Insite. [30]
Impact on Public Nuisance
“The Sydney MSIC client survey conducted in 2005, found that public injecting (defined as injecting in a street, park, public toilet or car), which is a high risk practice with both health and public amenity impacts, was reported as the main alternative to injecting at the MSIC by 78% of clients. 49% of clients indicated resort to public injection if the MSIC was not available on the day of registration with the MSIC. From this, the evaluators calculated a total 191,673 public injections averted by the centre.[31]
Public amenity can be further improved by reduced numbers of publicly disposed needles and syringes. Data from the Sydney MSIC’s 2003 report indicated reductions in needles and syringe counts and resident and business-operator sightings of injections in public places decreased marginally but could not be certain that there was any effect by the MSIC beyond the heroin drought which had commenced some months prior to the opening of the MSIC. [32] The Drug Free Australia analysis pointed to the needle, syringe and public sighting decreases being almost exactly equivalent to the 20% decreases in the number of needles distributed from local pharmacies, needle exchanges and the MSIC, thereby indicating no clear impact by the MSIC. [33]
Observations before and after the opening of Insite indicated a reduction in public injecting. [34]
Impact on blood-borne viruses
The evaluators of the Sydney MSIC found that it “had not increased blood-borne virus transmission” [35] with the data more specifically showing no improvement re HIV infection incidence, no improvement in Hep B infections, [36] either worse or no improvement (depending on the suburb studied) in new Hep C notifications,[37] no improvement in reuse of others' syringes and injecting equipment, no improvement in tests taken for HIV and Hep C and initial improvement in tests taken for Hep B but worsening again in 2002. [38]
The Expert Advisory Committee for Vancouver’s Insite found that journal studies with mathematical modeling by researchers from self-reports of users generated a wide range of estimates for HIV cases averted, but they were not convinced that the assumptions were valid.
Impact on community levels of overdose
Over a six year period the Sydney MSIC managed 2,106 overdose-related events with not one fatality[39] while Vancouver’s Insite had managed 336 overdose events in 2007 with not a single fatality.
The 2003 evaluators of the Sydney MSIC found it had made “no detectable change in heroin overdoses at the community level”, [40] with no improvement in ambulance overdose attendances in the area, no improvement in ambulance overdose attendance during hours the injecting room was open and no improvement in overdose presentations at hospital emergency wards. [41]
Research by injecting room evaluators in 2007 presented statistical evidence that there had been later reductions in ambulance callouts during injecting room hours,[42][43][44] but failed to make any mention of the introduction of sniffer dog policing, introduced to the drug hot-spots around the injecting room a year after it opened.[45]
Increases in the number of fatal overdoses in Vancouver since the introduction of Insite have made it difficult to assess its impact on overdoses at the community level. [46] Vancouver’s overdoses increased from 50 in 2003 to 77 in 2005. [47]
Site experience of overdose
While overdoses are managed on-site at Vancouver, Sydney and the facility near Madrid, German consumption rooms are forced to call an ambulance due to naloxone being administered only by doctors. A study of German consumption rooms indicated that an ambulance was called in 71% of emergencies and naloxone administered in 59% of cases. The facilities in Sydney and Frankfurt indicate 2.2-8.4% of emergencies resulting in hospitalization.[48]
A survey of consumption rooms in the Netherlands, Germany and Switzerland found overdose rates ranging from 1 overdose per 10,000 injections to 36 overdoses per 10,000 injections. [49] Vancouver’s Insite yielded 13 overdoses per 10,000 injections shortly after commencement, [50] but in 2009 had more than doubled to 27 per 10,000.[51] but in 2009 had more than doubled to 27 per 10,000.[52] The Sydney MSIC recorded overdose rates of 72 overdoses per 10,000 injections covering all drugs used in the centre, [53] but 96 overdoses per 10,000 injections for those using heroin. [54] Commenting on the high overdose rates in the Sydney MSIC, the evaluators suggested that,
- “In this study of the Sydney injecting room there were 9.2 (sic) heroin overdoses per 1000 heroin injections in the centre. This rate of overdose is higher than amongst heroin injectors generally. The injecting room clients seem to have been a high-risk group with a higher rate of heroin injections than others not using the injection room facilities. They were more often injecting on the streets and they appear to have taken greater risks and used more heroin whilst in the injecting room. [55]
The Drug Free Australia analysis of the Sydney MSIC 2003 evaluation found overdose levels in the MSIC 36 times higher than on the surrounding streets of Kings Cross.[56] The Drug Free Australia calculations used only the data published in the MSIC’s 2003 evaluation document, and used precisely the same assumptions utilized by the MSIC evaluators. Drug Free Australia has expressed concern that the evaluators, in using injecting room overdose data to calculate quite incorrect 'lives saved' estimates, failed to examine the extent to which overdoses were over-represented in the injecting room against data they had gathered on overdose rates in the Kings Cross area.
