Inside the Southern Hemisphere’s first medically supervised injecting centre

You could walk past the first medically supervised injection centre in Australia a hundred times and not realise it’s there. Discreetly drab, with its front concealed by an opaque glass facade, it sits directly opposite Kings Cross Station on the main drag: one of the busiest hubs in Sydney (pre-lockout laws, anyway), and the centre of the heroin epidemic in the '90s.

The fact of its existence is still something of a miracle. Despite reams of evidence that these places (also known as drug consumption rooms) save lives and heal communities ravaged by addiction, there is only one other supervised injecting centre in the country. That clinic, in Melbourne's North Richmond, opened two years ago after decades of advocacy. Knee-jerks still have profound influence on decision-making, and it took years before the success of the Uniting Medically Supervised Injecting Centre (MSIC) – as substantiated in crime statistics, shopkeeper testimony, peer-reviewed research and declining ambulance callouts – became so irrefutable the centre was able to transition out of its pilot stage. 

“When we first started, it was a case of keep your day job, we don't know how long we're going to be here … There was a big hoo-ha,” remembers Marguerite White, a clinical nurse specialist and the longest-serving staff member at the centre. Her hair is rinsed a deep ocean blue, and her eyes sparkle nervously behind thick glasses. She’s just spent an hour listening to a client disclose a personal story laden with trauma, and she admits it has affected her.

A former methadone nurse, White says she had “no idea of what I'd be walking into” when she first began.

“My expectation was everyone would be on the nod everywhere. That wasn't the case.”

Instead, she would often find people doing crosswords in the recovery room (the third and final stage at the centre). They still do, in fact. Just the other day, White overheard a discussion on string theory, and another on a documentary.

In the lead-up to the annual Art from the Heart of the Cross exhibition, clients can be seen splashing canvases with colour. While people can be a little “cranky” when they first enter the vestibule – especially now that ice use is higher than it used to be – by stage three, after they’ve all had their legal fix, they’re ready to relax and have a chat. 

It’s in this final room that the conversations about treatment can happen with staff. These discussions will often lead to referrals to local drug treatment providers, and are a critical component of the service. 

Despite this, “recovery” is not the main goal, says William Wood, a clinical nurse consultant (CNC) and referral coordinator. Survival is. 

“Even if you just make life bearable, for some people that's all that can be achieved,” says Wood. 

“Some will go on the journey to full abstinence. For others, they'll only be able to make small changes like getting a house, or they might change or reduce their drug use. 

“It's not about being cured. It's about respecting life.”

Mortality is the most dire statistic, but it hardly tells the full story of addiction, too. If a limb becomes trapped under an unconscious body, there can be nerve damage or even amputation. There are financial, emotional and psychological effects, which accumulate and interact in devastating ways. This could be the breakdown of a family, the derailment of a career, a prison sentence or brain damage. Realistically, loss of life is just one possible aspect of an interconnected and messy whole. MSIC’s principle of harm reduction takes on all of this.

The philosophy is baked into the staffs’ approach and the organisation’s scope of services. Beyond drug use, a client’s health and wellbeing is supported in myriad other ways. Of the 16,500 clients that have accessed the service since it opened in 2001, 14,500 have accepted referrals for ongoing support and care.

With users often stigmatised by mainstream healthcare systems (to the point of being turned away), the clinic provides a safe, judgment-free zone where care needs can be met. There is an on-site healthcare clinic, GPs who will visit three times a week, and links to STD treatments like Hepatitis C. With many clients homeless or in unstable housing, the clinic will connect them with links to housing providers. MSIC also partners with OzHarvest, which does a twice-weekly drop of fresh food. 

“We think about the person holistically,” says Wood. 

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Under COVID-19, the centre is still operating, albeit under the recommended restrictions to keep clients and staff safe. This includes the use of protective equipment, physical distancing and controlling the flow of clients through the building. 

“One of the hardest things is not being able to socialise and hang out with clients, as connection is a core part of what we do,” says medical director Dr Marianne Jauncey. “But we’re happy that we can still offer this valuable service to people who are very vulnerable during the pandemic, and hopefully get more people into treatment during this time.” 

