Drug consumption rooms: evidence-based but controversial

Drug consumption rooms are an evidence based intervention which can help people who use drugs do so in a safer environment. However, they remain controversial in many countries. In this blog, authors, Pierre Smith and Pablo Nicaise from the Institute of Health and Society at UCLouvain, highlight the experience of the city of Liège, Belgium.

“Prove that they are cost-effective, and your policy makers will open them!” said the head of the Drug Consumption Room (DCR) we were visiting in Amsterdam during our feasibility study. However, not all politicians, at least in Belgium, are so pragmatic. DCRs are legally sanctioned public health facilities that offer a hygienic and supervised environment where people who use drugs (PWUD) can do so safely.

For more than three decades, one hundred DCRs have spread across Western countries, mostly in Europe. During this period, a large body of evidence has accumulated about their public safety and public health effectiveness. However, their implementation remains controversial in many countries. This is the case in Belgium, where DCRs potentially conflict with a 1921 law that explicitly penalises the supplying of rooms to facilitate drug use. At the time, legislators were afraid of opium dens, such as Tintin’s Blue Lotus. Despite the evidence, amending the law has never reached political consensus.

Yet, against all odds, a DCR opened in the city of Liège in 2018. We recently published a case report assessing how political and legal barriers were overcome in the Liège DCR’s opening process. Perhaps this will be a source of inspiration for adverse contexts elsewhere?

More than three decades of scientific evidence…

A recent systematic review showed the effectiveness of DCRs on public health and safety outcomes. DCRs contribute to decreasing unsafe and unhygienic consumption behaviors (syringe sharing and reuse) and drug-related harm (overdose, HIV and hepatitis C virus contamination). They help reduce drug consumption in public spaces, the number of discarded syringes, and other public nuisances.

In addition, DCRs are effective for reaching and maintaining contact with hard to reach, socially marginalized groups. They facilitate access to health and social services, including addiction treatment programs. Feared negative consequences of DCRs are not borne out by experience: DCRs did not increase drug use in their vicinity, nor did they encourage drug use initiation. Over time, DCRs have been acknowledged as an effective public health intervention by international legislation (e.g. European Union Action Plan on Drugs 2017-2020, International Narcotics Control Board 2016 report).

…and still ideological controversy

However, DCRs remain highly controversial because of moral and ideology issues and fear of public disapproval, negative media response, and associated political consequences. Accordingly, the debate about implementing DCRs remains high on the political agenda in many countries worldwide, including the United Kingdom and United States.

The Belgian situation

International legislation mentioned previously recommend that DCRs be part of a national public health and harm-reduction strategy. Several countries adapted their legislation accordingly (i.e. Canada, France, and Luxembourg). In Belgium, the Federal authorities commissioned a feasibility study of DCR implementation in 2016 to address the debate. The publication of the study report coincided with local elections. This initiated an institutional debate about the political responsibility of DCRs as a public health intervention, with healthcare being mainly a matter of regional policy while the penal law was a federal responsibility.

The lack of consensus within the federal coalition government lead to a situation of political deadlock. This context offered Liège authorities the opportunity to reignite the local debate on DCRs. Local law enforcement, care professionals, residents, users, and the press, were all involved in the debate. Capitalizing on previous experiments, a local consensus was formed.

Despite the absence of any legal change, the DCR opened one month before the local elections, and the mayor of Liège was re-elected. The DCR has been working without major medical or legal incident since then. Other Belgian cities are now considering their own DCR in the near future.

What can we learn from this experience?

The strategy employed in Liège proved to be successful in overcoming negative public opinion. In this case, the local political support for DCR implementation was a factor of popularity in the electoral context. The local stakeholders reached a consensus with the support of a significant increase in public safety issues related to drug use over the past decade in the city and experiences of harm-reduction interventions. In addition, the communication strategy lead to the involvement of all stakeholders throughout the implementation process.

The feasibility study’s publication, which recalled the evidence on DCRs, as well as the local electoral context helped create momentum. The lack of political consensus at the national level made room for local leadership and autonomy for initiatives. Interestingly, the emphasis put on public nuisances in the policy issue’s formulation contributed to receiving the endorsement of local stakeholders and residents, while a policy formulation emphasizing DCRs as a public health instrument was used against the deadlock provoked by the federal authorities.

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