The Sydney MSIC has subsequently argued that the 2003 evaluators overestimated the number of injecting drug users in the Kings Cross area,[57] thereby inflating the overdose ratio between injections in the injecting room as compared to the streets outside. Their lower estimate of only 605 heroin injectors being in Kings Cross on any given day, rather than the 2,000 per day estimated by the evaluators,[58] reduces injecting room overdoses to 11 times higher than street levels of overdose, but Drug Free Australia noted that this lower daily estimate failed to be cognizant of the fact that the injecting room’s 2003 evaluation data showed 860 registered clients living within walking distance of the injecting room,[59] with this group representing just 23% of the room’s total clientele.
Against other measures the Sydney MSIC’s overdose rate is highly disproportionate. Estimates of the number of dependent heroin users in Australia completed for the year 1997,[60] compared with estimates of the number of total non-fatal and fatal overdoses in Australia for 1997/98[61] yields a rate of 2 overdoses for every 10,000 injections against the MSIC’s rate of 96 overdoses for every 10,000 injections. A review of the MSIC registration surveys recording each client’s previous overdose histories[62] reveals that MSIC clients’ previous overdose history were less prone to overdose than various other previously studied heroin injector cohorts in Australia.[63]
Calculations of Lives Saved
The conclusion of the Sydney MSIC evaluators was that “a small number of opioid overdoses managed at the MSIC might have been fatal had they occurred elsewhere”, calculating that the centre had saved 4 lives per annum during the evaluation period. [64] Estimates were directly calculated from the 329 heroin overdose interventions in the centre.
Drug Free Australia cites two statistics together which demonstrate that the Sydney MSIC cannot statistically claim to save even one life per year. The first is that 1% of dependent heroin users die from fatal overdose each year in Australia. The second is that a dependent heroin user averages ‘at least’ three injections per day according to the MSIC 2003 evaluation’s researchers. Taking these two statistics together, it is clear that the injecting room would need to host 300 injections per day (ie enough heroin injections for 100 heroin addicts injecting 3 times daily) before they could claim they had saved the life of the one (1%) of those 100 who would have died annually. But the injecting room averages just half that number with 156 heroin injections per day. Drug Free Australia has shown that the 2003 MSIC evaluators failed to factor the vastly elevated number of overdoses in the centre into their calculations of lives saved.[65]
While the Expert Advisory Committee for Vancouver’s Insite recognized that there were no overdose deaths amongst the 336 overdoses in the facility in 2007, their mathematical modeling, calculating between 400 and 500 injections per day at Insite, but for which they advised some caution regarding validity, suggested that INSITE saves about one life per year via its intervention in overdoses.
Increases in Crime
The Sydney MSIC was judged by its evaluators to have caused no increase in crime[66] and not to have caused a ‘honey-pot effect’ of drawing users and drug dealers to the Kings Cross area.[67] The Drug Free Australia analysis pointed to data within the report clearly demonstrating that drug-related loitering and drug dealing worsened at the station entrance 25 metres opposite the MSIC[68] and at the rear door of the centre.[69]
Testimony of ex-clients reported to the NSW Legislative Council[70] alleged that the extremely high overdose rates were due to clients experimenting with poly-drug cocktails and higher doses of heroin in the knowledge that staff were present to ensure their safety. The 2003 evaluation explanation for high overdose rates citing greater amounts of heroin used [71] has been cited by Drug Free Australia as cause for concern.
