Supervised Injecting Centre In the Eye of the ... - Melissa Sweet

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Supervised Injecting Centre In the Eye of the ... - Melissa Sweet

Downloaded from bmj.com on 20 July 2006In the Eye of the Needle: Diary of a MedicallySupervised Injecting CentreMelissa SweetBMJ 2005;330;48-doi:10.1136/bmj.330.7481.48Updated information and services can be found at:http://bmj.com/cgi/content/full/330/7481/48Rapid responsesEmail alertingserviceThese include:One rapid response has been posted to this article, which you can access forfree at:http://bmj.com/cgi/content/full/330/7481/48#responsesYou can respond to this article at:http://bmj.com/cgi/eletter-submit/330/7481/48Receive free email alerts when new articles cite this article - sign up in thebox at the top right corner of the articleNotesTo order reprints of this article go to:http://www.bmjjournals.com/cgi/reprintformTo subscribe to BMJ go to:http://bmj.bmjjournals.com/subscriptions/subscribe.shtml


eviewsBOOKS • CD ROMS • ART • WEBSITES • MEDIA • PERSONAL VIEWS • SOUNDINGSDownloaded from bmj.com on 20 July 2006In the Eye of the Needle:Diary of a MedicallySupervised Injecting CentreIngrid van BeekAllen and Unwin, $A29.95,pp 240ISBN 1 74114 381 0www.allenandunwin.comAlso available as an ebook,$A20.95 (www.ebooks.com)Rating: ★★★Early one Sunday evening in May2001, a young Sydney labourerstrolled through a nondescript shopfrontin the sleazy heart of Sydney’s KingsCross, and made medical history. The 19year old man became the first client of theNew South Wales government fundedMedically Supervised Injecting Centre,which had quietly opened its doors for thefirst time about an hour earlier. It had donethis without fanfare, hoping to avoid mediaharassment of clients. Newspaper photographerswho had staked out the premises froma hotel opposite for the previous fortnightwere oblivious, apparently because of arugby league match on television.The centre, a first for the English speakingworld, had a long and painful gestationinvolving protracted legal and political battles.Opponents ranged from the Vatican to a localbusiness organisation and the United NationsInternational Narcotics Control Board.Some of the highs and lows of its first 30months are revealed in In the Eye of theNeedle, by the centre’s medical director, DrIngrid van Beek, a public health andaddiction medicine physician.The centre was initially established as an18 month trial, licensed jointly by the NewSouth Wales police and health departmentsand run by a branch of the Uniting Church.Its operations have since been extendeduntil October 2007.Unlike some centres in Europe, it wasspecifically designed to have a clinicalatmosphere, to be more like a hospitalemergency department than a drop incentre. Dr van Beek says a centre that hassubsequently opened in Vancouver has alsoadopted the clinical model. “I hoped to sendthe message that every time IDUs [intravenousdrug users] put a needle in their armand inject a drug, they are taking their lifeinto their hands such that a high tech, clinicalset up with staff equipped to resuscitatemedical emergencies is required to keepthem alive,” she says. “By doing this, I hopethat over time other unsupervised injectingenvironments will become increasingly lessacceptable to the client base.”In its first 18 months the centre registered3818 injecting drug users, accommodatedover 50 000 injecting episodes on thepremises, and provided almost 1400 referralsinto treatment and care. Staff also managed429 overdoses without fatality, including 329heroin, 80 cocaine, and 20 temazepam orother benzodiazepine overdoses.British doctors have cited the centre’ssuccess in reaching the most marginaliseddrug users to argue against the Home Office’sdecision to support such services only if theyare part of a heroin prescribing programme.Prescribable heroin is most appropriate forlong term addicts who have not respondedto traditional treatment, whereas medicallysupervised injecting centres target the sociallyexcluded and homeless, according to a BMJarticle last year (BMJ 2004;328:100-2).When a publishing industry consultantapproached Dr van Beek about doing thebook, she agreed on condition that she didnot have to write it. Instead, over the nextfew years she spoke about a quarter of a millionwords into a dictaphone, a process thatat first she hated. “But by the end, the dictaphonehad become almost like my secondfriend,” Dr van Beek said in an interviewwith the BMJ. “I found it quite cathartic. Ilaughed and I cried into that machine.”The result is a book which is moreconversational than literary, and neither apublic health text nor a tell-all exposé. Rather,Dr van Beek has provided a personal accountof the struggles to provide such a controversialservice for clients who wield little politicalor public clout. “It was written from the bunkerwhen we were under siege,” she explains.In one entry, she writes: “Looking backover all the time that I’ve been involved withthis injecting centre I cannot help feelingthat it’s been very arduous. Whenever thingscould have been either hard or easy, theyalways seem to have turned out to be hard.”However, the book offers many entertainingvignettes, including a visit by Winky, arabbit living in the backpack of a homelessfemale client, and the security circus that surroundedPrincess Anne’s visit to Kings Crosspolice station to learn about the centre.