By Taylor Knopf
North Carolina Health News
February 4, 2019
GENEVA, Switzerland and PARIS, France — San Francisco came close to establishing the first drug consumption room in the United States last year.
In response to the nation’s rising number of drug-related overdoses, California state lawmakers approved the Bay Area city’s plan to open a drug consumption room as a three-year pilot program. Public health officials in San Francisco even set up a mock facility to show the community.
All plans came to a halt when California’s Democratic Gov. Jerry Brown vetoed the bill in September saying, “enabling illegal and destructive drug use will never work.”
His veto came on the heels of a warning from Washington promising “swift and aggressive action” toward any city that opened a drug consumption room. In a New York Times op-ed, U.S. deputy attorney general Rod Rosenstein wrote that “injection sites normalize drug use and facilitate addiction by sending a powerful message to teenagers that the government thinks illegal drugs can be used safely.”
“That is not the way to end the opioid crisis. Americans struggling with addiction need treatment and reduced access to deadly drugs,” he concluded. “They do not need a taxpayer-sponsored haven to shoot up.”
Meanwhile, there’s decades of evidence from several countries that suggest drug consumption rooms actually result in positive changes for drug users and the communities that host them.
Experts see drug consumption rooms (or safe injection sites) as another harm reduction tool, similar to syringe exchanges. Harm reduction strategies aim to lessen the damage caused to a person by their use of drugs.
HIV and Hepatitis C are bloodborne infections that can spread through sharing syringes. By offering drug users clean needles and supplies, it reduces the risk of disease spread. But drug consumption rooms go one step further by providing users with a safe place to use under supervision, which reduces the risk of overdose.
Harm reduction centers are also a non-judgemental, first point of contact for a group of people who are otherwise difficult to reach. Staff often give referrals to social, medical and treatment services.
Sarah, a patient at a heroin-assisted treatment facility in Geneva, Switzerland, said she first connected to treatment after visiting the local drug consumption room to inject during lunch breaks. She said she saw some attendees who appeared homeless while others dressed professionally and carried briefcases.
Sarah said she had a lot of respect for the people who worked at the drug consumption room, saying they were very understanding. Even after using heroin for decades, she said she was shocked by how violent injecting can be. Some in the drug consumption room would struggle to find a vein, and resort to injecting into an open wound, neck or groin, she said.
Switzerland was the first country to open a drug consumption room in the 1980s. The Swiss had “open-drug scenes,” high HIV infection rates and many drug overdose deaths. In 1994, the Swiss government incorporated drug consumption rooms into a comprehensive drug policy law that ultimately led to significant drops in death and infection rates.
In 2016, France opened its first consumption rooms in Paris and Strasbourg as part of a six-year pilot experiment.
French public health workers would like to open more drug consumption rooms, and there is one in the works in Bordeaux. But drug consumption rooms aren’t exactly embraced yet, especially in Paris.
How it works
The Paris drug consumption room is at the back of Lariboisière Hospital, a public facility north of the city center, near Gare du Nord one of the city’s seven main train terminals.
Drug users come directly into the room through a separate entrance, across from a corner cafe where people sit outside drinking coffee and wine at all times of the day.
Visitors must be 18 years or older and declare whether they are drug injectors or drug smokers. Inside, there are 12 injection spots and four smoking spots.
During their first visit, they must give some type of identifier in order to track the number of visitors. The facility in Paris has 1,200 registered users. They must also read and sign an agreement saying they are not allowed to share, sell or buy inside the consumption room. Staff spends 15 minutes with a first-time visitor to learn more about their drug use habits and talk about the risks of HIV and hepatitis C.
Rapid testing is available for both diseases. Consumption room staff store hepatitis C medications for people who live on the streets, so it’s not lost or stolen. About 25 percent of regular drug consumption room visitors are on hepatitis C treatment.
After checking in at the front desk and displaying the product they intend to use, visitors must wash their hands and get new syringes and supplies.
The brightly lit room has windows on one side, white tile walls and bright orange chairs. Some injection spots look like the types of desks you’d find in a library, with partial walls for privacy, and a yellow disposal bucket at each site for used supplies.
Others sites have no walls and are intended for couples who use together. If someone is used to their partner injecting them, that is allowed inside the drug consumption room as long as there is no product sharing and the injector is aware of the risks they take by injecting someone else.
They have 20 minutes to inject and then they can move to the “chill out” room, a stylish, comfy space with bean bag chairs, books and plants adjacent to the injection room. They can hang out there as long as they would like, and there is no limit to the number of times someone can visit in a day.
Medical staff is nearby in case of an overdose. There have been only three overdoses at the drug consumption room in Paris in two years.
Elisabeth Avril, medical director of the Paris consumption room, said her staff develops relationships with visitors and knows their usual doses. So if someone comes in with a higher dose on a given day, she said her staff will talk with them and ask “What’s going on?” and try to talk them into a lower dose.
Most people coming to the consumption room in Paris no longer inject heroin, Avril said.
“Heroin is finished in France,” she said, adding that most people inject morphine sulfate, buprenorphine or crack.
She explained that in the 1990s, France was “shocked by heroin,” and overdose and HIV rates were high. But in the late 90s, more and more users started using injectable morphine.
France doesn’t have a heroin-assisted treatment program, like Switzerland. One of Avril’s biggest fears are policies limiting morphine.
If morphine goes away, Avril fears something like fentanyl will enter the illegal market. “And they will die,” she said. “If you stop something, something else is coming.”
