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In the 1990s, a trial of prescribing pharmaceutical heroin for people with opioid-dependence had support from Australian State Health Ministers. However, in 1997 the proposal was vetoed by the federal Prime Minister in face of a negative tabloid media campaign. The debate then shifted to abstinence-orientated treatments. Later on, reduced heroin availability took opioid-related harms away from public sight. In this commentary, we aimed to explore the current need and the options to implement such program, lately referred to as supervised injectable opioid treatment (SIOT), in Australia. We argue that with the aging populations of opioid-dependent people who have not benefited from existing treatment options, increased misuse of prescription opioids, rising overdose rates, and the risk of unfolding overdose crisis, it seems timely to pilot SIOT here. Since the 1990s, seven RCTs as summarised in two systematic literature reviews, demonstrated that SIOT is effective for treatment-resistant opioid dependence. A sustainable SIOT model should, however, respond to key concerns related to its delivery, such as the lack of a patient exit strategy and the high cost of indefinite treatment. Evidence from long-term studies seem to support the notion that SIOT could be provided as a medium duration treatment (as opposed to short-term or indefinite), with the clear aim to stabilise patients, gradually wean them off injectable medication and transfer to opioid assisted treatment (OAT). Also, SIOT could be integrated into the existing public OAT clinics in Australia. This would reduce costs, but also provide a more patient-centred response to opioid dependence and further improve the acceptability and efficiency of OAT. The controversy that developed in the past should be mitigated by advances in research since the first Australian enquiry, use of a registered medication (open-label hydromorphone) rather than pharmaceutical heroin, and setting up clear treatment aims. [ABSTRACT FROM AUTHOR]

Background: Buprenorphine and buprenorphine/naloxone (BNX) were developed to improve the safety profile of opioid substitution treatment (OST) and reduce diversion and injection, yet continue to be injected, despite the risk of harm. Previous studies examining injection of these substances have relied on self-reported injection and overdose. Using data from the Uniting Medically Supervised Injecting Center (MSIC) in Sydney, this study aimed to assess the overdose risk associated with the use of buprenorphine and BNX and identify factors associated with injecting. Methods: Client data routinely collected from MSIC, a drug consumption room where clients can legally inject drugs under supervision, was used. Odds ratios (OR) to assess the risk of overdose and their associated 95% confidence intervals (95%CI) were calculated and compared to other substances. Univariate analysis using χ-square and multivariate logistic regressions were used to determine characteristics associated with buprenorphine and BNX injection. Results: Data from 1,020,782 injections by 15,832 individuals were analyzed. Risk of overdose was low for buprenorphine compared to other substances (OR 0.16; 95%CI: 0.07–0.19) and no overdoses occurred when BNX was injected. Injection of both buprenorphine and BNX was associated with male gender, homelessness, no income/reliance upon government payments, and prior imprisonment. Conclusions: Buprenorphine and BNX continue to be injected, albeit in small numbers. This is the first study to report on injection and overdose risk using direct observation, and has confirmed the lower overdose risk. MSIC clients who inject buprenorphine and BNX tend to be marginalized and may benefit from targeted harm reduction measures. [ABSTRACT FROM AUTHOR]

Issues: Drug consumptions rooms (DCR) and supervised injecting facilities (SIF) are expanding internationally. Previous reviews have not systematically addressed evaluation methodologies.Approach: Results from systematic searches of scientific databases in English until June 2017 were coded for paper type, country and year of publication. For evaluation papers, study outcome, methodology/study design and main indicators of DCR/SIF 'exposure' were recorded.Key Findings: Two hundred and nineteen eligible peer-reviewed papers were published since 1999: the majority from Canada (n = 117 papers), Europe (n = 36) and Australia (n = 32). Fifty-six papers reported evaluation outcomes. Ecological study designs (n = 10) were used to assess the impact on overdose, public nuisance and crime; modelling techniques (n = 6) estimated impact on blood-borne diseases, overdose deaths and costs. Papers using individual-level data included four prospective cohorts (n = 28), cross-sectional surveys (n = 7) and service records (n = 5). Individual-level data were used to assess safer injecting practice, uptake into health and social services and all the other above outcomes except for impact on crime and costs. Four different indicators of DCR/SIF attendance were used to measure service 'exposure'.Implications: Research around DCRs/SIFs has used ecological, modelling, cross-sectional and cohort study designs. Further research could involve systematic inclusion of a control group of people who are eligible but do not access SIFs, validation of self-reported proportion of injections at SIFs or a stepped-wedge or a cluster trial comparing localities.Conclusions: Methodologies appropriate for DCR/SIF evaluation have been established and can be readily replicated from the existing literature. Research on operational aspects, implementation and transferability is also warranted. [ABSTRACT FROM AUTHOR]