“There seemed to be quite a few of these tall,grey-suited men with wraparound sunglassespoking about around the garbage bins and soon,” says Dr van Beek. “Even one of the streetsweepers seemed to be fiddling with somethingin his ear, apparently speaking withoutanyone being within earshot. But then quite afew people do that in Kings Cross.”Dr van Beek also details the clinical andpolicy lessons, including the dangers to staffof needlestick injuries and the frustration ofdealing with bureaucrats and politicianswho are more focused on avoiding adversemedia coverage than clients’ needs.The book is dedicated to Dr van Beek’sfather, a member of the Dutch Resistanceduring the Nazi occupation of Hollandbefore migrating to Australia in 1950. VanBeek credits him with inspiring her sense ofsocial justice.Melissa Sweet freelance journalist specialising inhealth and medicine, Australiasweetcom@tig.com.auDr Ingrid van Beek: hoping to make unsupervised injecting environments seem less acceptableItems reviewed are rated on a 4 star scale(4=excellent)48 BMJ VOLUME 330 1 JANUARY 2005 bmj.com


Downloaded from bmj.com on 20 July 2006reviewsCannabis Use andDependence: Public Healthand Public PolicyWayne Hall, Rosalie Liccardo PaculaCambridge University Press, £40/$65, pp 298ISBN 0521 80024 2Rating: ★★★Young People andSubstance AbuseEds Ilana Crome, Hamid Ghodse, Eilish Gilvarry,Paul McArdleGaskell (Royal College of Psychiatrists), £15, pp 240ISBN 1 904671 01 2Rating: ★★★The two authors of Cannabis Use andDependence have extensive experiencein the area of drug consumptionand policy. Wayne Hall is the director ofthe Office of Public Policy and Ethics at theInstitute for Molecular Bioscience, Universityof Queensland, Australia, and RosalieLiccardo Pacula is an economist with theRAND Corporation and a research fellowwith the United States National Bureau ofEconomic Research.Their book, which focuses on recreational,not medical, use of the drug,addresses a broad range of issues relating tocannabis, providing a comprehensive summaryof current knowledge. It is a suitablereference work for those interested in theeffects of cannabis and/or policy relatedissues.The first part focuses on the effects ofcannabis, describing the psychopharmacologyof the drug (the effects of cannabis thatusers seek, its psychoactive constituents,mechanisms of action, doses and modes ofadministration) and the patterns of its use indeveloped societies such as the UnitedStates, Europe, and Australia. The authorspresent research findings on the acute andchronic effects of cannabis on the respiratory,cardiovascular, immune, and reproductivesystems, on motivation and cognitivefunction, and on the risk of psychosis. Theyalso examine the impact of the drug on adolescentdevelopment and compare theharms and benefits of cannabis with those ofalcohol and tobacco.The second part of the book focuses oncannabis policies and issues such as whetherprohibition has any deterrent effect on useand supply. The authors include internationaldata and provide a balanced presentationof the existing literature.Young People and Substance Misuse isaimed at a wide audience, including youthworkers, social workers, and teachers, as wellas health professionals. It takes a multidisciplinaryapproach to youth substance misuse,providing an overview of research onuniversal and targeted prevention strategies,including those that focus on drug useand those that are broader in theirapproach, aiming, for instance, to improvelife skills.Chapters helpful to clinicians includethat on the assessment of the young person,which provides a protocol for history takingand an overview of key points such asadolescent development, the assessmentof family and education, and the reliabilityof self report. There is also a list ofthe symptoms of intoxication andwithdrawal from the most commonly usedsubstances.Although this book is primarily directedat a UK audience, especially the chapter onthe epidemiology of substance misuse, internationalreaders would also benefit from itsclear and succinct overview.Yvonne Bonomo physician in adolescent medicineand addiction medicine, department of drug andalcohol studies, St Vincent’s Hospital, Melbourne,Australiaybonomo@bigpond.comThe Woman Manual: ThePractical Step-by-StepGuide to Women’s Healthfor MenIan BanksHaynes Group, £12.99,pp 152ISBN 1 84425 182 9She Being Brand New is a clevermetaphorical poem by E E