Observations before and after the opening of Insite indicated no increases in drug dealing or petty crime in the area. There was no evidence that the facility influenced drug use in the community, but concerns that Insite ‘sends the wrong message’ to non-users could not be addressed from existing data.[72] Critics have noted that no observed increases in petty crime may likely be due to more than 60 extra police assigned to a 5 block area surrounding Insite soon after the facility was opened. [73] The European experience has been mixed. [74]
Community support
The Sydney MSIC has enjoyed the support of the surrounding Kings Cross community, with the 2005 evaluation indicating 73% of residents supportive of its presence and 68% of business operators. [75]
The Expert Advisory Committee for Vancouver’s Insite found that health professionals, local police, the local community and the general public have positive or neutral views of the service, with opposition decreasing over time. [76]
Drug Free Australia has expressed concern that supporters, staff and various NSW politicians continually has represented each overdose intervention in the centre to the Australian media as a life saved, when such an equation was clearly false.[77]
Cost effectiveness
The cost of running Insite per annum is $3,000,000 Canadian. Mathematical modeling showed cost to benefit ratios of one dollar spent ranging from 0.97 to 2.90 in benefit. However the Expert Advisory Committee expressed reservation about the certainty of Insite’s cost effectiveness until proper longitudinal studies had been undertaken. Mathematical models for HIV transmissions foregone had not been locally validated and mathematical modeling from lives saved by the facility had not been validated.[78] The Sydney MSIC cost upwards of $2.7 million Australian per annum in 2007.[79] Drug Free Australia has asserted that in 2003 the cost of running the Sydney MSIC equated to 400 NSW government-funded rehabilitation places[80] while the Health Minister for the Canadian Government, Tony Clements, has stated that the money for Insite would be better spent on treatment for clients. [81]
See also
- Insite - Supervised Injection Site in Canada
- Illicit drug use in Australia
- Harm reduction
References
- ^ a b Alan Ogborne; et al. (March 31, 2008). "Vancouver's INSITE service and other Supervised injection sites: What has been learned from research? - Final report of the Expert Advisory Committee". Health Canada.
{{cite web}}
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(help) - ^ a b c d e Dagmar Hedrich; et al. (April, 2010). "Chapter 11: Drug consumption facilities in Europe and beyond". Harm reduction: evidence, impacts and challenges. EMCDDA.
{{cite web}}
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(help); Explicit use of et al. in:|author=
(help) - ^ Sidney MSIC, official homepage
- ^ "INCB 2001 Annual Report - Oceania" (PDF). Retrieved 2010-03-28.
- ^ a b c Dolan, Kate; Kimber, Jo; Fry, Craig; Fitzgerald, John; Mcdonald, David; Trautman, Franz (2000). "Drug consumption facilities in Europe and the establishment of supervised injection centres in Australia" (PDF). Drug and Alcohol Review. 19: 337–346. doi:10.1080/713659379.
- ^ a b Van Beek, Ingrid (2004). In the eye of the needle: Diary of medically supervised injecting centre. Crows Nest: Allen & Unwin. ISBN 9781741143812. OCLC 57515258.
- ^ "Report on the Establishment or Trial of Safe Injecting Rooms, Executive Summary". The Joint Select Committee into Safe Injecting Rooms, Parliament of New South Wales. Retrieved 2010-03-30.
- ^ EMCDDA"European report on drug consumption rooms" (PDF). Retrieved 2010-04-28. 2004 p 27
- ^ Davies G. "A Critical Evaluation of the Effects of Safe Injection Facilities". Retrieved 2010-01-09.
- ^ "MSIC Evaluations". 2008. Retrieved 2010-01-09.
- ^ "The Case for Closure" (PDF). Drug Free Australia. 2008. Retrieved 2010-01-09.
- ^ "NSW Upper House Hansard". Hansard. Retrieved 2010-05-30.26 June 2007
- ^ "Piers Akerman – Daily Telegraph". Retrieved 2010-05-30.Daily Telegraph 3 May 2007
- ^ "Graeme Turner on the Rhetoric of Alan Jones". Retrieved 2010-05-30.12 May 2007
- ^ Real Women of Canada "THE VANCOUVER DRUG INJECTION SITE MUST BE SHUT DOWN". Retrieved 2010-01-09.
