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Supervised Injecting Facilities
‘The case’
University College Cork
Wednesday 26th September 2012
Who am I
 Tim Bingham
Co ordinate The Irish Needle Exchange Forum
National harm reduction forum

22 years working in the field
Independent researcher and trainer
What is harm reduction
Harm reduction complements approaches that
seek to prevent or reduce the overall level of drug
Consumption. Harm reduction can often be
arranged in a hierarchy with the more feasible
options at one end (e.g. measures to keep people
healthy) and less feasible but desirable options at
the other end.
Abstinence can be considered difficult to achieve
but desirable option for harm reduction in such a
hierarchy.
History of Harm Reduction
Up until the 1980s, drug services around the world
were mainly directed towards ‘curing’ addictions.

The term ‘harm reduction’ became prominent in
the mid-1980s as a response to newly discovered
HIV epidemics amongst people who inject drugs in
some cities

Liverpool was one of the first to open needle
exchanges, and attracted hundreds of visitors each
year who wanted to learn about the 'Mersey Harm
Reduction Model'. 1st International Conference on
the Reduction of Drug Related Harm, held in
Liverpool, England in 1990.
Harm Reduction in Ireland
Commissioned by the NACD in response to
Action 100 of the National Drug Strategy, this
Review was prepared by a team from Dublin
City University (DCU) and the NACD is
grateful to them for their work.
It is clear from this Review that Irish harm
reduction services need to be more flexible,
be available in all health boards and in areas
of greatest need.
Alternative approaches should be considered
to support the expansion of harm reduction
services such as Community Pharmacy
Needle Exchange
Harm reduction services should have the
flexibility to cater for the provision and/or
exchange of a range of drug use
paraphernalia so as to reduce the risk of
contracting drug related infectious diseases
and other harm.

We know that Hepatitis C Virus, in particular,
is a very resilient organism and this has
implications for sharing any piece of drug
taking equipment. As part of that greater
flexibility, there is a need for enhanced
training for service providers
Supervised injecting facilities
What are they ?
Drug Consumption Rooms (DCR’s) are professionally
supervised healthcare facilities Hedrich (2010).
Providing safer and more hygienic environment for
drug users Stover (2000) Drug Consumption Rooms
are defined as ‘legally sanctioned low threshold
facilities which allow the hygienic consumption of
pre-obtained drugs under professional supervision
in a non-judgemental environment’
Supervised injecting facilities what
are they ?
The effect of a drug is determined by its
pharmacology, its administration, the person taking
it and the context its taken in, drug, set and setting
(Zinberg) 1984 these factors affect the risk and
harm of drug use.
Defined as ‘protected places for the hygienic
consumption of preobtained drugs in a nonjudgemental environment and under the
supervision of trained staff’ Akzept, (2000)
Supervised injecting facilities what
are they ?
Insite - Vancouver

