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The Guidelines for the operation and use of consumption rooms define Injecting rooms as "legally sanctioned and supervised facilities designed to reduce the health and public order problems associated with illegal ... drug use" ^[1] It describes various facilities where the consumption of illicit substances is legally permitted. The main focus for these facilities is reducing the harm associated with injecting drug use. There are few in existence; the majority are in Europe, with one in Australia and one in Canada. The European rooms operate as drug consumption rooms, which means that they are simply spaces where consumption of illicit substances is legal. The Australian and Canadian facilities were set up later, and operate as supervised injecting facility in Canada, and medically supervised injecting centre in Australia. In these facilities illicit drug use is permitted, but there is a more clinical approach to the service delivery, with a large staff of nurses overseeing proceedings, and basic life support equipment is available if needed.

A Harm Reduction Initiative

Injecting rooms are controversial because they are an attempt to decrease the negative consequences of existing drug abuse, rather than putting public financial resources into prevention or rehabilitation, or discouraging drug use via the punishment of drug users through law enforcement.

A common approach to drug policy, although not sanctioned under the United Nations' international drug Conventions,^{[citation needed]} is to use three approaches:

Harm prevention - to prevent people first using drugs
Supply reduction - to prevent drugs from reaching the population
Harm reduction - to prevent harm to people who use drugs despite the attempts of the previous two policy focuses. Injecting centres fall under this approach.

European drug consumption rooms

As of 2000, there were 16 legal drug consumption rooms in the Netherlands, the first being set up in the 1970s,^[2] 17 in Switzerland, the first in 1985,^[2] and 13 in Germany, the first in 1994^[2], in Oslo, Norway, opened in 2005 and Copenhagen, Denmark 2007. These centres are usually located in urban areas, with the primary aims to reduce negative health effects and minimise the public disturbance arising from street-based drug use.

Australian and Canadian supervised injecting centres

The Sydney Medically Supervised Injecting Centre (MSIC) opened in May, 2001, in Kings Cross, Sydney.^[3] It was set up as a recommendation of the Wood Royal Commission to combat street crime in the area and reduce police corruption.^[4] The Canadian Insite commenced operation in 2003. As well as public order and improving health, the major difference between the supervised injecting centres and the unsupervised European model is the more clinical nature of the service. Oxygen and Naloxone are administered in the case of opioid and heroin overdose.^[3]

Critisism

Where safer injection sites are used to alleviate the harms of illegal practices or behaviours, critics of this approach, such as the United Nations International Narcotics Control Board,^[5] cite concerns about its strategies sending a message of sanctioned acceptance of the very behaviours which the community, through its legislators, do not accept.^[6]

References

^ Schneider W, St¨over H (eds). Guidelines for the operation and use of consumption rooms. Developed at the conference: consumption rooms as a professional service in addictions– health. M¨unster: akzept Bundesverband 2000, trans J. Kimber.
^ ^a ^b ^c Dolan, Kate; Kimber, Jo; Fry, Craig; Fitzgerald, John; Mcdonald, David; Trautman, Franz (2000). "Drug consumption facilities in Europe and the establishment of supervised injection centres in Australia". Drug and Alcohol Review. 19: 337–346. doi:10.1080/713659379.
^ ^a ^b Van Beek, Ingrid (2004). In the eye of the needle: Diary of medically supervised injecting centre. Crows Nest: Allen & Unwin. ISBN 9781741143812. OCLC 57515258.
^ "Report on the Establishment or Trial of Safe Injecting Rooms, Executive Summary". The Joint Select Committee into Safe Injecting Rooms, Parliament of New South Wales. Retrieved 2010-03-30.
^ "Analysis of the World Situation". Report of the International Narcotics Control Board For 2001 (PDF). International Narcotics Control Board. 2001. p. 80. ISBN 9211481457. {{cite book}}: External link in |chapterurl= (help); Unknown parameter |chapterurl= ignored (|chapter-url= suggested) (help)
^ 2007 National Drug Strategy Household Survey: first results. Australian Institute of Health and Welfare. 27 April 2008. pp. 10–11. Retrieved 2010-04-20.

