Getting Back To Basics

by Liz McCulloch

There have been many attempts in the UK to introduce drug consumption rooms but never before has the matter been debated in Westminster.

Ronnie Cowan, MP for Inverclyde, secured the debate last Wednesday and introduced it by laying out need and evidence. Drug-related deaths are rising in the UK and Cowan described how drug consumption rooms (DCRs) have been successful in preventing drug-related overdose deaths, reducing the acute risk of disease transmission through unhygienic injecting, connecting high-risk drug users with addiction treatment and other health and social services and improving public order by reducing public drug use and amounts of discarded needles. Drug consumption rooms are professionally supervised healthcare facilities where people can consume drugs they have purchased elsewhere in safer conditions.

He references his question posed during PMQs at the end of last year, asking that drugs laws be devolved to the Scottish Parliament to allow the establishment of a DCR in Glasgow. The Prime Minister responded that she was aware that some people in the house were more liberal about drugs than herself, but that her opinion was that “we should recognise the damage that drugs do to people’s lives” and that “our aim should be to ensure that people come off drugs, don’t go on drugs in the first place and then people keep clear from drugs”. Cowan stated in the debate that the Prime Minister, “completely misses the point. It is not about having a liberal attitude but about compassion and treatment for vulnerable people”.

The Prime Minister perceives DCRs not as a health intervention, but simply an opportunity to let people do what they want, a glorified shooting gallery sanctioned and paid for by the state. Yet DCRs exist as a consequence of the recognition that there are high risks attached to using drugs and therefore, their use should be conducted in a supervised environment where there is support on hand. There purpose is not to let people take drugs, but to reduce the harm.

The first challenge against Cowan’s call for consumption rooms comes from MP for Moray, Douglas Ross, who asks,

“Will the hon. Gentleman explain what the police’s response would be if he were to get the powers devolved? Would they be asked to ignore people in possession on their way to such venues, regardless of how far away they were?”

Cowan answers that the law would allow people to carry in their own drugs, but cannot to respond when asked by Ross “from how far” as a limit has not been defined.

The debate then hears a common criticism of DCRs, one which has been repeatedly made by this serving government. Ross states,

“The answer is not to create state-sanctioned drug consumption rooms, but to address the real issue: the consumption itself. Our efforts must be focused on getting people off these drugs. Diversions such as drug control rooms only serve to distract from that purpose, or even make matters worse”.

Ross does not see DCRs as the answer, but his underpinning assumption is that there is one approach which can address problematic substance use in the UK. Ross insinuates that by introducing DCRs, we would then be turning its back on all services whose purpose is to support people to reduce or stop using drugs.

Of course there should be services which help people ‘get off drugs’ but the sole provision of these services would not be addressing the needs of the people who are interested in stopping or reducing their drug use. Equally, as described by Cowan, DCRs are not a “magic wand” or “silver bullet” and providing DCRs alone would be insufficient.

Dr Dan Poulter, MP for Central Suffolk and North Ipswich, also raised that DCRs provide essential engagement, which can be the first step towards people ‘getting off drugs’. Ross responds by stating “I disagree that the only place in which that engagement can take place is in these drug rooms”.

Indeed, this is a fair point. Why not increase investment in needle and syringe programmes which have been proven to build relationships with people not in treatment? A local needs assessment would have to identify if needle and syringe programmes were failing to engage some groups and whether a DCR would fill this gap in provision.

Ross also makes the point that there is ‘no safe way to take class A drugs’. It is is true that there are high risks attached to using heroin and crack cocaine as they are addictive, very potent and also illegal, so potency levels and content are unknown.

However, Ross again misses the purpose of DCRs. DCRs do not claim to make drug use safe, rather the service is built on the premise that it is safer to use drugs under the supervision of a professional, than it is to do so on the street or alone in a flat. A comparison can again be made to needle and syringe programmes, which do not claim to make drug injecting safe, but rather seek to make drug injecting safer by reducing the transmissions of blood borne viruses and bacterial infections.

