Allison M. Salmon

Injecting-related injury and disease among clients of a supervised injecting facility.

BACKGROUND The process of drug injection may give rise to vascular and soft tissue injuries and infections. The social and physical environments in which drugs are injected play a significant role in these and other morbidities. Supervised injecting facilities (SIFs) seek to address such issues associated with public injecting drug use. AIMS Estimate lifetime prevalence of injecting-related problems, injury and disease and explore the socio-demographic and behavioral characteristics associated with the more serious complications. DESIGN, SETTING, PARTICIPANTS Self-report data from 9552 injecting drug users (IDUs) registering to use the Sydney Medically Supervised Injecting Centre (MSIC). FINDINGS Lifetime history of either injecting-related problems (IRP) or injecting-related injury and disease (IRID) was reported by 29% of the 9552 IDUs; 26% (n=2469) reported ever experiencing IRP and 10% (n=972) reported IRID. Prevalence of IRP included difficulties finding a vein (18%), prominent scarring or bruising (14%) and swelling of hands or feet (7%). Prevalence of IRID included abscesses or skin infection (6%), thrombosis (4%), septicaemia (2%) and endocarditis (1%). Females, those who mainly injected drugs other than heroin, and those who reported a history of drug treatment, drug overdose, and/or sex work, were more likely to report lifetime IRID. Frequency and duration of injecting, recent public injecting, and sharing of needles and/or syringes were also independently associated with IRID. CONCLUSIONS IRPs and IRIDs were common. Findings support the imperative for education and prevention activities to reduce the severity and burden of these preventable injecting outcomes. Through provision of hygienic environments and advice on venous access, safer injecting techniques and wound care, SIFs have the potential to address a number of risk factors for IRID.

Prevalence and predictors of injecting‐related injury and disease among clients of Australia's needle and syringe programs

Objective: To identify lifetime prevalence and predictors of self‐reported injecting‐related injuries and diseases (IRID) and/or injecting‐related problems (IRP) among a national cross‐sectional sample of injecting drug users.

Risk of fentanyl overdose among clients of the Sydney Medically Supervised Injecting Centre.

BACKGROUND: Fentanyl is a powerful analgesic, the prescription of which has increased markedly in recent years. The emergence of the drug at the Sydney Medically Supervised Injecting Centre (MSIC) warranted a retrospective clinical audit to assess the risk of fentanyl overdose in comparison with other opioids, in the context of a drug consumption room. METHOD: Heroin, fentanyl or other prescription opioids (PO) injections resulting in overdose were audited (September 1, 2012 and August 31, 2015). Rates of overdose per 1000 injections and relative risks (RR) of overdose were calculated. RESULTS: In the audit period 189,203 injections by 4177 individuals occurred, with fentanyl injections increasing by 1000%, heroin injections increasing by 70% and, inversely, a sharp decline in other PO injections. Fentanyl injections had approximately four and half times the risk of resulting in overdose than heroin or other PO injections combined (RR=4.6); and, had two times the risk of heroin injections, and eight times the risk of resulting in overdose than other PO injections (RR=2.2 and RR=7.9). CONCLUSION: Findings from a drug consumption room, such as the Sydney MSIC can effectively inform harm reduction services and emergency services of the increased use of, and therefore risk of, fentanyl overdose relative to other opioids. The dynamic nature of drug markets mean that services such as MSIC are uniquely placed to provide not only real-time data on drug use trends, but also safer injecting advice to those engaging in new practices.Copyright

Supervised injecting facilities: how much evidence is enough?