External links

[kimber-1] Schneider W, St¨over H (eds). Guidelines for the operation and use of consumption rooms. Developed at the conference: consumption rooms as a professional service in addictions– health. M¨unster: akzept Bundesverband 2000, trans J. Kimber.

[dolan-2] Dolan, Kate; Kimber, Jo; Fry, Craig; Fitzgerald, John; Mcdonald, David; Trautman, Franz (2000). "Drug consumption facilities in Europe and the establishment of supervised injection centres in Australia". Drug and Alcohol Review. 19: 337–346. doi:10.1080/713659379.

[vanbeek-3] Van Beek, Ingrid (2004). In the eye of the needle: Diary of medically supervised injecting centre. Crows Nest: Allen & Unwin. ISBN 9781741143812. OCLC 57515258.

[wood-4] "Report on the Establishment or Trial of Safe Injecting Rooms, Executive Summary". The Joint Select Committee into Safe Injecting Rooms, Parliament of New South Wales. Retrieved 2010-03-30.

[UN_INCB-5] "Analysis of the World Situation". Report of the International Narcotics Control Board For 2001 (PDF). International Narcotics Control Board. 2001. p. 80. ISBN 9211481457. {{cite book}}: External link in |chapterurl= (help); Unknown parameter |chapterurl= ignored (|chapter-url= suggested) (help)

[6] 2007 National Drug Strategy Household Survey: first results. Australian Institute of Health and Welfare. 27 April 2008. pp. 10–11. Retrieved 2010-04-20.

