What Malaysia Can Learn From Melbourne’s Drug Injection Room

At the Medically Supervised Injecting Room (MSIR) in Melbourne, Australia, people inject drugs under medical supervision. MSIR provides other services, including Hep C testing, opioid replacement therapy, a GP clinic, and dental care. Should Malaysia adopt this?

At North Richmond Community Health in Melbourne, Australia, there is a room in the centre where people addicted to drugs can shoot up under medical supervision so that if they overdose, staff can respond immediately.

When people enter the facility with the Medically Supervised Injecting Room (MSIR), open every day until evening, they first register at the counter, greeted by friendly staff with smiles.

In a mimicked exchange with a client during a media visit last April 17, organised by Harm Reduction International at the sidelines of the non-profit’s HR23 conference, a counter staff member named Fiona asks 57-year-old Pudgey:

“How’s your day been? What will you be using today?”

“Heroin.”

“When was the last time you used?”

“Last 24 hours.”

There are 20 booths at the Medically Supervised Injecting Room (MSIR) at North Richmond Community Health in Melbourne, Australia, for people to inject drugs under medical supervision. Photo taken by Conor Ashleigh/ Harm Reduction International on April 17, 2023.

Pudgey, one of three clients authorised to speak to us journalists on the MSIR media tour, says the whole thing “doesn’t feel clinical at all”.

“They treat us like we know each other. You feel welcomed and respected and heard. The security guys are great – not like bouncers at a nightclub. They’re like friends.”

MSIR is clinical looking, with cold fluorescent lights shining above small partitioned booths with a steel desk and blue plastic chairs. Some booths are solo, while others have space for a pair; each booth is numbered at the top, like number 9 or 10A and 10B. There is room for 20 people to inject drugs.    

MSIR’s sanitary design is clearly medicine-oriented, rather than a recreational space for people to socialise while injecting harmful substances. The room is equipped with an array of drug paraphernalia – or medical devices, in this clinical setting – including different types of syringes, alcohol swabs, plastic spoons, sterile single-use preparation spoons to heat solutions for injection, cotton balls, and even vein finder tools.

During the media tour, we don’t actually see people shooting up, since that would be a violation of their privacy. 

Medical devices provided at the Medically Supervised Injecting Room (MSIR) at North Richmond Community Health in Melbourne, Australia, for people to inject drugs under medical supervision. These comprise alcohol swabs, cotton balls, spoons, and syringes. Photo taken by Conor Ashleigh/ Harm Reduction International on April 17, 2023.

“You just get a syringe, tourniquet, and plastic spoon, go to a booth, do your business, and dispose of the equipment,” Pudgey explains.

Staff sit with clients so that the latter can inject drugs safely at MSIR. 

“The staff are quite skilled in helping people find a vein,” says a staff member named Simon. “We have rules about what we can or can’t do. We can help to a certain point, but you have to administer it yourself.”

Another client named Alice, a young woman who uses methamphetamine daily and heroin sometimes, says she really likes MSIR as she can “safely use whatever substances” she wants to. “I just feel safe here; that I won’t die in an alleyway”.

A vein finder tool at the Medically Supervised Injecting Room (MSIR) at North Richmond Community Health in Melbourne, Australia, poses for a photograph. Photo taken by Conor Ashleigh/ Harm Reduction International on April 17, 2023.

MSIR – branded as a one-stop centre with multiple health care services (even dental!) for people who inject drugs – receives about 250 to 300 visits daily, up to 450 visits on a particular day. MSIR medical director Dr Nico Clark, an addiction medicine physician, proudly boasts of the centre saving up to 63 lives since its establishment in 2018.

A total of 6,782 overdose incidents were safely managed inside MSIR between June 30, 2018 and December 31, 2022, according to MSIR’s website. The majority of overdoses were managed using assisted breathing with oxygen, while more serious overdoses were treated with naloxone, an opioid antagonist medication that reverses the effects of heroin. MSIR clients can even bring home some naloxone.

“We are one of the busiest injecting rooms in the world,” Dr Clark says.

About 2 per cent of injections in MSIR result in overdoses, as staff do not control the amount of drugs that clients inject. Sometimes, people’s tolerance levels also change. Only 1 per cent of overdoses require ambulance services.

The only thing missing from MSIR is a supply of narcotics for clients.

Dr Nico Clark (left), medical director of the Medically Supervised Injecting Room (MSIR) at North Richmond Community Health in Melbourne, Australia, speaks to former New Zealand Prime Minister Helen Clark (right) during a media visit to MSIR. Photo taken by Conor Ashleigh/ Harm Reduction International on April 17, 2023.

“Switzerland has had prescription heroin,” says former New Zealand prime minister Helen Clark, who is also the current chair of the Global Commission on Drug Policy, during the media visit.