Cummingsthat compares the seduction of awoman to the starting of a new car.The publishers of the Haynes motoringmanuals have devised an “operating” healthguide for every make, model, and colour ofwoman. It is the latest in a line of healthawareness titles, including the Man, Cancer,Sex and Baby manuals, and aims to helpmen find out what is under the bonnet ofthese mysterious creatures. Traditionally,men have a poor understanding of thephysical and emotional health needs ofwomen, and although it may seem a worldaway from the mechanics of a car this bookillustrates what is required to keep womenticking over.It has been argued that womenhave been ill served by a male dominatedhealth service and that policies andpractices need to change to reflect the specificneeds of women. Imagine asking theaverage man on the street about everythingfrom thrush to breast cancer to premenstrualtension: most likely you would be metwith blank stares or confused answers.Stereotypically, most men are fixated onthe appearance of women’s bodies, ratherthan what is going on inside, leading toignorance, neglect, and misunderstandingwhen women close to them have “women’sproblems.”The discrepancies between men andwomen in understanding health issues arecompounded by the media. Take, for example,the title of a recent article in the men’smagazine FHM: “Help! My woman isbroken! Your girlfriend’s sexual malfunctionsand how to fix them.” This attitudeharms relationships and objectifies women.But is the idea that men won’t understandwomen’s bodies unless explained in referenceto a motor engine supposed to be a selfconscious joke in itself?Luckily this book takes a humorous andopen approach to explaining a whole hostof female health matters. Everything imaginableis described in straightforward, wellbalanced detail. Going for an ultrasoundscan for your first baby? Here’s what toexpect. Why does your grandmother have torun off to the bathroom every time shelaughs? Here are some amusing cartoonsand gory details. Is your wife going for a hysterectomy?This is what it involves—and,more importantly, this is how she will befeeling.Much of it is common sense—but, as weknow, our society lacks common sense, andthere is a drought of suitable information formen on what is going on with their wives,mothers, sisters, girlfriends, or daughters.This book should be given to all men whenthey first go to school. It’s accessible,interesting, and relevant.Paul Grant senior house officerClare Ilsley senior house officer, Conquest Hospital,Hastings, East Sussexdrpaul.grant@orange.netBMJ VOLUME 330 1 JANUARY 2005 bmj.com49


eviewsDownloaded from bmj.com on 20 July 2006NETLINESd Though the Coventry Pain Clinic’swebsite is primarily aimed at patients, ithas plenty to interest health professionals.Deep within the site is a useful analgesicflow chart showing appropriate steps oftreatment for varying pain levels(www.coventrypainclinic.org.uk/aboutpain-analgesicflowchart.htm). Thechart is elegantly laid out and easy tofollow. Names of drugs are hyperlinked todeeper explanations.d The highly acclaimed search engineGoogle has spawned “Google Scholar”(www.scholar.google.com), a service thatspecifically searches academic materialssuch as research papers, books, and onlineresources of educational establishments,using a simple search box similar to themain Google one. Such a focused searchcould be useful for health professional ina hurry. As with other Google services, thespeed of return of hits from a searchquery of the scholarly literature isblistering.d Weliveinahightechworld,butdespite all the tools at their disposal alldoctors should be conversant with thebasic skills of clinical examination. Sothanks go to the University of Californiafor its Practical Guide to Clinical Medicine(http://medicine.ucsd.edu/clinicalmed),which has a number of tutorials coveringphysical examination. Though aimed atmedical students, it is an ideal site for thepostgraduate practitioner to refresh skillsthat may not be used regularly. Mostsystems are covered, but some of thepages are rich in graphics and may take awhile to download, even on a fastconnection.d For an amusing, light heartededucational look at virology through theages, check out the virology time machine(www-micro.msb.le.ac.uk/Tutorials/Time/Machine.html). It runs from four billionyears ago through to 2001 and into thefuture—simply select a date and click the“travel in time” button and you will reachthe relevant page. As well as informationon virology relevant to that date, you getgeneral contemporary historicalinformation, making the page fun to read.d With widespread computer use, theability to copy and paste text into articleshas become easy. However, this carries therisk of plagiarism, and medicine is by nomeans exempt. For an excellent yet brieflook at this issue visit Drexel University’sonline tutorial (www.library.drexel.edu/resources/tutorials/plagiarism/plagiarism.html), which