STEP-BY-STEP THROUGH SOME OF THE KEY ISSUES
Drug consumption rooms provide hygienic and supervised spaces for people to inject or otherwise consume illicit drugs. When counted at the end of 2018, there were 117 sanctioned drug consumption rooms in 11 countries around the world, generating an evidence base of ‘real world’ trials for scrutinising their biggest appeals and detractors’ greatest fears. Evidence of their effectiveness is one motivation for introducing drug consumption rooms; another is that they provide a common sense solution to the suffering and risks associated with public injecting.
The Scottish Government has recognised mounting harms to the health, wellbeing, and dignity of people who use drugs, and supports trialling drug consumption rooms as part of an approach to substance use based on public health objectives and human rights principles. However, the UK Government based in Westminster (London) has blocked any such action. This stalemate provides the backdrop for a hot topic exploring the following questions:
• In communities dealing with the consequences of public injecting, could drug consumption rooms be part of the solution?
• Knowing the human cost of unsafe public injecting practices, would it be negligent for governments not to consider them at this point?
The mounting harms of public injecting
People who inject in public typically have nowhere else to go, and for complex reasons are unable or unwilling to engage with treatment for their drug dependence, or are in treatment but still using illicit drugs. They are very often homeless, and have reached a ‘boiling point’ of risk where they live with the daily prospect of bacterial infections, contracting blood-borne viruses, overdosing, and in the absence of someone witnessing the overdose and stepping in with life-saving support at the right time, dying on our streets.
Injecting in public places is a high-risk practice associated with an inability to inject in a sterile way, both due to unhygienic environments and difficulty maintaining personal hygiene, and hasty, unsafe injecting practices due to the threat of being seen by the public or police.
A 2006 study involving 100 people from Glasgow, Edinburgh, Bristol and London, whose day-to-day life at home or at work was likely to expose them to public drug use or its aftereffects, identified three types of locations used for public injecting:
• open areas including alleyways, car parks, cars, derelict or rubble/rubbish strewn open spaces, and train stations;
• neglected property including disused and seldom used parts of buildings, building sites, drug houses, and squats;
• publicly accessible places held as residential or commercial property including houses, cafés, pubs, toilets, gardens, bushes, backyards, doorsteps, stairwells, bin shelters, and garages.
However, participants’ sympathy for people who used drugs was often offset with blame and resentment for the impact public injecting had on them personally. Drawing a line in the sand, participants talked of people who used drugs as a group distinct from residents, tourists, workers, and patrons. This ranged from expressing their appreciation for people who used drugs “keep[ing] away from residential areas”, to condemning them for “blighting an area’s reputation and their own quality of life”.
Public injecting can indeed have an impact on other people, but as these participant responses illustrated, there is a danger of people who inject in public being represented as public order problems to communities to the exclusion or minimisation of the personal and individual harms they experience. Furthermore, the ‘public impact’ narrative can overlook the fact that people who inject in public are also members of communities, and rather than being held responsible for ‘blighting’ those communities, there could be recognition that they are carrying the burden of some of the worst health and social inequalities in society.
“Time for safer spaces”: Scenes of public injecting in Birmingham documented by Nigel Brunsdon
In August 2016, harm reduction advocate and photographer Nigel Brunsdon spent a day walking around Birmingham, documenting evidence of public injecting. He visited three known injecting areas – two on waste grounds next to car parks, and one in a main walkway in the centre of town – and found the ground covered in injecting equipment and general waste; needles alongside garbage and human excrement. “No one ‘chooses’ to inject in these spaces”, he said, “this is where the most desperate people in our society have been driven”.
A few years earlier in 2012, Philippe Bonnet explored these key issues in a documentary produced by Social Impact Films. He toured known injecting sites in Birmingham, and interviewed outreach workers, healthcare professionals, and people who were currently injecting (or had injected) drugs in public places. Injecting equipment was already available to the city’s population, and services were providing this equipment knowing that it would be used by people to inject illicit drugs. Many vulnerable people would go on to inject those illicit drugs in unsafe spaces – places that were cold, unhygienic, with poor lighting and no washing facilities. Describing the conditions as “completely appalling’, he said:
“The aim of this video is to highlight the problem we have in this city. Can we let people inject in these situations? Can we let the harm carry on?”
A core demographic of drug consumption rooms is homeless people who use drugs, due to links between homelessness and high-risk behaviours such as public injecting, sharing injecting equipment, and poor injecting hygiene.
The term homelessness covers a spectrum of living situations. Though traditionally associated with ‘rough sleeping’, someone who has a roof over their head can still be homeless. The broad categories of homelessness described by Crisis, the UK national charity for homeless people, are:
• ‘rough sleeping’;
• in temporary accommodation (night/winter shelters, hostels, B&Bs, women’s refuges, and private/social housing);
• hidden homeless (people dealing with their situation informally, ie, people who stay with family and friends, ‘couch-surf’, and ‘squat’);
• statutory homeless (people deemed ‘priority need’ who their local authority have a duty to house).
By its very nature, homelessness exposes people to materially poor living conditions – increasing their exposure to risky situations and decreasing their capacity to protect themselves from harm. This supplementary text details some of the life-limiting diseases and disorders experienced by homeless people, some of which are complications of risky drinking and drug use, and many of which are preventable and treatable. The Guardian drew attention to this in 2019 (for original data source, see NHS Digital website), writing:
“Thousands of homeless people in England are arriving at hospital with Victorian-era illnesses such as tuberculosis, as well as serious respiratory conditions, liver disease and cancer.”
In 2011, when UK homelessness charity Crisis reviewed deaths among homeless people, the situation was very bleak. They found that homeless people die on average 30 years before the general population (48 for men and 43 for women, compared to 74 and 80 respectively), and a third of these deaths are related to drink and drugs. According to recent assessments, the situation may be getting worse rather than better. Figures from the Office for National Statistics revealed that 597 homeless people died in England and Wales in 2017, an increase of 24% from the 482 deaths recorded in 2013. Most of these were men (84%), with an average age of 44 years old (44 years for men, 42 years for women), and more than half died from causes related to drugs (32%), alcohol (10%) or suicide (13%) – much higher than the 3% of deaths attributable to drugs, alcohol, or suicide in the general population the same year.
A 2018 study analysed the social distribution of homelessness and found that in the UK homelessness is not randomly distributed across the population – the odds of experiencing it are systematically structured around a set of identifiable individual, social and structural factors, most of which are outside the control of those directly affected. Poverty (especially childhood poverty) is central to understanding people’s pathways to homelessness, and on the flipside, the ‘protective effect’ of social support networks is key to understanding how people can avoid homelessness.
Where harm is concentrated in the general population and what that harm looks like are of critical relevance to the question of whether to introduce drug consumption rooms. The heightened level of risk among homeless people suggests that at the very least the debate needs to be able to navigate the different environments and contexts in which people take illicit drugs. Just as not all drugs were created equal, not all people who use drugs were created equal. As Nigel Brunsdon said: “No one ‘chooses’ to inject in these spaces, this is where the most desperate people in our society have been driven”.
What happens inside a drug consumption room?
Cubicles for hygienic, supervised injecting inside a drug consumption room
Drug consumption rooms are legally sanctioned spaces where people can bring their own pre-obtained illegal or illicit drugs, and either inject or inhale them using sterile equipment under the supervision of nurses or other medical professionals. This differentiates them from:
• illegal ‘shooting galleries’ run for profit by drug dealers – though colloquial references to drug consumption rooms in the media can blur this line (1 2);
• hostel or housing services that tolerate drug use among residents but provide no medical supervision;
• programmes which prescribe pharmaceutical heroin (diamorphine) for consumption by their patients under medical supervision (1 2).
Until the 1970s there were informal, ad hoc facilities including the ‘fixing rooms’ of London’s Hungerford and Community Drug Projects, and Blenheim in west London, which had a toilet where people routinely injected. These stopped running primarily due to the knock-on effects of people using barbiturates, a sedative which can result in ‘drunken’ behaviour. Staff felt unable to support users safely and were disillusioned at facilities becoming ‘crash pads’ for people turning up already stoned.
