Twenty‐one years at the Uniting Medically Supervised Injecting Centre, Sydney Australia: addressing the remaining questions

Early research established that the MSIC did not result in a “honeypot” effect, but led to improved and sustained public amenity

This year marks the 21st anniversary of the Uniting Sydney Medically Supervised Injecting Centre (MSIC). The MSIC provides a safer place where people who inject drugs can self‐administer substances in hygienic conditions under the supervision of qualified staff. The MSIC was opened in 2001, following the 1999 New South Wales Drug Summit1 held in response to the 1990s heroin epidemic that saw sharp increases in opioid overdose death and ongoing blood‐borne virus transmission.2

There is a substantial evidence base on the efficacy of supervised injecting facilities (SIFs).3,4 Early research established that the MSIC did not result in a “honeypot” effect (ie, attract new users to the area), but led to improved5 and sustained public amenity.6 Yet, there are currently only about 120 SIFs operating globally, with two in Australia. The MSIC remains the only NSW service, despite robust arguments7 for additional facilities in Sydney locations, where opioid overdose deaths have been increasing, including a NSW Special Commission recommendation for more SIFs8 and multiple Coronial recommendations.9

This 21st anniversary provides an opportunity to highlight the successes of the MSIC. In doing so, we address six complex questions10 regarding the organisational and legal challenges of SIF operation, previously considered as barriers, by drawing on the international literature and our service data and experience.

Should injecting particularly dangerous drug mixtures, doses, or body sites be prohibited?

Drug mixes

Regulatory restrictions deny entry to intoxicated clients, but various substances that could be considered dangerous drug mixtures have been injected at the MSIC, including pharmaceutical opioids, psychostimulants and benzodiazepines, without fatality. In 2014–15 there was a marked increase in pharmaceutical fentanyl injections at the MSIC associated with increased overdoses.11 Each fentanyl overdose was managed onsite and none required hospital transfer.11 Other potentially harmful substances have also been injected. In 2009, five clients unknowingly injected insulin.12 Early identification of the symptoms resulted in all but one client being managed onsite. The one client transferred to hospital was subsequently released without complication.

The MSIC data clearly demonstrate that injecting drugs under supervision — even particularly dangerous substances such as fentanyl — is safer than injecting in an unsupervised environment because many harms can be mitigated with close supervision. The injection of especially harmful substances presents the service with a unique opportunity for clients to be educated and improve practice around this potentially dangerous activity.13 It is reasonable to conclude that, in the absence of the MSIC, these same substances would have still been injected but with potential dire consequences.

Drug doses, overdose, and frequent attendance

Although the service does not allow entry to clients who are intoxicated, there is no restriction on the number of times an MSIC client can visit per day or the amount of substance they can inject. The mean daily count was two visits per person between 2015 and 2019 (range, 1–12).

There is no practical way to determine how much of an illicit substance a client will inject, nor what may be a tolerable amount for that individual. However, in 21 years, there have been 1 232 951 supervised injections by 17 960 registered clients and 10 890 overdoses managed without a single fatality. First‐line management of opioid overdose is oxygen and airway management. Due to very early intervention, this is generally sufficient, with only 20% of overdoses requiring naloxone administration. From 2010 to 2020, 1% of the more than 7000 overdoses managed by the MSIC required an ambulance (n = 76) — strong evidence that overdose, whatever the cause, can be swiftly and effectively managed. Therefore, supervised injection is always safer than injecting elsewhere.

Injecting sites

Neck and groin (femoral) injecting practices are more common among people who have been injecting drugs for many years, have poor venous access, and experience more problematic drug use.14 Groin injection has been rare at the MSIC, and neck injecting was prohibited for the first 10 years of operation. However, this was reviewed as the client cohort aged and issues related to their long term injecting emerged.

A 2017 trial of neck injecting, overseen by an expert clinical group and with ethics committee approval, found that supervised neck injecting was no more associated with adverse events than any other forms of injecting.15 Specific clinical guidelines including closer supervision and specific educational resources for staff and clients were developed, providing an opportunity for staff to give health interventions to clients engaging in this practice. Twenty‐one years of MSIC operation have shown that working with people with long term injecting drug use requires careful monitoring of, and response to, their needs.