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@@ Line 21: / Line 21: @@
   | accessdate = 2010-03-30}}</ref> The Canadian [[Insite]] commenced operation in [[2003]]. As well as public order and improving health, the major difference between the supervised injecting centres and the unsupervised European model is the more clinical nature of the service. [[Oxygen]] and [[Naloxone]] are administered in the case of [[opioid]] and [[heroin]] overdose.<ref name=vanbeek />
+==Critisism==
-== Objectives of supervised injecting centres ==
+Where safer injection sites are used to alleviate the harms of illegal practices or behaviours, critics of this approach, such as the United Nations [[International Narcotics Control Board]],<ref name="UN INCB">{{Cite book
-Community expectations for the Sydney MSIC were established during the 1999 NSW Government’s Drug Summit, directing that it should “decrease overdose deaths, provide a gateway to treatment, reduce the problem of discarded needles and users injecting in public places. <ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p 3</ref>
+  | title = Report of the International Narcotics Control Board For 2001
+  | chapter = Analysis of the World Situation
-The stated objectives of the Vancouver Insite facility are to increase access to health and addiction care, reduce overdose fatalities, reduce transmission of blood-borne viral infections and other injection related infections and improve public order. <ref>see Background {{cite web |url= http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php#insite |title=Final Report of the Vancouver Insite Expert Advisory Committee |accessdate=2010-04-19}} 2008</ref>
+  | publisher = International Narcotics Control Board | year = 2001
+  | url = http://www.incb.org/incb/annual_report_2001.html
-European consumption rooms share the stated objectives of the two non-European sites, and also share an emphasis on reaching as much of the target population as possible and stabilizing and promoting the health of service users. <ref>EMCDDA{{cite web |url= http://www.emcdda.europa.eu/attachements.cfm/att_2944_EN_consumption_rooms_report.pdf |title= European report on drug consumption rooms |accessdate=2010-04-28}} 2004 p 71</ref>
+  | chapterurl = https://www.incb.org/pdf/e/ar/2001/incb_report_2001_3_oceania.pdf |format=PDF
+  | isbn = 9211481457 |page=80}}</ref> cite concerns about its strategies sending a message of sanctioned acceptance of the very behaviours which the community, through its legislators, do not accept.<ref>{{Cite book
-== Evaluations of safe injecting centres ==
+  | title = 2007 National Drug Strategy Household Survey: first results
+  | publisher = Australian Institute of Health and Welfare
-In the late 1990s there were a number of studies available on consumption rooms in Germany, Switzerland and the Netherlands.  “The reviews concluded that the rooms contributed to improved public and client health and reductions in public nuisance but stressed the limitations of the evidence and called for further and more comprehensive evaluation studies into the impact of such services.” <ref>EMCDDA{{cite web |url= http://www.emcdda.europa.eu/attachements.cfm/att_2944_EN_consumption_rooms_report.pdf |title= European report on drug consumption rooms |accessdate=2010-04-28}} 2004 p 27</ref>  To that end, the two non-European injecting facilities, Australia’s Sydney Medically Supervised Injecting Centre (MSIC) and Canada’s Vancouver Insite Supervised Injection Site. have been more rigorously evaluated.
+  | date = 27 April 2008
+  | url = http://www.aihw.gov.au/publications/index.cfm/title/10579
-The NSW Government has provided extensive funding for ongoing evaluations of the Sydney MSIC, with a formal comprehensive evaluation produced in 2003, 18 months after the centre was opened.  Other later evaluations studied various aspects of the operation - service provision (2005), community attitudes (2006), referral and client health (2007)  and a fourth (2007) service operation and overdose related events.
+  | accessdate = 2010-04-20
+  | pages = 10–11}}</ref>
-The first 2003 Evaluation found that the MSIC had “made service contact with its target population, including many who had no prior treatment for drug dependence”, “had no detectable change in heroin overdoses at the community level”, a small number of opioid overdoses that might have been fatal if managed elsewhere, “made referrals for drug treatment, especially among frequent attendees”, not increased blood-borne virus transmission”, “no overall loss of public amenity”, “no increase in crime” locally and “the majority of the community accepted the MSIC initiative”. <ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p xvi</ref>
-The Vancouver Insite facility was evaluated during the first three years of its operation by researchers from the BC Center for Excellence in HIV/AIDS with published and some unpublished reports available.