The Sydney Medically Supervised Injecting Centre (MSIC) is a supervised injecting facility (SIF) where people who inject drugs (PWID) can do so legally, under health professional supervision. The majority of clients have low levels of education and employment, high rates of incarceration and unstable housing and poor social networks, and 70% do not access local health services. These factors increase the risk of poor mental health, and it has been documented that PWID have elevated rates of mood, anxiety, personality and psychotic disorders; post-traumatic stress disorder (PTSD); and higher rates of trauma exposure, suicidality and self-harm. The current study is the first to investigate the mental health among clients of a SIF. Validated instruments to examine clients' mental health, social networks and trauma histories were administered to 50 frequently attending clients by a mental health nurse. The majority of respondents were unemployed, homeless and had a history of incarceration, and 82% report they had been diagnosed with a mental health problem, but only 24% report they were receiving treatment. Respondents had poor social networks, had poorer mental health symptoms compared to US inpatients and had experienced multiple traumatic events, and a high number of respondents had scores indicative of PTSD. These results highlight the need for mental health clinicians to be employed in SIFs and other drug consumption rooms (DCRs) to assist clients to address their mental health and psychosocial needs, particularly in light of the fact that these services are often the only places these PWID engage with in an ongoing way. [ABSTRACT FROM AUTHOR]

Issue addressed: High smoking rates among the disadvantaged lead to inequalities in health, quality-of-life and financial well-being. Non-government social and community service organisations (SCSO) are a promising setting for tobacco control interventions targeting disadvantaged smokers. Methods: Financial grants were provided to twenty SCSO in New South Wales to support multi-level changes in service culture, smoking-related policies and cessation support between 2007 and 2009. Evaluation was conducted using a mixed-methods approach that included key informant interviews, document analysis and staff survey data. Results: SCSO working with disadvantaged clients can feasibly implement tobacco control activities, including smoking-related policy changes and cessation support. Tobacco control activities were generally acceptable to staff and clients, and staff pessimism regarding their clients' ability to quit reduced, as did the acceptability of staff smoking with their clients. Improvements in levels of organisational support for cessation training and resources, smoking policies and provision of free nicotine replacement therapy (NRT) were reported. Within mental health SCSO there was a positive response from staff to cessation support, financial benefits of quitting and the role of NRT. Conclusions: The evaluation pointed to the acceptability and feasibility of engaging disadvantaged smokers by SCSO, and that tobacco policy and attitude changes can be achieved by small investments, such as grant programs. [ABSTRACT FROM AUTHOR]

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 Australia's large network of social and community services as allies in this work should be vigorously pursued.[O'Brien J, Salmon AM, Penman A. What has fairness got to do with it? Tackling tobacco among Australia's disadvantaged. Drug Alcohol Rev 2012;31:723-726] [ABSTRACT FROM AUTHOR]

Aims Supervised injecting facilities (SIFs) are effective in reducing the harms associated with injecting drug use among their clientele, but do SIFs ease the burden on ambulance services of attending to overdoses in the community? This study addresses this question, which is yet to be answered, in the growing body of international evidence supporting SIFs efficacy. Design Ecological study of patterns in ambulance attendances at opioid-related overdoses, before and after the opening of a SIF in Sydney, Australia. Setting A SIF opened as a pilot in Sydney's ‘red light’ district with the aim of accommodating a high throughput of injecting drug users (IDUs) for supervised injecting episodes, recovery and the management of overdoses. Measurements A total of 20 409 ambulance attendances at opioid-related overdoses before and after the opening of the Sydney SIF. Average monthly ambulance attendances at suspected opioid-related overdoses, before (36 months) and after (60 months) the opening of the Sydney Medically Supervised Injecting Centre (MSIC), in the vicinity of the centre and in the rest of New South Wales (NSW). Results The burden on ambulance services of attending to opioid-related overdoses declined significantly in the vicinity of the Sydney SIF after it opened, compared to the rest of NSW. This effect was greatest during operating hours and in the immediate MSIC area, suggesting that SIFs may be most effective in reducing the impact of opioid-related overdose in their immediate vicinity. Conclusions By providing environments in which IDUs receive supervised injection and overdose management and education SIF can reduce the demand for ambulance services, thereby freeing them to attend other medical emergencies within the community. [ABSTRACT FROM AUTHOR]

Abstract: 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. [Copyright &y& Elsevier]

