Drug Consumption Rooms: A Welsh Response · Drug Consumption Rooms: A Welsh Response 4 1....

Drug Consumption Rooms:

A Welsh Response

Rob Barker-Williams

Winston Churchill Memorial Trust

Fellowship 2017

Drug Consumption Rooms: A Welsh Response

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Copyright © December 2017 by Rob Barker-Williams. The moral right of the author has been asserted. The views and opinions expressed in this report and its content are those of the author and not of the Winston Churchill Memorial Trust, which has no responsibility or liability for any part of the report


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Contents Page

1. Acknowledgements 4

2. Abbreviations 5

3. About the author 6

4. Executive Summary 7

4.1 Background 7

4.2 Aim and objectives of the Fellowship 8

4.3 Recommendations 9

5. Introduction – What are Drug Consumption Rooms? 10

6. Setting up a Drug Consumption Room 11

6.1 Needs analysis 11

6.2 Legality 13

6.3 Key partnerships 13

6.3.1 Peer involvement 14

6.4 Consultation 15

6.5 Media and Key messages 15

6.6 Challenges and solutions 16

7. Operations 18

7.1 Different models of a Drug Consumption Room 18

7.2 Location 20

7.3 Staffing 20

7.4 Administration of substances 21

7.5 Opening times 22

7.6 Accessing the Drug Consumption Room 23

7.7 Operational policies 24

8. Effectiveness of Drug Consumption Rooms 25

9. Miscellaneous learning from the Fellowship 26

9.1 Dealing with the fentanyl crisis in Canada 26

9.2 Good Samaritan Drug Overdose Act 28

10. Recommendations 28

11. References 30

12. Appendix 33


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1. Acknowledgements

First and foremost, I would like to thank the Winston Churchill Memorial Trust for awarding

me a Travelling Fellowship and allowing me to experience a once in a lifetime opportunity.

The hope is that my findings from my Travelling Fellowship will benefit some of the most

marginalised and vulnerable individuals within our society.

I would also like to thank numerous individuals that took time out of their busy work

schedules to meet with me while completing my Travelling Fellowship, or signposted me on

to the appropriate individuals. Without these people, the completion of this project would

not have been possible.

UK: Ifor Glyn (previously of Drugaid Cymru) and Caroline Phipps (Drugaid Cymru) for

allowing me 5 working days to go towards completing my Fellowship as well as encouraging

me to undertake this research. Also for the opportunity to visit other key organisations (Ana

Liffey, Dublin) and Drug Consumption Rooms (Barcelona) separate to this Fellowship, in

work time. Service users of Drugaid Cymru who completed an anonymous survey regarding

injecting behaviour and their perceptions of Drug Consumption Rooms.

Toronto: Shaun Hopkins (The Works); Jason Alternberg (South Riverdale Community Health

Centre); Susan Shepherd (Toronto Drug Strategy/ Toronto Public Health); Jann Houston

(Toronto Public Health); Donna May (mumsDU).

Vancouver: Miranda Compton (Vancouver Coastal Health); Shannon Riley (Vancouver

Coastal Health); Professor Jane Buxton (British Columbia Centre for Disease Control); Tim

Gauthier (Insite); Hugh Lampkin (VANDU); Kevin Yake (VANDU).

Victoria: Dr. Bruce Wallace (Centre of Addictions Research BC, University of Victoria); Kate

Vallance (Centre of Addictions Research BC, University of Victoria); Amanda Farrell-Low

(Centre of Addictions Research BC, University of Victoria).

Seattle: Dr. Jeff Duchin (Health Officer of Public Health, King County); Dr. Caleb Banta-Green

(University of Washington); Karen Hartfield (Health Services Administrator, HIV/ STD

Program Public Health, Seattle and King County); Steve Gustaveson (Department of

Community and Human Services, King County); Brad Finegood (King County Behavioural

Health and Recovery Division); Patricia Sulley (Public Defence Association); Kris Nyrop

(Public Defender Association).

Calgary: Claire O’Gorman (Safeworks); Leslie Hill (HIV Community Link).

Copenhagen: Ivan Christensen (Maendenes Hjem); Michael (Maendenes Hjem); Louise

Mortensen (H17); Maria (H17).

Hamburg: Tobias Arnold (Staying Alive Project); Lisa and Dorothee (Staying Alive Project);

Olivia Deobald (Ragazza e.V.); Gudrun Greb (Ragazza e.V.).


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2. Abbreviations

AM Assembly Member(s).

APoSM Advisory Panel on Substance Misuse.

BBVs Blood Borne Virus(es).

BCCDC British Columbia Centre for Disease Control.

CHELs Community Health Engagement Locations.

DCR Drug Consumption Room.

DRD Drug-Related Death.

DTES Downtown East Side.

EHRC Enhanced Harm Reduction Centre.

EMCDDA European Monitoring Centre for Drug and Drug Addiction.

HCV Hepatitis C Virus.

IDU Injecting Drug Use(r).

MP Member(s) of Parliament.

NPT Neath Port Talbot.

NSP Needle Syringe Programme.