-In March 2008 a Final Report of the Expert Advisory Committee appointed by the Canadian Ministry of Health was released, evaluating the performance of the Vancouver Insite against its stated objectives.  Its findings<ref>see Research Conclusions and Limitations - 1. INSITE Utilization and User Characteristics {{cite web |url= http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php#insite |title=Final Report of the Vancouver Insite Expert Advisory Committee |accessdate=2010-04-19}} 2008</ref> were that:
-* 8,000 people had visited INSITE, with 18% accounting for 80% of all visits to INSITE, less than 10% using the site for all injections, a median number of 8 visits across all clientele, and 600 visits per day, of which 80% were to inject, showing that the facility was near capacity.
-* Two surveys of approximately 1,000 users established some key user characteristics – clients averaged 15 years of drug use, 51% injected heroin and 32% cocaine, 87% were infected with Hepatitis C virus and 17% with HIV, 20% were homl;ess with numerous others living in single resident rooms, 80% had been incarcerated, 21% were using methadone and 59% reported a non-fatal overdose during their lifetime.
-* Users rate the service as highly satisfactory and health professionals, local police, the local community and the general public have positive or neutral views of the service, with opposition decreasing over time.
-* Insite had referred clients such that it had contributed to an increased use of detoxification services and increased engagement in treatment.
-* There were no overdose deaths in the facility and mathematical modeling on the 336 overdose events in the year 2006 suggested that INSITE saves about one life per year via its intervention in overdoses.
-* Mathematical modeling by researchers from self-reports of users generated a wide range of estimates for HIV cases averted, but the Expert Advisory Committee was not convinced that the assumptions were valid.
-* Observations before and after the opening of Insite indicated a reduction in public injecting, and there was no evidence of increases in drug-related loitering, drug dealing or petty crime in the area.
-* There was no evidence that the facility influenced drug use in the community, but concerns that Insite ‘sends the wrong message’ to non-users could not be addressed from existing data.
-* Insite cost $3,000,000 per annum to run.  Mathematical modeling showed cost to benefit ratios of one dollar spent ranging from  0.97 to 2.90 in benefit.  However the Expert Advisory Committee expressed reservation about the certainty of Insite’s cost effectiveness until proper longitudinal studies had been undertaken.  Mathematical models for HIV transmissions foregone had not been locally validated and mathematical modeling from lives saved by the facility had not been validated.
-=== Overdoses in Safe Injection Sites ===
-A survey of consumption rooms in the Netherlands, Germany and Switzerland found overdose rates ranging from 1 overdose per 10,000 injections to 36 overdoses per 10,000 injections.[37] Vancouver’s Insite yielded 13 overdoses  per 10,000 injections shortly after commencement,[38] but in 2009 had more than doubled to 27 per 10,000.[39]   The Sydney MSIC recorded overdose rates of 72 overdoses per 10,000 injections covering all drugs used in the centre, but 96 overdoses per 10,000 injections for those using heroin.
-Commenting on the high overdose rates in the Sydney MSIC, the evaluators suggested that,
-: “In this study of the Sydney injecting room there were 9.2 (sic) heroin overdoses per 1000 heroin injections in the centre. This rate of overdose is higher than amongst heroin injectors generally. The injecting room clients seem to have been a high-risk group with a higher rate of heroin injections than others not using the injection room facilities. They were more often injecting on the streets and they appear to have taken greater risks and used more heroin whilst in the injecting room.[41]
-== Evidence-based Opposition ==
-{{POV|date=March 2010}}
-{{Globalize|section|date=March 2010}}
-{{Essay|date=May 2010}}
-Where safer injection sites are used to alleviate the harms of illegal practices or behaviours, critics of this approach, such as the United Nations [[International Narcotics Control Board]],<ref name="UN INCB">{{Cite book| title = Report of the International Narcotics Control Board For 2001
-| chapter = Analysis of the World Situation
-| publisher = International Narcotics Control Board | year = 2001
-| url = http://www.incb.org/incb/annual_report_2001.html
-| chapterurl = https://www.incb.org/pdf/e/ar/2001/incb_report_2001_3_oceania.pdf |format=PDF
-| isbn = 9211481457 |page=80}}</ref> cite concerns about its strategies sending a message of sanctioned acceptance of the very behaviours which the community, through its legislators, do not accept.<ref>{{Cite book
-| title = 2007 National Drug Strategy Household Survey: first results
-| publisher = Australian Institute of Health and Welfare
-| date = 27 April 2008