Sydney - MISC
European Picture
DCRs varies across the region, with
nationwide coverage in Switzerland and the
Netherlands, regional coverage in Germany
and Spain, and DCRs in the
capital cities only in Norway and Luxembourg. I
In total there are 85 DCRs across 56 cities in
these six countries, the majority of them
integrated into more general health and social
service provision networks.
The Global State of Harm Reduction 2012
Towards an integrated response
UK Picture
The legal issue
Article 4 of the 1961 Convention, which obliges those states
which have signed up to the convention (which Ireland has)
states that the ‘trade in’, use and possession of drugs is limited
exclusively to medical and academic purposes.
In Ireland, the Misuse of Drugs Act 1977 and 1984 ensures
Irelands compliance under International Law.
HOWEVER The legal issue
However the UNDCP Legal Affairs Section, (2002) say ‘It might
be claimed that this approach SIFs is incompatible with the
obligation to prevent the abuse of drugs…
It should not be forgotten, however, that the same provisions
create an obligations to treat, rehabilitate and reintegrate
drug addicts, whose implementation depends largely on the
interpretation by the Parties of the terms in question.
If, for example, the purpose of treatment is not only to cure
a pathology, but also to reduce the suffering associated with
it (like in severe pain management), then reducing IV drug
abusers exposure to pathogen agents such as HIV and
hepatitis should be considered as ‘treatment.’
HOWEVER The legal issue
Needless to say that, to be consistent with a
comprehensive demand-reduction strategy, any
such approach would also require counselling
and other health and welfare services, aimed at
promoting healthier life-styles and, eventually,
abstinence. FLEXIBILITY OF TREATY PROVISIONS AS REGARDS HARM REDUCTION
APPROACHES (Decision 74/10)
Yes …. We can do it
David Cameron who in 2002 voted in
favour of supervised injecting rooms
being launched in the UK.
Evaluation
 40 % of clients referred on by MSIC
to addiction treatment services had
never previously accessed treatment
for their drug addiction.
 Regular interaction with health
services over time can increase the
likelihood that a client will seek help
for their drug use.
 The MSIC data show that while all
clients are offered referral and
assistance, the proportion of clients
who accept a referral increases
dramatically the more visits they
have made
The majority of surveyed clients agreed with
the statements:
‘Since coming here, the MSIC has helped me’:
‘get in contact with other service (i.e. use the
telephone at the MSIC to call another
service’ (82%)
‘get help with other issues such as accessing
services such as housing and legal
services’ (73%)
.
‘Have you accessed other health or support
services since you have come to the
MSIC?’
The majority of clients reported that they had
accessed other non-AOD services
since they started using the MSIC.
The evidence
The evidence
 People using Insite are more likely to enter withdrawal
management (detox) programs than injection drug users who do
not use the facility.
 The likelihood of entering detox goes up even further if the person
uses Insite weekly, and first speaks with an addiction counsellor.
 The research shows that patterns of drug use in the community did
not worsen as a result of Insite, and crimes related to drug use
have not increased.
 A reduction of the number of people openly injecting on the
streets and the amount of injection-related litter that was left
behind.
The evidence






FACT Medical Supervised Injecting Centres (MISC) saves lives
FACT Does not attract drug users to the area
FACT Provides a gateway to drug treatment and counselling
FACT Local residents supports MSIC
FACT Reduces problems with public injecting and discarded
needles and/or syringes
 FACT Decreasing drug overdose deaths
 FACT Reducing the spread of diseases such as HIV and
Hepatitis C
This is not new
2002 Merchants Quay Ireland conference on SIF/MISC
2003 – Minister for Justice – Michael McDowell
“ Controlled injecting rooms might be an idea, because I know it has been
suggested…. The question you have to ask yourself is, is it good enough
simply to give needle exchanges, to exchange needles, new needles for
people to stop the spread of AIDS without at the same time giving some
facilities? What do you expect people who pick up needles to do? “
“I would be very, very loath to have official injecting rooms…I don’t think
that’s a good idea, no. It’s an indictable offence to have heroin………..I’m not
going to go down the road of providing places for people to shoot up
heroin” (RTE 2003)
Supervised Injecting Facilities ‘The case’
So why have a MISC in Ireland
So today where are we today?

2012
The issue of substance-related anti-social
behaviour is primarily a public health
issue and any sustainable long term
solution can only be delivered in that
context
The establishment of medically
supervised injecting centres
So today where are we ?
Support the establishment of a
pilot project of a Medically
Supervised Injecting Centre to
enable the gathering of evidence
on the effectiveness on this
initiative to reduce harm for drug
users engaged in risky behaviour
(HSE)
And then ……
DÁIL QUESTIONS addressed to the Minister of State at the Department of
Health (Ms. Shortall) 18/09/2012
It is not my intention to introduce supervised injection sites for heroin users.
Rather my focus is on
ensuring that there is an increased emphasis on providing the opportunities
for people to move on from illicit drug use, through drug treatment and
rehabilitation, to a drug-free life where that is achievable.

