22 July 2006

Sydney Medically Supervised Injecting Centre: Some statistics after 5 years

Dear Colleagues,

I have attended the Sydney Medically Supervised Injecting Centre about once per week for the past 5 years. I have had a 'guided tour' of the centre as well as being a local resident delegate on their 'community consultative committee'. The service now has strong majority support (up to 80%) from residents and businesses in Kings Cross and has been supported by most police, medical, church and health authorities.

Quite apart from the documented practical benefits for local drug users and residents, this service has given us a unique insight into drug use in Sydney over the past five years. It has been a barometer of street drug trends, while also emphasising the shortage of treatment services, both abstinence orientated and otherwise.

We learned very early that drug users were taking enormous risks with unsafe injecting practices. In many cases, there was 'blood everywhere' while injecting took place. This observation was one of the first useful 'messages' passed out by staff at medical meetings, written reports and local briefings to other health care workers. Many thought that by providing clean needles, we could be sure that infections in drug users would be curtailed. While this was true of HIV, it certainly did not apply to hepatitis B or C and skin infections.

Over 5 years, almost 9000 individuals have been reminded by staff to wash their hands before and after injecting. They have been provided with clean injecting equipment, good lighting and a safe and closely supervised environment to inject themselves in almost a third of a million injecting episodes between 9.30am and 9.30pm most days over the 5 year period of service.

The latest information is that heroin availability has declined dramatically since January this year and just as common now are prescribed pain killers morphine/oxycodone (31%). These have shown to produce a far lower overdose rate (less than half that of street heroin). Also, for the first time in 20 years, brown heroin (38%) from Afghanistan has appeared on the Sydney market. 'Crystal meth' or 'ice' is still popular (6%) and cocaine is used by 21% of attendees.

On average about 200 visits occur each day and some days there are more than 300 injecting episodes in the centre. I have noted that most mornings, there are usually one or two people in the waiting room but on exceptional occasions have counted up to 13 people waiting to be assessed at the front reception. This is not unlike many other businesses.

There were 87 overdoses recorded on average per quarter ranging from 47 to 175, possibly reflecting the variable strength/cost of street drugs over the years. Thus every one of the 1747 overdoses observed was a potential death statistic yet nobody died. We will never know the proportion who would have died without treatment. However, out of 300,000 injections we would certainly expect some deaths and considering these include some of the most high risk drug users, dozens of deaths might be predicted. Yet none occurred. The independent report estimated a number of lives were saved during the initial trial period. Many more lives have probably been saved since then.

Well known and consistent longitudinal studies on the natural history of opioid use show that of the 9000 people who have used these facilities, a high proportion are opioid dependent. Of these, after 7 years, approximately one third are likely to be drug free. Up to 50% could be expected to be on some form of maintenance treatment, 5-10% are likely to be dead with a similar proportion incarcerated.

Major Watters has said that if the injecting centre is shown to save lives that he would support it. Further, I understand that he supports all measures which result in (alive) abstinent citizens. I can only hope he can follow up on these sentiments as we need all the support we can get for this underprivileged group in our society. I know a number of (completely) drug-free citizens who may be alive today due to their attendance at the injecting centre when their drug using was at its most chaotic.

Some may expect the injecting room to lead to abstinence yet on the other hand, we do not expect the hospice to 'cure' many if any patients. Both services have shown their different places in the health care system. I support closing this injecting centre when its use falls below sustainable levels. However, on current usage, and with a continued shortage of available treatment options in New South Wales, I cannot see that happening for many years. Call me a pessimist.

Comments by Andrew Byrne ..

14 July 2006

Lung cancer and cannabis. No association found in literature review, but precancerous changes shown in some

Arch Intern Med. 2006;166:1359-1367

The Association Between Marijuana Smoking and Lung Cancer: A Systematic Review.
Mehra R, Moore BA, Crothers K, Tetrault J, Fiellin DA.

Dear Readers,

Our attention is drawn to this week's Archives of Internal Medicine with its catchy, capitalized headline "The Association Between Marijuana Smoking and Lung Cancer". Despite the appearance of an assumed association, in fact the researchers published findings, after examining 19 rigorous studies, were that there was NO association between cannabis smoking and cancer. So why would the journal's editors imply in big letters that such an association exists?

The authors state: 'Observational studies of subjects with marijuana exposure failed to demonstrate significant associations between marijuana smoking and lung cancer after adjusting for tobacco use'. <snip> 'Therefore, we must conclude that no convincing evidence exists for an association between marijuana smoking and lung cancer based on existing data.'

Many of us believe that there probably is an association between any smoked organic product and lung damage. However, when 19 rigorous studies fail to show an association with cancer, we are entitled to conclude that the effect must be relatively small, and substantially less than the long accepted causation with tobacco. The authors' conclusions is that 'physicians should advise patients regarding potential adverse health outcomes' of cannabis.

It would appear that politics even pervades peer reviewed journals. Reefer madness is still with us! I note that the study and one of its authors were partially supported by the National Institute on Drug Abuse (NIDA) in America. This is the second 'difficulty' for Director Nora Volkow in a week (see magic mushroom story elsewhere).

Further evidence of the disconnect between science and drug policy is that even the most serious scientists and clinicians in America still often use the slang term 'marijuana' rather than the correct scientific (Latin) 'cannabis' or common English 'Indian hemp'.

Comment by Andrew Byrne ..

Mehra R, Moore BA, Crothers K, Tetrault J, Fiellin DA. The Association Between Marijuana Smoking and Lung Cancer: A Systematic Review. Arch Intern Med. 2006;166:1359-1367