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John Malouf 1
Retired Chair of the Ethics and Legislation Committee
Pharmaceutical Society of Australia (NSW Branch).
Community pharmacist.
1999
As an invited attendee of 1999 Drug Summit in the search for solutions to our drug problem, I was amazed by the emotion and rhetoric which carried many motions through the meetings held in the NSW Parliament. In my opinion, much of what was said was well-meaning but dangerously simplistic and out of desperation seeking immediate answers. Ignorance of the pharmacology of illicit drugs and their associated history was apparent. International successes against reducing illicit drugs were practically ignored along with comparative data in relation to Australia and the rest of the world. In the meantime illicit drug use spirals out of control in Australia as our policies are now tragically an acknowledged failure except by some influential individuals who would have us believe that Australia is a leader in the world and the envy of most. Only one of these proposals from the Summit this writer will address here and it is as follows....
"The government will support an 18 month trial of a medically supervised injecting room on one site only. This facility will provide a gateway to treatment and aim to lessen the impact of drugs on the community."
Some of the proponents of the establishment of injecting rooms believe that they are the only ones with a mortgage on compassion and so those who do not support their position are lacking in compassion. They view themselves as leaders of reform and contrary views to theirs have no place.
So when legal injecting rooms were promoted at the Drug Summit they were adopted despite the warnings about legal "shooting galleries" from the United Nations in Vienna and from similar failures tried elsewhere.
As a concerned pharmacist, I have no alternative but to strongly oppose this naive move on ethical and practical grounds but at the same time having due regard for the opposite position, held by many well-meaning persons many of whom are unconsciously and naively used by the drug-legalization lobby.
Today it is fashionable to reduce ethics down to compassion. Ethics are the basis for all moral choices. Addiction is slavery and the very antithesis to freedom. To help sustain an addiction is to help sustain slavery of the mind and body to chemical agents. On the other hand, to break an addiction is to release the sufferer and help him or her regain freedom. Breaking addiction should be the first priority instead of sustaining or substituting it.
Providing legal injecting rooms would break the basic ethic and oath of medical practice which has been the benchmark for two and a half thousand years.
"I will use treatment to help the sick according to my ability and judgment, but never with a view to injury or wrongdoing. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course."
It appears that this famous oath from Hippocrates, which has served society so well, is now to be put aside. It is obvious that the establishment and operating of an injecting room will be doing just that by aiding and abetting the use of any highly dangerous addicting drug for injection especially heroin. Of course, that is not the ideal of the "rooms" but in essence that is what they will become. Other illicit and licit drugs, as well as heroin, may be used as well as there will be no way or no control over just what will be used in the room. Those providing the service will be unaware of what other drugs the user has in his or her system which may be potentially incompatible, synergistic or additive to the drug being injected. By far and away, most heroin addicts are polydrug users and autopsies show that death from "opioid related substances" show multiple combinations of other central nervous system depressants such as codeine, methadone, alcohol and benzodiazepines, together with the morphine (which of course has resulted from the hydrolisation of diacetyl morphine [heroin] ).
I realise that the objective of supplying an alleged "safe" place for injecting is to accommodate the intention of aiding the addict (or experimenter) with the ultimate intention of directing him or her into another place for treatment and also to give help if the person collapses from an overdose. The idea of doing nothing to assist the injector in a back street situation is of course not to be condoned, and nor should it be. The choice is not one or the other. The choice is not one of providing legal injecting places in preference to shooting-up in some lonely back alley. Both are abominations! The choice should be the provision of effective rehabilitation centres.
If the addicts have to resort to crime to support their habit, they are not only a risk to themselves but also to others. They should have little choice but to have their addiction broken whether they like it or not. This has nothing to do with civil liberties. To rely on the addicts' freedom to choose as to when the "window of opportunity" exists is not good enough, because many die tragically before this ever eventuates. It must be stressed that the average age of deaths of dependent persons is just over 34 years of age in N.S.W. With this knowledge, can we afford to wait till the chronic user decides he or she wants to quit. There are just too many years to wait, and pitifully too late for many who have waited for this realisation that their addiction could be successfully treated.
As any assistant, in the injecting place, will have no idea of what other drugs are in the user's system which could contribute to death or what illegal psychoactive drugs the person is taking which would have a detrimental affect on his or her judgment. The users are notoriously unreliable and often manifest an impaired memory.
What duty of care would the Church have towards their clients? How would the Church be certain that their employed helpers would be of continuing high standards of excellence?
As the Church or association will have medically trained personnel in attendance, many of these trained personnel will have a conflict of their ethics as they witness the continuing harm the intravenous drug user is doing to his or her veins, let alone the administration of the drug itself.
Ethics are the very foundation for all moral choices. Soft options can be very dangerous if they arise from apparent compassion alone, without reflecting on the full repercussions of the choice.
As heroin is a short-acting drug only lasting a few hours, it needs to be topped-up between 3 to 8 times in any single day by the addict, a question immediately arises, how many times a day would the Church or organisation allow an individual to enter and use the facility? Would there be a limit? What advice would they give the user?
A trial of one injecting room in Sydney will not prove anything as there would have to be many throughout Sydney, suburbs and rural towns to prove anything. There is no way an addict will travel a long distance from where he or she lives OR where he or she has purchased the drug several times a day. Yet it would be inconceivable if injecting rooms were established widely as the detrimental effects would be magnified many times. As a pharmacist, I realise trials of course are important.
