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Kinnard E.N., Howe C.J., Kerr T. et al.
Harm Reduction Journal: 2014, 11:29.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Kinnard at Elizabeth_Kinnard@brown.edu.
According to clients of this Danish drug consumption room, access to a safe injecting facility reduced their public injecting and unsafe syringe disposal.
Summary A mobile safe injecting facility opened in Copenhagen (Denmark) in 2011 followed by a building-based (non-mobile) facility in 2012 for people to inject illicitly obtained drugs under the supervision of healthcare professionals, and access other related services. The law had been amended to allow such facilities to operate, including provisions which instructed police and prosecutors not to search, seize, and prosecute users who were in possession of “small quantities” of controlled substances for personal use “in and nearby” safe injecting facilities.
Clients using a Danish safe injecting facility were invited to participate in a study about their injecting behaviours and practices.
Most reported less rushed/stressful injections, less public injecting outdoors and no longer sharing needles after the facility opened.
As a public health intervention, the facility successfully reached people engaging in high-risk behaviours.
The building-based facility opened in the Vesterbro neighbourhood, where drug dealing and public injection drug use have historically been concentrated. Users of the safe injecting facility were restricted to injecting inside, but were permitted to smoke or sniff illicit drugs in the designated outside area, “thus, Danes often refer to the greater health facility as a more all-encompassing drug consumption”. The research team of the featured paper approached people who were sat in the outside area, to ask if they would be willing to take part in a study about their injecting behaviours and practices. They hypothesised that risky injecting behaviours (eg, syringe sharing) and unsafe syringe disposal (eg, dropping used equipment on the ground) would decrease after using the facility. Only those who reported having injected drugs at that facility at least once since its opening were eligible to participate.
Between February and August 2013, 41 people were interviewed. Most were male (90%) and under 40 years old (61%). When asked about their current housing situation, eleven people reported being homeless (27%), 12 in temporary housing (29%), and 18 in a permanent residence (44%). For 25 (61%) their primary injecting location before the facility opened was outdoors (eg, street, park, parking lot), followed by their own dwellings (56%), someone else’s house (39%), and a public washroom (39%) (participants could choose more than one option).
Most (61%) reported using the facility at least once a week. Cocaine was the most frequently used drug at the facility, reported by 30 participants (73%), followed by heroin, reported by 25 participants (61%). The number of people who reported disposing of their used syringes by returning them to the needle exchange or safe injecting facility increased from 14 (34%) before the facility opened to 36 (88%) after it opened. The only unsafe disposal method that was still reported by participants after the opening of the facility was throwing syringes in the garbage, but this behaviour decreased from 23 participants (56%) before to five participants (12%) after its opening. All other unsafe methods (eg, dropped on the ground, gave to another user, flushed down the toilet) were reported infrequently before the facility opened, but not reported at all after it opened. In total, 24 people (59%) reported changing their syringe disposal practices following the opening of the facility, of whom 23 (96%) reported changing from not always disposing safely to always disposing safely, while only one person (4%) reported the reverse change.
Three-quarters (31 people or 76%) believed their behaviours had changed since using the services at the safe injecting facility. Compared with their behaviours before the facility opened, 26 (63%) reported less rushed/stressful injections, 23 (56%) reported less injecting outdoors, 22 (54%) reported no longer sharing needles, and 18 (44%) reported cleaning the injecting site on their skin more often. Most (66%) did not feel that their frequency of injecting had changed, but five (12%) reported a decrease in injecting frequency, while only two (5%) reported an increase.
This study adds to evidence about the effectiveness of drug consumption rooms, finding that use of a building-based safe injecting facility in Copenhagen was associated with safer injecting (eg, less rushed/stressful injections, less injecting outdoors, and no longer sharing needles), and practices that benefited the local area (eg, safer syringe disposal). The facility successfully reached people engaging in high-risk behaviours and did not lead to an increase in overall frequency of injecting.
commentary The featured report reinforces a large body of evidence suggesting that safe injecting facilities (also known as drug consumption rooms) help to reduce public injecting and associated harms – a topic explored in detail in a recent Effectiveness Bank hot topic.