The first officially approved supervised consumption room opened in Bern (Switzerland) in 1986. Rooms were then introduced in Germany and the Netherlands in the 1990s, and in Spain, Australia and Canada in the early 2000s. As of April 2018, when the European Monitoring Centre for Drugs and Drug Addiction updated their overview of provision and evidence (for earlier version, click here), there were 31 facilities in 25 cities in the Netherlands, 24 in 15 cities in Germany, five in four cities in Denmark, 13 in seven cities in Spain, two in two cities in Norway, two in two cities in France, one in Luxembourg, and 12 in eight cities in Switzerland. Outside Europe, at the time of the 2018 Global State of Harm Reduction report there were two facilities in Australia and 26 in Canada.
Most rooms are integrated into existing, easy-access (or ‘low threshold’) services for people who use drugs and/or homeless people, giving them access to ‘survival-orientated’ services including food, clothing and showers, needle exchange, counselling, and activity programmes. Less common are facilities exclusively for people who use drug consumption rooms that offer a narrow range of services directly related to supervised consumption (1 2). Spain, Germany and Denmark also have mobile facilities offering a more flexible service (ie, going where people who use drugs are) but with limited capacity.
The most recent drug consumption room census, facilitated by the International Network of Drug Consumption Rooms in 2017, included 51 responses collected from 92 drug consumption rooms operating in Australia, Canada, Denmark, France, Germany, Luxembourg, Netherlands, Norway, Spain and Switzerland. This found that almost all drug consumption rooms (94%) provided referrals to treatment and distributed sterile injecting equipment for taking away. Many also provided condoms (89%) and HIV-related counselling (70%), personal care (76%), including shower and laundry facilities, and support with financial and administrative affairs (74%). Frequently provided were HIV testing (54%), outpatient counselling (46%), mental health care (44%), hepatitis B vaccinations (41%), legal counselling (39%), take-home naloxone (37%), and opioid substitution treatment (24%), as well as meals (61%), recreational activities (57%), work and reintegration projects (41%) and use of a postal address (39%). Almost half of services also reported offering tours or open days to the public (49%).
Demystifying what happens within the four walls of a drug consumption room, Marianne Jauncey from the University of New South Wales described the operating practices of a facility in North Richmond, Victoria (Australia):
• Stage one: First-time visitors register with the service. This involves them talking to a member of trained nursing or counselling staff, and providing a brief medical history. If they wish, people attending can use an alias; they are not required to leave either their full names or their real names. Once registered, attendees are asked what drug they are seeking to use, as well as what other drugs they have used recently, which gives staff a sense of what to expect.
• Stage two: Staff provide clean injecting equipment, typically including small 1 ml syringes, swabs to clean the skin, a tourniquet, water, filters, and a spoon. Clients sit at one of eight stainless steel booths, and inject themselves. Staff are not legally able to inject a client, but their role as clinicians trained in harm reduction is to reduce the risks associated with that injection. This may involve talking to someone about where and how they inject, encouraging them to wash their hands and use swabs, ensuring they don’t share any equipment, and other techniques aimed at ensuring they understand the risks of blood-borne virus transmission.
• Stage three: After the injection, clients safely dispose of their used equipment, and move to a more relaxed space in the next room. Drawing on the therapeutic relationship they build, staff and clients have discussions about health and wellbeing, what to do in the event of an overdose (eg, the recovery position and rescue breathing), and how to access other services, including mental health treatment, dental services, hepatitis C treatment, wound care, relapse prevention, counselling and referral to specialised treatment.
For now the closest contemporary Britain comes to having safer injecting centres are the few clinics where patients inject legally prescribed pharmaceutical heroin (diamorphine) under clinical supervision. These clinics are unlikely to engage the target group of drug consumption rooms, but nonetheless provide a service to people who have not benefitted from more conventional treatment. Furthermore, it could be argued, they provide an experience- and skills-base for drug consumption rooms in the UK as they have to exercise the same monitoring of patients and have the same capacity to respond to overdose incidents as drug consumption rooms.
Determining whether they produce sufficient benefits (with no countervailing problems)
Evidence of the need for and impact of drug consumption rooms tends to be divided into “public harms which affect communities, such as discarded syringes in public parks and toilets”, and “private harms which affect individuals, such as overdose death and blood-borne viruses”. The extent to which each is used to justify the introduction of drug consumption rooms differs from country to country. For example, overdose deaths were a key driving force in Norway, Spain, Canada and Switzerland, while public disorder and local concerns about drugtaking in public places were important in Canada, pivotal in the Netherlands, and have been raised in towns and cities around the UK, such as Neath Port Talbot, Brighton and Hove, and Manchester, though Britain is yet to see a single drug consumption room.
Outcomes from the first drug consumption rooms were “relatively inaccessible to the international research community” until 2003/2004, at which time Professor John Strang, a leading figure in British substance use practice and policy, cautioned that “claims” of harm reduction from drug consumption rooms would need to be more robustly tested. Although the evidence base has grown considerably since then, it remains difficult to evaluate the rooms’ impacts in ways that meets the scientific ‘gold standard’.
Randomised controlled trials feature at the top of “traditional evidence hierarchies”. They involve researchers randomly allocating participants to two or more groups – an intervention versus an alternative intervention, a ‘dummy’ intervention, or no intervention at all. The following extract explains the logic behind randomised controlled trials, and hence why they prove to be so desirable:
“When a new treatment is administered to a patient and an improvement in her condition is observed, the possibility of drawing a conclusion from the fact is hindered by the absence of a counterfactual: possibly the patient would have recovered anyways if left untreated, or maybe a different treatment would have been more effective. In [a randomised controlled trial], participants are divided into two groups, one that receives the experimental treatment and another that acts like a control, providing the answer to the ‘what if’ counterfactual question. For the concept to work as intended, though, the administration of the experimental treatment should be the sole difference between the experimental and the control group.”
As drug consumption rooms tend to emerge from local initiatives aimed at reducing the harms of public drug consumption, they are not designed or implemented with the random allocation of people in mind. Instead, researchers undertake evaluations in ‘real world’ circumstances, for example comparing changes in outcomes in a neighbourhood that opened a drug consumption rooms versus a comparison area that did not. The limitation of this approach is that the effects of drug consumption rooms are obscured by complex sets of factors not under a researcher’s control. In Sydney, for instance, calculating lives saved by harm reduction measures has been complicated by “dramatic changes in the availability of heroin”. What was colloquially referred to as the ‘Australian heroin drought’ affected the amount of heroin being used, and probably resulted in a reduction in associated problems such as heroin-related overdose.
Expecting evidence for drug consumption to rooms come from randomised controlled trials also raises ethical issues. Drug consumption rooms provide a range of services, some of which are unique to this intervention. If one group of people who inject drugs were randomly allocated to drug consumption rooms, that would mean another group of people who inject drugs would be denied access. If the study was recruiting participants from the target group of drug consumption rooms – a particularly vulnerable and marginalised cohort of people who typically have nowhere else to go, and for complex reasons are unable or unwilling to engage with treatment for their drug dependence, or are in treatment but still using illicit drugs – participants without access to a drug consumption room would likely continue to inject in public places with the extremely high levels of risk this carries.
ASSESSING IMPACT
Europe’s monitoring centre on drugs described (1) improving survival and (2) increasing social integration as the overarching aims of drug consumption rooms. Indicators that these aims are being achieved include:
✔ establishing contact with hard-to-reach populations;
✔ identifying and referring clients needing medical care;
✔ reducing immediate risks related to drug consumption;
✔ reducing morbidity and mortality;
✔ stabilising and promoting clients’ health;
✔ reducing public disorder;
✔ increasing client awareness of treatment options and promoting clients’ service access;
✔ increasing chances that client will accept a referral to treatment.