A 2012 report from the European Monitoring Centre for Drugs and Drug
Addiction (EMCDDA) indicates that heroin-assisted treatment is made
available only in a small number of European countries. While the report
found some evidence that this treatment can be effective for a small minority
of entrenched opioid users, the EMCDDA made clear that it was reporting
only, rather than advocating the provision of such services.
So the evidence ……
Proving safer injecting facilities should be viewed as a
treatment option to provide the opportunities for people
to move on from illicit drug use, through drug treatment
and rehabilitation, to a drug-free life where that is
achievable.
All the pieces to the jig saw fit ……
Recommended books ……
Thanks for listening
Tim Bingham
Email tim@inef.ie
Website www.inef.ie

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Supervised Injecting Facilities ‘The case’

  • 1. Supervised Injecting Facilities ‘The case’ University College Cork Wednesday 26th September 2012
  • 2. Who am I  Tim Bingham Co ordinate The Irish Needle Exchange Forum National harm reduction forum 22 years working in the field Independent researcher and trainer
  • 3. What is harm reduction Harm reduction complements approaches that seek to prevent or reduce the overall level of drug Consumption. Harm reduction can often be arranged in a hierarchy with the more feasible options at one end (e.g. measures to keep people healthy) and less feasible but desirable options at the other end. Abstinence can be considered difficult to achieve but desirable option for harm reduction in such a hierarchy.
  • 4. History of Harm Reduction Up until the 1980s, drug services around the world were mainly directed towards ‘curing’ addictions. The term ‘harm reduction’ became prominent in the mid-1980s as a response to newly discovered HIV epidemics amongst people who inject drugs in some cities Liverpool was one of the first to open needle exchanges, and attracted hundreds of visitors each year who wanted to learn about the 'Mersey Harm Reduction Model'. 1st International Conference on the Reduction of Drug Related Harm, held in Liverpool, England in 1990.
  • 5. Harm Reduction in Ireland Commissioned by the NACD in response to Action 100 of the National Drug Strategy, this Review was prepared by a team from Dublin City University (DCU) and the NACD is grateful to them for their work. It is clear from this Review that Irish harm reduction services need to be more flexible, be available in all health boards and in areas of greatest need.
  • 6. Alternative approaches should be considered to support the expansion of harm reduction services such as Community Pharmacy Needle Exchange Harm reduction services should have the flexibility to cater for the provision and/or exchange of a range of drug use paraphernalia so as to reduce the risk of contracting drug related infectious diseases and other harm. We know that Hepatitis C Virus, in particular, is a very resilient organism and this has implications for sharing any piece of drug taking equipment. As part of that greater flexibility, there is a need for enhanced training for service providers
  • 7. Supervised injecting facilities What are they ? Drug Consumption Rooms (DCR’s) are professionally supervised healthcare facilities Hedrich (2010). Providing safer and more hygienic environment for drug users Stover (2000) Drug Consumption Rooms are defined as ‘legally sanctioned low threshold facilities which allow the hygienic consumption of pre-obtained drugs under professional supervision in a non-judgemental environment’
  • 8. Supervised injecting facilities what are they ? The effect of a drug is determined by its pharmacology, its administration, the person taking it and the context its taken in, drug, set and setting (Zinberg) 1984 these factors affect the risk and harm of drug use. Defined as ‘protected places for the hygienic consumption of preobtained drugs in a nonjudgemental environment and under the supervision of trained staff’ Akzept, (2000)
  • 9. Supervised injecting facilities what are they ? Insite - Vancouver Sydney - MISC
  • 10. European Picture DCRs varies across the region, with nationwide coverage in Switzerland and the Netherlands, regional coverage in Germany and Spain, and DCRs in the capital cities only in Norway and Luxembourg. I In total there are 85 DCRs across 56 cities in these six countries, the majority of them integrated into more general health and social service provision networks. The Global State of Harm Reduction 2012 Towards an integrated response
  • 12. The legal issue Article 4 of the 1961 Convention, which obliges those states which have signed up to the convention (which Ireland has) states that the ‘trade in’, use and possession of drugs is limited exclusively to medical and academic purposes. In Ireland, the Misuse of Drugs Act 1977 and 1984 ensures Irelands compliance under International Law.
  • 13. HOWEVER The legal issue However the UNDCP Legal Affairs Section, (2002) say ‘It might be claimed that this approach SIFs is incompatible with the obligation to prevent the abuse of drugs… It should not be forgotten, however, that the same provisions create an obligations to treat, rehabilitate and reintegrate drug addicts, whose implementation depends largely on the interpretation by the Parties of the terms in question. If, for example, the purpose of treatment is not only to cure a pathology, but also to reduce the suffering associated with it (like in severe pain management), then reducing IV drug abusers exposure to pathogen agents such as HIV and hepatitis should be considered as ‘treatment.’