The study investigated changes in self-reported injecting behaviours and practices among a small group of people accessing the (then) newly opened safe injecting facility. The methodology had some limitations, described below. Because of time constraints the researchers used a convenience sampling approach to recruit participants, inviting clients sat outside the facility during a specific period to take part. Of the people who researchers spoke to, and who agreed to participate, the majority were men. Compared with a survey of clients in another facility, it appears that women were under-represented in this sample (10% versus 30% female participants). As the authors themselves say, the results therefore “may not capture the true lived experiences and behavior changes of women who use the [safe injecting facility]”. Participants were surveyed at one point in time, asking them to recollect injecting behaviours and practices before the facility opened – a less reliable way of capturing what happened than asking at the time or close to the time. The survey was also not delivered uniformly to all participants, it was either self-administered or read aloud by a research assistant, and delivered in either English or Danish. It is conceivable that when asked by research assistants, participants could have felt inhibited from giving true answers to sensitive questions (particularly when concerning stigmatised behaviours). It is also possible that neither English or Danish were the first language of clients, constraining their answers – particularly as many visitors to drug consumption rooms in Copenhagen have reportedly been from a nearby region in Sweden (before additional border and passport controls were imposed in the summer of 2015, Copenhagen could be reached in 30 minutes by train). Two main reasons for this have been identified: firstly, better-quality heroin Swedish visitors to Copenhagen say that the quality of (white) heroin available there is superior to the (brown) heroin in Sweden, and the price lower. available on the Copenhagen illegal drug market; and secondly since the opening of the drug consumption rooms in Copenhagen, a more attractive, accessible, humane treatment environment than in Sweden. Given this local context, it may have been beneficial/appropriate to add Swedish to the languages used to survey and interview clients.
The context for the emergence of safe injecting facilities in Denmark was elaborated on in another paper. It explained that (much like in the United Kingdom) politicians and health authorities had resisted drug consumption rooms, despite growing numbers of people dying from overdoses, and other harm reduction strategies not making a substantial impact. But then, “in an act of civil disobedience, in 2011, Danish NGOs [non-governmental organisations] bought two old ambulances and opened the first mobile drug consumption rooms with nurses and doctors volunteering their professional services”. In 2012, the law was changed to allow drug consumption rooms. The political motivation was “to reduce the number of deaths by overdose, to improve life situations for people who use drugs by building bridges to the healthcare system, drug treatment facilities and social services, and to reduce the nuisance of public drug intake to surrounding neighbourhoods”. In Denmark, momentum for drug consumption rooms has been built largely from the grassroots up. Instrumental in this was the Danish Drug Users Union (BF), representing people who are currently or actively using drugs, with objectives to further the social and health interests of drug and methadone users.
As of February 2016, there were five drug consumption rooms across three cities in Denmark. A qualitative study involving observation of and interviews with clients and staff across all five found that an attitude of acceptance from staff fostered a “welcoming and humanizing [… and] friendly climate” and created a “safe haven from the often chaotic environments which [… people who inject drugs] tend to face outside on the street”. This characteristic was perceived to pave the way for the successful prevention of overdose, for steering clients towards social and health care services, and for taking a step towards the de-marginalisation and de-stigmatisation of vulnerable and marginalised people.
The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) concluded in 2004 that drug consumption facilities are able to reach and maintain contact with high-risk drug users who are not ready or willing to stop using drugs, and found no evidence to suggest that they compromise the safety and security of drug users (or others) by increasing drug use, frequency of injecting or local drug-related crime. Their conclusion was based on evaluations of an ever-growing number of drug consumption rooms – 74 counted in Europe by the EMCDDA in May 2016.
But whilst the pool of evidence is quite large, doubts have been cast over its quality. Evaluations of drug consumption rooms tend to be conducted in real-world environments, as opposed to (what is considered) the ‘gold standard’ randomised controlled trial which randomly assigns participants to an intervention versus an alternative intervention or no intervention at all. A methodological challenge for researchers, therefore, is separating out the impact of safe injecting facilities from other services that people who inject drugs may use (and may even be facilitated to use through drug consumption rooms), and from other factors not under their control. And presumably a challenge for policymakers is to not let “the methodological problems involved here […] detract from [drug consumption rooms’] considerable success”. On balance, these services have been shown to have a positive impact on the health of their clients, ensuring (relatively) safe and hygienic injecting in the facility, providing personalised advice and information on safe injecting practices, recognising and responding to emergencies, and providing access to a range of other on-site and off-site interventions and support.
Thanks for their comments on this entry in draft to Blaine Stothard, an Independent Consultant in Health Education. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 13 December 2016. First uploaded 17 November 2016
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