However a trial of one injecting room will prove very little. It would be anticipated there would be great resistance from residents in many areas if it became known that an injecting room was to be established nearby in their neighbourhood because of the honey-pot effect of attracting dealers to where they would know there was a ready market.
Is it really conceivable that the addict will return to the injecting place to inject that number of times in any one day? As it is, most are using other drugs in the meantime. Surely, their whole lives would be spent in travelling back and forth to the centre. How are they going to travel? Are they going to be allowed to drive? Would the Church or organisation not have an obligation to advise the addicts under no circumstances should they be allowed to drive? Where would the legal and ethical obligation to the general public finish? Would road safety regulations be relaxed to persons on illegal drugs to the detriment of other users of the road? Wouldn¹t the Church have a responsibility to other road users? What would the duty of care be if the Church became aware that the user, having injected a large amount of drugs, then intended to drive away? Are they going to use public transport? Would they call the police? What degree of privacy would be given to the Church¹s personnel and to the users? If privacy were allowed the user, then how would the Church administer control to stop dealing and other illegal acts? For injecting rooms to have any credibility, there would have to be a facility on nearly every street corner. Another major practical problem, as yet unanswered, is the proposed policing of such centres.
How close would the police be allowed to approach? 25 metres, 50 metres or 100 metres? More or less? If they are allowed too close, no addicts would use the rooms. Yet if guidelines are given to the police not to approach within a certain distance, then "safe-from-police" areas will be immediately established in which dealers and users will use and deal. Such has been the case with many failed experiments before in Switzerland from "needle park" and later to the Letten area which this author has seen in Zurich. There, the politicians, through the government, directed the police, in such a way, that no-go areas for the police were established. The result was that dealing and use flourished. It was a failure! Once these lawless zones were established, other allied and associated crime flourished To speculate that it will be different here is impractical and ignores overseas experiences.
What thought has been given to the age limit would be before entry would be given to a safe injecting room? How would the Church respond to the claim that the user was only using for "recreational use" and was not addicted? What would the Church's attitude and responsibility be towards a first-time or experimental user?
Advocates must address these problems, it is not sufficient to dismiss this by saying "It can be worked out later". The truth is there are no answers.
It is little wonder that the Vatican and the University of NSW could not lend their support to the 18 month trial.
As would be anticipated, the very same individuals who advocate liberal drug policies and drug legalisation for Australia, with the assistance of elements within the media, are vociferous advocates of legal injecting rooms. Many of these individuals believe that if acceptance of legal injecting rooms and normalisation can be promoted, then it is only a short step to having society accept legal heroin supply and use. Of course It will later be claimed by them that the injecting rooms are not working as well as they might because of the use of unknown drugs of unknown strength. They will further claim that legalised "medical drugs" will be the answer. If this ever occurs it is no secret that big businesses will have the potential to make huge profits if they are granted an exclusive market. Churches and organisations should be aware they could be used by other forces that do not share the same altruism as they do.
The following are extracts are from the annual releases of statements from the United Nations' drug arm, the International Narcotics Control Board in Vienna in 1998 and 1999. Why aren't we heeding this advice from international experts and this body? "Preventing the abuse of drugs is becoming an increasingly difficult endeavour, at least partly because and the rapid and growing spread of messages in the environment that PROMOTE drug abuse. Many of them can be regarded as public incitement and inducement to use and abuse drugs." 2
"Some States in Europe have established so-called shooting galleries, where drug abusers can administer drugs under supervision and supposedly hygienic conditions. The Board urges those States to consider carefully, all the implications of such "shooting galleries" including the legal implications, the congregation of addicts, the facilitation of illicit trafficking, the message that such places may send to the general public and the impact on general perception of drug abuse." 3
By all ethical and moral standards the end can never be justified by the means adopted; injecting rooms are no exception.
Before churches or any other organisation can be associated with legal injecting rooms, it must be understood that many questions remain unanswered. To dismiss these difficulties and problems by claiming that they can be settled later is no where good enough. The unsettled issues are not minor ones and cannot be settled by fine tuning.
Church organisations can really help solve the scourge of drug addiction in Australia by being far more involved as is the Salvation Army which works at the cliff face. A lot can be learned from this church body. I admire the other Church¹s concern for drug dependent people, as nearly all of us are, they have no mortgage on this.
There are solutions, but unfortunately legal injecting rooms, are not amongst them. All churches have the ability to be actively involved in working against the drug epidemic which is rapidly becoming endemic in Australia. They could be an active force in:
Churches could become centres of excellence in attacking the problem. They would have universal support from the community if this was done properly, especially if the highly successful methods adopted by Sweden were adopted while at the same time noting the failed policies of Switzerland and Holland.
Finally, please consider down what path legally sanctioned injecting rooms would take us and where they would stop and please take heed of the international experts and the specific warnings from the United Nations. Advocates for these injecting rooms are in direct conflict from expert advice from the U.N. and their international authorities.
John Malouf
1 Co-author of Drug Precipice (UNSW Press)
2 United Nations Release N.Y. 1998 International Narcotics Control Board. The 1988 UN Nations Convention of which Australia is a signatory and ratified by the Australian Parliament outlaws "public incitment" or inducing others to use narcotic drugs or psychotropic substances by any means. Signatories of the treaties are to have declared this a criminal offence under its domestic law.
3 United Nations Release NY 1998. International Narcotics Control Board. The 1988 UN Nations Convention of which Australia is a signatory and ratified by the Australian Parliament outlaws "public incitment" or inducing others to use narcotic drugs or psychotropic substances by any means. Signatories of the treaties are to have declared this a criminal offence under its domestic law.
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