“That would make it the perfect service,” Pudgey enthuses. “That would be the dream.”

Although drug possession is illegal in the state of Victoria, there is specific legislation that legalises possession of under 3g of illegal drugs at the North Richmond Community Health centre, says Dr Clark.

Police don’t hang around waiting to bust addicts entering or exiting the facility either; they direct people who inject drugs in public spaces nearby to do it in MSIR instead. 

After addicts get their fix at MSIR, they go to another room for tea and coffee, and perhaps to read the newspaper. On the wall hangs a poster in colourful letters that reads: “Not just injecting but connecting”.

“This is our most informal area, since they’ve already used their drugs. We check in on them and do a suicide assessment,” says Dr Clark.

A care coordinator named Sarah says basic counselling is provided, including on employment, as the problem of drug abuse is multifactorial.

Fingerstick RNA testing for the Hepatitis C virus at North Richmond Community Health in Melbourne, Australia. Photo taken by Conor Ashleigh/ Harm Reduction International on April 17, 2023.

MSIR also provides fingerstick RNA testing for the Hepatitis C virus that yields results in just an hour; about 30 per cent of clients at MSIR test positive for Hepatitis C, 2 per cent for Hepatitis B, and 1 per cent for HIV. Doctors at MSIR can write prescriptions immediately for people who test positive to go to the pharmacy to get medications.

Pudgey, who had Hepatitis C for two decades, was cleared of the viral HCV infection after taking medication for a month. 

“We’ve tested 1,500 people. In 2021, we treated more than 300 people with HCV. We’re the largest site for HCV treatment in Victoria,” says Dr Clark. “The prevalence of HCV has come down. We can eliminate Hepatitis C in our community.”

At North Richmond Community Health, people who inject drugs also get other health and social services like legal aid, mental health support, and nutrition and occupational therapy, besides dental care from a hygienist and opioid replacement therapy like methadone and long-acting buprenorphine. There is even a general practitioner (GP) clinic at the facility.

“The oral health of many people who inject drugs is terrible,” says Dr Clark.

Buprenorphine is provided free for clients at MSIR, paid for by the Victorian state government. Ninety per cent of clients prefer the long-acting injectable buprenorphine that lasts for at least a month, unlike methadone where people are unable to go to the chemist if they miss a doctor’s appointment, says Dr Clark.

Outside MSIR, people can get methadone and Suboxone at the chemist for about AU$5.00 a day (RM15), the price of a cup of coffee in Australia. 

A client (right) of the Medically Supervised Injecting Room (MSIR) at North Richmond Community Health in Melbourne, Australia, takes a selfie with former New Zealand Prime Minister Helen Clark (left) during a media visit to MSIR. Photo taken by Conor Ashleigh/ Harm Reduction International on April 17, 2023.

Saade, a 49-year-old client at MSIR who has been on buprenorphine for three years after coming to North Richmond Community Health in 2019, says he once tried experimenting with heroin while on the long-acting opioid partial agonist treatment. “It was like water; I didn’t feel anything. It was a waste of money.”

Saade, a scaffolder who flashes a wide smile with perfectly good teeth for professional photographs at the end of the media tour, used heroin for a few months at MSIR before switching to buprenorphine. 

When former New Zealand PM Clark asks when MSIR staff tell clients to stop using drugs, Dr Clark says people sometimes get a shock when they overdose. “We say – are you aware of this treatment?”

“We start people on opioid treatment every day,” he adds.

MSIR has 6,191 registered clients. Some people come just once, while others come more regularly, says Dr Clark. 

When I ask if the main objective of MSIR is to prevent deaths or to get addicts onto treatment, Dr Clark says, “Providing a range of services is just as important as preventing overdose deaths.”

Dr Nico Clark (far left), medical director of the Medically Supervised Injecting Room (MSIR) at North Richmond Community Health in Melbourne, Australia, former New Zealand Prime Minister Helen Clark (to Dr Nico Clark’s left), a client of MSIR (centre), and journalists during a media visit to MSIR. Photo taken by Conor Ashleigh/ Harm Reduction International on April 17, 2023.

A review of MSIR by an independent panel, published by the Victorian state government last February, found a range of views among the local North Richmond community on MSIR – some residents feel unsafe due to public injecting, discarded needles and syringes, and loud gatherings near MSIR, and erratic or violent behaviour.

“Given the focus on the trial in public discussions, it is understandable that the impacts of drug use in North Richmond tend to be strongly associated with the MSIR. Yet these effects are not only the result of the MSIR’s operations, but also of the ongoing public burden of a drug market that existed long before the trial began,” states the review.

MSIR, which began as a trial in 2018, has been approved by the Victorian state government as a permanent fixture in North Richmond after two independent reviews.