And about 150,000 people are in opioid substitution programs, which is covered through the French universal health care system.
Proof in lives saved
In 2012, the International Drug Policy Consortium compiled a briefing paper on drug consumption room evidence and practices throughout Western Europe and Canada. Public health data were collected from each country with one or many drug consumption rooms. Some common themes emerged.
Many countries reported less “injection-related litter in public spaces” after opening drug consumption rooms. HIV and hepatitis C infections also decreased.
There was a broader public awareness about drug use and harm reduction. And a few countries reported that there was a feeling of inclusion for drug users as a result of drug consumption rooms, a population that’s often alienated by societal stigma.
Two Norwegian studies found that the country’s 17 drug consumption rooms “increased the promotion of the dignity of the group in question, both generally and for the individual,” according to the briefing paper. And drug consumption rooms increased access to health and social service resources and decreased the risk of overdose death.
As in Switzerland, Germany had open-air drug scenes in its past. In 2000, Germany legalized drug consumption rooms and now there are more than two dozen across the country. A study done in the largest province of Germany from 2001-2009 found that DCR staff responded to 3,271 “drug emergencies” and there were no overdose deaths.
In the Netherlands, “public disturbance related to drug use, such as dealing and using in the streets, decreased significantly,” according to the briefing.
The tiny country of Luxembourg has one drug consumption room, and a 2009 review found that its staff successfully responded to 1,025 overdoses with no fatalities in the program’s first four years.
In Spain, drug overdose deaths decreased by 60 percent across the country in the 17 years after establishing drug consumption rooms.
And in 2010, Vancouver’s first drug consumption room had 221 overdose interventions, 3,383 clinical treatments, and 5,268 referrals to social and health services, which the briefing notes were mostly for detox and addiction treatment.
In contrast, the U.S. overdose rate has risen steadily in the past decade. According to the Centers for Disease Control and Prevention, from 2013 to 2017, opioid overdose rates rose in 35 states and the District of Columbia, claiming 47,600 lives in 2017 alone.
“The opioid overdose epidemic continues to worsen and evolve because of the continuing increase in deaths involving synthetic opioids,” wrote the authors of a CDC report published online last month.
Not in my back yard
In France, many supportive policies help drug users, including more than 400 addiction treatment facilities and more than 300 harm reduction centers.
But despite the evidence of success, the neighbors complain about drug consumption rooms.
“We have a real NIMBY problem in Paris,” said Jean-Michel Delile, president of La Fédération Addiction, the French harm reduction network made up of more than 800 members, including hospitals, sleep centers, treatment facilities and needle exchanges.
He says Paris would be better served by five or six consumption rooms, but it was politically challenging to open one.
“Between Arc de Triomphe and the Louvre, especially, they don’t want drug users,” said Delile, referring to the heavily touristed center of the city. “They are pushing them north and to the suburbs.”
He said it’s easier to convince the public of the need for a drug consumption rooms in places that once had more visible drug scenes, such as Switzerland and Germany. In those places, many see it as a win because drug users have safe places and the public no longer sees people injecting.
But in countries where citizens have no experience with open-air drug use, such as France, it’s harder to convince the neighbors that the users were actually always there.
Avril said that for 10 years, there was a mobile syringe exchange in front of the hospital before the drug consumption room opened in Paris. Staff met 2,800 different drug users each year, which is why the hospital was chosen for the facility.
But some very vocal neighbors have claimed there were never drug users in their street until the drug consumption room opened, Avril said.
“There is a small population of people that take up the war on social media,” she said.
“The people that are unhappy complain loudly to anyone who will listen, the press, the police, the prime minister.”
The area around the hospital has always had problems, Avril pointed out. It’s near Gare du Nord, one of the largest train stations in Europe, which brings with it black market activity, violence and prostitution, she said.
But the NIMBY attitude is not simply about drug-related facilities.
“Any structure you open in France nowadays, if you open for disabled people, old people, poor people, you have the same reaction,” she said. “They don’t want migrants, people with psychiatric problems, and of course they don’t want drug users.”
Avril said it feels like she’s losing the battle of public perception, even though she has the support of the city government and the police.
Some police officers will catch people injecting in the street, and instead of making an arrest, they escort them to the drug consumption room. The Paris police have done this around 1,500 times in the past two years.
More holistic approach
Delile, who lives in the more rural area of Bordeaux, hopes they will be able to open a drug consumption room there before the pilot program expires in 2022. He said there haven’t been people actively opposing it, but it’s not widely supported.
Delile thinks it would be more feasible to establish a mobile drug consumption room in Bordeaux, and that it would be more beneficial to the population, which spreads out into rural areas surrounding the city.
Right now, he said there are many North African immigrants in Bordeaux who are not well connected to harm reduction services and drug treatment. A mobile program would be helpful to go to where they live, show them how to inject safely, and build connections.
“[Drug consumption rooms] can improve our efficiency as a supplementary tool, but are not the universal solution,” Delile said.
In keeping with a more holistic approach to drug use in France, Delile said he believes that wrap around services are necessary to help users.
“The most important is the link between nurses and social workers and drug users,” Delile said. “From this point, we can build something. They want housing? They want work?”
Delile’s goal is to help them get the things they need and build trust. Later, the hope is that they will enter mental health or addiction treatment, he said.
“But these need to come as secondary offers after we start with their needs,” Delile said. “We have to start with their needs and demands, not ours.”