Grahame Morris, MP for Easington, asks Ross, “why does he believe that dangerous, private shooting galleries are preferable to drug consumption rooms?”

This question is ignored by Ross who instead moves on to quote research from Professor Neil McKeganey from the Centre for Substance Misuse.

“After surveying over 1,000 drug addicts in Scotland, the research found less than 5% said they wanted help to inject more safely, with the overwhelming majority saying they wanted help to become drugs free.”

However, the research was only conducted among people who were, at the time, in drug treatment. People not in drug treatment were not consulted, who are the incidentally the group are highest risk of drug-related death. Evidence has strongly indicated that DCRs are successful in attracting marginalised groups not in contact with services.

The debate then moves back to how a facility which permits the use of illicit drugs would be policed, when our existing rug laws prohibit their possession. Lloyd Russell-Moyle, MP for Brighton Kemptown said,

“I feel the policing issue is something of a straw man argument. If there is a centre that people are asked to go to for treatment and to abstain from drugs and stop their addictions entirely, should those people be stopped from going to the centre on the off chance that they might have drugs on them because they are addicts? Should they be followed home? Should we try to entrap them? We do not do that at the moment, so suggesting that the police would need to do that with DCRs is a straw man argument. No law is perfect, and there are grey zones, but surely it is better to work within those legal grey zones, deal with issues through dialogue with the police and save lives, than to have a system in which we have a hard and fast rule and thousands and thousands of people die.”

Discretion is a commonplace when policing drug services as people in attendance are likely to have drugs on their possession, but police are aware that targeting the people who attend these services would have a detrimental impact on public health.

The difference, however, between DCRs and other drugs services is that in a DCR, people are permitted to use drugs on site. In response to Russell-Moyle’s statement, Ross said,

“There is a reasonable concern that, if someone in the vicinity of a drug room is stopped and searched and found to be in possession of something like heroin, they could say they are on their way to the drug room and may therefore not be charged. That is why the Lord Advocate in Scotland was not able to give his permission for the example in Glasgow.”

Volteface contacted Rudi Fortson QC, barrister, and Visiting Professor of Law Queen Mary University of London, to ask what whether this was indeed a valid concern. Fortson stated,

“It is doubtful that this formed a significant part of the Lord Advocate’s reasoning. Such a view would not be well-founded. Without statutory provision, it would not be a defence for a person in unlawful possession of a controlled drug to say that ‘I was on my way to a Drug Consumption Room’. However, it has never been the law of the UK that every violation of the criminal law that comes to the attention of the police, must be prosecuted to conviction. The police and prosecuting agencies have discretion in the exercise of their powers. It is a discretion that they exercise every day. DCRs exist in the interests of public health as well as the well-being of drug users – a fact not lost in countries where such facilities exist with the cooperation of the police and other agencies.”

A DCR does not offer legal protection against possession outside of the facility, but equally is should be expected that police will operate under discretion and in the interest of public health.

Crispin Blunt, MP for Reigate, brings the debate back to the evidence by highlighting thatalthough thousands of overdoses have occurred in DCRs, no one has ever died of an overdose in a DCR. However, Ross makes the argument that it ‘does not mean that no one who has used a drug consumption room has died as a result of drug taking’. As some people will not go to a DCR every time, there will inevitably be incidents where people fatally overdose outside of a DCR. Ross’s point is that DCRs should not be introduced as they will “only” save some lives, not all lives. The bar is not set as high for other drug services. For example, there will be people who use needle and syringe programmes but who will still sometimes share needles and may consequently become injected with HIV. However, the claim is not commonly made that needle and syringe programmes are redundant as some people who use the service still become infected with HIV.

The final case that can be made against DCRs is that people will not want one in their local community and especially not one next door. However, Russell-Moyle argues that,

“the reality is that they are in people’s backyards—quite literally. I remember canvassing up flights of stairs in tower blocks, and people were shooting up right in front of me.”