“The service was put here because this is where people get their drugs, not the other way round,” says Dr Nathan Stam, the executive manager for MSIR and alcohol and drug programmes, during the media tour.

Sarah Hiley, a harm reduction team leader at North Richmond Community Health, says they make pizza every Wednesday. “People want to live full and happy lives.”

I ask Dr Stam if MSIR can be perceived to be less successful with transient clients, as such people would not be able to be followed up with treatment to get them off drug addiction. 

“Some people use on a regular basis, whereas other people’s use may not be as regular – they might use for a period of time when they’re not doing so well, or they might use and they go, ‘I want to stop using. Something’s changed in my life, and I don’t feel the need to use anymore’. Then something may happen down the track, they’re not doing so well, and they might use again,” Dr Stam replies.

“We sometimes see people every day, we sometimes see people at various points, and so it can be tricky, because a lot of it might actually depend on what’s happening in their life.”

He corrects my perception that people who use heroin inject daily. “Some people might use multiple times a day, some people would use infrequently, like only on weekends. Other people might only use when they’re not doing so well, and that’s the most risky time for them – when they haven’t used for a while and they’re coming back to it. And for other people, there could be another reason why they haven’t used for a while – they might have gone into rehabilitation, they might have been in jail.”

Saade, a 49-year-old client at the Medically Supervised Injecting Room (MSIR) at North Richmond Community Health in Melbourne, Australia, poses for a photograph. Photo taken by Conor Ashleigh/ Harm Reduction International on April 17, 2023.

Malaysia has had quiet but tremendous success in curbing HIV transmission among people who inject drugs due to harm reduction programmes that have been around for more than 15 years – the needle and syringe exchange programme and opioid substitution therapy with methadone. New HIV cases in Malaysia fell from a peak of 6,978 cases in 2002 to 3,146 cases in 2020.

The country’s HIV epidemic landscape has changed from predominant transmission via drug injection to sexual transmission; the proportion of sexual transmission of HIV infection increased to over 90 per cent in 2019.

If Malaysia were to set up an equivalent to MSIR, we would likely see police officers hanging around the vicinity to make easy arrests – unless there is significant engagement with the authorities, the local community, and the general public, as well as former drug users themselves who may not automatically support a drug consumption room.

While MSIR’s range of services is impressive, I’m not completely convinced that providing a legal space for people to inject drugs will curb the use of drugs itself – which, to me, should be the end game of drug policies.

Interestingly, the objectives of MSIR, as per the February 2023 independent review, do not include reducing drug use in the community or increasing usage of opioid substitution therapy.

In any public policy, the State should aim to reduce access to “bad” things, like sugary drinks, cigarettes, and drugs, and to increase access to “good” things, like health care, education, or public parks. Reducing access doesn’t necessarily equate to bans or prohibitions (though narcotics should remain illegal), but to just make it difficult for people to get certain things that are deemed harmful.

For now, Malaysia will benefit from expanding access to methadone at public health clinics by providing a bigger supply — at least one week or two weeks’ worth — of the treatment to people who use drugs instead of on a daily basis, or to make it available after working hours or on weekends. Opening access to medication outside business hours is especially crucial for people who use drugs because they need to keep their jobs that are likely to be low-income with inflexible working hours.

Government clinics provide women two months’ worth of birth control pills at a time, for example. It would be even better if the government could provide and subsidise long-acting buprenorphine that only needs to be taken monthly.

Providing a space for people to inject drugs should be accompanied with a strong emphasis on treatment, beyond simply leaving it — out of an extreme fear of appearing judgmental — to individuals to make their own (bad) choices in life, or for taxpayers to continue subsidising substance abuse indefinitely.

While harm reduction is a legitimate goal, the term itself, “harm reduction”, shows there is still harm from the use of highly addictive substances that should not be ignored in public policy or arbitrarily dismissed as “lies” and “disinformation”.   

Saade is a “model” user, or former user, of drugs as he is on treatment, has a job, and plans to have children with his fiancée. Other clients of MSIR may be content with just feeding their drug habit, which, I suppose, is fine if they don’t harm other people. 

There is no doubt that the War on Drugs has failed spectacularly. A hardline prohibitionist approach that treats addicts as criminals creates a host of other problems, including the not insignificant violation of human rights and unacceptable death penalty for drug trafficking. 

Replacing law enforcement type drug policies with a health approach must include the clinical evidence for the harms of illegal narcotics, with the ultimate aim of getting people off drugs to turn them into productive members of society. The solution is not to legalise dangerous substances.

That is what it means to have a “full and happy” life, beyond making pizza after getting high.

Correction note: Several corrections were made in the section below the photograph of fingerstick RNA testing for Hepatitis C.

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