Denmark’s initiatives to tackle drug-related deaths could give valuable pointers to reshaping drug policy in the UK, says Blaine Stothard
As part of his programme of international visits looking at drug policy, Home Office minister Norman Baker visited Copenhagen in February 2014. This visit, one of many from the UK, included a roundtable discussion at the British Embassy and trips to the Danish Drug Users Union, a building-based drug consumption room, and the Christiania cannabis market near the centre of Copenhagen. At the time of writing (May 2014) we don’t know what impressions the minister brought back. But there has been sufficient recent activity in Denmark to consider what might be coming our way.
Denmark’s population of 5.6m includes an estimated 17,000 injecting drug users, principally using opiates but with an increasing use of cocaine. National statistics for drug-related deaths, collected by the police since 1970, and by the health service since 1995, show that since 2000 there have been around 250 annual drug-related deaths (DRDs), falling to 210 in 2012. Reducing this high death rate has long been the aim of campaigning groups, including BrugerForening (Danish Drug Users Union) and Gadejuristen (Street Lawyers: slogan ‘hard-core harm reduction’).
In 2004 Anders Fogh-Rasmussen’s Conservative-led government acted on its zero tolerance policy on drugs. Against police, Copenhagen City Council and others’ advice, the illegal but tolerated cannabis market in Christiana (‘Pusher Street’) was closed down. As predicted, this resulted in the displacement of the market elsewhere and its integration into existing illegal drugs markets mainly controlled by rocker and biker gangs. Challenges by other criminal organisations led to violent turf wars and shootings, predicted by those questioning the clampdown.
The negative consequences of the closure of Pusher Street resulted in a detailed proposal by Copenhagen City Council for the regulation of cannabis on a trial basis. The proposals envisage a state or local authority controlled and regulated cannabis market – cultivation (a stage in the cycle not included in most similar proposals elsewhere), distribution and retail. Sale to the public would be through dedicated outlets, with staff present to advise purchasers on concerns they might have. The results would be monitored and evaluated to assess impact. The proposals, which have extensive cross-party support from Copenhagen City Council (and majority public support) have, so far, been rejected by governments, most recently in 2012. But they remain ‘live’ following the November 2013 local elections and the formation of a new city council.
An open cannabis market has been re-established in Christiania. Booths sell cannabis behind curtained entrances, a stark contrast to the pre-2004 market, where tables groaned under the weight of bricks of resin. The existence of these booths seems to have given some UK visitors the impression that cannabis is freely available in Denmark: signs – in Danish, English, Spanish and German – mark entry to the Green Light District, request that there is no photography, and emphasise that the cannabis trade remains illegal in Denmark.
In 2007, Fogh-Rasmussen’s government introduced medically prescribed heroin, with clinics in four cities, including Copenhagen. A result of parliamentary pressure and a media campaign, this programme has contributed to stabilising the health of its clients, mostly older, formerly chaotic, injecting heroin users, and to reducing crime and associated nuisance. Users attending the programme are required to inject, not smoke – a harm-reduction behaviour adopted by some long-term users the programme was intended to attract who have, as a result, declined to register. About 250 users are registered. Thrice-daily attendance at clinics is required for prescriptions to be issued and injected, making it difficult for users to maintain family commitments, employment, or education and training. The programme is expensive, employing health and medical staff on high salaries and using pharmaceutical products which could be obtained at a fraction of the cost from alternative suppliers. Commentators conclude that the programme was well intended but poorly thought through.
At an October 2013 local election meeting in Copenhagen’s Vesterbro district, home to several agencies working with socially excluded groups and the city’s principal illegal drugs market, the majority of the candidates who spoke endorsed the activities and spending of the city council which responded to the needs and situations of socially excluded groups, including injecting drug users. Five of the candidates specifically referred to the need to maintain a floor of taxation levels if such programmes were to continue, and warned against parties and politicians who promised tax reductions.
BrugerForeningen is one example of the environment in Denmark, or at least Copenhagen. Housed in a building in the Nørrebro district of Copenhagen whose other occupants include a youth centre, a library and a nursery (British nimbies please note), BF provides a morning drop-in service for injecting drug users; harm-reduction sessions for existing users; a ‘clean-up’ team of users who regularly clear discarded paraphernalia from areas used by injecting drug users, and organises courses and seminars for relevant professional bodies – police, social workers and health professionals. Copenhagen City Council provides some funding. Lessons here include the ability of long-term heroin users to plan, organise, manage and campaign, in collaboration with residents and social agencies, when able to use in safe and sterile conditions.
