This article was originally published by YouthRise.
In April 2013, the Independent Drugs Commission for Brighton and Hove published a report that attracted much attention from the national press. Among the recommendations was a call for the local council affiliated public health and order agencies to consider the inclusion of drug consumption rooms (DCRs)a in the city’s harm reduction strategy. Whilst this was not the first report to make similar recommendations nationally, support from local politicians and officials has generated confidence that Brighton and Hove, home to around two thousand problem users of heroin and cocaine, will soon host the first DCR in the UK. This essay is an attempt to briefly outline and place into context the current situation, summarise the arguments and evidence for and against DCRs and discuss the way forward.
Drug Consumption Rooms: Concept and Context
DCRs are officially sanctioned healthcare facilities, where people can use pre-obtained drugs under the supervision of trained staff, in a hygienic, safe and non-judgemental environment. They are operated primarily for people with a history of problem drug use, dependency and addiction.[b] Most DCRs are physically integrated with other services for people who use drugs (PWUDs), typically providing needle and syringe exchange, drug treatment, advice on safer drug use, general healthcare, counselling and social support.[c] While traditionally most DCRs have focussed on people who inject drugs (PWIDs), an increasing number supervise drug inhalation as well.
The first officially approved DCR opened in Berne, Switzerland, in 1986. There are now over ninety in Europe (in Switzerland, the Netherlands, Germany, Spain, Norway, Luxemburg and, most recently, Denmark), with a single facility in Sydney, Australia, and another in Vancouver, Canada. These sites have been established for a range of stated reasons, with differing rationales reflecting local and national drug-related concerns and priorities. The most commonly cited problems are high rates of fatal drug overdose, prevalence of blood borne viruses (HIV, Hepatitis B (HBV) and C (HCV)) and public harms, such as discarded injecting equipment and anti-social behaviour, including public drug use. How do these issues correlate with the situation in the UK, and what evidence is there that DCRs are able to address them?
Preventing Fatal Drug Overdoses in the UK
In the UK, around 380,000 people are engaged in problem drug use and the number of drug-related deaths, around two thousand per year, is consistently among the highest in the European Union. Approximately eight hundred of the fatalities involve heroin or morphine; the majority as a result of overdose. Non-fatal overdoses, which are more common, can cause hypoxia-induced brain damage and a host of other injuries.
The doctors, nurses and other trained staff at DCRs are able to respond rapidly to suspected overdoses, for example by the provision of oxygen and/or the opioid antagonist naloxone. The evidence from existing DCRs is unambiguous: they prevent deaths from drug overdose, and have the potential to significantly reduce the harm caused by non-fatal episodes. This is most succinctly demonstrated by the fact that after millions of consumption episodes in DCRs around the world, over almost three decades, not a single overdose death has been recorded.
Introduction of the large DCR in Vancouver has been associated with a 35% reduction in the rate of fatal drug overdose, with a similar decrease in deaths in the subgroup where cocaine use was deemed contributory. This latter result, along with the observation that approximately one third of facility visitations were for injection of cocaine, is potentially significant given the absence of interventions demonstrated to reduce the risk of fatal stimulant overdose.
Tackling Unhygienic and Public Use
Consumption of drugs with shared and reused equipment, often in unhygienic settings, is associated with substantial risks to health, including the transmission of blood borne viruses (BBVs) and contraction of other infections. In the UK, the majority of drug injections are made with used (but not necessarily shared) needles and 17% of PWIDs report to have shared needles or syringes in the past month. The prevalence of HIV among PWIDs in the UK, approximately 1.1%, is relatively low compared to other countries with less successfully deployed harm reduction strategies. However, there remains significant regional variation (prevalence in London is almost four times the national average) and other blood borne viral infections are more common and have increased over the past decade. Almost half of PWIDs now have HCV.
DCRs can reduce the prevalence of BBVs and other harms associated with sharing and reuse by providing sterile equipment to facility users, preventing sharing on-site, operating BBV testing and vaccination programmes and offering education and advice on safer drug use practices and sexual health. Bacterial and fungal infections, damage to veins and other health problems can be further reduced as drug use is relocated from public spaces and other unhygienic settings to clean, well lit environments, free of the pressure to rush injections.6 The results are impressive: a 70% reduction in equipment sharing among frequent DCR users, reduced injection-related injuries and non-viral infections and widely reported improvements in injection hygiene.