Even without a randomised trial, it is possible to at least estimate the likelihood that an intervention (in this case, a drug consumption room) is having a positive or negative impact. For example, it may not be possible to determine impact on the transmission of infectious diseases, but it is possible to observe impacts on self-reported needle and syringe sharing, the key cause of transmission among people who use drugs. Furthermore, there are other high-quality research methods that instill confidence in the results, including ‘natural experiments’ that compare changes in outcomes in neighbourhoods where a drug consumption room had opened to control areas where they had not, and simulation studies that estimate the costs and benefits of existing drug consumption rooms at reducing disease transmission and overdose.
As the Joseph Rowntree Foundation’s Independent Working Group on Drug Consumption Rooms put it, “the methodological problems involved here should not detract from [drug consumption rooms’] considerable success” and their mechanisms for improving the health and wellbeing of their clients – ensuring hygienic and (relatively) safe injecting in the facility, providing personalised advice and information on safe injecting practices, recognising and responding to emergencies, and providing access to a range of other on-site and off-site interventions and support. Below we look at some of the outcomes and mechanisms for achieving those outcomes referred to by the Joseph Rowntree group.
Forging therapeutic relationships
Drug consumption rooms are aimed at “limited and well-defined groups of problem drug users” – typically, people who inject on the streets, who are not in treatment, and who are characterised by extreme vulnerability to harm, for example due to social exclusion, poor health and homelessness. The temperament and attitude of staff, as well as the ‘house style’, are critical to whether drug consumption rooms can engage with their target client groups – for example, the extent to which they encourage rather than deter potential clients, and are sympathetic and non-judgemental towards people with multiple problems who may be ostracised in other spaces.
In Danish drug consumption rooms, staff strive to be welcoming, and have prioritised forging relations with people who use drugs. The effect is that both clients and staff see the facilities as providing a ‘safe haven’ – one in which acceptance can clear the path for prevention, treatment and support. This view of drug consumption rooms as ‘sanctuaries’ and ‘spaces of healing’ was shared by a colleague in Victoria (Australia):
“An injecting centre provides the setting and the possibility for a new type of connection with our clients. The power of suspending judgement for those who are the most judged and vilified in our society can be transformative.”
For highly marginalised people who use drugs in particular, drug consumption rooms can be the first step into the health and social care system. Though they do not guarantee that clients access treatment – making use of the drug consumption room conditional on accepting treatment would undermine the ethos of harm reduction – they do remove some of the traditional barriers to treatment, which can ultimately make treatment a more realistic prospect. To support this suggestion, reviews have consistently found that drug consumption rooms are associated with an increase in the uptake of treatment including opioid substitution therapy and supervised withdrawal (1 2).
Though little is known about the potential of co-locating drug consumption rooms with services for supervised withdrawal, findings from the Insite facility in Vancouver (Canada) suggest that drug consumption rooms may be a useful point of access to “detoxification services” for high-risk people who inject drugs. Between 2010 and 2012, 11% of people injecting drugs who used the safer injecting facility (147 of 1316 total) reported enrolling in withdrawal programmes at least once. This was more likely among people residing near the consumption room, frequently attending the consumption room, and among people who reported enrolling in methadone maintenance therapy, injecting in public, injecting frequently, and recently overdosing.
Reducing public injecting
How much drug consumption rooms can significantly reduce public drug use depends on their accessibility, opening hours, and capacity. Understanding the characteristics of drugtaking among local people is essential for providing sufficient capacity to meet demand, remain accessible, encourage regular use, and achieve adequate coverage of the injecting population. For example, facilities focusing on or seeking to explicitly include sex workers may need to remain open in the evening and at night.
A 2014 survey by the International Network of Drug Consumption Rooms found that (among participating organisations) drug consumption rooms across Europe were open for an average of eight hours a day. Despite 20 of the 34 also opening on weekends, this left large periods of time when clients who would otherwise use the facilities had to inject elsewhere. In Hamburg, over a third of people surveyed who attended drug consumption rooms had also used drugs in public during the past 24 hours, citing among their main reasons waiting times at injecting rooms, distance from place of drug purchase, and limited opening hours.
Germany has the strictest admission criteria in Europe, which includes excluding people in opioid substitution treatment. In an unnamed consumption room, potential clients were denied access on 544 occasions because they were:
• not residing in the vicinity of the drug consumption room (250);
• drunk or intoxicated (150 times);
• in opioid substitution treatment (109);
• first-time or occasional users (four);
• under 18 years of age without permission from their parents (two).
Even when admission criteria are strongly justified – for example, on the basis that they protect clients and staff, and enable staff to run a safe facility – they do leave a proportion of people who, without access to a drug consumption room, may continue to inject in public. For reasons outside of admission criteria, studies of existing facilities suggest that drug consumption rooms may not yet be accessible to all groups at risk from public injecting, especially pregnant women and those who cannot self-inject, or people whose patterns of drug use mean that they need 24-hour access, for instance people primarily using cocaine who might “go without sleep for days on end”.
Litter and public disorder
The chief political defence for drug consumption rooms is to mitigate the public nuisance, disorder and crime associated with public injecting. Consequently they are usually sited where concentrated public drug use and discarded paraphernalia ‘spoil’ the environment, and hamper or undermine regeneration. Service user Nick Goldstein, whose article “The Right Fix?” was published in the November 2018 edition of Drink and Drugs News, and who was admittedly not enamoured of drug consumption rooms as an approach, stressed the imbalance inherent in this:
“I must admit that one of my pet peeves is that drug treatment is rarely designed for the primary purpose of helping drug users. Instead it tends to be designed to protect wider society from drug users by reducing crime, reducing the spread of [blood-borne viruses] in society and even by attempting to make drug users more economically productive.”
“At my most cynical I feel there’s something disturbing about an approach that can easily be seen as saying ‘come in for half an hour, have a shot so you don’t scare the public and then fuck off back to your cardboard box’.”
This is an understandable criticism considering that the more vulnerable and desperate people become, the more ostracised and stigmatised they tend to be in our communities. However, it could be argued that ‘moving injecting drug use off the streets’ directly serves vulnerable people who use drugs in two key ways: (1) it recognises the dignity of homeless people by considering the impact of discarded paraphernalia and public injecting drug use on them too, including homeless people who might be forced to inject drugs where they live; and (2) gives an opportunity to build the political profile of this considerably underrepresented population by bringing people together under one roof.
Compelling evidence about the impact of drug consumption rooms on litter and public disorder comes from Vancouver (Canada), where acceptance of the facility among residents and workers had been generated by the distressing sight of public injecting and injecting-related litter, and despite a large local needle exchange, risky injecting, disease and overdose deaths had remained high. After the facility opened there was a significant reduction in people seen injecting in public places from a daily average of 4.3 to 2.4. Also roughly halved were discarded syringes and injecting-related litter in the surrounding area. In Barcelona a fourfold reduction was reported in the number of unsafely disposed syringes being collected in the vicinity of safer injecting facilities from a monthly average of over 13,000 in 2004 before they opened to around 3,000 in 2012 after they opened (source paper in Spanish).
Injecting- and drug-related harm
In Vancouver alone, 88% of drug consumption room clients were found to have hepatitis C, and up to a third had HIV. This baseline level of harm exemplified the need for drug consumption rooms to function not only as a means of preventing harm among clients themselves – and facilitating access to treatment for blood-borne viruses and infections – but preventing harm being transmitted to others (eg, by sharing contaminated needles and syringes).
Regular use of drug consumption rooms has been linked to the use of sterile injecting equipment, and in particular a self-reported decrease in syringe sharing and re-use of syringes. Furthermore, although studies generally focus on harm reduction outcomes inside facilities, reductions have been seen outside drug consumption rooms in clients’ risk-taking behaviour, and it seems likely that ‘safer use’ messages could be transmitted to a wider population of people who use drugs via consumption room attendees.
While reducing risky behaviours such as syringe sharing could be expected to reduce risk of HIV and hepatitis C, the impact of drug consumption rooms on this is not directly observable. Drug consumption rooms have limited coverage and tend to go hand-in-hand with other services, and therefore it would be difficult to isolate their effect.