Abstract: Background and Objectives: There is currently limited evidence on medium to long term community perceptions of public amenity where supervised injecting centres operate (SIC). Our objective was to investigate if community perceptions of public amenity have changed over time, comparing data collected prior to the establishment of the Sydney Medically Supervised Injecting Centre (MSIC), after 18 months and then following four and a half years of operation. Methods: Telephone surveys were conducted among random samples of local residents and business operators in the vicinity of the MSIC at baseline, in the short term (following 18 months of operation) and in the medium term (following four and a half years of operation). Respondents were asked about their perceptions of drug use and its consequences in their neighbourhood, and to describe what they saw as advantages and disadvantages of the Sydney MSIC. Responses were compared over time and according to demographic characteristics of the survey participants. Results: The survey was completed by 515, 540 and 316 residents and 269, 207 and 210 businesses in the 3 years respectively, with response rates generally above 75%. There was a significant decrease in the proportion of residents and business operators who reported having witnessed public injecting and publicly discarded injecting equipment, in the last month, with no significant change in proportions offered drugs for purchase. Residents were less likely to have seen public injecting in the last month if they were female, retired, lived over 500m from the MSIC or participated in the survey in 2005. Business operators who had witnessed public injecting or discarded needles and syringes in the last month were less likely to report either if located over 500m from the MSIC. Those businesses operating for over 5 years were more likely to have seen publicly discarded needles and syringes than those who had opened within the last year. Approximately 90% of both samples reported at least one advantage of the MSIC located in their area, citing the control of HIV/AIDS and hepatitis C and reduced overdose risk for injecting drug users among potential advantages. Conclusion: While the Sydney MSIC continues to attract political controversy, local residents and business operators perceived significant improvements in public amenity indicators since the opening of the service. Community members appear to be cognizant of both public health (potential reduction in blood borne virus transmission and overdose among injecting drug users) and public amenity benefits of the service. [Copyright &y& Elsevier]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Among people who inject drugs (PWIDs) the prevalence of tobacco smoking exceeds 80%; making smoking cessation intervention a priority for this population. This study aims to examine staff and client perspectives from a supervised injecting facility regarding: i) whether an organizational change intervention increased rates of smoking cessation care delivery (pre- to post-intervention); and ii) acceptability of the intervention.Methods: A pre-and-post intervention pilot study in a supervised injecting facility was conducted in Sydney, Australia between July 2014-December 2015. The intervention employed an organizational change approach and included six components. Cross-sectional samples of staff (pre n = 27, post n = 22) and clients (pre n = 202, post n = 202) completed online surveys pre and post intervention.Results: From pre to post-intervention staff reported smoking cessation practices significantly increased for the provision of verbal advice (30% to 82%; p < 0.001), offer of free or subsidized nicotine replacement therapy (30% to 91%; p < 0.001), referral to a general practitioner (19% to 64%; p = 0.001), and follow-up to check on quit smoking progress (18.5% to 64%; p = 0.001). Significantly more clients reported receiving all smoking cessation strategies post-intervention. Over 85% of staff agreed that it was acceptable to address client smoking as part of usual care and 95% of clients agreed that it was acceptable to be asked by staff about their tobacco smoking.Conclusions: Increasing the provision of smoking cessation care using an organizational change approach is both feasible for staff and acceptable to staff and clients of supervised injecting facilities. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction and Aims. The purpose of this study was to document treatment outcomes for methamphetamine users receiving outpatient counselling from the Stimulant Treatment Program (STP) in Australia. Design and Methods. Clients attending the STP for methamphetamine use (n = 105) were assessed on entry to the service and at 3 (n = 86) and 6 months (n = 83) after starting treatment. At each interview methamphetamine use (days of use, severity of dependence), other drug use and health and social functioning (HIV risk behaviour, crime, disability, psychotic symptoms and hostility) were assessed for the past month. Results. Participants received a median of six counselling sessions (interquartile range 1-11) over a period of 89 days (interquartile range 41-148 days). Past month methamphetamine use fell from 79% at treatment entry to 53% at the 3-month follow-up (P < 0.001) and 55% at the 6-month follow-up (P < 0.001). There were statistically significant reductions in psychotic symptoms, hostility and disability associated with poor mental health. There was no change in other drug use, crime or HIV risk behaviour. Reductions in methamphetamine were more common among younger participants, those who had no history of drug treatment and those without concurrent heroin use. Discussion and Conclusions. Methamphetamine users entering the STP showed reductions in methamphetamine use and improvements in their mental health after treatment. Improved treatment responses are needed to address polydrug use and other harms within in this population.[McKetin R, Dunlop AJ, Holland RM, Sutherland RA, Baker AL, Salmon AM, Hudson SL. Treatment outcomes for methamphetamine users receiving outpatient counselling from the Stimulant Treatment Program in Australia. Drug Alcohol Rev 2013;32:80-87] [ABSTRACT FROM AUTHOR]