With the UK’s first ever consumption room set to open later this year in Glasgow, an EMCDDA webinar explored the lessons learned from existing facilities across Europe – not least the ability to be flexible and adapt to new challenges.
‘We are at a moment of great danger for harm reduction,’ director of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) Alexis Goosdeel told delegates at the agency’s Drug consumption rooms in Europe – current practices and future scenarios webinar. The drug situation was rapidly changing, he said, with new risk behaviours and new potential harms. ‘Our toolbox will need to change, just as the substances have changed. We can’t just repeat the same solutions – some of which we had a lot of difficulty agreeing on and applying.’
One threat to harm reduction programmes was unrealistic expectations, he warned, which meant that drug consumption rooms (DCRs) had to be part of an overall system – not just a single service. ‘We need to be careful that we don’t pretend that DCRs on their own could solve all the problems related to substance use. That would be the best way to kill them and destroy their huge benefits.’
‘DCRs cannot work in isolation,’ agreed Roberto Perez Gayo, coordinator at the European Network of Drug Consumption Rooms. There were now more than 100 DCRs implemented in Europe, and they were constantly adapting to the changing needs and profiles of the people they worked with, alongside shifts in the drug market. Many were now offering spaces for smoking and facilities for people using stimulants, for example, rather than solely catering for people injecting opioids, and some were also integrating drug checking and sexual health services. Others were housed within mental health services, while the Woodstock facility in The Hague was located in a care home to provide services for older drug users.
BERN
The first drug consumption room was implemented in Bern in 1986, so there were decades of international experience to learn from, delegates heard. ‘Our reference models were Switzerland and Canada, but they’re countries that are very different,’ said director of harm reduction at the Asociación Bienestar y Desarrollo, Ester Aranda, who had managed a consumption room in Barcelona. ‘We can reproduce some programmes when we’re implementing a DCR, but we’re different in terms of cultural aspects.’
There had been four waves of DCRs in Barcelona, she said. ‘Originally we had the DCR but we didn’t have the people to use it,’ so the team had to design materials and implement strategies to attract them. There had also been rigid opening hours and no access for people showing signs of intoxication. ‘You have to change the approach,’ she stated.
‘We’d been trying to open a DCR in the Czech Republic for 30 years,’ said Viktor Mravčík, research director at Czech NGO Podane Ruce, which last year finally implemented the country’s first DCR – a mobile facility in Brno. ‘It’s those national and local policies and circumstances that shape the design – not the other way around’ he said. ‘But evidence about how they’re designed, how they work, the outcomes and experiences of other colleagues are very important for those trying to start this kind of programme.’ His team had learned a great deal from facilities in Lisbon, he said, as well as Berlin, which had both stationary and mobile DCRs.
GERMANY
Germany had been a key player in DCR implementation, with a variety of different models.
The Hamburg-based resource centre for women who use drugs, Ragazza e.V., had been operating a mobile outreach project for street sex workers since 1991 – as many women in the city financed their drug use with sex work – and in 2000 had opened a consumption room. ‘There was already a lot of experience and good networking among the colleagues – there had been a mobile service for needle exchange, medical care and counselling,’ explained social worker at the project Marylin Pohler. ‘But establishing a facility for drug-using women at that time was quite unique, so there weren’t many references’.
On the question of how local determinants were incorporated in plans and development, Ragazza was located at the centre of the city’s drug scene near the main station, she said. ‘There was poverty, marginalisation, criminalisation going on, so it was obvious that Ragazza made sense at that place. As it was already a big drug scene the residents were nervous, but we were able to defend the location because the scene isn’t very mobile. The women come in, so it makes sense that we’re nearby.’
BARCELONA
Any discussion of harm reduction in Barcelona, meanwhile, was impossible without talking about homelessness and violence, said Aranda. Catalonia and Barcelona’s local administration had also been applying a social determinants of health model, she said, ‘so it’s very easy to add harm reduction into this.’ The DCR catered not just for injection but for inhalation and oral use, she pointed out, and the team was also now implementing an alcohol maintenance programme.
Collaboration with the police had been challenging to begin with, but they now worked very closely together, she said, with meetings every week. ‘We have very good relations with both the municipal and state police,’ added Mravčík, although there could sometimes still be issues regarding possession offences. ‘But we’ve prepared very well and done our legal analysis, so it’s accepted and tolerated – we communicate and cooperate.’
Relationships with police varied widely, said Perez Gayo – from cases like the Netherlands, where the police were one of the main supportive forces, to the opposite – but one model that always worked well was the establishment of local roundtables involving the police, along with standard operating procedures so boundaries were clearly understood. ‘It means the police provide evidence that there are no problems, and back up the support for the DCR.’
THE CZECH REPUBLIC
The Czech Republic’s DCR came out of the country’s ongoing legislative move away from punitive prohibition, said Mravčík. ‘As part of this package, we created the concept of consumption rooms and discussed it nationally and inter-ministerially.’ When it came to the local situation in Brno, good governance was important, he stressed. ‘We have a good drug policy – pragmatic and evidence-based – so DCRs have become part of the city’s strategy.’ There was support from the local district where the DCR operated, and a working group that included law enforcement. ‘We communicated the concept well in advance, so it was done in full cooperation.’ The open drug scene in part of the city centre had ‘public nuisance and social exclusion’, he said, ‘so the district government for this area of the city very much supported our plans’.
The DCR operated from a second-hand ambulance, and was now working for four hours a day – up from two when it launched last September. ‘But doubling the operating hours means doubling the budget, so that’s challenging,’ said Mravčík. ‘We know the coverage and the impact is limited so far, so our challenges for the future are how to reduce barriers and increase the confidence of the target groups – especially the Roma community – because the ambulance can look too official.’ There were now plans to open DCRs in drop-centres in other parts of Brno, as well as catering for methamphetamine users alongside opioid users. ‘We’re facing the challenges and trying to ensure the sustainability of the programme – that’s the most important thing,’ he said.
DCR models had to be ‘flexible, flexible, flexible’ Aranda reiterated. ‘All of us have to have the ability to adapt to different forms, different substances, different contexts.’ Ragazza’s model had been evolving, with spaces created for smoking, extended opening hours and ‘re-thinking old rules’, said Pohler. ‘We’ve created spaces for people to sleep overnight, because poverty and homelessness are a big problem, and we’re exploring what new medical treatments we can offer.’ Funding was an ongoing challenge, along with opposition from politicians, media and some local residents, which meant the organisation was also heavily involved in networking and PR work.
Two of the key words when it came to DCRs were humanity and citizenship, Goosdeel concluded. ‘We still face problems with stigma, as well as this idea that there’s one typical drug user. This wasn’t true 30 years ago and it’s even more wrong today. There are so many different substances and so many different users, and DCRs aren’t necessarily the answer for all of them.’
This called for a renewed vision – not just for DCRs, but for harm reduction, he said. ‘It will never be enough to just talk about needle exchange or substitution treatment. But we don’t need to reinvent the wheel – we just need to integrate harm reduction to the new substances and new risk behaviours. That’s the way to design the best DCRs – as a response to a specific problem, in a specific location, with clear and achievable objectives.’