The Government has previously rejected calls for the introduction of DCRs, partly due to a lack of research. However, much more evidence now exists, from projects around the world. The IWG was set up to take an objective look at this growing evidence and to consider whether DCRs would have a significant impact on the particular problems in the UK. Chaired by Dame Ruth Runciman, the IWG included senior police officers, academics, health professionals and a practising barrister.
Over a 20-month period, the IWG reviewed published evidence, commissioned new research, heard from relevant witnesses and visited DCRs abroad. The report:
- reviews the UK policy context and how the idea of DCRs articulates with past and current drug policy;
- examines in detail the particular harms – to both users and communities – associated with injecting drug-use in the UK;
- looks at evidence of the effectiveness of DCRs and whether they might reduce the problems caused by drugs;
- considers a range of potential barriers and concerns, including legal issues, making a number of recommendations for the future.
The IWG concludes that DCRs offer a unique and promising way to work with the most problematic users – to reduce the risk of overdose, improve their health and lessen the costs to society – and recommends that pilot DCRs are set up and evaluated in the UK.
Drug Consumption Rooms - Summary report of the Independent Working Group
Drug Consumption Rooms (DCRs) are places where dependent drug users are allowed to bring their illegally obtained drugs and take them in supervised, hygienic conditions. There are approximately 65 DCRs in operation in eight countries around the world but there are none in the UK.
The Independent Working Group (IWG) on Drug Consumption Rooms was set up to address the question of whether DCRs would have a significant impact on drug-related problems in the UK and whether they should be trialled in this country. Over a 20-month period, the IWG reviewed the growing body of evidence, commissioned research where there were significant gaps, visited DCRs abroad and heard from relevant witnesses.
The IWG has concluded that DCRs are a rational and overdue extension to the harm reduction policy that has produced substantial individual and public benefits in the UK over the last two decades. DCRs 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 IWG therefore recommends that pilot DCRs are set up and evaluated in the UK.
Main findings and conclusions
Harms associated with injecting drug use in the UK
- Over the past decade, the UK has consistently had the highest number of drug-related deaths in Europe.
- Health problems include blood-borne viruses, abscesses and cellulitis, frequently resulting in hospitalisation.
- There is a substantial population of homeless, injecting drug users in the UK, who often inject in public places.
- In England alone, the number of drug injections occurring in public places is likely to be of the order of tens of thousands per month.
- Large quantities of syringes and drug-related litter are dropped in public places across the UK, causing considerable impact on local residents and businesses.
Impact of DCRs
- DCRs can prevent drug-related deaths, prevent needle-sharing and improve the general health of users.
- DCRs can lead to a reduction in injecting in public places and an associated reduction in discarded, used syringes and drug-related litter.
- Most of those who use DCRs are local drug users.
- DCRs do not appear to either increase or decrease levels of acquisitive crime.
- Public disorder and drug-dealing in the vicinity of DCRS are infrequent and can generally be prevented through good interagency co-operation.
Would DCRs have an impact in the UK?
- The IWG concludes that well-designed and well-implemented DCRs would have an impact on some of the serious drug-related problems experienced in the UK.
Would they be legal?
- The IWG concludes that national or international law need not be insuperable obstacles to the piloting of DCRs.
- A number of pilot Drug Consumption Rooms should be set up in the UK, founded on local accords between the key agencies.
- Pilots should be developed in parts of the country where there is already considerable local support for the idea and significant problems with public drug use and overdose deaths.
- Ideally, this piloting process would be supported and co-ordinated by central government. However, if the Government is unable to play this role, the IWG hopes that local agencies will be able to devise local schemes where it is in the public interest to do so.
- Provided that properly enforced rules and clear local accords are in place, DCRs can and should be piloted without legislative change.
- Initial pilots should consist of injecting rooms only. Well-run Needle and Syringe Exchange Projects appear to offer a promising location for setting up DCRs in the UK.
- DCRs should be integrated within local drug services, providing access to advice on drug use (including referral to treatment), accommodation, benefits, employment and self-care.
- Local communities and stakeholders should be closely involved in the development of pilot projects.
- There needs to be a set of minimum standards relating to DCRs, governing the behaviour of users, the procedures followed by staff, the level of training required for staff and the number of staff needed to provide a safe and proper service.
