Home Affairs Committee - Drugs: Breaking the CycleWritten evidence submitted by Charlie Lloyd and Neil Hunt (DP156)
Executive Summary
The case for the piloting of Drug Consumption Rooms (DCRs) is even stronger in 2012 than it was in 2002.
The 2002 Home Affairs Select Committee recommended that “safe injecting houses” (or DCRs) should be piloted without delay.
A DCR is a room for the medically-supervised, hygienic consumption of pre-obtained, controlled “street” drugs.
There are more than 90 DCRs operating around the world but none in the UK.
Since 2002 the evidence-base on DCRs has grown, showing that they can prevent drug-related deaths, improve the health of service users, reduce public injecting and discarded needles, increase referrals to treatment and save money.
Arguments against the piloting of DCRs, such as their legal status and fears concerning crime and disorder are readily countered by the evidence and experience from abroad.
An Independent Working Group supported by the Joseph Rowntree Foundation considered all of the available evidence and concluded in 2006 that DCRs should be piloted in the UK. This recommendation was positively received by many, including David Cameron, then Leader of the Conservative Party.
1. This memorandum addresses the following question within the Select Committee’s terms of reference:
Whether detailed consideration ought to be given to alternative ways of tackling the drugs dilemma, as recommended by the Select Committee in 2002
One of the recommendations made by the 2002 Select Committee was that “an evaluated pilot programme of safe injecting houses for [illicit] heroin users is established without delay and that if, as we expect, this is successful, the programme is extended across the country” (Home Affairs Committee, 2002, p 44). This memorandum will outline what has happened since 2002 and argue that the case for piloting Drug Consumption Rooms is even stronger in 2012 than it was in 2002.
2. A Drug Consumption Room (DCR) is a room specifically set up for the medically supervised, hygienic consumption of pre-obtained, controlled, “street” drugs. This distinguishes them from “crack houses” or “shooting galleries” where there is no professional supervision and, frequently, unhygienic conditions. It also distinguished them from heroin prescription programmes, in which there is often supervised, hygienic consumption of pharmaceutical heroin, provided on prescription. More than 90 DCRs have been set up around the world: in Switzerland, Germany, Spain, Norway, the Netherlands, Luxembourg, Denmark, Australia and Canada. The majority of these facilities are designed for injecting drug users, although drug smoking rooms (often for crack inhalation) also operate in Europe.
3. Some DCRs have focused on specific groups, such as the homeless; others have an open-door policy. However, users are usually registered in some way. People who inject bring their drugs with them, are given clean injecting equipment and then go to a room where they prepare their drugs and administer them. Trained project workers observe the process and are able to intervene if people overdose or have other problems. Counsellors and medically trained staff are usually also present elsewhere in the facility or nearby, to treat health problems, give safe injecting advice, discuss treatment options and refer on to other agencies.
4. In the 10 years since 2002, the evidence-base on the effectiveness of DCRs has got a lot stronger. Well-designed and well-resourced evaluations have been undertaken of the large DCRs in Sydney and Vancouver. Evidence from these studies, along with numerous evaluations undertaken of the European projects, has shown the following:
DCRs can prevent drug-related deaths. Millions of injections have taken place in DCRs and thousands of overdose events have occurred which have been effectively managed. The only death to have occurred within a DCR was a case of anaphylaxis (a rare allergic reaction).
They can improve the health of users, prevent needle-sharing and probably reduce transmission of blood-borne viruses such as HIV and Hepatitis C.
They can lead to reductions in public injecting and discarded needles and other drug-related litter. In one project such litter dropped by 50%.
They have been associated with increases in referrals to drug treatment services. One project showed a 30% increase in DCR-users entering detoxification services.
Research undertaken in the UK shows that high-risk drug injectors would use a DCR if one were available.
5. With regard to cost, different DCR models generate very different cost estimates. Large, pilot services accommodating hundreds of injections a day in highly specialised centres (eg Sydney or Vancouver) cost approximately £1.3 to 1.5 million per annum, including evaluation costs. Despite their relatively high cost, economic evaluations have shown these centres to be cost-effective. In the Netherlands, services are often limited to around 20 of the highest risk local users and cost far less. One option for UK pilots would be to integrate DCRs with existing needle and syringe programmes or other parts of the treatment system, which should make them even more cost effective than stand-alone models.
6. DCRs are not “the solution to the drug problem”. Rather, they offer the potential to reduce some of the problems associated with homeless and other high risk, injecting drug users: keeping them alive, improving their health, reducing some of the damage they cause to local communities and offering the chance for them to move on to treatment within a recovery-oriented integrated system. DCRs would therefore only be useful and viable where there are already large populations of injecting drug users, high rates of drug-related deaths and problems with injecting in public places, such as parks, private gardens and public toilets. There are certainly a number of locations with such problems in cities and towns around the UK.
7. Nevertheless, a number of arguments have been made against the introduction of DCRs in the UK, some of them by the Home Office in its evidence to the 2002 Home Affairs Select Committee. These arguments are addressed below:
DCRs contravene the UN Drug Conventions. As evidenced by the number of countries that have already introduced DCRs, the UN Drug Conventions are clearly not an insuperable obstacle. Moreover, advice produced in 2002 by the Legal Affairs Section of the (then) United Nations Drug Control Programme concluded that DCRs do not necessarily contravene the Conventions.