Together with the NGOs Gadejuristen and Antidote, BF campaigns for the increased availability of naloxone (a team of BF members has been trained and licensed to administer naloxone, the first non-health personnel in Denmark to be permitted to do so); for the provision of foil as part of harm-reduction and needle-exchange work, and the provision of drug consumption rooms. Current health service guidance emphasises the health risks of smoking, used as an argument against allowing those on medically prescribed heroin programmes to smoke rather than inject. Health service guidance also refers to the health risks of using foil in smoking heroin, obstinately failing to distinguish between plain foil and foil coated or treated for the catering trade, the coatings and their carcinogenic fumes representing the risks. The 2010 ACMD report on foil is being used in this campaign.
The opening of consumption rooms has the ‘best’ lesson for the UK. As part of their aim to reduce drug-related deaths, Danish campaigners had long argued for drug consumption rooms. Part of their case was the evidence of lives saved, emerging from studies where DCRs operate. While still in opposition, the parties now in government (since September 2011) undertook to introduce legislation enabling DCRs to be established. The new government introduced its bill to permit DCRs, enable local authorities to commission and operate them, and provide for their funding. The law came into force on 1 July 2012 after gaining parliamentary approval.
Two building-based drug consumption rooms have since opened in Vesterbro, one in the premises of Mændenes Hjem (The Men’s Home), a project for homeless people which, despite its name, works with all who are homeless and responds to their needs. This room (Skyen: The Cloud) has two sections, for injecting and for smoking, separated by a transparent, air-tight partition. When I visited in October 2013, all 14 places were occupied, mostly by men, some Swedish. Users check in with the m
edical staff present. Pseudonyms may be used, if constant, and the drug/s used noted – on my visit, cocaine was the principal drug used.
In January 2014 the Home Office stated that drug consumption rooms were not in prospect for the UK, being in breach of domestic legislation and international conventions. Lesson from Denmark: always seek a second legal opinion when governments say ‘it breaches national law and international conventions’ – national governments have the power to change domestic law if the political will exists.
The provision of sterile and safe injecting facilities was catalysed by the establishment of a mobile DCR by a citizens’ initiative in Vesterbro. This converted ambulance, Fixelance (Fixerum (consumption room) + ambulance), took to the streets on 11 September 2011 – before the election and the subsequent change in the law. Staffed by volunteers, including medical professionals and social workers, and funded by individual and small-business donations, Fixelance initially operated on tenterhooks, with legal teams from Gadejuristen on call in case of challenge or interventions by the authorities. There were none. Shortly after Fixelance 1 started operating, a second was donated by the national emergency service, Falck. Once the legislation was passed, Copenhagen City Council took over the running and funding of the two Fixelance. The citizens’ initiative was dissolved. Its originator, Michael Lodberg Olsen, now campaigns, as Antidote, with BrugerForening for improved access to naloxone. Fixelance 1 has since been replaced by a purpose-built vehicle.
The Fixelance initiative was started by local residents in Vesterbro, where many injecting drug users and other marginalised social groups congregate. They were concerned at the poor health, living and social conditions of those groups, and rather than trying to exclude or displace them, developed positive responses, an ongoing, decades-long task. The focus has been to restore a sense of dignity and worth to the lives of injecting drug users at the same time as reducing the impact their lifestyles have on local residents. (Moves to set up a DCR in Birmingham are based on similar principles.) The results have included less discarded injecting equipment; increasing use of the mobile and building-based consumption rooms, rather than playgrounds, backyards and stairwells, to inject; an absence of DRDs in the consumption rooms, and significant changes in public opinion. Here is a further potential lesson for the UK – process, public support, pragmatism.
Campaigners expect the consumption rooms to contribute to a further reduction in drug-related deaths (DRDs). While the significant 2012 fall in DRDs, recorded in the 2013 EMCDDA Focal point report, is welcomed, all involved express caution in attributing the fall to the DCRs and Fixelance. The statistics covered the whole of 2012: the building-based DCRs had only been operating for two months – and there was an increase (from 32 to 37) in Copenhagen DRDs. The 2013 statistics are awaited with great anticipation.
The Danish National Museum, curators of the Viking exhibition currently at the British Museum, has added Fixelance 1 to its collection, using it to illustrate themes in contemporary Danish history. It was formally ‘unveiled’ at the museum in April, in a courtyard next to one of the museum’s ancient runic stones, with the spire of Christiansborg, the parliament building, in the background. Maybe there is a further lesson here about acknowledging social issues and challenges and the individuals affected rather than denying, dismissing or demonising them. They exist and are part of contemporary society, and are better responded to when understood, not subjected to scorn, misrepresentation and stigma.
Blaine Stothard is an independent consultant in health education, www.healthed.org.uk