The case for supervised injecting
Her mouth is blue, but she’s not wearing lipstick. She is slumped back in the green plastic chair, with a nurse calling her name. When no response comes, the nurse calls for oxygen and straps the mask to her face.
It is my job to count the breaths and mark them down on the overdose chart. There is nothing to count. Her chest does not rise, the muscles of her neck do not strain. Then a breath finally comes, deep and sighing. The first in nearly 30 seconds.
This is what a heroin overdose looks like. To say that death from an overdose like this is unnecessary is not a mere platitude, it is the medical truth. Swallow handfuls of paracetamol and you may wake to find yourself in the queue for a liver transplant. Overdose on the wrong kind of antidepressant and you can be left quivering with seizures hours after doctors have pumped your stomach.
Heroin on the other hand simply takes away your breath. This makes it potentially lethal, but also simple and reversible. Usually it can be handled with the application of oxygen alone. When this isn’t enough, heroin has its own antidote, a medication called naloxone.
This overdose I was measuring breath by breath took place at the Sydney Medically Supervised Injecting Centre in Kings Cross. I have spent the past month here, learning the language of fits and tips, handing out clean syringes and sterile water and filters to the people who come here to inject drugs.
In its first 10 years of operation this centre managed 4400 overdoses like this, without a single fatality. It bears repeating because it is extraordinary. Since the centre opened in 2001, as many as 200 people have shot up here each day, seven days a week, with not a single fatal overdose.
The scandal is that the centre remains the only one in the country, despite its success over 14 years and the success of the other 90-odd centres that have opened in Europe and Canada since the early 1980s.
Now hope is growing that a second centre will finally open in Australia, in the Melbourne suburb of Richmond, a neighbourhood with a considerable history of public injecting.
Periodically this neighbourhood catches the attention of the media. In the middle of February, the Sunday Herald Sun splashed with a story about traders and residents “tired of junkies littering Richmond’s streets with discarded syringes” and opposing the prospect of a supervised injecting centre.
In reality the proposal has more support than opposition, from a wide and unlikely band that includes local councillors, the Victorian branch of the Australian Medical Association and most recently Jeff Kennett, former Liberal premier of Victoria and current chairman of beyondblue, the depression and anxiety charity.
Responding in the Herald Sun, Kennett noted he had changed his view on injecting centres after learning of the high number of drug users suffering serious mental illness. Kennett visited the Sydney injecting centre personally, he knows the research about the connections between mental illness and drug abuse and how commonly both grow from childhood trauma, and he is exactly right.
“No one seems to want to help this group of people, and beyondblue should be helping all people in need, not just those who are employed, in families, well dressed and articulate,” Kennett wrote.
The most arresting sight at the injecting centre is the injecting itself. A client will take a seat at one of the stainless-steel benches, prepare the drugs, then nudge the sharp tip of the syringe through knots of scar tissue until they find a vein. This moment is marked by the swirl of scarlet back into the barrel of the fit, a tiny lava lamp of blood and heroin and water.
As my time passed at the centre I came to find the most valuable learning experience was the chats with the clients, “this group of people” that Kennett talks about. The topics of conversation ranged from shearing work and rodeos in the far west of New South Wales to the perils of injecting into the veins of the neck. Another time, with another client, we discuss the relative merits of the various London broadsheets, and with another the state of the abscess on her leg which, now she had mentioned it, did look rather angry.
But it is not the diversity of the centre’s clientele that is striking, so much as the common themes. I wince with shame at how many of the clients are Aboriginal, how many had histories of child abuse and sexual assault and trips on the carousel from foster care to addiction to crime to jail.
Here I planned to pull at your heartstrings about the parents desperately willing their addict children to live, but I fear this to be the minority. The opioid-using population is ageing; people here are commonly in their 30s and 40s. This is a world of prison-green tattoos smudged by time, arms with the scars of infections past. Clients are as likely to have children willing them to live as parents, and just as likely to have no one at all.
And, yes, as Kennett notes, mental health problems are a common theme. Sometimes psychosis is florid, sometimes psychiatric problems are only hinted at by the unexpected and unexpectedly medicinal effects of the drugs, whether it is heroin, crushed pain pills or crystal methamphetamine they are injecting. One tough man grows chatty and personable on heroin; another girl, anxious and charged, calms to serenity on ice.
Over the years thousands of these clients have been referred to housing, rehabilitation and psychiatry appointments. But it strikes me that one of the most valuable things provided here is dignity, afforded to people who spend their days being moved on or ignored. In one corner a man has begun sweating profusely. The nurse calls him “darling” and cools his forehead with a damp paper towel. “It’s okay, darling, you’re safe,” she says.
This should be enough right? The argument should be won by this point. It should be won on the grounds of disease prevention, dignity and lives saved. But we are human. Our hearts do not always bleed for others. It is hard enough making them bleed for our own drug addicts – the alcoholic father, the aunty on methadone – let alone other people’s drug addicts. When our hearts do bleed on this issue, they may bleed most for our property values.
Which brings me to the argument I would rather not make, but which is true. An injecting centre is a fabulous thing for residents and business people, for neighbourhood amenity. Serendipitously it is where the interests of drug addicts, property owners, shopkeepers and residents run together. Nimbys should want this in their backyard.
This is something I know from personal experience. I lived in Kings Cross before the injecting centre, and after. I can remember what it was like when the gutters were sharp with needles, what it was like to reverse-park over the crunch of syringes. How it was commonplace to turn a corner suddenly and face the intimate scene of a desperate person tightening a tourniquet, how I would mumble a fearful apology then dash past.
Then the injecting centre came and things changed. Some of the credit must also go to the end of what is now termed the heroin glut. But whatever each contributed, life was different. Ambulance callouts to Kings Cross dropped by 80 per cent. Walking the streets became less frightening, parking the car less fraught. Now I happily take my children to play in the waterfront park I once felt fearful about visiting with adults.
I am not alone. In 2010, a report by the professional services firm KPMG found that 70 per cent of local businesses and 78 per cent of local residents supported the centre.
Sadly, in spite of strong support from so many, the Victorian government has not acted. Premier Daniel Andrews says the Labor government will continue to oppose injecting rooms in Victoria. A policy that should have bipartisan support has bipartisan opposition. It is a position that is neither correct nor populist. It makes no sense at all.
Injecting rooms deserve support not because we are in the flurry of a crisis and need radical action. The reason is more compelling than that. New centres must be built because opioid addiction and IV drug use are perennial problems and we have many years of good evidence that these centres can save lives and prevent disease transmission.
As for the woman with the blue lips, there is no twist to her story. She was saved, as all others before her have been saved. When the oxygen mask proved inadequate she was brought back with a shot of naloxone into her arm, a shot as simple to administer as a flu vaccine.
Within half a minute she was breathing deeply and shaking. She was alive and for that moment she was cared for, as she deserved to be.
This article was first published in the print edition of The Saturday Paper on Mar 7, 2015 as "The needless inaction and the damage done". Subscribe here.