  • 14. HOWEVER The legal issue Needless to say that, to be consistent with a comprehensive demand-reduction strategy, any such approach would also require counselling and other health and welfare services, aimed at promoting healthier life-styles and, eventually, abstinence. FLEXIBILITY OF TREATY PROVISIONS AS REGARDS HARM REDUCTION APPROACHES (Decision 74/10)
  • 15. Yes …. We can do it David Cameron who in 2002 voted in favour of supervised injecting rooms being launched in the UK.
  • 16. Evaluation  40 % of clients referred on by MSIC to addiction treatment services had never previously accessed treatment for their drug addiction.  Regular interaction with health services over time can increase the likelihood that a client will seek help for their drug use.  The MSIC data show that while all clients are offered referral and assistance, the proportion of clients who accept a referral increases dramatically the more visits they have made
  • 17. The majority of surveyed clients agreed with the statements: ‘Since coming here, the MSIC has helped me’: ‘get in contact with other service (i.e. use the telephone at the MSIC to call another service’ (82%) ‘get help with other issues such as accessing services such as housing and legal services’ (73%) . ‘Have you accessed other health or support services since you have come to the MSIC?’ The majority of clients reported that they had accessed other non-AOD services since they started using the MSIC.
  • 19. The evidence  People using Insite are more likely to enter withdrawal management (detox) programs than injection drug users who do not use the facility.  The likelihood of entering detox goes up even further if the person uses Insite weekly, and first speaks with an addiction counsellor.  The research shows that patterns of drug use in the community did not worsen as a result of Insite, and crimes related to drug use have not increased.  A reduction of the number of people openly injecting on the streets and the amount of injection-related litter that was left behind.
  • 20. The evidence      FACT Medical Supervised Injecting Centres (MISC) saves lives FACT Does not attract drug users to the area FACT Provides a gateway to drug treatment and counselling FACT Local residents supports MSIC FACT Reduces problems with public injecting and discarded needles and/or syringes  FACT Decreasing drug overdose deaths  FACT Reducing the spread of diseases such as HIV and Hepatitis C
  • 21. This is not new 2002 Merchants Quay Ireland conference on SIF/MISC 2003 – Minister for Justice – Michael McDowell “ Controlled injecting rooms might be an idea, because I know it has been suggested…. The question you have to ask yourself is, is it good enough simply to give needle exchanges, to exchange needles, new needles for people to stop the spread of AIDS without at the same time giving some facilities? What do you expect people who pick up needles to do? “ “I would be very, very loath to have official injecting rooms…I don’t think that’s a good idea, no. It’s an indictable offence to have heroin………..I’m not going to go down the road of providing places for people to shoot up heroin” (RTE 2003)
  • 23. So why have a MISC in Ireland
  • 24. So today where are we today? 2012 The issue of substance-related anti-social behaviour is primarily a public health issue and any sustainable long term solution can only be delivered in that context The establishment of medically supervised injecting centres
  • 25. So today where are we ? Support the establishment of a pilot project of a Medically Supervised Injecting Centre to enable the gathering of evidence on the effectiveness on this initiative to reduce harm for drug users engaged in risky behaviour (HSE)
  • 26. And then …… DÁIL QUESTIONS addressed to the Minister of State at the Department of Health (Ms. Shortall) 18/09/2012 It is not my intention to introduce supervised injection sites for heroin users. Rather my focus is on ensuring that there is an increased emphasis on providing the opportunities for people to move on from illicit drug use, through drug treatment and rehabilitation, to a drug-free life where that is achievable. A 2012 report from the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) indicates that heroin-assisted treatment is made available only in a small number of European countries. While the report found some evidence that this treatment can be effective for a small minority of entrenched opioid users, the EMCDDA made clear that it was reporting only, rather than advocating the provision of such services.
  • 27. So the evidence …… Proving safer injecting facilities should be viewed as a treatment option to provide the opportunities for people to move on from illicit drug use, through drug treatment and rehabilitation, to a drug-free life where that is achievable.
  • 28. All the pieces to the jig saw fit ……
  • 30. Thanks for listening Tim Bingham Email tim@inef.ie Website www.inef.ie