The reduction in public drug use brought about by DCRs has been repeatedly demonstrated and is important not only in reducing the private harms mentioned above, including overdose deaths, but also in addressing public harms. These are discussed further below.
A Unique Interface
The primary target population for DCRs are those at greatest risk of fatal overdose, BBVs, poor general health, homelessness and marginalisation. These same people are the most difficult for health and social services to engage with. In this regard, DCRs offer a unique interface through which a traditionally difficult to reach group can access drug treatment, counselling, accommodation, education, health and other social services. 15-50% of DCR users have never been in drug treatment before and many others are out of contact with treatment services. Uptake of provisions, on-site or by referral, is generally high and there is some evidence that DCRs may bring about an increase in participation with drug treatment programs.
Clearly, the positive effects of DCRs are not limited to safer practices within the facility. Their utility in engaging difficult to reach PWUDs with a wide range of services and, uniquely, providing tailored education and advice on safer drug use extends their benefits far beyond the site walls. With patient consent, consumption rooms can also facilitate collection of data on drug use patterns and the efficacy of harm reduction strategies, including of DCRs themselves, to inform an evidence-based drug policy.
Fears of Increased Drug Use & High Risk Behaviour
Despite the substantial and growing body of evidence showing DCRs to be effective in the reduction of drug-related harm, they remain controversial compared to more established harm reduction approaches. In addition to the reactionary responses given to many pragmatic, evidence-based harm reduction strategies, there are some commonly raised specific concerns and objections to DCRs. These are addressed below.
Critics have argued that DCRs may encourage initiation and continuation of injected drug use. To mitigate risk of the former, facilities generally exclude people who would be injecting for the first-time, as well as under-18 year olds. Drug distribution and sharing is prohibited within the facilities and patients and staff are not allowed to directly assist novice users (or indeed anyone else) with injections.
Evidence from existing facilities suggests that the fears of an initiating effect are unfounded. Only 0.5-4.5% of DCR users report first injecting in a facility and it is not known what proportion of this group would have begun injecting in the absence of DCR provision. A typical DCR user is over thirty years of age, has used heroin and/or cocaine for at least ten years and is likely to have a history of public injecting. The European Monitoring Centre for Drugs and Drug Addiction has concluded that “[t]here is no evidence that naive users are initiated into injecting as a result of the presence of consumption rooms.”
The evidence also contradicts fears that DCRs could delay entry into treatment and promote continued and high risk use. A study monitoring the impact of the DCR in Vancouver, echoing the results from other sites, found: “no substantial differences in rates of relapse…or stopping injected drug use”. This study also saw no increase in binge use or decrease in methadone use, though encouragingly a small decrease in the rate of relapse to binge use was observed.
In summary, studies from Europe, Canada and Australia have shown no evidence to suggest that DCRs cause increased drug use, nor initiation, relapse, delay to treatment or high risk consumption behaviour. There is however some evidence that DCRs may be associated with a reduction in binge drug use and, as mentioned previously, that they may bring about an increase in use of drug treatment services.
Why do ‘They’ Deserve it? Resources, Cost and Public Harm
Other raised objections relate to the impact of DCRs on society, both in terms of resource diversion and the potential public harms resulting from DCR establishment. The former can manifest as moral disapproval: why do ‘they’ deserve these facilities? With a considered analysis of outcomes, this type of objection is easily addressed.
DCRs not only reduce harm to PWUDs but also to society as a whole. Public using is in itself an anti-social behaviour, and so too is the resultant discarding of used drug administration equipment (including needles and syringes) in parks, public toilets, car parks and residential areas. These are both harms about which the public often express particularly strong feelings, and are both reduced substantially by DCRs. It should also be noted that the costs involved in operating a DCR are off-set by reduced demand for other services, including ambulance call-outs and hospitalisations due to drug overdose, BBVs and other symptoms of poor health. Costs can be further reduced by integrating DCRs within existing facilities, such as needle and syringe exchange programs, rather than operating stand-alone units.
In any case, the question “why do ‘they’ deserve these facilities?” can also be answered with a simple moral retort. The principle users of DCRs are among the most socio-economically deprived people in society, with low levels of general health (physical and psychological) and a high likelihood of traumatic life experiences and homelessness. Even ignoring the benefits to public health and order, a strong moral case can be made that would-be DCR users are among the most deserving recipients of social support.