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 p xvi
- ^ NCHECR, "Sydney Medically Supervised Injecting Centre Evaluation Report No. 4" (PDF). Retrieved 2010-01-09. 2007 pp 14-17
- ^ "The Case for Closure" (PDF). Drug Free Australia. 2008. Retrieved 2010-01-09. 2007
- ^ Drug Free Australia "The Case for Closure - Detailed Evidence" (PDF). Drug Free Australia. Retrieved 2010-01-09. 2007 p 12
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 p 38
- ^ NCHECR, "Sydney Medically Supervised Injecting Centre Evaluation Report No. 4" (PDF). Retrieved 2010-01-09. 2007 p 7
- ^ see Research Conclusions and Limitations - 1. INSITE Utilization and User Characteristics "Final Report of the Vancouver Insite Expert Advisory Committee". Retrieved 2010-04-19. 2008
- ^ Hedrich, D "A Report on European Consumption Rooms" (PDF). Retrieved 2010-05-28. EMCDDA 2004 pp 31-33
- ^ EMCDDA"European report on drug consumption rooms" (PDF). Retrieved 2010-04-28. 2004 pp 35,6
- ^ EMCDDA"Drug Consumption Rooms in Rotterdam: An Explorative Description". Retrieved 2010-04-28.
- ^ Hedrich, D "A Report on European Consumption Rooms" (PDF). Retrieved 2010-05-28. EMCDDA 2004 p 35
- ^ Davies G. "A Critical Evaluation of the Effects of Safe Injection Facilities". Retrieved 2010-01-09. Journal of Global Drug Policy and Practice Vol. 2 Iss. 1
- ^ NCHECR, "Sydney Medically Supervised Injecting Centre Evaluation Report No. 4" (PDF). Retrieved 2010-01-09. 2007 p 7
- ^ NCHECR, "Sydney Medically Supervised Injecting Centre Evaluation Report No. 4" (PDF). Retrieved 2010-01-09. 2007 p 21
- ^ see "Final Report of the Vancouver Insite Expert Advisory Committee". Retrieved 2010-04-19. 2008
- ^ NCHECR, "Sydney Medically Supervised Injecting Centre Evaluation Report No. 4" (PDF). Retrieved 2010-01-09. 2007 p 21
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 p 125
- ^ "The Case for Closure - Detailed Evidence" (PDF). Drug Free Australia. 2008. Retrieved 2010-01-09.p 32
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 p xvi
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 p xvi
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 pp 71,2
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 p 80
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 pp 91-8
- ^ NCHECR, "Sydney Medically Supervised Injecting Centre Evaluation Report No. 4" (PDF). Retrieved 2010-01-09. 2007 p 7
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 p xvi
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 pp 60-62
- ^ Salmon, Allison; Van Beek, Ingrid; Amin, Janaki; Kaldor, John; Maher, Lisa (2010). "The impact of a supervised injecting facility on ambulance call-outs in Sydney, Australia". Addiction. 105 (4): 676–683. doi:10.1111/j.1360-0443.2009.02837.x. PMID 20148794.
{{cite journal}}
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and|last1=
specified (help); Unknown parameter|month=
ignored (help) - ^ Beletsky, Leo; Davis, Corey S; Anderson, Evan; Burris, Scott (2008). "The law (and politics) of safe injection facilities in the United States". American Journal of Public Health. 98 (2): 231–7. doi:10.2105/AJPH.2006.103747. PMC 2376869. PMID 18172151.
{{cite journal}}
: Unknown parameter|month=
ignored (help) - ^ Kerr, Thomas; Kimber, Jo; Rhodes, Tim (2007). "Drug use settings: an emerging focus for research and intervention". The International Journal on Drug Policy. 18 (1): 1–4. doi:10.1016/j.drugpo.2006.12.016. PMID 17689337.
{{cite journal}}
: Unknown parameter|month=
ignored (help) - ^ "Police to crack down on Kings Cross drug trade". Retrieved 2010-01-09. 2003
- ^ Mangham C. "A Critique of Canada's INSITE Injection Site and its Parent Philosophy: Implications and Recommendations for Policy Planning". Retrieved 2010-01-09.