Supervised injecting facilities (SIF) have been shown tobe highly effective interventions in reducing the harmsassociated with injecting drug use. To date a total of 28methodologically rigorous studies have been publishedin leading peer-reviewed medical journals [1]. Thisgrowing body of evidence indicates that SIFs areassociated with reductions in needle and syringesharing, overdoses, public injecting and numbers ofpublicly discarded syringes [2–6], increased uptake ofdrug detoxification and addiction treatment pro-grammes [7] and have not led to increases in drug-related crime or rates of relapse among former drugusers [8,9].Despite this evidence, SIFs continue to attractopposition from governments and politicians [10,11],with indications that the evaluation goalposts may beshifting. For example, in Canada, the Minister forHealth recently argued that the ultimate determinant ofsuccess is whether SIFs contribute to lowering drug useand fighting addiction [11]. Within the context of anincreasingly politicised environment surrounding harmreduction initiatives such as needle and syringeprogrammes and SIFs, politicians often claim that suchinterventions lack community support. However, evi-dence suggests that this is not the case.The Sydney Medically Supervised Injecting Centre(MSIC) was established in 2001 in order to trialpotential public health and public amenity benefitsassociated with supervised injection facilities [6,12]. Aspart of ongoing evaluation efforts, community supportfor the Sydney MSIC has been measured andmonitored through repeat random telephone surveysof local residents and businesses prior to and followingits establishment [13]. A total of 1371 Kings Crossresidents have been interviewed in three separatesurveys and at each time-point at least three in five(460%) Kings Cross residents agreed with the estab-lishment of the Sydney MSIC (68% in 2000, 78% in2002 and 73% in 2005; p-trend¼0.06). There is alsosignificant support for the MSIC from the localbusiness community. Among the 629 Kings Crossbusiness operators surveyed at the three time-points,there was a statistically significant increasing trend infavour of the establishment of the service (i.e. 58% in2000, 63% in 2002 and 68% in 2005; p-trend¼0.03).A review of drug consumption facilities found thattheir establishment in local neighbourhoods led tomajor public debate in most of the 36 European citieswhere they operate [4]. Results from our evaluationindicate that, in the Australian context, approximatelythree in five local residents and businesses agreed withthe establishment of the Sydney MSIC prior to itsopening and that this level of support has beensustained over time. Our results also suggest that localcommunity members are cognisant of both potentialpublic health (perceived reduction in blood-borne viralinfections and overdose) and potential public amenityadvantages of the Sydney MSIC [13]. In a climate ofongoing political and policy debates surrounding harmreduction strategies, these data contribute to thegrowing evidence base supporting the benefits of SIFs.However, while community support may be animportant determinant of political will, it is not ameasure of efficacy and should not be the litmus test bywhich SIFs or, indeed, any health intervention, areevaluated. A well-designed and conducted randomisedcontrolled trial (level 1 evidence) remains the best studydesign for determining a causal relationship between apublic health intervention and its putative outcomes.The scientific, practical and ethical issues involved inapplying this methodology to evaluating complex publichealth interventions such as SIFs mean that the

Frequency and severity of non-fatal opioid overdoses among clients attending the Sydney Medically Supervised Injecting Centre.

BACKGROUND Pharmaceutical opioid overdose rates have increased in recent years. The current study aimed to compare rates per 1000 injections of non-fatal overdose after heroin or oxycodone injection, and their comparative clinical severity. METHODS Analysis of prospectively collected data from the Sydney Medically Supervised Injecting Centre (MSIC). Severity of overdose was measured using the Glasgow Coma Scale, oxygen saturation levels, and the administration of naloxone. RESULTS Heroin overdoses occurred at three times the rate of oxycodone overdoses (12.7 v 4.1 per 1000 injections). Heroin overdoses appeared to be more severe than oxycodone overdoses, with higher levels of compromised consciousness (31 v 18%) and severe respiratory depression (67 v 48%), but there were no differences in naloxone doses (20 v 17%). Concurrent use of other depressants at the time of overdose was also associated with compromised consciousness, and the need for naloxone. CONCLUSIONS Heroin overdoses occurred at a greater rate than oxycodone overdoses, and had more severe clinical indicators.

What has fairness got to do with it? Tackling tobacco among Australia's disadvantaged

ISSUE While population wide smoking rates are falling steadily the rates remain high among the disadvantaged. The future we face is one where the differentials in smoking rates will continue to widen and will flow through to increased health inequalities. APPROACH How best to reduce smoking rates among the disadvantaged? Alongside existing population level initiatives and social policy initiatives is an urgent need for a targeted, comprehensive approach that acknowledges the serious impact of smoking on the disadvantaged. In 2006 Cancer Council NSW embarked on a statewide, multi-component Tackling Tobacco Program to encourage and support non-government social and community services to address smoking among their clients. KEY FINDINGS Tackling Tobacco Program results have shown that the 1600 staff from 400 organisations trained to provide smoking care can attain the knowledge and confidence to address tobacco and that clients are very receptive to receiving quit support from them. Improvements in quality of life for clients who do quit have been encouraging and the Tackling Tobacco Program has challenged assumptions and attitudes that disadvantaged people are uninterested and unable to quit. IMPLICATIONS Alongside population and social policy approaches must be a serious investment in tackling smoking among the disadvantaged. CONCLUSIONS Tackling Tobacco Program is an innovative example of how to engage disadvantaged smokers, de-normalise smoking and encourage and support quitting using familiar settings. Engaging Australias large network of social and community services as allies in this work should be vigorously pursued.

An evaluation of a pilot capacity building initiative for smoking cessation in social and community services: The Smoking Care project

INTRODUCTION AND AIMS New strategies are required to reach subpopulations with high smoking rates. This study reports on an evaluation of the Smoking Care intervention-a 2-year organisational capacity building strategy--for social and community service organisations (SCSOs) to provide smoking care to clients. DESIGN AND METHODS The Smoking Care intervention consisted of: awareness raising seminars (half-day); smoking cessation training (1 day) and; nicotine replacement therapy grants (3 months). Baseline and 3-month follow-up data were collected within participating SCSOs and the primary outcomes measured were: changes in staff attitudes, confidence and practice of smoking cessation care. Changes in client self-reported smoking behaviours, quit attempts and interest in quitting were also measured. RESULTS Of 600 staff who attended training, 306 (51%) returned pre- and post-intervention surveys. At 3-month follow-up staff reported statistically significant increases in positive attitudes to providing smoking cessation care, increased confidence in providing such care and increases in cessation practice. Of 400 client surveys distributed, 367 (92%) were returned at pre-intervention and 255 (64%) at post-intervention. Fewer clients reported daily smoking at post-intervention, while use of nicotine replacement therapy and group counselling increased significantly. Client interest in quitting and receiving quit support from case workers was high at both pre- and post-intervention. DISCUSSION AND CONCLUSIONS The intervention had an impact on SCSO staff attitudes, confidence and provision of smoking care. Results show clients were receptive to this support. More rigorous testing of similar interventions in SCSOs is warranted.