Bristol West MP, Thangam Debbonaire, added

“we already have a drug consumption room in Bristol: it is called Bristol. It is called the square outside my office, the doorstep into my office and the blocks of council flats at the side of my office. It is called virtually every part of the city centre.”

MP for Glasgow Central, Alison Thewliss invited the Minister to come to her constituency to see how people are living,

“she could then see whether she would like to put up with what my constituents put up with every day, or whether she would find it acceptable for somebody she cared about to drop their trousers and inject heroin into their groin in a manky back court surrounded by excrement and contaminated needles.”

The debate finishes with words from Carolyn Harris, MP for Swansea East, who concludes,

“in an ideal world, no-one would take those harmful substances, but we do not live in an ideal world. Therefore, we cannot base life or death decisions on ideology. We have to go with what works. If the evidence is clear that drug consumption rooms prevent overdose deaths and the spread of disease, we at least need to trial them”.

The room now turns to Home Office Parliamentary Under-Secretary, Victoria Atkins, who responds with a clear opening statement,

“We have no intention of introducing drug consumption rooms, nor do we have any intention of devolving the United Kingdom policy on drug classification and the way in which we deal with prohibited drugs to Scotland”.

However, it then becomes apparent that the Minister has been poorly briefed on the subject of the debate as she explains her rationale.

“There has been a certain naivety in some of these arguments about what these international gun-toting criminals will do if we, the UK, regulate prohibited drugs. They are not going to run away and study university degrees and lead law-abiding lives. They are going to find ways of undercutting the regulated market, which presumably the hon. Gentleman is calling for, with prices. They will find ways of getting to their addicts. They will still continue their awful trade; it is just that under the hon. Gentleman’s model, as I understand it, it will be the taxpayer who is helping to pay for some of the drugs that we are against.”

The Minister’s response is frankly bewildering and completely irrelevant. The room is not proposing to regulate prohibited drugs, nor is the state paying for or providing drugs. DCRs do not exist to disrupt drug markets, they are a health intervention which is  targeted towards people who are already using and purchasing illicit drugs, much like needle and syringe programmes.

The Minister also confuses the purpose of DCRs. Similarly, to the Prime Minister, her understanding is that “their purpose is to provide a place where illicit drugs that have been bought in the local area are then consumed in a place funded either by the taxpayer or charities”. This is the service they provide, but their purpose to improve the health of people who use drugs.

Her objections also stem from the view that DCRs are incompatible with the UK Drug Strategy as they recovery is an optional part of usage, rather than the sole purpose of it. If we interpret recovery as the Minister is likely to interpret it; as reducing or stopping the use of drugs, then the Minister is neglecting that needle and syringe programmes that operate in the UK place no obligation that its service users reduce or stop using drugs. The Drug Strategy published under this government advises that availability of needle and syringe programmes should be maintained.

The Minister is also ignoring the evidence from robust literature reviews, which have concluded that DCR attendance is associated with an increase in diverse types of dependence care, such as referral to an addiction treatment centre, initiation of a detoxification programme and initiation of methadone therapy. By building relationships with marginalised groups not in contact with services, DCRs provide a pathway into treatment.

The Minister then moves onto the international experience of DCRs. She comments that,

“Canada has kept its provider, Insite, not because of the evidence that the services provided by Insite work, but because the users of Insite brought two court actions, and the Canadian Supreme Court ordered the Minister who wanted to close them to grant an exception to Insite in order to respect the constitutional rights of facility users and staff. I read that, with my legal hat on, not as an endorsement of the effect of DCRs but as a constitutional issue.”

This statement severely misrepresents the case. The Supreme Court’s decision to keep Insite open was because of facilities effectiveness at keeping people alive. The court concluded that were Insite to be shut,

“This deprives the clients of Insite of potentially lifesaving medical care, thus engaging their rights to life and security of the person.”

The court’s decision to allow Insite to continue to operate was made because,

“Insite saves lives. Its benefits have been proven. There has been no discernible negative impact on the public safety and health objectives of Canada during its eight years of operation…The effect of denying the services of Insite to the population it serves is grossly disproportionate to any benefit that Canada might derive from presenting a uniform stance on the possession of narcotics.”