-| url = http://www.aihw.gov.au/publications/index.cfm/title/10579
-| accessdate = 2010-04-20
-| pages = 10–11}}</ref>
-=== High cost for little benefit ===
-Saving lives is the most dominant justification for the significant expense of running an SIS. Costing the Canadian public $3,000,000 per annum to run the site,<ref>see {{cite web |url= http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php#insite |title=Final Report of the Vancouver Insite Expert Advisory Committee |accessdate=2010-04-19}} 2008</ref> the Canadian Government Expert Advisory Committee of 2008 found that the facility, despite hosting 4-500 injections daily, could only claim to save one life per annum from fatal overdose according to its mathematical modeling.<ref>see Executive Summary {{cite web |url= http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php#insite |title=Final Report of the Vancouver Insite Expert Advisory Committee |accessdate=2010-04-19}} 2008</ref>
-The Sydney MSIC, now costing upwards of $2.7 million per annum,<ref>NCHECR, {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Sydney Medically Supervised Injecting Centre Evaluation Report No. 4 |accessdate=2010-01-09}} 2007 p 35</ref> and averaging a lesser 150 opiate injections daily,<ref>{{cite web |url= http://www.sydneymsic.com/__data/assets/file/0004/35689/FACE_UP_9_-_January_2009.pdf
-|title= Face Up Newsletter Issue 9 |accessdate=2010-04-20}} 2009 p 4</ref> can only on defensible mathematical modeling<ref>In Australia and Canada about 1 in 100 dependent heroin users die each year due to fatal heroin overdose. {{cite web |url= http://mja.com.au/public/issues/173_10_201100/hall/hall.html |title=How many dependent heroin users are there in Australia? |accessdate=2010-04-28}} and also see ratio of fatal overdoses in Canada in 2002 against total dependent opioid user numbers{{cite web |url= http://www.oatc.ca/research/An.overview.of.illegal.opioid.use.and.health.pdf |title=An overview of illegal opioid use and health services utilization in Canada |accessdate=2010-04-28}}. The Australian evaluators of the MSIC calculated their 'lives saved' estimates on dependent heroin users injecting 3 times per day {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} p 58 thus deriving a figure of 300 heroin injections daily in the MSIC before it can claim to have saved the life of the one heroin user ie the one percent, that would have died as per Australian heroin mortality. The Canadian Expert Committee worked on a more realistic 4 injections per day - see section titled 'Background' {{cite web |url= http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php#insite |title=Final Report of the Vancouver Insite Expert Advisory Committee |accessdate=2010-04-19}} whereby Insite would need to host 400 opioid injections per day to claim one life saved, calculating on cocaine mortality as well.</ref> claim to save a life from fatal overdose once in every two years,<ref>Drug Free Australia {{cite web |url= http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Booklet.pdf |title=The Kings Cross Injecting Room - The Case for Closure |accessdate=2010-04-20}} p 4</ref> or consequently one life for a cost of AUD$5,000,000. Drug Free Australia’s analysis of the MSIC’s 2003 evaluation which claimed that it saved 4 lives from fatal overdose per annum,<ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 pp 58,9</ref> has demonstrated that the evaluators failed to factor the vastly elevated number of overdoses in the centre into their calculations,<ref>Drug Free Australia {{cite web |url= http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Detailed_Research.pdf |title=The Case for Closure: Detailed Evidence |accessdate=2010-01-09}} p 26ff</ref> which according to their own data and assumptions, were 36 times higher than on the streets of Kings Cross immediately outside the centre.<ref>Drug Free Australia {{cite web |url= http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Detailed_Research.pdf |title=The Case for Closure: Detailed Evidence |accessdate=2010-01-09}} p 12ff</ref>
-While it is universally agreed that the cost of a life is infinite, the finite resources relied upon by governments in providing intervention and care for illicit drug users must necessarily become subject to a different calculus. When the extremely high cost of saving one life in safe injection sites is compared with the cost of rehabilitation, where the Sydney centre costs as much as 400 NSW government-funded rehabilitation places,<ref>In 2002 a NSW rehab centre in Port Macquarie was given $47,000 of State funds to cover the cost of 4 rehab beds for 6 months each {{cite web |url= http://www.parliament.nsw.gov.au/prod/PARLMENT/hanstrans.nsf/V3ByKey/LA20020529 |title=NSW Parliamentary Hansard |accessdate=2010-04-20}} NSW rehabilitation funding expected 4 drug users to be rehabilitated per year for each $23,500 per annum per bed</ref> the millions of dollars to save just one life are considered by critics to be untenable, leading to their calls to close the facilities.
