Supervised drug consumption facilities, where illicit drugs can be used under the supervision of trained staff, have been operating in Europe for the last three decades. As the debate about opening new drug consumption facilities remains high on the political agenda in a number of European countries, including Scotland, this analysis, drawn from the EU Drugs Agency (EMCDDA) ‘Perspectives on Drugs’ series, aims to provide an objective overview of their characteristics and current provision, and of the effectiveness of this intervention.
What are drug consumption facilities?
Drug consumption facilities, sometimes known as medically supervised injecting facilities or safer consumption facilities, primarily aim to reduce the acute risks of disease transmission through unhygienic injecting, prevent drug-related overdose deaths and connect high-risk drug users with addiction treatment and other health and social services. They also seek to contribute to a reduction in drug use in public places and the presence of discarded needles and other related public order problems linked with open drug scenes.
Typically, drug consumption facilities provide drug users with: sterile injecting equipment; counselling services before, during and after drug consumption; emergency care in the event of overdose; and primary medical care and referral to appropriate social healthcare and addiction treatment services.
With the recent outbreak and spread of human immunodeficiency virus (HIV)in the Glasgow area, linked to drug injecting, a range of responses geared towards reducing the harms associated with drug injection and other high-risk forms of use have been investigated.
One of the more controversial responses has been to make space available at local drugs facilities where drug users could consume drugs under supervision. Concerns have sometimes been expressed that consumption facilities might encourage drug use, delay treatment entry or aggravate the problems of local drug markets, and initiatives to establish drug consumption facilities have in some cases been prevented by political intervention.
Where should they be situated?
Facilities for supervised drug consumption tend to be located in settings that are experiencing problems of public use and targeted at sub-populations of users with limited opportunities for hygienic injection (e.g. people who are homeless or living in insecure accommodation or shelters). In some cases clients who are more socially stable also use drug consumption facilities for a variety of reasons, for example because they live with non-using partners or families.
Where else are there drug consumption facilities?
In terms of the historical development of this intervention, the first supervised drug consumption room was opened in Berne, Switzerland in June 1986. Further facilities of this type were established in subsequent years in Germany, the Netherlands, Spain, Norway, Luxembourg, Denmark and Greece. A total of 74 official drug consumption facilities currently operate in six EMCDDA reporting countries, following the closure of the only facility in Greece in 2014. In January 2016 in France a law approved a six-year trial of drug consumption facilities, and the first French Supervised Injecting Facility opened in October 2016.
Outside Europe there are two facilities in Sydney, Australia and one medically supervised injecting centre in Vancouver, Canada.
What is the evidence?
The effectiveness of drug consumption facilities to reach and stay in contact with highly marginalised target populations has been widely documented (Lloyd-Smith et al., 2009), as well as wider health and public order benefits.
Research has also shown that the use of supervised drug consumption facilities is associated with self-reported reductions in injecting risk behaviour such as syringe sharing. This reduces behaviours that increase the risk of HIV transmission and overdose death (e.g. Kimber et al., 2010), due in part to the facilities’ limited coverage of the target population and also to methodological problems with isolating their effect from other interventions.
Some evidence has been provided by ecological studies suggesting that, where coverage is adequate, drug consumption facilities may contribute to reducing drug-related deaths at city level (Salmon et al., 2010).
In addition, the use of consumption facilities is associated with increased uptake both of detoxification and drug dependence treatment, including opioid substitution. For example, the Canadian cohort study documented that attendance at the Vancouver facility was associated with increased rates of referral to addiction care centres and increased rates of uptake of detoxification treatment and methadone maintenance (DeBeck et al., 2011).
Evaluation studies have found an overall positive impact on the communities where these facilities are located. However, as with needle and syringe programmes, consultation with local key actors is essential to minimise community resistance or counter-productive police responses. Drug treatment centres offering supervised consumption facilities have generally been accepted by local communities and businesses.
The effect of the Sydney supervised injecting facility on drug-related property crime and violent crime in its local area was examined using time series analysis of police-recorded theft and robbery incidents (Wood et al., 2006). This showed no increase in local drug-related crime.
In areas reporting an increase in the use of inhalable drugs, such as smoking crack cocaine or heroin, drug consumption facilities that originally targeted only injectors have started to broaden their services to include supervised inhalation. Findings suggest that supervised inhalation facilities offer the potential to reduce street disorder and encounters with the police (DeBeck et al., 2011).
In summary, the benefits of providing supervised drug consumption facilities may include improvements in safe, hygienic drug use, especially among regular clients, increased access to health and social services, and reduced public drug use and associated nuisance. There is no evidence to suggest that the availability of safer injecting facilities increases drug use or frequency of injecting. These services facilitate rather than delay treatment entry and do not result in higher rates of local drug-related crime.
What are the other benefits?
Drug consumption facilities have the ability to reach and maintain contact with high-risk drug users who are not ready or willing to quit drug use. In a number of European countries supervised consumption has become an integrated component of low-threshold services offered within drug treatment systems.
The emergence of new forms of stimulant injection, including new psychoactive substances, has resulted in potentially increased risks for drug users. In this context, drug consumption facilities are currently the subject of political discussion in some European countries, such as Scotland, as calls for their implementation are debated. As frontline, low-threshold services, drug consumption facilities are often among the first to gain insights into new drug use patterns and thus they also have a role to play in the early identification of new and emerging trends among the high-risk populations using their services.
Lloyd-Smith, E., Wood, E., Zhang, R., et al. (2009), ‘Determinants of cutaneous injection-related infection care at a supervised injecting facility’, Annals of Epidemiology 19(6), pp. 404–9.
Kimber, J., Palmateer, N., Hutchinson, S., et al. (2010), ‘Harm reduction among injecting drug users: evidence of effectiveness’, in Rhodes, T. and Hedrich, D. (eds), Harm reduction: evidence, impacts and challenges, EMCDDA Scientific Monograph Series No. 10, Publications Office of the European Union, Luxembourg, pp. 115–63.
Salmon, A. M., Van Beek, I., Amin, J., Kaldor, J. and Maher, L. (2010), ‘The impact of a supervised injecting facility on ambulance call-outs in Sydney, Australia’, Addiction 105, pp. 676–83.
DeBeck, K., Kerr, T., Bird, L., et al. (2011), ‘Injection drug use cessation and use of North America’s first medically supervised safer injecting facility’, Drug and Alcohol Dependence 15 January, 113(2–3), pp. 172–6.
Wood, E., Tyndall, M. W., Lai, C., Montaner, J. S. G. and Kerr, T. (2006), ‘Impact of a medically supervised safer injecting facility on drug dealing and other drug-related crime’, Substance Abuse Treatment, Prevention, and Policy 4, pp. 1–4.