Despite fears to the contrary, there is no evidence that DCRs will lead to an increase in net or local crime. In fact, with increased interaction between people with problem drug use and treatment and social services, it may be that DCRs will indirectly cause crime rates to fall. Related anxieties about a ‘honey pot effect’ are again largely unfounded. Several studies have shown that DCR users are generally unwilling to travel any significant distance from a drug market to consume drugs. In existing facilities between 63% and 93% of patients are local. It is precisely for this reason that for DCRs to achieve their harm reduction aims, they must be located close to existing drug markets. Surveys of community attitudes have shown that establishment of DCRs can be associated with a decrease in anti-social behaviour and nuisance to local residents.
Legal & Political Obstacles
The international legal environment has been discussed elsewhere. In summary, the UN drug conventions emphasise the requirement for “treatment, education…and social integration” of PWUDs as well as control of drugs. It has been interpreted that harm reduction measures, such as DCRs, may be compliant with the conventions. Indeed the UN’s own legal experts agree.[d] It would seem that there is sufficient scope for interpretation of international laws to proceed with the introduction of DCRs. Countries who have already done so, all of whom are signatories to at least two of the three UN drug conventions, have conducted analyses of the international legal position and found that DCRs do not represent an infringement. Where necessary, national and/or local laws have been amended to protect service users, staff and others from arrest and prosecution. It is likely that, in the UK, the Misuse of Drugs Act 1971, among others, may have to undergo such an amendment process. With political will, this is not a barrier to progress.
How to Progress from Here
The arguments and evidence in support of DCRs are compelling. They provide a safer, more hygienic environment for use and have been shown to save and improve lives, by preventing fatalities from drug overdose, reducing infectious disease transmission and providing an interface through which hard-to-reach PWUDs can engage with medical and social support services. Via advice, education and provision of clean consumption equipment, their positive effects extend beyond use within the facilities. By reducing public use and discarding of needles and syringes, DCRs reduce public as well as private harms. Studies from multiple existing sites indicate that these benefits can be achieved without increases in drug use, high risk behaviour or crime.
Despite the case for DCRs appearing to be relatively clear cut among harm reduction advocates, they remain controversial. This is true not least among social conservatives, who are often instinctively averse to harm reduction programs, some preferring an ‘abstinence at all costs’ approach, often in the pursuit of a utopian drug-free society. Some of these critics have much less concern for the welfare of PWUDs than for reducing the visibility and proximity of anti-social behaviour to the rest of society (sometimes utilising a crude and puritanical cleanliness narrative, such that priority is given to the removal of the behaviour and those engaging in it from the public space, i.e. to getting it/them “off the streets”). Harm reduction advocates should acknowledge the political reality of this diversity in perspective and priority, and seek to achieve broad support for DCRs by emphasising the potential for reductions in public drug use, violence, low-level crime and discarded consumption equipment, as well as the array of benefits to public health.
The Independent Drugs Commission for Brighton and Hove’s report was discussed by the Safe in the City Partnership Board at the end of April, and an announcement on the proposal to include DCRs in the local harm reduction strategy will be made in 2014. Experience from existing sites has shown that success with consumption rooms is most pronounced when coupled with broad popular and political support. Armed with a wealth of literature, harm reduction advocates must now work to foster that support and bring the UK, in this regard at least, towards an evidence based drug policy.
[a] Drug consumption rooms are also known elsewhere as ‘safe(r) consumption sites’, ‘safe(r) injection facilities’, ‘supervised injection facilities’ (SIFs), ‘fixing rooms’ and ‘shooting galleries’. The term ‘drug consumption room’ is used in this article so as to include the growing number of facilities that allow the smoking and inhalation of drugs as well as injection, and to distinguish from unofficial, unsupervised, often unhygienic and high-risk venues for illegal drug use.
[b] Problem drug use is defined by the European Monitoring Centre for Drugs and Drug Addiction as “injecting drug use or long-duration or regular use of opioids, cocaine or amphetamines”.
[c] Service provisions vary between existing DCRs; whereas a few are stand-alone and routinely refer patients to other sites, some are comprehensive, with on-site services including subsidised catering, showering facilities, laundrettes and social spaces, in addition to the services listed above.
[d] Though the INCB, for whom the advice was prepared, take a contrary and characteristically conservative view.
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