-=== Ineffective in meeting their objectives ===
-Critics of this intervention point to evaluations of safe injection sites. For example, the 2003 evaluation of the Sydney Medically Supervised Injecting Centre<ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003</ref> found, in measuring its performance against its own objectives, that:
-* there was no evidence that the injecting room reduced the number of overdose deaths in the area (p 62)
-* no improvement in ambulance overdose attendances in the area (p 61)
-* no improvement in ambulance overdose attendance during hours the injecting room was open (p 60)
-* no improvement in overdose presentations at hospital emergency wards (p.&nbsp;60).
-Research by injecting room evaluators in 2007 presented statistical evidence that there had been later reductions in ambulance callouts during injecting room hours,<ref>{{Cite journal |last1= Salmon |first1= Allison |last2= Van Beek |first2= Ingrid |last3= Amin |first3= Janaki |last4=Kaldor |first4= John |last5= Maher |first5= Lisa | author = Allison M. Salmon, Ingrid van Beek, Janaki Amin, John Kaldor & Lisa Maher | year = 2010 | month = February | title = The impact of a supervised injecting facility on ambulance call-outs in Sydney, Australia | journal = Addiction | volume = 105 | issue = 4 | pages = 676–683| DOI = 10.1111/j.1360-0443.2009.02837.x | url =http://www3.interscience.wiley.com/journal/123278060/abstract?CRETRY=1&SRETRY=0 |pmid=20148794 }}</ref><ref name="pmid18172151">{{cite journal
-| last1 = Beletsky |first1= Leo |last2= Davis |first2= Corey S |last3= Anderson |first3= Evan |last4= Burris |first4= Scott
-| title = The law (and politics) of safe injection facilities in the United States
-| journal = American Journal of Public Health
-| volume = 98
-| issue = 2
-| pages = 231–7
-| year = 2008
-| month = February
-| pmid = 18172151
-| pmc = 2376869
-| doi = 10.2105/AJPH.2006.103747
-| url = http://www.ajph.org/cgi/pmidlookup?view=long&pmid=18172151
-}}</ref><ref name="pmid17689337">{{cite journal
-| last1 = Kerr |first1= Thomas |last2= Kimber |first2= Jo |last3= Rhodes |first3= Tim
-| title = Drug use settings: an emerging focus for research and intervention
-| journal = The International Journal on Drug Policy
-| volume = 18
-| issue = 1
-| pages = 1–4
-| year = 2007
-| month = January
-| pmid = 17689337
-| doi = 10.1016/j.drugpo.2006.12.016
-| url = http://linkinghub.elsevier.com/retrieve/pii/S0955-3959(06)00262-3
-}}</ref> but failed to make any mention of the introduction of sniffer dog policing, introduced to the drug hot-spots around the injecting room a year after it opened.<ref>{{cite web |url= hhttp://www.abc.net.au/news/newsitems/200205/s558480.htm|title=Police to crack down on Kings Cross drug trade |accessdate=2010-01-09}} 2003</ref>
-The 2003 evaluation further indicated:
-* no improvement re HIV infections (p.&nbsp;71)
-* no improvement in Hep B infections (p.&nbsp;72)
-* either worse or no improvement (depending on the suburb studied) in new Hep C notifications (p.&nbsp;80)
-* No improvement in reuse of others' syringes and injecting equipment (pp 92,3)
-* No improvement in tests taken for HIV and Hep C (p 96)
-* Initial improvement in tests taken for Hep B but worsening in 2002 (p 98)
-* discarded syringe counts on street reduced only in line with reductions in numbers handed out due to heroin drought (p.&nbsp;123)
-* drug-related loitering and drug dealing worsened at the station entrance immediately opposite the centre (p.&nbsp;147).
-* improvements in vein care
-=== Low rates of utilization ===
-A Drug Free Australia analysis of the Sydney MSIC 2003 evaluation by an epidemiologist, addiction medicine practitioner, and social researchers and practitioners found that clients were averaging only one in every of their 35 injections in the room, evidencing low utilization rates in light of the ever-present risk of fatal overdose to each heroin user.<ref>{{cite web |url=http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Booklet.pdf |year= 2008 |title=The Case for Closure |publisher= Drug Free Australia |accessdate=2010-01-09}} More detail at http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Detailed_Research.pdf p 12</ref> Given that injector safety is the most prominent rationale for the establishment of injecting rooms, such low utilization rates raise questions as to their purpose. It is noted that the Sydney MSIC has capacity for 330 injections per day.<ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p 38</ref>
-The utilization rate for Vancouver's Insite is more difficult to judge.
-:"Over 8,000 people have visited INSITE to inject drugs. Eighteen percent, or 1506 of these 8,000 people, account for 80% of the overall visits to INSITE. Less than 10% used INSITE for all injections. The median number of visits is approximately eight. An average of more than 600 visits a day shows that INSITE operates at close to capacity."<ref>see Research Conclusions and Limitations - 1. INSITE Utilization and User Characteristics