High HIV testing and low HIV prevalence among injecting drug users attending the Sydney Medically Supervised Injecting Centre

Objective: Measure the self‐reported prevalence of HIV, history of HIV testing and associated risk factors among injecting drug users (IDUs) attending the Sydney Medically Supervised Injecting Centre (MSIC).

Bipartisan support for Australia's supervised injecting facility: a decade in the making.

TO THE EDITOR: This year marks 10 years of successful operation of the Sydney Medically Supervised Injecting Centre — Australia’s only supervised injecting facility (SIF). It is one of 90 such facilities globally, with SIFs operating in eight different countries for up to 25 years. Legislation to lift the trial status of the Sydney centre was passed in the lead-up to the recent New South Wales state election, nearly a decade after the centre opened. Despite not having explicitly supported the centre while in opposition, at the Centre’s 10-year anniversary event on 6 May 2011, the newly elected Liberal– National coalition government signalled its willingness to contribute to bipartisan support of the centre. While the Sydney SIF has survived this transition into institutional “adulthood”, operation of the only other SIF in the English-speaking world, located in Vancouver, Canada, remains a politically sensitive issue. Indeed, the Supreme Court of Canada is currently deciding whether the right to establish and operate a SIF lies with the provincial or the federal government. The Australian and Canadian SIFs have much in common: both have a history of politicisation, both were established under trial conditions, and both have been subject to rigorous independent scientific evaluations. They have each contributed much to the large body of evidence showing the benefits provided by SIFs to individual drug users and to surrounding communities. Specifically, SIFs have been shown to reduce numbers of deaths from drug overdose,1 reduce numbers of ambulance call-outs2 and hospital admissions, improve client outcomes,3 enhance referral to drug treatment programs,4 improve public order (eg, by reducing injecting drug use and syringe disposal in public locations),5 and be cost efficient.6 No adverse consequences have been associated with their operation. There is widespread support for SIFs. This includes many Australasian specialist medical colleges as well as the Australian Medical Association and many scientific and research institutions. The majority of the Australian population also support SIFs, as shown in the recent National Drug Strategy Household Survey.7 Yet despite this, and the continually accumulating evidence showing the public health benefits of SIFs, the idea of establishing new facilities remains politically charged in the Australian context. In Melbourne, a local council recently urged the Victorian state government to consider establishing a SIF in an area with entrenched, street-based drug use. However, this was swiftly rejected, and calls for SIFs in other Australian states have been similarly refused by state governments. Indeed, the current legislation in NSW precludes the operation of any additional SIFs. But for the Sydney SIF, it appears that the repeated political hurdles which characterised its first decade of operation have finally diminished. In this single instance at least, the scientific evidence on SIFs has prevailed.

The impact of OxyContin reformulation at the Sydney Medically Supervised Injecting Centre: Pros and cons

Abstract Background Oxycodone is implicated in a large number of overdose deaths, many involving intravenous administration of preparations designed for oral administration. International responses have included education strategies, regulatory changes, and tamper-resistant preparations to discourage injecting. Reformulated OxyContin ® was introduced in Australia in April 2014 and this study examines its impact on service utilisation, defined as visits to inject drugs at the Sydney Medically Supervised Injecting Centre (MSIC) and opioid overdoses at the MSIC. Methods Data from February 2007 to February 2016 are presented for drug type injected and onsite opioid overdose. The reformulated OxyContin ® effect was modelled using an interrupted time series approach. Results Client visits declined >1000 per month, or 18%, following reformulation, largely explained by a reduction in visits to inject oxycodone, partially offset by increased morphine or fentanyl injections. Despite this significant reduction in visits, there was no corresponding decrease in the number of overdoses managed, explained somewhat by a partial displacement from oxycodone to other opioids. Stable overdose numbers within the context of decreased visit numbers were consistent with increases in heroin and morphine overdose, with an extra 22 heroin and 12 morphine overdoses on average per month. This increase was offset by the decrease of 17 OxyContin ® , overdoses per month. Conclusions This study replicates the trend towards substitution of OxyContin ® with other opioids following the introduction of reformulated OxyContin ® in Australia and extends initial findings by showing the rate of overdose per MSIC visit increased following reformulation. These unintended consequences need to be considered when evaluating the success or otherwise of these kinds of changes in product formulation.