DRUG CONSUMPTION ROOMS IN THE UK:

The evidence base and policy backdrop

Charlie Lloyd Department of Health Sciences

University of York

Neil HuntHonorary Research Fellow,

The Centre for Research on Drugs and Health BehaviourLondon School of Hygiene and Tropical Medicine

Overview

• Introduction• Evidence of effectiveness• Evidence of need • The story of non-implementation

Introduction

• Place where problem drug users are allowed to bring their illegally-obtained drugs and take them in a supervised, hygienic environment. Sterile injecting equipment. Closely observed, in order to give medical assistance should they overdose.

• c. 90 DCRs operating in 10 countries: Switzerland, Germany, the Netherlands, Spain, Norway, Luxembourg, Australia, Canada, Denmark and Greece. Advanced plans in France

Vancouver

Zurich

Evidence of effectiveness 1

• DCRs can prevent drug-related deaths: • millions of injections in DCRs, only one death. • Vancouver Insite implementation – 35% drop in lethal overdoses in vicinity of project.

• Reduction in ambulance callouts to overdose incidents (Sydney)

• If coverage, capacity and opening hours appropriate, likely to contribute to reducing DRDs at city level.

Evidence of effectiveness 2• Improve the health of users, reduce risky injecting and

prevent self-reported needle-sharing. No direct evidence of viral transmission prevention.

• Reduce public injecting, discarded needles and litter. 50% reductions – Vancouver.

• Increase in referral to treatment services. 30% increase in DCR-users entering detox – Vancouver.

• Studies have found DCRs to be cost-effective

Evidence of effectiveness 3

• Most of those using DCRs are local drug users.• No increase in crime or drug dealing in area around DCR (Vancouver and Sydney).

• In Europe, public disorder and drug-dealing around DCRs have occurred but have been successfully addressed through interagency working.

Evidence of need • Prevalence of problematic drug use and drug-related

death rate comparatively high in the UK• Non-fatal overdose much more common.• HIV and Hep C prevalence among injectors appear to be

stable but Hep C high (c. 50%)• Abscesses, cellulitis and damaged veins common• Substantial population of homeless users• Injecting in public places common (42% NSP users

injected in pp at least once/last week – Hunt et al. 2007).• Problems coalesce in particular areas in particular cities

Conclusions on evidence of effectiveness and evidence of need

• Increasingly strong evidence base showing DCRs to be a cost-effective way to reduce overdose deaths, ambulance call-outs to overdose events, needle-sharing and public injecting. They are also associated with increases in PWID entering treatment.

• Levels of relevant needs and concentration in particular cities suggest that DCRs may have an impact in the UK.

So why no DCRs in the UK? The story of non-implementation• 2002 Home Affairs Select Committee recommended:

‘…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.’

•  Reasons for Home Office rejection included: •International legal position means that the rooms could be (but have not been) open to legal challenge.•The Government could be accused by the media and others of opening "drug dens".•There may be problems in some areas on occasion with drug dealers congregating near to venues, leading to reduced local tolerance for the presence of injecting rooms in their neighbourhood.•No evaluations of DCRs developed in other European countries.

Blunkett and heroin prescription• In a 2003 interview with Druglink, Blunkett (then Home

Sec) ruled out ‘shooting galleries’ on the basis of need for stronger evidence of effectiveness but also the fear that they might create ‘a backlash and undermine our progressive step-by-step policy in terms of prescribing’

• The following year (2004), in the HO response to proposal for mobile DCR in Cardiff, central focus was legal status: • The UK will not contravene or undermine UN conventions or the

Misuse of Drugs Act. We believe facilities for supervising the consumption of illegal drugs would fall foul of these. Therefore, no authority could be given to the piloting of initiatives to supervise the consumption of illegal drugs.

Increasing evidence of effectiveness• Important review of the evidence undertaken in 2004 for

the EMCDDA (Dagmar Hedrich)• Increasingly sophisticated evaluations undertaken of the

new facilities in Sydney and Vancouver• JRF set up Independent Working Group on DCRs in

2005, reported May 2006• Concluded that sufficient positive evidence to warrant

trialling DCRs in the UK• Widespread coverage and debate

Responses to the IWG• David Cameron, leader of the opposition:

• ‘I certainly wouldn’t rule them out because anything that helps us get users off the streets and in touch with agencies that provide treatment is worth looking at.’

• Mixed coverage across the newspapers, TV and radio but clear support from The Independent and The Mirror

• Lancet editorial: ‘After 4 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.’

• But…no change in Government position• Published amid prisoner deportation crisis, poor local

election results and departure of Charles Clarke.

Since 2006• Relatively quiet• Some local areas have got close to establishing pilot

projects but fallen through due to range of circumstances• Most recent: Brighton. Independent Drugs Commission

recommended that local authorities examine the feasibility of opening a DCR. Not considered a priority due to unlikely impact on deaths in Brighton, cost and legal advice from the HO.

• Meanwhile DCRs have spread to many more countries

So why not in the UK?• Not the sort of policy to put on the front of your manifesto• Govt’s response to 2002 HASC rec candid – media could

accuse them of opening ‘drug dens’. Perhaps a harder sell in the UK than elsewhere due to British press

• Lack of local autonomy: local response to local problems• No ‘open drug scenes’ akin to those seen in Germany,

Austria and Vancouver• Chance. UK came close in 2006 but winds of political

fortune changed and Govt in turmoil

Conclusions• Good evidence for the effectiveness of DCRs (as good as

can be expected in absence of RCTs)• However, not a ‘universal service’ for PWID: local

response to high rates of public injecting and overdose incidents

• Likely to have a significant impact in some areas of some cities in the UK

• Political barriers considerable