DCRs would be illegal in the UK. Most potential problems under UK law could be managed with a clear set of rules, as used in DCRs in other countries, which prohibit behaviours such as providing drugs to others or helping others to inject. However, possession of Class A drugs would still be an offence and would have to be tolerated for DCRs to function. The local police force would therefore need to work as partners committed to the public health priorities of DCRs and avoid routinely arresting drug users for possession in, and in the near vicinity of, the DCR. Such partnership approaches already occur in the context of needle and syringe programmes.
DCRs will lead to crime and disorder in the immediate vicinity. Research evidence suggests that such problems can arise but good co-ordination between the police and the DCR can successfully prevent this.
Unsafe injecting will occur while the DCR is closed. Therefore they tend to have longer opening hours than many routine services.
It will be difficult for the police not to take action in one part of a city and yet take action elsewhere. Already a feature of policing in British cities, where users are allowed to access needle and syringe exchange facilities, despite being frequently in possession of Class A drugs.
Given the shortage of funding in the NHS why should we fund a project for drug users? Funding could be found from other sources, including the charitable sector.
Setting up a DCR would condone drug use and might lead to an increase in use. Evidence elsewhere suggests it is unlikely that a pilot DCR would have an immediate impact on levels of drug use, one way or another.
Those responsible for implementing a DCR could be accused by the media and others of setting up ‘drug dens’. Some negative media coverage is probable but much will depend on the publicity strategy employed.
The evidence-base is insufficient. The evaluation of complex interventions like DCRs is notoriously difficult to undertake rigorously. However, increasingly sophisticated evaluations have been undertaken, the findings of which point in the same (positive) direction. The evidence threshold for a pilot project is, in any case, lower than that for a permanent service.
8. When the last Select Committee recommended piloting DCRs there was another, particular concern on the part of the Home Office. The then Home Secretary, David Blunkett, was keen to pilot heroin prescription in the UK and there were fears that there would be confusion in the media and elsewhere about the difference between heroin prescription pilots and DCR pilots. Now that a heroin prescription trial has been successfully conducted and a process recently identified for its expansion as a treatment option, concerns about such confusion can be laid to rest.
9. Various attempts have been made to explore the potential for setting up a DCR in the UK over the past decade. One significant development was the establishment of the Independent Working Group on Drug Consumption Rooms, which was supported by the Joseph Rowntree Foundation and reported in 2006. The members of this group, chaired by Dame Ruth Runciman, included senior police officers, senior academics, a GP consultant and a barrister specialising in drug offences. They considered the evidence on the need for DCRs in the UK, reviewed the evaluation evidence from abroad and concluded that pilot DCRs should indeed be set up in this country. The resulting response to the report was largely positive, including the reaction from the then Leader of the Conservative Party, David Cameron (who also sat on the 2002 Select Committee): ‘Anything that helps get addicts off the streets is worth looking at’. However, the report came out at a particularly bad time for the Home Office: the prisoner deportation crisis was at its zenith and John Reid had just arrived and declared some parts of the organisation “unfit for purpose”. Coupled with the Labour Party’s very poor results in the recently-held local elections, the political space for experimentation with DCRs was probably non-existent.
10. In conclusion, there is a considerably stronger platform of evidence now than in 2002 from which to argue that DCRs should be piloted in the UK. To quote a Lancet editorial written in response to the Independent Working Group’s report in 2006: “After four years, and thousands of needless drug-related deaths, a thorough trial of DCRs is a requirement the Government cannot afford to refuse a second time.” After 10 years, perhaps it could be a case of third time lucky.
Charlie Lloyd is a Senior Lecturer and Joint Lead of the Addiction Research Group in the Health Sciences Department at the University of York. He has a background in criminology, undertaking research at the University of Cambridge and then the Home Office on sex offences, probation, prisons and reoffending. He went on to manage a programme of research for the Drug Prevention Initiative, where he published a review on the risk factors for problem drug use. He then moved to the Joseph Rowntree Foundation, where he managed research programmes on young people, drugs, alcohol and social evils. In 2010 he moved to the University of York, where he is undertaking research and teaching on drug and alcohol issues. He has recently published a report on the stigmatisation of problem drug users and current areas of research include the Department of Health’s Alcohol Improvement Programme, Alcohol Health Workers in hospital, new synthetic drugs and a trial of drinking interventions with hospital patients.
Neil Hunt (MSc Social Research) is an Honorary Senior Research Associate at the School of Social Policy, Sociology and Social Research, University of Kent; and, Honorary Research Fellow with the Centre for Research on Drugs and Health Behaviour, London School of Hygiene and Tropical Medicine, University of London. He also works as a freelance researcher and trainer. A founding director of the UK Harm Reduction Alliance, his work has covered issues including injecting and risk, understanding drug trends, peer influence and young people, clubbers’ drug use, human rights and drug user involvement. He developed the “Break the Cycle” intervention to reduce injecting, which has been disseminated nationally by the Department of Health. Currently, he is working as a consultant to UNICEF and advising on adaptations of the programme in Canada and within Europe. He worked on the Joseph Rowntree Foundation’s publications on Drug Consumption Rooms and the subsequent development of guidance for their operation in the UK. Recent publications include research on the use of ultrasound to reduce harms among femoral injectors and a chapter on the interface between harm reduction and recovery.
January 2012