A point that is becoming increasingly salient as governments pay attention to new psychoactive substances is the potential for frontline staff in drug consumption rooms to “play [a role] in the early identification of new and emerging trends among the high-risk populations using their services”. In the UK, the national response to new psychoactive substances has been focused on legislation (the Psychoactive Substances Act 2016) and its effectiveness, while relatively little consideration has been given to developing a treatment response. Research undertaken in Manchester (England) between January and June 2016 uncovered two changes – the first of which may have consequences for traditional drug consumption room clients, and both of which represent new challenges for harm reduction services: (1) a shift away from heroin and crack cocaine among homeless people to spice; and (2) a change in the ingestion route of drugs within the emergent chemsex scene among men who have sex with men from the conventional recreational use of substances such as ecstasy and cocaine (1 2) to intravenous injection of crystal methamphetamine or mephedrone.
Mortality
While drug consumption rooms do provide safer spaces for injecting, “dangerous situations that require intervention arise frequently … (as they do in any drug-injecting context)”; the difference is the capacity to respond to these emergencies and prevent them progressing to serious harm or death:
“The aim of an injecting centre is to physically accommodate the injection of drugs that would normally occur somewhere inherently more dangerous, and often public.”
Because there is no quality control for illicitly sourced drugs, part of the harm comes from simply not knowing what may or may not be in the mixture, so staff are always on the look-out for unexpected reactions.
Essay on overdose deaths in the UK
The main cause of opioid-related deaths is respiratory failure, caused by opiate-type drugs switching off the part of the brain that reminds you to breathe. If no one intervenes in the event of this type of overdose, oxygen will be depleted and eventually the heart will stop, causing death. Staff can prevent overdoses becoming fatal by: protecting a person’s airway; providing supplemental oxygen; providing resuscitation (artificially breathing for the person using a bag/valve/mask); and administering the opiate overdose antidote naloxone.
Staff in two facilities in Hamburg (Germany) estimated that nearly three quarters of emergencies were related to heroin use. More difficult to manage, they suggested, were cocaine-related emergencies characterised by increased anxiety, psychotic states, or epileptic seizures. Whereas the response to opioids was driven by the need to aid breathing, interventions after problematic cocaine use generally involved calming and protecting the person who had used drugs.
Only one death has been documented in a drug consumption room since the first opened in 1986, and this was not linked to the drug consumption room itself; in 2002, a person who used drugs died from anaphylaxis (an acute allergic reaction) in a German facility (1 2). While ‘nobody has died from an overdose inside a drug consumption room’ serves as a strong argument for them having a positive effect, this in itself is not a principal and necessary measure of success, but rather a comment or observation on the history of drug consumption rooms to date.
Conservative estimates of lives saved by drug consumption rooms include the prevention of four fatal overdoses per year in Sydney (Australia), and ten deaths per year in Germany. In Vancouver (Canada), there was a 35% decrease in fatal overdoses, and an estimated two to 12 fatal overdoses were prevented each year.
Costs and benefits
Costs for supervising drug use (the most distinctive function of drug consumption rooms) have been estimated at roughly the same in Vancouver and Sydney – the equivalent in Canadian currency of C$7.50–C$10 per injection. This would bring the cost of supervising all injections for someone who injects twice a day to about C$5,500–C$7,300 per year, which is in the same ballpark as the cost of providing methadone for a year to a patient in the United States.
Focusing almost exclusively on Vancouver, simulation studies have found that the value of averting a fatal overdose or HIV infection is so high that drug consumption rooms can pass the cost–benefit test even if the number of people affected is small (1 2). However, many other interventions also pass that test, including medication-assisted treatment, needle and syringe exchanges and naloxone, raising the question of how best to distribute scarce financial resources across such interventions.
It is unclear whether greater benefit would be achieved by investing the same amount of resources in interventions other than drug consumption rooms due to a lack of evidence about the magnitude of population-level benefits – firstly, because the literature can blur the lines between the impact of a drug consumption room’s entire suite of interventions and its supervision of consumption, and secondly, because supervised consumption can have spillover effects on behaviour outside drug consumption rooms as well as within the four walls.
Though other interventions may serve some of the functions of drug consumption rooms, they may not all be equally accessible to the target group of drug consumption rooms. For example, some would seem to be appointment-based rather than, as with drug consumption rooms, attended on a drop-in basis. Therefore, while it is understandable to question whether greater benefit would be achieved by investing the same amount of resources in interventions other than drug consumption rooms, this excludes the more fundamental argument about why drug consumption rooms should be considered in addition to existing interventions.
Adverse effects
‘Honeypot effect’ applies to bees, not consumption rooms
The published literature is large and almost unanimous in its support for drug consumption rooms, and there is little to no basis for concern about drug consumption rooms producing adverse effects. However, fears of adverse effects persist.
One of the concerns about drug consumption rooms is that they will aggravate public disorder and crime in surrounding local areas by attracting people who use drugs and dealers from elsewhere – termed the ‘honeypot effect’. While if this did happen it would also presumably extend the benefits of drug consumption rooms to non-local people who use drugs, neither the adverse nor the beneficial results of the honeypot effect have materialised in practice; where used, the term is alluding to a ‘phenomenon’ based in fear (or fear-mongering) rather than fact.
The European Union’s drug misuse monitoring centre found no evidence that drug consumption rooms result in higher rates of drug-related crimes in the vicinity (eg, trafficking, assaults, robbery). Most consumption room users live locally, and typically reflect the profiles of people buying drugs in local markets, and for this reason, facilities located any distance from drug markets tend to attract very few users. Explaining why, people who use drugs and gave evidence to the Joseph Rowntree Foundation’s Independent Working Group pointed out that:
“…An addicted injecting heroin user is likely to be primarily driven by the need to obtain their drugs. If they have the money, their first port of call will be a dealer. If there is somewhere nearby where they can safely use their drug (and obtain a clean syringe), then this is likely to be their next step. If they need to go any distance to reach such a place, their need to inject their drug is likely to lead to them using somewhere else (often a public area nearby).”
Although, on balance, research suggests that drug consumption rooms make drug use safer (eg, increasing access to health and social services, identifying and responding to emergencies, and reducing public drug use), and that fears (eg, encouraging drug use, delaying treatment entry, or aggravating problems arising from local drug markets) are not grounded in evidence (1 2 3), policy is not informed by evidence alone.
Evidence ‘just one ingredient in the policymaking process’
Drug consumption rooms have been seriously considered in the UK on several occasions since the turn of the millennium, but have arguably never been a realistic prospect because of government opposition. Though each time there has been genuine concern about harms associated with injecting drug use, followed with a review to understand the effectiveness of drug consumption rooms in mitigating these harms, ultimately the evidence base did little to convince decision-makers.
In 2002, a Home Affairs Select Committee on drugs policy recommended that drug consumption rooms be piloted in the UK:
“We recommend that an evaluated pilot programme of safe injecting houses for heroin users is established without delay and that if, as we expect, this is successful, the programme is extended across the country.”
However, the ‘New Labour’ government rejected this recommendation, arguing that the evidence appraised by the committee was insufficient to justify implementation, despite the pilot programme being proposed at least in part to generate evidence specific to the UK.
Looking at the wider context, it seems the political conditions were “not ripe for drug consumption rooms”. Concerns which likely had a prohibitive effect on the policy included (1 2):
• the potential for public confusion between drug consumption rooms and existing supervised heroin prescribing pilots;
• the potential for drug consumption rooms to be perceived as inconsistent with the government’s commitment to being “tough on crime, tough on the causes of crime”;
• the potential for the government to be accused by the media and others of opening ‘drug dens’;
• being open to legal challenges.
For this government, their future electoral success largely depended on being (and appearing to voters as) “tough on crime”, and drug consumption rooms risked appearing to condone the use of illegally bought drugs. ‘Heroin prescribing’, on the other hand, was a policy that New Labour was amenable to; the UK Government agreed to expanding diamorphine prescribing, approving a trial of three heroin prescription maintenance clinics in London, Brighton, and Darlington between 2005 and 2007. Unlike drug consumption rooms, this could be framed as ‘tough on crime’ – obviating the need for patients to commit acquisitive crimes to fund dependent heroin use.
