Doorstep Challenge

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Strong partnerships could overturn nimbyism and make supervised injecting facilities a reality, DDN reports.

Read the full article in DDN Magazine

Professor Alex Stevens, University of Kent
Professor Alex Stevens, University of Kent

A supervised injecting facility (SIF, also referred to as a drug consumption room or DCR) is not the only answer to reducing drug-related deaths, but could fit into ‘a multi-component strategy’ to reduce vulnerability, overdose risk and fatal outcomes from overdose. Introducing an online session, Professor Alex Stevens of the University of Kent wanted to discuss the evidence, the obstacles and a way forward for making SIFs a reality.

‘Not only do they save lives, they help people to improve their injecting technique, access treatment and harm reduction services, and address other vulnerabilities in their lives,’ he said.

Niamh Eastwood, executive director of Release
Niamh Eastwood, executive director of Release

looked at whether a SIF could be legal. With the government ignoring the ACMD’s recommendations and continuing to oppose such a facility, three offences relevant to a DCR/SIF stood out in particular – possession, encouraging or assisting a person to commit an offence, and contravening the Anti-Social Behaviour Act.

With legislation unlikely to change anytime soon, she suggested that a way forward would be through multi-agency agreements between the police, local authorities, PHE, health providers and prosecution services. ‘Letters of comfort’ could be provided by police to allow local services to provide harm reduction equipment such as citric acid and foil. ‘The impetus comes from local activity,’ she said.

DCI Jason Kew gave thoughts on working with the police to open a SIF. His strong view was that it was a health matter – ‘a medical facility, a harm reduction facility’ – and it wasn’t the police’s place to lead on this work. The data on drug misuse deaths showed ‘a clear picture of where we need to act sooner,’ he said. With 78 legalised DCRs operating in Europe without a single drug-related death, we needed to ‘humanise the statistics’. ‘Is there really the public interest in prosecuting a healthcare professional trying to safe somebody’s life? Absolutely not,’ he added.

DCR Canada
Health authority staff members work at SafePoint, a supervised injection site in Surrey, Canada. Credit: Xinhua/ Alamy

‘DCRs attract a great deal of emotion for or against them,’ said Rudi Fortson QC. A local memorandum of understanding was the best way forward, he suggested. ‘One has to look at the reality of the situation, which is that despite 14 years of campaigning to even pilot a DCR within the United Kingdom, we haven’t got one. Why not? It comes back to those fundamental issues of public acceptability of a DCR on their doorstep.’

Saket Priyadarshi, medical lead at Glasgow Alcohol and Drug Recovery Service, had been closely involved in making the case for a DCR in the city – a move provoked by an outbreak of HIV in people who injected drugs. A formal health needs assessment by public health colleagues had resulted in recommendations for a heroin-assisted treatment service (HAT) and a SIF. Glasgow’s health and social care partnership – which included police and people with lived experience of using drugs in public places – had accepted the recommendations and asked for a business plan for a SIF in the city.

The model they proposed was co-located with HAT and a very low threshold service ‘to capture as many of our target population as possible’, including pregnant drug users. The large fixed-site model ‘would manage the clinical governance concerns being expressed’ and it included an aftercare area.

The project is currently snagged by ‘a constitutional stand-off between Edinburgh and Westminster’ but they have made plans around public engagement to manage local concerns and ‘have an evaluation and research agenda in place’. A HAT service has already been implemented in the interim, and they anticipate that the SIF will be a ‘scaled-up version’.

DCR in Canada
Health authority staff members work at SafePoint, a supervised injection site in Surrey, Canada. Credit: Xinhua/ Alamy

The West Midlands had also been developing a model, as Megan Jones, head of policy for the Office of the West Midlands Police and Crime Commissioner, explained. The office had begun by looking at the scale of the drug problem in the region, with the cost of heroin and crack cocaine users calculated as £1.4bn and the cost of crime committed by the average heroin or crack user as £26,000.

A drug policy summit had involved the public in looking at a new approach, with the drivers of reducing harm, reducing crime, and reducing cost. The eight recommendations had included DCRs, and an independent report – Out of Harm’s Way, written by Ernie Hendricks in March 2020 – covered evidence from the UK and across the world. Its two main recommendations were to develop a business case through a multi-agency steering group, and to work with government and the steering group to support a DCR pilot site in the West Midlands.

We had to be led by the evidence, take the public with us and have an ‘open mature conversation about drug policy and its failings,’ she said. It needed to be done with existing treatment providers and people with lived experience, be linked to the homelessness agenda, and be done through a partnership approach.

Martin Blakebrough had been asked to talk about developing a model for Wales, and as CEO of Kaleidoscope he had experience of an early SIF model. In the ’70s and ’80s Kaleidoscope ran a club that also had a needle and syringe exchange in it, with a methadone dispensing system and doctors and nurses: ‘In many ways it was a drug consumption room, but it wasn’t actually publicised as that.’

Looking at other places, such as Cardiff, ‘we know there are unofficial consumption rooms there, in hostels,’ he said. ‘So it’s not quite right to say we don’t have consumption rooms – but we don’t have DCRs that can call themselves that, or that are recognised in law.’

Martin Blakebrough, CEO of Kaleidoscope
Martin Blakebrough, CEO of Kaleidoscope

The idea that the facility had to be an expensive option was ‘ridiculous’, he added. ‘In Wales we’re saying “it’s just a room”. The idea that we need to create ridiculously safe spaces that are sterile is also difficult – would you want to be drinking beer in a sterile environment? We have to create services that are hugely attractive to the people we want to serve. And they need to be involved in the design and development of that service.’

Peer mentors were the best people to advise someone on how to inject drugs, and the idea should be around creating a space for service users to help each other – ‘and if it’s part of a drug service or adjacent to it, I don’t really see the public outcry,’ he said. ‘Let’s make this happen by using the skills and passion of our drug using community and champions’, giving them the money to run the services, the legal cover, and the clinical assistance they needed to run the place safely.

Mat Southwell, technical consultant specialising in community mobilisation for people who use drugs, agreed on the value of peers’ central role and added that it was really important to give drug users choice around a highly medicalised model or a drop-in style community centre approach. ‘If you involve people in the design of a project they’re going to have more investment,’ he said.

Mat Southwell, technical consultant specialising in community mobilisation for people who use drugs
Mat Southwell, technical consultant specialising in community mobilisation for people who use drugs

It was important to think about their inclusion in staffing too, as part of an ‘empathic committed service’. Drug user groups had been ‘pivotal’ to delivering NSP around the country and different parts of the world and were well placed to carry on managing many DCR environments, as they did already.

‘It’s not about saying either nurses or peer educators, but saying what’s the combination we can put together to maximise the impact of a system,’ he commented.

Summing up the session, Alex Stevens said it was really important to build the evidence base, both in the UK and globally, for whether and how SIFs work. Three clear stages of development, piloting and evaluation could be taken from the Medical Research Council’s framework and ‘all this needs to be done alongside service user involvement from the very early stages’.

DCI Jason Kew
DCI Jason Kew

We were not starting from scratch, but had research to build on, including a ‘logic model’ of how these services work from Australia and Canada. A look at costs and benefits could lead to a template that people could plug their local data into.

Joining in the summing up, the senior police representative Jason Kew added: ‘This is depoliticising it, about saving people’s lives, about keeping people safe – it’s as basic as that. People talk about going soft on drugs, but there’s nothing soft about preventing deaths. Nothing.’