What are the age limits and other restrictions?

Only people aged 18 years or older, with a previous history of injecting, are legally permitted to access the MSIC. Internationally, most SIFs place age limits on access,16 and the evidence suggests that few young people attempt to attend these services.2 This is unsurprising, as the initiation age to injecting drug use for most is 18 years.17,18 Indeed, people who inject drugs and access SIFs tend to be older than their counterparts who do not access SIFs.17,19

The literature offers little rationale for age restrictions, with the decision being more political than evidence‐based.20 Even though very few young people aged under 18 years have attempted to access the MSIC, the issue remains contentious as it imposes a barrier to safety and care for vulnerable young people.20 Similarly, due to current legislation, pregnant women are also excluded from the MSIC, thus denying an important opportunity for antenatal care and substance use treatment. This restriction is in urgent need of review.

What is the medico‐legal responsibility?

Careful legislative arrangements are necessary for SIFs to successfully operate. The MSIC operates under specific legislation (Part 2A of the Drug Misuse and Trafficking Act²¹), which exempts staff from prosecution for aiding and abetting drug offences and exempts clients from small quantity possession and self‐administration offences. If staff actively participated in drug administration, by either inserting a needle or depressing the plunger, they could potentially be held liable for any adverse outcome. Therefore, the MSIC policy prohibits staff from injecting clients and clients from injecting other clients. The medico‐legal responsibility in the event of death remains untested because no overdose deaths have occurred onsite at the MSIC and, to our knowledge, at any SIF worldwide.

Is the MSIC aiding, abetting and fostering more frequent drug use?

Multiple evaluations undertaken throughout the first 10 years of the MSIC operation found no increased frequency of drug use among registered clients — findings robustly supported by the evaluation of the comparable Vancouver INSITE SIF.22,23,24,25 Indeed, early evaluation found that greater frequency of MSIC attendance was associated with increased referral to treatment.26 These findings have been replicated in Canada, with SIF clients more likely to seek drug treatment than non‐SIF clients.25,27 Put simply, SIFs do not facilitate more frequent or increased drug use.

What are the risks of onsite buying and selling of drugs?

Clear rules are in place at the MSIC to prevent the buying or selling of drugs onsite, and the service design limits opportunities for such behaviour, including close staff oversight throughout the service. Where contentious behaviour is suspected, temporary exclusions from the service can be imposed.

Service data show that from 2017 to June 2021, 442 individual clients received 1241 sanctions (temporary, 24‐hour exclusion from the service for unacceptable behaviour), but fewer than 20% were sanctioned for possible onsite sharing of substances. The remainder were most commonly excluded for unacceptable behaviour, such as specific threats of violence and verbal and/or physical aggression.

Providing a service with few barriers to access, that supervises people while they inject drugs and also limits any exchange of drugs can be challenging, but it can be managed with appropriate service design, well trained staff, and therapeutic client relationships.

Is the MSIC effective for harm reduction?

The MSIC clearly reduces harm for clients attending the service.28 At the end of April 2022, the MSIC had supervised 1 232 951 injections with no deaths onsite, successfully managed 10 890 overdoses, and made 20 420 referrals to health and social services.

Clients spend, on average, 38.6 minutes in the service, and adverse events have occurred in fewer than 1% of all injections. Put simply, when a safer place to inject drugs is provided, the associated short term harms are greatly reduced. The longer term harms are also reduced with increased access to services, including drug treatment,17,26 hepatitis C care,29 and smoking cessation.30

Conclusion

By drawing on the 21 years of MSIC experience, which is broadly reflective of SIFs internationally, we have addressed key questions regarding SIF operations and contend that there is sufficient evidence to support SIF rollout and expansion. The key themes to emerge are that good policy, with clear legislation and careful management of clients within a harm reduction framework, can and does alleviate problems that may be perceived as inherent to the operation of such services.

Given the solid evidence, current governments, in Australia and elsewhere, should expand SIF services without unnecessary protracted trial periods.4 The key challenge in SIF expansion is supporting legislation. In NSW, an amendment to current state legislation to permit more than one facility is required.

Questions regarding the scientific and operational merit of SIFs have been answered. After 21 years of success, it is time for robust support for further services to be implemented both within Australia and internationally.