Two years later, the British Medical Journal published a paper arguing that “the case for piloting supervised injecting centres in the United Kingdom [was] strong”, and that its rejection should be overturned. Diamorphine prescribing was an important tool in the box, the authors acknowledged, but would appeal to, and benefit, different groups to drug consumption rooms – the former, long-term heroin addicts who have not responded to traditional treatment, and the latter, people who are socially excluded and homeless:
“…Neither is a panacea…holistic provision should include both”.
The next time drug consumption rooms came under review in the UK was in 2006 by the Independent Working Group on Drug Consumption Rooms, made up of senior police officers, senior academics, a GP consultant, and a barrister specialising in drug offences. The group found that while there were “high levels of injecting drug use in particular areas of the UK, these did not appear to be associated with the sort of extensive public injecting that had been instrumental in the setting up of some of the European [drug consumption rooms]”. Although this did not deter them from making a strong recommendation in favour of piloting drug consumption rooms, their comment revealed that without these large open drug scenes associated with serious health and public order problems, the case for drug consumption rooms might appear weaker to politicians and the wider public. Nevertheless, their conclusion was:
“The [Independent Working Group] considers [drug consumption rooms] to be a rational and overdue extension to the harm reduction policy that has produced substantial individual and public benefits in the UK. They offer a unique and promising way to work with the most problematic users, in order to reduce the risk of overdose, improve their health and lessen the damage and costs to society.”
The political response to the Independent Working Group report was warm. However, the proposition was once again rejected.
Moving away from the national stage, cities have often taken the lead in continental Europe, and in Britain too they have not simply accepted the central government’s position. An important case study in this respect is Brighton, which had an unenviable reputation for one of the nation’s highest rates of drug-related mortality. Prompted by a call from Brighton’s Green Party MP, an Independent Drugs Commission was set up in Brighton in 2012. The following year the commission agreed that “where it is not possible to stop users from taking risks, it is better that they have access to safe, clean premises, rather than administer drugs on the streets or in residential settings”. Brighton’s Safe in the City Partnership should, they recommended, consider the feasibility of incorporating “consumption rooms into the existing range of drug treatment services in the city,” focusing on ‘hard-to-reach’ groups and those not engaged in treatment. These points were key: drug consumption rooms were to be deliberated as part of a larger framework of services; and drug consumption rooms were to be focused on a particularly vulnerable and marginalised cohort, as opposed to all injecting people who use drugs.
The feasibility study was undertaken, but in 2014 the commission’s final report concluded “that a consumption room was not a priority for Brighton and Hove at this time – the working group was convinced by the international evidence on the potential benefit from these facilities, but thought that they would have little impact on the types of factors that were contributing to deaths in the city”. Perhaps more importantly, “members of the working group were…concerned at the cost implications, in a time of budget pressure, and also advice from the Home Office that opening such facilities would contravene UK law”.
Drink and Drugs News article on what would persuade a city to accept a drug consumption room
A month later in June 2014, the feasibility working group explained that there was insufficient support at the time to consider drug consumption rooms; both the Association of Chief Police Officers and Sussex Police were opposed, as were other organisations. Resistance was partially attributed to a “shift in focus for substance misuse services from harm reduction to recovery [which placed…] a greater emphasis on abstinence”. It was unclear whether as a group stakeholders were aligned with the values of abstinence-based recovery, or whether the policy and funding climate was forcing their hand. However, Brighton’s local paper The Argus reported that weeks after the feasibility study was launched, several stakeholders spoke out against drug consumption rooms, revealing a less than open mind in advance of the enquiry being concluded. This included Andy Winter, chief executive of Brighton Housing Trust, who said he wanted to see “something far more positive [done] with addiction and recovery”. Frustrated at what he considered a ‘distraction’ from recovery, treatment and abstinence, he resolved to “oppose any further waste of public funds, time and effort on exploring [their] feasibility”. With members like this on the group, whose minds were made up from the beginning, it would have been a surprise if drug consumption rooms were deemed feasible in Brighton.
In 2016, the Advisory Council for the Misuse of Drugs recommended that “consideration be given – by the governments of each UK country and by local commissioners of drug treatment services – to the potential to reduce [drug-related deaths] and other harms through the provision of medically-supervised drug consumption clinics in localities with a high concentration of injecting drug use”. However, a 2017 letter from the Home Office to the advisory council clarified that the government would not change its position on drug consumption rooms. The following year the government restated its position in public (1 2):
“We have no intention of introducing drug consumption rooms, nor do we have any intention of devolving the United Kingdom policy on drug classification and the way in which we deal with prohibited drugs to Scotland” (Home Office Minister Victoria Atkins, January 2018, House of Commons debate on drug consumption rooms).
“There is no legal framework for the provision of drug consumption facilities in the UK and we have no plans to introduce them” (Prime Minister Theresa May, July 2018, Prime Minister’s Questions).
In 2017, an advisory panel on substance misuse in Wales pledged to address the feasibility of establishing “enhanced harm reduction centres” – the term preferred by service providers to “reflect a desire to consider much more than simply providing a safe, clean place for individuals to inject but to expand the services on offer to include other harm reduction interventions (such as advice, wound care, blood borne virus testing, sexual health provision and links with wraparound services such as housing)”. Reminiscent of other ‘serious considerations’, the panel concluded just under a year later that, “based on the current available evidence”, it could not recommend the implementation of drug consumption rooms:
“In summary, there is evidence to suggest that [drug consumption rooms] are effective in decreasing drug-related mortality and morbidity […and, drug consumption rooms] should therefore be considered a successful tool as part of broader harm reduction interventions and strategies.”
“However…uncertainty about the generalisability of available research to the Welsh context must be taken into account in any consideration.”
Leaving the door ajar, the panel suggested a feasibility study “to inform decisions about possible implementation”, including what outcomes such facilities would seek to achieve, how these could be measured, operating procedures, and the inward and outward referral pathways.
‘Lack of evidence’ has repeatedly been cited as a barrier to implementing drug consumption rooms, despite reviews of the international evidence indicating that drug consumption rooms more likely than not remove harm (and do not cause harm), and despite the fact that pilot drug consumption rooms have been recommended in Britain at least in part to generate evidence of their viability and effectiveness in the domestic context. For cities like Glasgow in the midst of a crisis, calls for more rigorous research with no clearly defined end in sight is difficult to comprehend – “no reasonable person would wait for a randomized control trial evaluating parachutes before donning one when leaping from a plane”. The satirical paper published in the British Medical Journal that inspired this quote highlighted the absurdity of claiming that only randomised controlled trials will suffice in every scenario. As for resolving “whether parachutes are effective in preventing major trauma related to gravitational challenge”, the authors suggested two options for moving forward:
“The first is that we accept that, under exceptional circumstances, common sense might be applied when considering the potential risks and benefits of interventions. The second is that we continue our quest for the holy grail of exclusively evidence based interventions and preclude parachute use outside the context of a properly conducted trial.”
Growing acceptance of safer injecting facilities and increasing concern about overdoses in Canada prompted a rapid escalation in efforts to establish consumption rooms in various cities. However, for a long time only one facility existed, and this remained in “perpetual pilot status for over a decade”. For Canada, political opposition to drug consumption rooms was the most significant barrier to expansion. The shift came in October 2015 with the election of a new government, which had expressed support for safer injecting facilities. Between 2016 and 2018 the country went from having two facilities to 26.
Through successive political parties, the UK Government has remained opposed to drug consumption rooms. Recent statements (
view above) exemplify unwavering commitment to the prohibition of drugs, which drug consumption rooms are perceived to contradict or undermine.
The ‘legal hurdles’
The message that has filtered down from government is that drug consumption rooms are incompatible with UK law. In Brighton, one of the reasons that stakeholders were collectively unwilling to recommend trialling drug consumption rooms was “advice from the Home Office that opening such facilities would contravene UK law”. However, that is not the end to the story. Though there may be some legal barriers, they could be easily overcome if the political will were there.