The Minister then states “there is one room open in Catalonia for one hour a day from Monday to Friday”, alluding that the reason there has never been a death in a DCR is because there are few facilities, which are barely open enough to be used. It is firstly incorrect that there is only one facility in Barcelona as a Catalonian paper from 2015 reports that 12 DCRs operate in the region. The opening hours of the Catalonia example is also atpyical and not reflective of the DCRs which operate across the globe. The Barcelonan hospital based DCR, CAS Val d’Hebron, is open Monday-Friday 8:00-20:00, the Hamburg Staying Alive Project is open 12:00-19:00 Monday to Friday and the Sydney Uniting Medically Supervised Injecting Centre is open all week, typically 12 hours a day. If DCRs are placed within the vicinity of an existing drug using population, its services are well used, with Insite reporting in 2016 that it had 214,898 visits by 8,040 individuals and delivered 1,781 overdose interventions.

The Minister’s final objections to DCRs are that,

“We do not know, because nobody has done the research yet, what happens to addicts when they leave DCRs. DCRs are not residential. Addicts are there for a number of hours. We do not know what happens when ​they leave those clinics and walk down the street. We do not know the impact. As we have heard, they are not there every single day. This is not a regular form of treatment, and that is precisely why I will now turn to the drug strategy.”

It is not clear what the Minister is alluding to as she does not explicitly outline what her concerns are, but she is incorrect that we do not know what happens when people leave a DCR. We know they are less likely to share syringes, due to the promotion of enhanced health education. We know they spend less time in hospital as the facility provides improved access to primary care. And we know they are less likely to be injecting in public or inappropriately disposing of needles and syringes, as a consumption space is being provided with safe disposal facilities.

Whether or not a DCR exists, people will still be using drugs. The question is whether the consumption takes place down an alleyway or under the supervision of professionals, who can offer support and pathways into other health and social care services.

The Minister also curiously frames the model as high risk because it is not residential and does not oblige its users to attend every single day, but these comments reflects a lack of understanding of how the majority of drug services operate in the UK, most of which are non-residential and whose service users typically attend every one or two weeks.

The quality of the Minister’s responses display a worrying lack of knowledge on the issue at hand.

The best laid criticisms against DCRs come prior to the Minister’s response, when reference was made to a statement by the Lord Advocate, that travel to a DCR could be used as a defence against possession charges. MPs did not confidently respond that this would not be a valid defence, indicating that policing is a subject which requires further consideration among advocates. It is interesting that the legality of DCRs was not raised once during the debate.

However, before any proper debate can be had on DCRs, we must be clear on two matters: what DCRs actually do and what the UK is already offering. There was confusion over what was being proposed, with the Minister alluding to the regulation of prohibited drugs, and different interpretations given of the purpose of DCRs. Some members of the house were of the view that the end goal is to provide a space for people to use drugs and centred their criticisms on this premise, whereas, in fact, DCRs are an intervention whose purpose is to improve the health of people who use drugs. There is also a disconnection from drugs services that currently operate in the UK, with DCRs framed as a significant departure, when in reality they are an extension of current service provision.

Meanwhile, the pressure outside of Westminster is mounting and it will not be long until the issue comes to a head. Last week, Southampton councillors were debating whether DCRs should be considered as an intervention for reducing drug-related litter and repeated calls have been made by the North Wales Police and Crime Commissioner for DCRs to be introduced in Wrexham. Scotland are currently seeking devolved powers over drug laws to allow a DCR to operate in Glasgow. Numerous other discussions are likely to be taking place at the local level, outside of the public eye.

The debate reflects a willingness to talk openly about the possibility of DCRs operating in the UK. However, if we are to move forward on DCRs we must return back to basics, a common understanding of what they are, what purpose they serve and how compatible they are with the UK’s current approach to drugs.

To read the full debate, please click here

Liz McCulloch is Policy Advisor at Volteface. Tweets @mccullochlizzi1 

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