Before the shutdown, which has caused a slight dip in visits, there was an average 170 clients daily. Many of these are what Nursing Uniting Manager Julie Latimer calls “frequent flyers” – clients who come through up to six times each day. Over a year, they’ll supervise the injection of around 2500 individuals, most of whom are using various substances (but still primarily heroin). Each client is at the extreme margins of society, and at high risk of overdose.

Occasionally, an overdose will happen inside the centre. But not once has it resulted in a death, and very rarely does it require an ambulance. 

“It’s very easy for us to step in quickly and manage an overdose,” explains Latimer. Under normal circumstances, they’ll start with putting someone they identify as requiring help on oxygen. If things become more serious, they’ll escalate to airway management. Then, if there’s no response after five minutes, a nurse will give the client naloxone (or Narcan) – a medicine capable of temporarily reversing the effects of opioids. 

COVID-19 has changed this procedure. Where previously a nurse would respond with ‘bag valve mask’ resuscitation, this involved a direct flow of foreign air particles to a client. Naturally, this now presents an untenable risk for virus transmission.

Instead, after the patient's airway has been checked, naloxone is immediately supplied. Bag valve mask resuscitation will only go ahead if repeated doses of the drug are unsuccessful, and only with the safeguard of personal protective equipment.

This year, NSW, WA and South Australia began a ‘take home naloxone’ intervention trial under a section of the Pharmaceutical Benefits Scheme. The pilot follows on from a successful University of Sydney research study trial in which MSIC participated. It enables “trained health workers at needle and syringe programs and alcohol and other drugs services [to] supply naloxone at no cost to the consumer, carer or family member” in a pre-filled syringe for injection and an intranasal spray. Training is also given on how to administer the medicine properly and safely.

Some harm minimisation experts are even urging recreational drug users to carry the substance after several Sydneysiders were poisoned by a lethal mix of cocaine laced with fentanyl this year. In the United States, which has seen a devastating loss of life from the opioid epidemic, children as young as six are being trained how to administer the nasal spray on an overdosed adult.

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All nurses that work at MSIC are highly trained professionals. They must be nursing graduates of at least two years, with experience in either drug and alcohol nursing, mental health or emergency nursing. Before her role at the clinic, where she’s worked for 12 years, Latimer was a mental health nurse in London, and worked on a pilot study for prescribed injectable heroin in the UK. Wood also has a history in mental health nursing, as well general nursing and emergency care.

All staff must also attend a series of workshops every three years, which cover everything from suicide risk assessment to drug preparation. 

These are the essential, practical skills that save lives. Yet just as important, and just as apparent in each of the staff who work at MSIC, is a deep-seated humanism and recognition of every person who walks in as a person needing care.

“A nurse is supposed to be a certain way and we can be actually quite bossy,” says White. “‘Get out of bed, do this.’ We are a bossy bunch, and I guess I don't see myself as being that. I don't know that bossiness works here terribly well.”

Rather than tell people what to do, she listens. 

“There's all sorts of things that you could say, highfalutin stuff, but really these guys have no respect out there. They're pushed along,” she says. “I can tell you some awful horror stories of people who were unwell and being mistreated, where their stories or what's happened to them are dismissed because they’re a drug user.” 

She came up against this today, she tells me, when a guy came in with an abscess on his neck. “The first thing I asked was ‘Do you neck inject?’ And he said, ‘No, it’s an ingrown hair’. She believed him; other conventional services might not.

Wood hears stories like this all the time, and it angers him. Equal access to healthcare is a basic human right, after all, and he finds it totally abject that this tenet can be so callously ignored by professionals. He’ll hear of clients who go to local hospitals and are denied medications and drugs essential to their care, or who are subject to verbal denigration by staff.

“If I showed up at a health service at a point when I'm at my most vulnerable and feel judged and discriminated against, I would withdraw,” says Wood.

“What happens is they end up terminating their care early and leaving, which then leads them down this path where they have no access to health or support, particularly mental health support.

“It's very common for our clients who go to hospital with significant infections to leave and stop taking their antibiotics prematurely because they feel judged by their healthcare providers.”

By the time individuals reach the Kings Cross centre, their trust in the system is often severely frayed. One of the most important things that an MSIC nurse can do is attempt to build a rapport with each client, on their own terms, and seek to establish a sense of trust. If and when a client does allow this to happen, it is an incredible privilege.