-{{cite web |url= http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php#insite |title=Final Report of the Vancouver Insite Expert Advisory Committee |accessdate=2010-04-19}} 2008</ref>
-Taking the 1,506 injectors who most regularly use the centre, who would cumulatively inject somewhere between 6,000 and 9,000 times daily,<ref>The Background section estimates four injections for opioid users daily and six for cocaine {{cite web |url=http://supervisedinjection.vch.ca/research/supporting_research/ |title=Final Report of the Vancouver Insite Expert Advisory Committee |accessdate=2010-04-19}} 2008</ref> the less than 500 injections in Insite daily<ref>{{cite web |url=http://supervisedinjection.vch.ca/research/supporting_research/ |title=User statistics |accessdate=2010-04-19}}</ref> represents at best one injection in every 12 inside the facility. In a Vancouver study only 45% of the sample reported ever using INSITE, while 57%, a majority of the sample, reported using the facility for less than a quarter of their injections.<ref>Wood E. et al{{cite web |url= http://www.emcdda.europa.eu/attachements.cfm/att_2944_EN_consumption_rooms_report.pdf |title= Do Supervised Injecting Facilities Attract Higher-Risk Injection Drug Users? |accessdate=2010-04-28}} 2005 p 127</ref> Because Insite runs close to capacity it is not clear as to how this ratio would be affected if its capacity was expanded, however given the promoted dangers of ever-threatening overdose, the client utilization rate could be expected to be higher.
-What is clear from the utilization rates for the Sydney and Vancouver facilities is that Sydney clients were injecting at least 34 out of 35 injections in unsafe situations - at home, at a friend's place or squat, at a dealer's home, on the street, in a car, in a public toilet or in an illegal shooting gallery, while for Vancouver the ratio was an average of 11 out of every 12 injections in unsafe conditions.
-The European situation is more difficult to analyze. Studies on sites in Frankfurt and Zurich found that clients used facilities 5 times a week<ref>EMCDDA{{cite web |url= http://www.emcdda.europa.eu/attachements.cfm/att_2944_EN_consumption_rooms_report.pdf |title= European report on drug consumption rooms |accessdate=2010-04-28}} 2004 pp 35,6</ref> and in Rotterdam 6 times a week and twice in the previous 24 hours.<ref>EMCDDA{{cite web |url= http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowAbstract&ArtikelNr=000068807&Ausgabe=228974&ProduktNr=224233 |title=Drug Consumption Rooms in Rotterdam: An Explorative Description |accessdate=2010-04-28}}</ref> Sufficient information is not available on the injecting habits of these clients to judge their prevalence of supervised injection, where, for instance, one or two injections in the consumption room for 5 days weekly may still represent only 14% of injections for a heavily dependent user injecting 10 times per day.
-=== High Overdose Rates ===
-The Drug Free Australia analysis of the Sydney MSIC 2003 evaluation also found overdose levels in the MSIC 36 times higher than on the surrounding streets of Kings Cross.<ref>{{cite web |url=http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Detailed_Research.pdf |year= 2008 |title=The Case for Closure - Detailed Evidence |publisher= Drug Free Australia |accessdate=2010-01-09}}p 14</ref> The Drug Free Australia calculations used only the data published in the evaluation document, and used precisely the same assumptions utilized by the MSIC evaluators. Drug Free Australia has expressed concern that the evaluators, in using injecting room overdose data to calculate quite incorrect 'lives saved' estimates, failed to examine the extent to which overdoses were over-represented in the injecting room, against data they had gathered on overdose rates in the Kings Cross area.
-The Sydney MSIC has argued that the 2003 evaluators overestimated the number of injecting drug users in the Kings Cross area,<ref>E-mail from MSIC staffer Bernadette Keeffe sent to Drug Free Australia, posted on ADCA’s Drugtalk bulletin board 26 July 2006 1.30 PM</ref> thereby inflating the overdose ratio between injections in the injecting room as compared to the streets outside. Their lower estimate of only 605 heroin injectors being in Kings Cross on any given day, rather than the 2,000 per day estimated by the evaluators,<ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p 58</ref> reduces injecting room overdoses to 11 times higher than street levels of overdose, but this lower daily estimate failed to be cognizant of the fact that the injecting room’s 2003 evaluation data showed 860 registered clients living within walking distance of the injecting room,<ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p 17</ref> with this group representing just 23% of the room’s total clientele.