In 2016, plans to open a consumption room in Scotland were reported to be ‘pressing forward’, with advocates awaiting approval from James Wolffe QC, Scotland’s chief legal officer, in order to ensure compliance with the law. However, his legal opinion put the brakes on their perceived momentum (1 2). While the Lord Advocate had the power to instruct police not to refer people caught with illegal drugs for criminal proceedings, he said he could not remove the designation of those acts as illegal. In 2017, the Lord Advocate ruled that a change to the Misuse of Drugs Act 1971 would be necessary before drug consumption rooms could be introduced. Speaking to the Scottish Affairs Committee in 2019, he said:
“The introduction of such a facility would require a legislative framework that would allow for a democratically accountable consideration of the policy issues that arise and would establish an appropriate legal regime for its operation.”
To this end, the Supervised Drug Consumption Facilities Bill 2017–19 was introduced to the House of Commons in March 2018, containing provisions to make it lawful to take controlled substances within supervised consumption facilities. This included amendments to the Misuse of Drugs Act 1971, which would protect anyone employed within or using the drug consumption facilities.
The following year, a cross-party group of , , , , , and politicians wrote a letter to The Telegraph urging the government to reconsider its “failing” approach to illicit drug use:
“These rooms have proved successful in many countries, including Germany, Canada and Australia. As it stands, they sit in a legal grey zone. It’s time for Britain to catch up with the rest of the world by providing a clear legal framework to trial drug consumption rooms in areas with high levels of drug-related harm.”
Clarifying the law, Release, the national centre of expertise on drugs law, has said that the Misuse of Drugs Act 1971 does not in fact make it illegal to allow someone to possess or inject controlled drugs on your premises, but does make it illegal to allow their production or supply or the smoking of cannabis and opium, which would suggest that a carefully managed facility could operate within the law despite its clients breaking laws prohibiting possession of controlled drugs – though this may not relieve concerns among professionals such as nurses and doctors about their liability in the event of a serious issue and the coverage of their medical insurance.
Asking the police to turn a ‘blind eye’ to illicit drugs may seem like it is asking them not to fulfil one of their key obligations – enforcing the law. However, this is not their only role; the police also have a responsibility for maintaining public order and public safety. Indeed, there are already examples of criminal justice objectives being compromised or reconsidered at the discretion of police forces for the ‘greater good’ – including to facilitate treatment and harm reduction, and better utilise limited resources – which could translate to drug consumption rooms if the political, institutional, and social will was there. Recent comparable examples include the following:
• Thames Valley Police are trialling an approach whereby police will urge people found with small quantities of controlled drugs to engage with support services, rather than arresting them. Dismissing allegations of being ‘soft on crime’, Assistant Chief Constable Jason Hogg said there is “nothing soft about trying to save lives”.
• Drug safety testing services have been piloted at a UK festival with the support of local police, who agreed to ‘tolerance zones’ where they would not search or prosecute for possession in order for members of the public to be able to bring drugs for testing and receive results as part of an individually tailored brief intervention.
Police and Crime Commissioners, who would be essential to build the local support for drug consumption rooms, have been prominent among those lobbying for the facilities. Several key figures have used their unique positions to advocate for a compassionate and pragmatic harm reduction-based approach to drugs, which they say should include drug consumption rooms. At least four have publicly come forward – Ron Hogg (Durham), Arfon Jones (North Wales), David Jamieson (West Midlands), and Martyn Underhill (Dorset) – and seven in total signed a letter to the Home Secretary, Sajid Javid MP, which called on him to end the government’s ‘policy’ of blocking the implementation of drug consumption rooms.
As part of its remit, the Independent Working Group on Drug Consumption Rooms commissioned an analysis by a leading expert on UK drugs law, Rudi Fortson. While he concluded that some adjustments of the law might further shield rooms from legal challenge, the group was “not persuaded that this would be a necessary and unavoidable first step. Pilot [drug consumption rooms] could be set up with clear and stringent rules and procedures that were shared with – and agreed by – the local police (and crime and disorder partnerships), the Crown Prosecution Service (CPS), the Strategic Health Authority and the local authority.” Despite this information being added to the public discourse, ambiguity over the legal footing of drug consumption rooms has prevailed.
Rudi Fortson has also investigated how facilities in Canada (see Effectiveness Bank analysis of the Insite project) and Australia operate, providing a glimpse into the workings of drug consumption rooms in countries with legal systems similar to that of the UK. For more click here.
In terms of international law, signatories to the United Nations’ international drug control conventions (including the UK, Australia and Canada) have another issue to consider: whether drug consumption rooms violate their obligations under those conventions. Charged with policing adherence to the conventions is the International Narcotics Control Board. From in 1999 an extreme condemnation claiming the rooms breach the conventions because they “facilitate illicit drug trafficking”, by 2015 the board seemed to admit that if a facility “provides for the active referral of [persons suffering from drug dependence] to treatment services”, they might be admitted within the spirit and letter of the conventions. For more click here.
For Rudi Fortson the thousands of words on whether drug consumption rooms contravene UN conventions had missed the wood for the trees. He observed that there has been a tendency to focus on the parts that impose restrictions and prohibitions, yet “conventions often embody statements of political will, intent, or hope”, and in this case prohibition was intended to be at the service of promoting public health and wellbeing, not its opposite. Moreover, none of the three main UN conventions have direct application in the UK; they are interpreted into UK law by parliament, and it is those interpretations on which the courts rely in their judgements.
When countries view drinking and illicit drug use through the lens of public health, laws often follow that prioritise the safety and wellbeing of people who use drugs and those around them, instead of prioritising the inviolability of prohibition. For instance, so-called ‘Good Samaritan laws’ have been enacted in the context of overdose-related deaths in Canada and various states in the US. In Canada, the Good Samaritan Drug Overdose Act was introduced in 2017, providing legal protections (eg, from charges for possession of a controlled substance or breach of parole) for people who experience or witness an overdose and call the emergency services.
Acceptance is at the root of benefits and criticisms
Essay on harm reduction
Drug consumption rooms seek to minimise the harms of drugtaking for a cohort of people who, for complex reasons, are unable or unwilling to engage with treatment for their drug dependence, or are in treatment but still using illicit drugs.
What makes drug consumption rooms distinct from and more disruptive than other harm reduction approaches such as needle exchanges, is that they employ staff who bear witness to illicit drug use, as opposed to staff who advise and provide resources but are ultimately absent for the act of drugtaking. This enables the dissemination of specific (rather than generic) harm reduction advice based on direct observation of “consumption patterns, risky dosages and improper handling of equipment”:
“In order to successfully promote harm reduction topics, staff expressed that safer-use messages must be related to drug use practice, connected to daily life experiences and be given in one-on-one conversations.”
It also enables people who inject drugs to be fully seen and accepted – even and especially while engaging in behaviour that is typically shrouded with so much stigma and shame.
“…There’s no doubt that for the drug users this is a really, really good step in the right direction. Before they used to shoot up outside in the cold, in staircases, or in playgrounds using water from puddles. They shared syringes and they lived miserable lives. For many years they have been crying out: ‘…Maybe I cannot help using drugs but give me a decent life and some dignity’…It has been horrible for them. So I think that it means a lot to get off the streets, and to not be looked down on by other people.” (Nurse, Danish drug consumption room)
What drug consumption rooms set out to achieve is to “fundamentally reconfigure…each event of drug use”, producing “pleasurable and positive modes of engagement” that can improve survival and increase social integration.
However, the features above are not universally viewed as strengths; critics have persistently positioned drug consumption rooms as legitimising drug use, and therefore doing rather than alleviating harm. Speaking out against proposed consumption room pilots in Brighton in 2013, Kathy Gyngell from the right-wing Centre for Policy Studies questioned the premise of a ‘safe space’ for injecting altogether, saying that drug consumption rooms are “described as safe despite the very unsafe street drugs used in them, and despite the intrinsic risk of addicts continuing to inject drugs at all”. In 2016 a pilot drug consumption room opened in Paris near a busy central station where drug crime is common. For France’s health minister it was “a very important moment in the battle against the blight of addiction”, but for a politician from the centre-right opposition, the country was “moving from a policy of risk reduction to a policy of making drugs an everyday, legitimate thing. The state is saying ‘You can’t take drugs, but we’ll help you to do so anyway’” – wildly differing perspectives on the same facility.