- These pilots must be carefully evaluated and the calculation of the cost of this piloting exercise should include resources for an extensive evaluation, which would incorporate local community and user surveys and an assessment of cost-effectiveness.
DCRs have been set up in Germany, Switzerland, the Netherlands, Spain, Norway, Luxembourg, Australia and Canada. The first was set up in June 1986 in Berne, Switzerland. There are thought to be in the region of 65 DCRs operating in these eight countries.
A confusing range of terms have been used in this area but the IWG has used the term ‘Drug Consumption Room (DCR)’ to refer to any room specifically set up for the supervised, hygienic consumption of pre-obtained, controlled drugs. This distinguishes them from ‘crack houses’ and ‘shooting galleries’, which are largely unsupervised and where the drugs are often purchased; and from premises where prescribed heroin is consumed under supervision. In the majority of cases, DCRs only allow the injection of drugs. However, increasingly, European DCRs are adding smoking rooms, where users can smoke crack or heroin. Reflecting the chief concern with injecting drug use in the UK, the main focus of the IWG has been on DCRs for injecting users.
The recommendation to set up pilot DCRs was made to the Government by the Home Affairs Select Committee in 2002. However, this recommendation was rejected for a number of reasons, including a lack of evidence, legal concerns, likely media and public hostility and the likelihood of drug dealers being attracted to the area around a DCR. All of these issues were addressed as part of the IWG’s inquiry into DCRs and their operation in other countries.
In other respects, the aims and objectives of DCRs chime well with the increasing emphasis within government drug policy on reducing the harms associated with drug use. Moreover, the IWG sees it as something of an anomaly that the UK Government, which has been in the vanguard with regard to the introduction of harm reduction measures such as needle-exchange, should prove so reluctant to introduce DCRs.
A typical Drug Consumption Room (DCR)
DCRs vary considerably in terms of their target groups, aims and operation. However, it may be useful to provide a snapshot of a ‘typical’ project.
DCRs are usually placed in urban areas, close to established drug markets. Users (who have tended to be predominantly men) are often required to be registered to use the facility and will arrive and give their details to a receptionist. They may then wait a short time before being allowed to go into another room. This room will contain a number of booths or injecting spaces with a chair and a clean table or ledge. All of these will be observable by employed staff. On entry, users are given a sterile syringe and other items such as a tourniquet, sterile water for dissolving the drug prior to injection etc. The user then goes into the injection area, prepares the drug and injects it. Should he have problems injecting the drug, a trained member of staff can give advice but cannot physically help with the injection process. Should he collapse, the staff member can go to his assistance. Afterwards, there is usually a place to sit and relax before leaving the building. Other medical, nursing, welfare or counselling staff will often be on hand to talk to those that want help and refer them to other services where appropriate.
Evidence of need
DCRs abroad have been set up in response to a range of concerns and needs. For ease of reference, these can be categorised as private harms which affect individuals, such as overdose death and blood-borne viruses, and public harms which affect communities, such as discarded syringes in public parks. However, the IWG, in its examination of the extent to which such problems occur in the UK, was conscious that most harms have both an individual and a public dimension.
The UK has consistently reported the highest number of drug-related deaths in Europe since 1996. The figure for England and Wales was 1,388 in 2003. This number has been decreasing in recent years. Non-fatal overdoses are considerably more common, with 20 to 40 per cent of injecting heroin users reporting having had such an experience. Non-fatal overdoses are often associated with emergency call-outs and hospital treatment and can lead to brain damage and a range of other physical injuries.
Blood-borne viruses are readily transmitted from one user to another through sharing syringes and other contaminated injecting paraphernalia. HIV prevalence among users in the UK is much lower than most other countries in Europe, primarily due to the widespread provision of clean syringes over the past two decades. However, recent research has shown a higher than expected rate among newer injectors, suggesting that historically low rates may now be beginning to climb.
There is a high, and rising, prevalence of hepatitis C. Prevalence of hepatitis B is relatively stable.
Many users infected with blood-borne viruses remain unaware of their infection (decreasing the likelihood of their preventing others from becoming contaminated). While hepatitis B can be prevented through vaccination, less than half the population of injecting drug users has been vaccinated.