- ^ Real Women of Canada "THE VANCOUVER DRUG INJECTION SITE MUST BE SHUT DOWN". Retrieved 2010-01-09.
- ^ Hedrich, D "A Report on European Consumption Rooms" (PDF). Retrieved 2010-05-28. EMCDDA 2004 p 46
- ^ Davies G. "A Critical Evaluation of the Effects of Safe Injection Facilities". Retrieved 2010-01-09.
- ^ Kerr T, Tyndall MW, Lai C, Montaner JSG, Wood E. "Drug-related overdoses within a medically supervised safer injection facility" (PDF). 2008. Retrieved 2010-05-01.
{{cite web}}
: line feed character in|title=
at position 42 (help) - ^ see "User Statisitics". 2009. Retrieved 2010-05-01.
- ^ Insite "Insite User Statisitics". 2009. Retrieved 2010-05-01.
- ^ Davies G. "A Critical Evaluation of the Effects of Safe Injection Facilities". Retrieved 2010-01-09.
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 p 24
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 p 59
- ^ "The Case for Closure - Detailed Evidence" (PDF). Drug Free Australia. 2008. Retrieved 2010-01-09.p 14
- ^ E-mail from MSIC staffer Bernadette Keeffe sent to Drug Free Australia, posted on ADCA’s Drugtalk bulletin board 26 July 2006 1.30 PM
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 p 58
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 p 17
- ^ Hall W, Ross J, Lynskey M, Law M, Degenhardt L "How many dependent heroin users are there in Australia?". Retrieved 2010-05-01. MJA 2000; 173: 528-531
- ^ Warner-Smith M, Lynskey M, Darke S, Hall W "Heroin overdose: prevalence, correlates, consequences and interventions" (PDF). Retrieved 2010-05-01. p 12
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 p 16
- ^ "The Case for Closure - Detailed Evidence" (PDF). Drug Free Australia. 2008. Retrieved 2010-01-09.p 55
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 pp 58,9
- ^ Drug Free Australia "The Case for Closure: Detailed Evidence" (PDF). Retrieved 2010-01-09. p 26ff
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 p xvi
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 p 204
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 pp 146,7
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 pp 140
- ^ NSW Parliament Hansard "Rev Dr Gordon Moyes Injecting Room Hansard". Retrieved 2010-01-09. 26 June 2007
- ^ 2003 MSIC Evaluation Committee "Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre" (PDF). Retrieved 2010-01-09. 2003 p p 62,63
- ^ see Executive Summary of "Final Report of the Vancouver Insite Expert Advisory Committee". Retrieved 2010-04-19. 2008
- ^ Mangham C. "A Critique of Canada's INSITE Injection Site and its Parent Philosophy: Implications and Recommendations for Policy Planning". Retrieved 2010-01-09.
- ^ see Sections A7 to A9 of Appendix B "Final Report of the Vancouver Insite Expert Advisory Committee". Retrieved 2010-04-19. 2008
- ^ NCHECR "Interim Evaluation Report No 2: Evaluation of Community Attitudes towards the Sydney MSIC, March 2006" (PDF). Retrieved 2010-01-09. p 3
- ^ see Executive Summary of "Final Report of the Vancouver Insite Expert Advisory Committee". Retrieved 2010-04-19. 2008
- ^ "The Case for Closure" (PDF). Drug Free Australia. 2008. Retrieved 2010-01-09. p 2
- ^ see "Final Report of the Vancouver Insite Expert Advisory Committee". Retrieved 2010-04-19. 2008
- ^ NCHECR, "Sydney Medically Supervised Injecting Centre Evaluation Report No. 4" (PDF). Retrieved 2010-01-09. 2007 p 35
- ^ Drug Free Australia "The Case for Closure: Detailed Evidence" (PDF). Retrieved 2010-01-09. p 39
- ^ Clement, T. "Canadian Parliament Hansard". Retrieved 2010-05-31.2 June 2008
External links
- Official homepage of the Sydney Medically Supervised Injecting Centre
- Official homepage of Insite