Though the loudest voices may be people totally in favour of, or totally against, harm reduction services, many people sit somewhere in the middle – perhaps accepting the need for needle exchanges, but instinctively opposed to drug consumption rooms, believing that they cross an ideological red line from reducing harm to facilitating drug use. It is in this space that misunderstandings and misrepresentations of drug consumption rooms can flourish.
Claims that drug consumption rooms ‘enable’ drug use are hard to shake, but fail at face value. The target group of drug consumption rooms do not need help or encouragement to take drugs; they need support to take drugs without preventable risks. If harm reduction measures aren’t in place, they will likely continue to take drugs, just in a riskier way. Introducing a Bill to the House of Commons which would make the necessary legal provisions for drug consumption rooms, Alison Thewliss MP said in March 2018:
“On Monday, one of my constituents mentioned to me that Glasgow already has drug consumption facilities: they are behind the bushes near his flat and in his close when it rains. Right now, they are also in bin shelters, on filthy waste ground and in lonely back lanes. They are in public toilets and in stolen spaces where intravenous drug users can grasp the tiniest modicum of dignity and privacy for as long as it takes to prepare and inject their fix. Often they are alone, and, far too regularly, drug users will die as a result. As a society, we can and must do much better than that.”
Drug consumption rooms recognise these realities and ‘meet people where they’re at’ – creating a bubble of acceptance of drugtaking within a broader context of criminalisation. With stigma and shame alleviated, and relationships forged with harm reduction professionals, this may open a door to treatment further down the line. However, it may also ‘just’ lead to safer injecting practices; it may ‘just’ lead to overdoses being prevented, lives being saved, health and wellbeing improved, and dignity and social connections restored.
If there is an ideological ‘green line’ over which people must cross to support drug consumption rooms, that line is agreement with the idea that where harms can be minimised or prevented, they should be – even if that means a degree of toleration of illegal drug use. One can still hold that position while believing that people’s lives would be improved if they stopped taking drugs, or even that illicit drugs have a deleterious impact on society overall. This perspective prioritises the current health, wellbeing and dignity of people, over judgements about their behaviour or wishes for their future selves.
Reframing drug consumption rooms and the people who use them
Drug consumption rooms go by many names, including overdose prevention centres, safer injecting facilities, enhanced harm reduction centres, medically supervised injecting centres, safe injecting sites, drug injection rooms, and drug fixing rooms. Each have different connotations. For example, ‘safer injecting facility’ refers narrowly to venues where people can more safely inject illicit drugs, though there are also consumption rooms where people can inhale or inject, depending on the landscape of harms in the locality. The term ‘enhanced harm reduction centres’ takes an expanded view of the harm reduction services and routes into treatment on offer, but could have the (unintended) consequence of minimising the importance of the supervised drug consumption element.
In academia and the news media, drug consumption rooms are often framed as a controversial prospect, highlighting how far they lean away from the status quo of prohibition and law enforcement. Sometimes articles use the word ‘controversial’, sometimes they imply it by listing concerns (even if unfounded or so far disproved by the evidence base) about drug consumption rooms, and sometimes articles achieve it through innuendo, for example referring to them as ‘shooting galleries’, which are illegal venues run for profit by drug dealers.
In the UK, this can have the effect of cementing (rather than merely reflecting) their political reality as ‘extreme’ and ‘unrealistic’ – perpetuating the thinking that current drug policy is the neutral position to take, and ignoring the fact that drug consumption rooms have become a “normalised harm reduction approach across Europe and other countries”. It also embeds a debate defined around the problem of implementing drug consumption rooms, rather than drug consumption rooms being a potential solution to the problem of public injecting.
“Words matter,” stressed commentators in North America in an article about the role of language in advancing or inhibiting evidence-based responses to the worldwide opioid crisis. Our choice of words can have an impact on how people who inject drugs are perceived, and the extent to which we advance solutions to drug-related harm based on a person’s “individual responsibility” versus wider situational, environmental, political and social factors such as inadequate distribution of naloxone, contaminated drug supply, social isolation, and lack of social support.
An analysis of how the UK news media represented proposals to introduce drug consumption rooms in Glasgow identified the use of derogatory language (such as ‘junkies’) to describe people who inject, and this was not confined to articles that opposed drug consumption rooms, but also present in articles that supported drug consumption rooms. Articles also tended to define individuals primarily by their drug use, reducing their humanity to a stigmatised behaviour, and doing nothing to contest the “morally charged” perception of individuals causing harm to themselves and wider society through their continued drug use.
The UK Government’s approach to illicit drugs is built on the pillars of prohibition and abstinence, which themselves rest on the belief that drugs are inherently harmful to people who use them, and to wider society. Therefore, any messages which contradict or soften the prioritisation of drug criminalisation and abstinence-based approaches are seen as undermining the ability of criminal justice and treatment systems to ‘protect’ people from harm.
While proponents of drug consumption rooms may be able to see drug consumption rooms as compatible with services based on both harm reduction and abstinence, opponents tend to position them as mutually exclusive – arguably because of what they represent, as well as what they do. Drug consumption rooms challenge the dominant interpretation of where harm (and subsequently blame) lies, showing how the environment in which drugs are consumed can decrease or increase, mitigate or compound, the harms people experience; in other words, drugs may produce harms (as well as benefits), but a fatal overdose or blood-borne virus need not be the price a person pays for taking drugs. Drug consumption rooms were specifically established to address the disproportionate level of harm that disadvantaged people who use drugs experience. They radically change the conditions in which people take drugs, and serve as a brick and mortar reminder of the structural inequalities that make it necessary to offer this alternative to public injecting.
“Current discussions about drug consumption rooms risk excluding, minimising, or erasing the current, specific, and urgent problem of public injecting”
Philosophical differences between “those calling for a change in UK drug policy to incorporate harm reduction, and those who attempt[…] to maintain status quo responses based on abstinence[,…] recovery” and prohibition account for a large part of the disagreement about drug consumption rooms. Though understandable, discussion framed around these higher-level philosophical differences may risk excluding, minimising, or erasing the current, specific, and urgent problem of public injecting.
One thing proposed which could help interested parties navigate their differences in “harmony” is a better appreciation for how and why someone’s professional and intellectual background informs their view of drug consumption rooms, and specifically their appraisal of the evidence base. Published in the Addiction journal (and analysed in the Effectiveness Bank), a paper by Caulkins and colleagues distinguishes between three types of decision-makers (the politician, the planner, and the pioneer), and three types of thinkers (the academic, the advocate, and the allocator of scarce resources), arguing that there is plenty of nuance between the commonly-heard extreme positions.
This nuance is helpful, particularly introducing concerns that may hold people back in a practical sense from endorsing drug consumption rooms. For instance, commissioners – people allocating already stretched resources – may support drug consumption rooms personally or politically, but also need to know on paper how drug consumption rooms fare against interventions already in place (or themselves needing expansion) such as naloxone and opioid substitute medications:
‘Would drug consumption rooms save more lives per dollar than other available alternatives?’
‘Would we need to disinvest in other services to pay for drug consumption rooms?’
What the paper did not do, was acknowledge the power dynamics between stakeholders, for example the way that politicians may act as or be perceived as gatekeepers or roadblocks to lifesaving interventions. It didn’t recognise that the status quo in countries like the UK, maintained by stakeholders including politicians, represents unwavering opposition to drug consumption rooms. Stakeholders may have different perspectives about these facilities, informed by their decision-making responsibilities and intellectual backgrounds, but how is the power to make decisions and influence public opinion distributed, and how close are the people in positions of power and influence to the day-to-day realities of the target groups of drug consumption rooms?
Time for safer injecting spaces in Britain?