-Against other measures the Sydney MSIC’s overdose rate is highly disproportionate. Estimates of the number of dependent heroin users in Australia completed for the year 1997,<ref>Hall W, Ross J, Lynskey M, Law M, Degenhardt L {{cite web |url= http://www.mja.com.au/public/issues/173_10_201100/hall/hall.html |title=How many dependent heroin users are there in Australia? |accessdate=2010-05-01}} MJA 2000; 173: 528-531</ref> compared with estimates of the number of total non-fatal and fatal overdoses in Australia for 1997/98<ref>Warner-Smith M, Lynskey M, Darke S, Hall W
-{{cite web |url=http://www.ancd.org.au/images/PDF/Researchpapers/rp1_heroin_overdose.pdf |title=Heroin overdose: prevalence, correlates, consequences and interventions
-|accessdate=2010-05-01}} p 12</ref> yields a rate of 2 overdoses for every 10,000 injections against the MSIC’s rate of 96 overdoses for every 10,000 injections. A review of the MSIC registration surveys recording each client’s previous overdose histories<ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf#Final%20Report%20of%20the%20MSIC%20Evaluation |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p 16</ref> reveals that MSIC clients’ previous overdose history were less prone to overdose than various other previously studied heroin injector cohorts in Australia.<ref name="Drug Free Australia">{{cite web |url=http://www.drugfree.org.au/fileadmin/Media/Reference/DFA_Injecting_Room_Detailed_Research.pdf |year= 2008 |title=The Case for Closure - Detailed Evidence |publisher= Drug Free Australia |accessdate=2010-01-09}}p 55</ref>
-A survey of consumption rooms in the Netherlands, Germany and Switzerland found overdose rates ranging from 1 overdose per 10,000 injections to 36 overdoses per 10,000 injections.<ref name="Drug Free Australia"/> Vancouver’s Insite yielded 13 overdoses /10,000 injections shortly after commencement,<ref>Kerr T, Tyndall MW, Lai C, Montaner JSG, Wood E. {{cite web |url=http://www.harmreduction.org/downloads/Kerr_Overdose_IJDP.pdf |year= 2008 |title=Drug-related overdoses within a medically
-supervised safer injection facility |accessdate=2010-05-01}}</ref> but in 2009 had more than doubled to 27 per 10,000.<ref>see {{cite web |url=http://supervisedinjection.vch.ca/research/supporting_research/ |year= 2009 |title=User Statisitics |accessdate=2010-05-01}}</ref>
-It is these high rates of overdoses in safe injection sites which raises questions for critics of the evidence-base as to what is happening inside the rooms which is not happening outside.
-=== Safety encouraging experimentation ===
-Testimony of ex-clients of the MSIC reported to the NSW Legislative Council<ref>NSW Parliament Hansard {{cite web |url=http://www.parliament.nsw.gov.au/Prod/parlment/hanstrans.nsf/V3ByKey/LC20070626 |title=Rev Dr Gordon Moyes Injecting Room Hansard |accessdate=2010-01-09}} 26 June 2007</ref> alleged that the extremely high overdose rates were due to clients experimenting with poly-drug cocktails and higher doses of heroin in the knowledge that staff were present to ensure their safety. The 2003 evaluation explanation for high overdose rates was, among other things, that clients "appear to have taken greater risks and used more heroin whilst in the injecting room." <ref>2003 MSIC Evaluation Committee {{cite web |url= http://www.druginfo.nsw.gov.au/__data/page/1229/NDARC_final_evaluation_report4.pdf |title=Final Report of the Evaluation of the Sydney Medically Supervised Injecting Centre |accessdate=2010-01-09}} 2003 p p 62,63</ref>
-=== Increasing drug use ===
-Given the evaluators own statements about higher than normal overdoses in the room being due to clients using, and by logical extension, buying more heroin than usual before entering the room, there is reasonable concern that the injecting room is increasing the trade for local drug dealers.
-Much of the controversy over injecting centres is about the distribution of resources between Australia's three drug policy approaches. For example the conservative Australian politicians [[Gordon Moyes]] and [[Fred Nile]] say that little to no money should be spent on harm minimisation strategies, and instead redirect funds to preventative measures. Opponents argue that the sites send a message that the government supports illegal drug use, and that the sites themselves are unnecessary, costly, and contribute to crime in the area which they are situated. Many of the assessments carried out on the Canadian and Australian projects have found no evidence to back the latter claim of increased crime.<ref name=Vancouver>"[http://www.vch.ca/sis/research.htm Research Results]." ''Vancouver Coastal Health: Insite.'' Retrieved August 1, 2006.</ref><ref name=C&J>{{cite journal |last1= Donnelly |first1= Neil |last2= Snowball |first2= Lucy | year = 2006 | month = November | title = Recent trends in property and drug-related crime in Kings Cross | journal = Contemporary Issues in Crime and Justice | volume = 105 | pages = 1–7 | url = http://www.sydneymsic.com/Bginfo.htm//?a=29441 |format=PDF}}</ref>
 ==See also==