has much usefuladvice for learners and educators as wellas the rest of the medical community.Harry Brown general practitioner LeedsDrHarry@DrHarry.co.ukWe welcome suggestions for websites to beincluded in future Netlines. Readers shouldcontact Harry Brown at the above emailaddress.Penicillin Man: AlexanderFleming and the AntibioticRevolutionKevin BrownSutton Publishing, £20,pp 320ISBN 0 7509 3152 3Rating: ★★★★In the preface to his tale of the discoveryand development of penicillin, KevinBrown says, “This is the book I neverintended to write.” The story is medicallegend: Fleming, a modest man from StMary’s, returned from holiday to find somemould growing in one of his discardedstaphylococcus culture plates. It made himstop and say, in classic understatement,“That’s funny,” as, around the mould, staphylococcihad been killed. He experimentedand found a culture of the mould preventedstaphylococcus growth. He called theactive agent penicillin—an innovation thatchanged forever the treatment of bacterialinfections such as pneumonia, syphilis,diphtheria, scarlet fever, and previously fatalwound and childbirth infections. It madeFleming as much a household name asAlbert Einstein.Brown is trust archivist and curator ofthe Alexander Fleming Museum at St Mary’sNHS Trust. Given Brown’s connection withSt Mary’s, where Fleming spent his entirecareer, you might expect this biography tobe fawning and sycophantic. It isn’t. This fascinatinglife history of the public andintensely private Fleming is written withhonesty, intelligence, and just enoughgossip—about subjects like his lifelong commitmentto freemasonry—to make it asmuch a beach book as a bench book.With scientific precision, Brown presentsevidence from Fleming’s papers and conversationsthat he has had with many who knewFleming. In doing so, he debunks many ofthe myths surrounding one of the greatestmedical discoveries.Fleming, known as Alec to his family,had a rather idyllic childhood on anAyrshire farm. His “rags to riches” story is somuch a part of medical folklore that readersmight have heard that young Alec went toschool barefoot as his family was so poor.Brown points out that the family was in factcomfortably off. On rainy days, the Flemingchildren did indeed go to school with theirboots and socks around their necks,apparently to keep them dry in wet weatherand because their mother, Grace, thought itwould make them hardy. In later life,Fleming is said to have attributed his goodhealth to his barefoot excursions. Heremained healthy despite years of hardwork, chain smoking, and heavy drinking,before dying suddenly, aged 74, from a coronarythrombosis.Instead of the humdrum, grainy imagesproffered in so many scientific biographies,there are some wonderful visual treats inBrown’s centre pages. Of course there is theobligatory young Fleming at his microscope,but he is accompanied by classy silhouettesof the 1920s inoculation department, aposter exhorting men to build a penicillinfactory to aid the war effort, a snapshot ofso-called “penicillin girls” employed toattend to cultures, and a photograph of theoriginal contaminated Petri dish.Previous biographers have describedFleming as a dour, earnest Scot. Brown’saccount of Fleming’s relationship with SarahMarion McElroy, who died in 1949, and hissecond marriage four years later to acolleague at St Mary’s, Amalia Koutsouri-Voureka, shows a softer, warmer side.Former BMJ editor Hugh Clegg calledFleming “modest to the point of shyness.”Although Brown contests that he was shy, hewas clearly self effacing: when knighted in1944, he insisted on pouring out drinks foreveryone, even the tea lady.Brown lists 25 honorary degrees, 26medals, 18 prizes, 13 decorations, and membershipof 87 scientific academies and societiesawarded to Fleming, and he quips thathe was as proud of his 1903 medal from theLondon Scottish Regiment Swimming Clubas he was of the Nobel prize he received in1945. He suggests that “good luck had madehim the best known and most revereddoctor in the world.”Many other historians have supposedthat Fleming would have been anotherobscure bacteriologist if serendipity had notleft its calling card in his Petri dish. GivenBrown’s account of Fleming’s scholarlyyears, from winning the University ofLondon’s Gold Medal on graduation, to hisdays as a fledgling surgeon who caught thebacteriology bug, it seems an odd conclusion.Fleming appeared predestined forgreatness: a precise, painstaking man whoknew how to look when a spore drifted intohis lab and made sense of what he saw. Inthis era of antibiotic resistance, this lessonmay yet be his greatest legacy.Sabina Dosani specialist registrar in child andadolescent psychiatry, Maudsley Hospital, Londons.dosani@medix-uk.comInside Britain’s secret wartime penicillin factoryFOX PHOTOS/STRINGER/GETTY IMAGES50 BMJ VOLUME 330 1 JANUARY 2005 bmj.com

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