“There's the professional boundaries, which we work amongst," says Wood. "But there's also the accidental intimacy that comes from witnessing the most vulnerable part about client's lives; something which they historically have done very furtively.

“There's a great deal of shame around the whole injecting process that our clients carry. When you're working together collaboratively, they can let go of the shame and you have those general 'off the cuff' conversations about people's lives. 

“The people that others cross the street to avoid, we get to hear their history and connect with them in a really powerful way. I find that the most rewarding.”

When clients return to use the service, White is genuinely overjoyed. Today, even though it’s not strictly allowed, she had a client she’d known for a very long time give her a hug. Against the continual change, the roughhousing of the streets, and the impersonal and often cold carousel of different health workers, hers was a friendly face that stayed.

“They're making it back here,” White says. “How marvellous. They're safe and they're choosing to come back here, so we must be doing something right if they're coming back.

“Here is a community that they don't have, which is safe. For people on the streets who are using, it can be a bit dog-eat-dog out there. It's not here.”

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Kevin can attest to this. A brawny 63-year-old with a flinty stare and a pink shirt, he has had 2600 admissions to the Kings Cross centre for an opioid addiction. Currently, he is no longer using. He’s proud of this, and proud that it’s given him the motivation to give up smoking, too. 

“I was a little bit suspicious of the place when it opened up,” he admits. He was a hard user with a criminal history, and figured he’d be under constant surveillance the moment he walked in. 

“A friend of mine talked me into coming in one day and registering, and when I got downstairs they told me I could use any name I want. I didn't have to show any ID. I picked my own password. And then I went through the service and I felt quite comfortable because no one was judging me because I was using heroin.

“It was clean, too. The injecting equipment. People spoke to you. Staff started remembering my name, which was really important to me. After a couple of visits people say, 'Kevin, hi, how are you?' And I'm not used to that." 

Before the centre existed, people in his circumstance had no recourse to safely inject when the cravings hit. 

“I'd have to find you a little dark spot to shoot up in where I couldn't be seen. Now there was a problem with that,” he says. “If you can't be seen and you overdose, actually you can't be seen. You possibly die. Sneaking into people's yards, using people's taps, you had to carry fits around with you at the time … You could be arrested and charged with self-administration of drugs.

“I've lost a lot of friends to overdoses before this place was around. I’ve gone to quite a number of funerals. If this place was only here 20 years ago, they might still be alive.”

Kevin is now an advocate of the centre, and has encouraged many of his friends to use it over the years. The fact that the place doesn’t demand of its clients any personal information – not an address, not a real name – is hugely significant in making clients feel comfortable walking through the doors.

For a couple of years, Kevin has been a member of the centre’s Consumer Action Group, which holds meetings every month. When St Vincent’s Health in Melbourne was considering the proposal of an injection clinic in Victoria, the group participated in a teleconference, putting forward the benefits of the centre. 

The main misconception, Kevin says, is that clinics will create addicts. This he calls bullshit. Buildings don’t create users; most often, trauma does.

“I didn't grow up as a kid thinking I'm going to become a heroin addict,” he says flatly. “I used heroin because of PTSD. I used heroin because of sexual abuse as a child. I used heroin because I went through the whole child welfare institutions and it wasn't a very nice place to be a young kid in. I primarily used heroin to mask all the symptoms of PTSD and depression and stuff. And when you've been using the drug for 20 or 30 years, it just becomes a way of life. It just becomes part of your day.”

Kevin points to Wood as the person who helped connect him with a treatment program. Some programs can be difficult to get into without the right people to back you – a phone call from an MSIC referral coordinator means a lot.

In the one-and-a-half years since getting on the program, life has changed a lot for Kevin. For one, he has a lot more time. An addict (as anyone who has read William Burroughs’ Junkie will know) spends an inordinate amount of time acquiring drugs. For Kevin, this meant long, boring queues.

Now with a lot more time, he got restless, and asked the MSIC nurses for direction. They pointed him to Uniting – a services and care provider run by the Uniting Church, which also operates MSIC – which started him on data entry. Gradually, his responsibilities increased and today, he’s a volunteer campaigner there for NSW drug reform. 

The centre in the Cross, “it’s not just a place to come and shoot up drugs,” says Kevin. “It's far from that.”

You can learn more about the Medically Supervised Injecting Centre on the Uniting website.

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