Abscesses and cellulitis (inflammation of the skin caused by bacterial infection) are common among injecting drug users. One-third of a recent sample of users reported an abscess, sore or open wound at an injection site in the previous year. Damaged and collapsed veins are also common, frequently leading to injecting in the neck or groin which, in turn, is associated with deep vein thrombosis and impaired blood circulation.
Such problems are particularly prevalent among homeless users and there is a substantial population of such users in the UK, mostly based in hostels or sleeping rough. They frequently inject in public places, leading to public nuisance and discarded injecting equipment. Research conducted for the IWG found that 42 per cent of a sample of 398 needle exchange users had injected at least once in a public place in the previous week. All except one of the rough sleepers had done so and half of the hostel dwellers had done so, compared with a quarter of those living in their own accommodation.
As well as the substantial health risks, the IWG has emphasised the great loss of dignity and the mental anguish associated with injecting drugs in run-down backstreets, alleyways, toilets and parks. Without some level of self-esteem, it is hard to see how such users can make a realistic attempt to address their multiple problems, including their dependence on drugs.
Large quantities of used needles and drug-related litter are dropped in public places all over the UK. A national survey in England found that 147,345 used needles were collected by local authorities over the year 2003/4. This problem is especially serious in areas close to drug markets. Nearly a third of the 717 residents interviewed in a JRF study reported finding discarded needles and nearly a sixth reported seeing people injecting drugs. Overdose incidents in such areas are also common and often involve local people. Such experiences cause considerable distress among local residents and undermine communities.
Evidence of effectiveness
Millions of injections of potentially dangerous illicit drugs have taken place in DCRs since they were introduced, often involving users with serious health problems, and yet only one person has died. Moreover, this death was from anaphylaxis (a severe, whole-body allergic reaction) rather than overdose. DCRs clearly prevent drug-related deaths.
They are also effective in providing medical care and referring users to other medical services, thus contributing to the general health of users. It is likely that DCRs also reduce the risk of the transmission of blood-borne viruses such as HIV and hepatitis C, but this is very difficult to show conclusively.
There is good evidence that DCRs can lead to a reduction in injecting in public places and growing evidence that they can lead to a reduction in discarded syringes and drug-related litter.
Fears that large numbers of users from outside the area would be attracted to DCRs appear to be misplaced: the experience from abroad is that the large majority of DCR users are from the local area. Public nuisance has often been reduced by the introduction of DCRs but in some cases there have been (usually temporary) increases in public nuisance and dealing. Research has shown that the key to preventing such problems is good interagency co-operation between DCRs and the local police.
There is no evidence of either increases or decreases in crime, although this is unsurprising as DCRs do not provide prescription drugs and cannot therefore directly affect crime committed to obtain drugs. However, where they are successful in providing access to treatment, DCRs may have an indirect effect on crime levels.
Potential barriers and concerns
The three UN Drug Conventions provide the framework for international co-operation in the drugs field and whether or not DCRs are compliant with them is contested. However, the IWG does not regard the Conventions as a significant block to the implementation of DCRs in the UK. DCRs would contribute towards a number of the Conventions’ central aims. Moreover, the relevance of the Conventions to modern harm reduction measures can be questioned, given that they were written before the main development of such interventions in Europe.
United Kingdom law also does not appear to present an insurmountable obstacle. Provided a clear set of properly enforced rules are instituted, within the context of strong co-operation between the key local agencies, the IWG concludes that DCRs could be piloted within the UK without legislative change. Legal risks would remain but the IWG has concluded that the potential benefits substantially outweigh these risks.
This area is replete with ethical concerns, the weight and implication of which is hard to judge impartially. A number of these can only really be addressed through a rigorous evaluation of pilot projects in the UK. Others need to be discussed as part of the wider public debate on the worth of this idea, which the IWG hopes its report will engender.
Drug Consumption Rooms certainly cannot provide the answer to all the ills associated with problem drug use. Furthermore, they seem only to offer a palliative when everyone would prefer to see a cure. However, while the IWG holds the view that no drug intervention should ever give up on the possibility of treatment and, ultimately, abstinence, there are a large number of problem users in this country who are, for whatever reason, currently unable or unwilling to control or reduce their use.
The IWG considers DCRs 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.