In Scotland, record-breaking levels of drug-related deaths and an outbreak of HIV among people who inject drugs have been at the of discussions about the need to expand services for people with drug and alcohol problems – without which it is feared that substance use in the context of deprivation and homelessness will remain a threat to the life and quality of life of vulnerable people.
“…A public health and humanitarian crisis which must be addressed urgently”
Figures released by National Records of Scotland in July 2019 showed that drug-related deaths in Scotland had increased by 27% from 2017 to 2018. At 1,187 in 2018, Scotland was looking at the highest rate of drug-related deaths since records began in 1996 – three times that of the UK as a whole, and indeed higher than reported for any other EU country. In a press release for the National AIDS Trust, Director of Strategy Yusef Azad said: “The high rate of drug-related deaths constitutes a public health and humanitarian crisis which must be addressed urgently.”
In Glasgow city centre there were 47 new diagnoses of HIV among people who inject drugs in 2015, compared to an annual average of 10. This problem caught the attention of the European Monitoring Centre for Drugs and Drug Addiction, which reported 119 new cases of HIV in Glasgow between November 2014 and January 2018, specifically among homeless people who inject drugs. The agency described this as “the largest cluster of people who inject drugs infected with HIV…in the United Kingdom since the 1980s”. An important feature of this outbreak was its strong link to cocaine use, which surveillance data from needle and syringe programmes using dried blood testing and data from syringe residues in 2017 indicates is increasingly being injected (with or without heroin). Critically, harm reduction services (including the provision of injecting equipment and opioid substitution treatment) were available before and during the outbreak – needle and syringe programmes in Glasgow distribute over one million syringes per year – suggesting that circumstances had changed or were changing and required a different or intensified response.
In Taking away the chaos, the local health service and Glasgow’s drug service coordinating partnership reviewed the health and service needs of people who inject drugs in public places in the city centre. Resulting recommendations were to develop existing services, including extending assertive outreach services and developing a peer network for harm reduction, and to introduce new services, such as a pilot safer injecting facility in the city centre to “address the unacceptable burden of health and social harms caused by public injecting”. However, to date the Scottish Government has been constrained by legal judgements that drug consumption rooms would fall under the purview of the UK Government (and UK-wide Misuse of Drugs Act 1971).
The Scottish Government’s approach to drugs and alcohol reflects the belief that substance use problems are predominantly public health and human rights issues, which enables it to pursue policies that save and improve lives. This puts it at odds with the UK Government, which has been unwilling to depart from treating substance use as a issue. As with minimum unit pricing, Scotland has been nudging the UK position on drug consumption rooms, referring in a 2018 strategy to the Scottish Government’s efforts to “press the UK Government to make the necessary changes in the law, or if they are not willing to do so, to devolve the powers in this area so that the Scottish Parliament has an opportunity to implement this life-saving strategy in full.” Not letting this be a footnote in the strategy, the Minister for Public Health, Sport and Wellbeing Joe FitzPatrick used drug consumption rooms in his opening remarks (see page 3) as an example of “supporting responses which may initially seem controversial or unpopular”:
“Adopting a public health approach also requires us all to think about how best to prevent harm, which takes us beyond just health services. This, requires links into other policy areas including housing, education and justice. It also means supporting responses which may initially seem controversial or unpopular, such as the introduction of supervised drug consumption facilities, but which are driven by a clear evidence base.”
If there was an evidentiary threshold for trialling drug consumption rooms in the UK, the Home Affairs Select Committee on drugs policy, Independent Working Group on Drug Consumption Rooms, and Advisory Council on the Misuse of Drugs were confident in 2002, 2006, and 2016 (respectively) that this had been passed. That successive governments have not accepted recommendations for a pilot study indicates that factors outside of the evidence base are fundamental to determining the acceptability and feasibility of drug consumption rooms in Britain.
A 2004 briefing explained that in order for drug consumption rooms to be accepted and allowed to supplement the UK’s repertoire of substance use interventions, three broad areas inhibiting policymakers would need resolving:
• Principle: “How do policy makers justify providing a service that enables people to engage legitimately in activities that are both harmful and illegal?”
• Messages: “Do [drug consumption rooms] legitimise drug use, encourage more people to use hard drugs or – at the local level – increase drug-related problems in the areas where they are situated?”
• Effectiveness: “Do [drug consumption rooms] reduce drug related harms and, even if they do, are they the most appropriate and cost effective way of reducing these harms?”
The last two points are arguably the easiest to address. On messages, the answer is clear: there is an evidence base of ‘real world’ trials determining that drug consumption rooms produce sufficient benefits, with no countervailing problems; specifically, there is no evidence that they encourage more people to use ‘hard drugs’ or increase drug-related problems in the vicinity of drug consumption rooms. On effectiveness, there is sufficient evidence that drug consumption rooms reduce drug-related harms among the target population, however: (1) this evidence does not rise to the ‘gold standard’ of randomised controlled trials, though the ethics of holding harm reduction interventions to this bar before implementation should be rigorously challenged; and (2) there is a need to pilot them in the UK context to understand how they could respond to local drug-using populations and fit within wider communities. The principle on which drug consumption rooms rest is where most of the conflict lies.
Despite similar levels of drug-related harm in Germany and the UK, only Germany has responded to the problem with drug consumption rooms (accruing 24 at the time of publication). Researchers from both countries identified differences that could account for this, pointing in particular to:
• limited local powers in the UK compared to Germany, enabling German cities to introduce drug consumption rooms, which could eventually lead to federal support;
• large open drug scenes in Germany (not found to the same degree in the UK), which are associated with serious health and public order problems and played a pivotal role in persuading communities and local politicians that something had to be done;
• historical tendency of the British press to stoke up fears around drug use and people who use drugs; whenever the issue has been discussed, much of the reporting has been negative, with frequent derogatory references to ‘shooting galleries’.
Should the outrage and solutions proposed in Scotland start to shift mindsets, Britain already has a good-practice blueprint to guide implementation. In 2008, the Joseph Rowntree Foundation published guidance for local multi-agency partnerships looking into opening a drug consumption room. It addressed minimum operational standards, domestic and international legal issues, as well as the commissioning process, operational policies and procedures, monitoring and evaluation. It also stressed that local agreement is absolutely essential – something not generated previously in Brighton ( above), though with “accumulating evidence of poor health and social outcomes for [people who inject drugs]” in Scotland and the political will, the story may end differently.
Concluding thoughts
When we first published this hot topic on drug consumption rooms in 2016 we suggested “there seem two scenarios in which support for drug consumption rooms could be generated in the future”:
“…firstly, if there were to be a policy shift towards harm reduction, not just as a mechanism to engage drug users with treatment, but as a legitimate goal in itself; and secondly, if the UK were to reach a ‘tipping point’ in the degree of distress and nuisance perceived to be caused by public injecting, or the degree of concern over the concentration of overdose fatalities and infectious diseases in certain locations.”
Three years on, central government’s position on drug consumption rooms in the face of mounting harms to vulnerable and socially-excluded people injecting in public casts doubt of the notion of reaching such a ‘tipping point’.
Drug consumption rooms are not a replacement for abstinence, treatment, or law and order; they provide respite from public injecting, restore a vital connection to healthcare and social support services for a highly-marginalised and highly-stigmatised group of people, and put the interest and wellbeing of people who use drugs at the heart of drug policy. Consistent evidence of their effectiveness suggests that it would be prudent and overdue to trial drug consumption rooms in UK cities. Whether Westminster will reconsider remains to be seen. Meanwhile, as more and more countries integrate this pragmatic harm reduction approach into their drugs policy, any claim to the moral high ground in Westminster seems easily refuted.
Thanks for their comments on this entry in draft to Blaine Stothard (Co-Editor, Drugs and Alcohol Today), Dr Will Haydock (Visiting Fellow, Bournemouth University), Claire Brown (Editor, Drink and Drugs News), Philippe Bonnet (Chair, National Needle Exchange Forum), and Naomi Burke-Shyne (Executive Director, Harm Reduction International). Commentators bear no responsibility for the text including the interpretations and any remaining errors.
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