OD Overdose.

OPS Overdose Prevention Site.

OST Opioid Substitution Therapy.

PCC Police and Crime Commissioner.

PQWCHC Parkdale Queen West Community Health Centre.

PWUD People Who Use Drugs.

SCS Supervised Consumption Services.

SIS Supervised Injecting Services.

SRCHC South Riverdale Community Health Centre.

THN Take Home Naloxone.

TOSCA Toronto and Ottawa Supervised Consumption Assessment.

UK United Kingdom.

http://ctchc.org/


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USA United States of America.

VANDU Vancouver Area Network of Drug Users.

VCH Vancouver Coastal Health.

WCMT Winston Churchill Memorial Trust.

3. About the author

Since gaining a BSc Psychology degree from Bangor University in 2008 and an MSc Addictive

Behaviours degree from University of Liverpool in 2010, I have worked in the substance

misuse field in Wales. Since entering the world of drug and alcohol treatment seven years

ago, I have predominantly been based in Swansea, firstly at Sands Cymru, but more recently

at Drugaid Cymru, since the two organisations merged in January 2016. I have held many

positions over the last seven years from a Young Persons support worker and a Training

Coordinator to various Service Manager positions, including my most recent managerial

post in Cwm Taf. I am extremely passionate and interested in drug policy reform including

the implementation of Drug Consumption Rooms within the UK and the legal regulation of

current illicit substances. I also have a keen interest in other developments within substance

misuse treatment services that help to reduce various social issues including the stigma

faced by people who use drugs and drug-related deaths.

@RobBarkerW

robbwsite.wordpress.com

Email: [email protected]

mailto:[email protected]


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4. Executive Summary

4.1 Background

In 2016, Drug-Related Deaths (DRDs) in the UK hit record levels again, surpassing the

“highest since records began” figure in 2015. In total, 3,744 individuals passed away from a

drug poisoning death involving legal or illegal substances in 2016. In Wales, DRDs were

steadily declining on an annual basis until 2015 when 238 people died as a result of using a

legal or illegal drug, an increase on the 2014 figure. Fast forward a year and this figure rose

to 271. The proportion of deaths associated to opioids in Wales were 50% higher than that

in England in 2016. Breaking this down further within Wales, Neath Port Talbot (NPT)

recorded the highest per 100,000 people in relation to DRDs at a rate of 11.6. A total of 46

individuals lost their lives in NPT. Swansea was the second highest locality in Wales with a

rate of 9.7 DRDs per 100,000 people. Despite this, Swansea recorded the highest number of

fatalities in any locality with Wales, with a total of 67 people tragically losing their lives due

to substance use (Office for National Statistics, 2017).

The Take Home Naloxone (THN) was introduced in Wales in 2009. Naloxone is a substance

that can reverse the effects of an opioid overdose (OD). Currently in Wales, the kits

dispensed are in the form of an intramuscular injection. This has been a pivotal harm

reduction measure that has seen over 10,500 kits being issued since its inception in July

2009 and over a 1000 of these kits being used in drug poisoning situations. However, more

work needs to be done to get naloxone out into the community and to those most at risk of

being victim to a fatal opioid OD. There are an estimated 25,767 opioid users in Wales, yet

just under 5,000 unique individuals have been supplied with the opioid OD antidote

(Morgan & Smith, 2016).

With growing concerns around the rate of DRDs in Wales, as well as the continuation of

frequent non-fatal overdoses occurring in and around 3rd sector organisation such as drug

and alcohol services and homeless projects, a Welsh national steering group was set up in

May 2016. The group has subsequently been called the ‘Enhanced Harm Reduction Centre’s

(EHRC) Steering Group’. The group consists of representation from various 3rd and statutory

sector substance misuse treatment providers; housing providers; substance use legal expert;

Public Health Wales; University of South Wales; representatives of various welsh Police and

Crime Commissioners (PCC); medical consultants; and service users. This group is currently

looking at the need and feasibility of Drug Consumption Rooms (DCRs) within Wales as a

development of current services to help deal with issues such as discarded drug

paraphernalia on the streets, Blood Borne Virus (BBV) rates and the rising DRD statistics.

Alongside this group, the Advisory Panel on Substance Misuse (APoSM) have also

established a working group that is currently researching the effectiveness of DCRs in

relation to reducing the impact of such issues. APoSM advise the Cabinet Secretary for

Health and Social Services in the Welsh Government on substance misuse related matters.

Various countries have since established DCRs as part of the services they provide within

substance misuse treatment. At time of reporting, 123 DCRs operate, with the majority


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based within Europe (European Monitoring Centre for Drug and Drug Addiction). Such

evidence relating to their effectiveness in achieving its aims have been highly positive thus

the reason for Wales looking at the feasibility of introducing them to currently established

drug and alcohol services.

A recent survey (appendix 1) has been conducted at various needle syringe programmes

(NSP) within Drugaid Cymru, which found that out of the 47 individuals that completed the

questionnaire, 47% responded as to having shared injecting equipment with another

person. Also, 65% had used unclean or old injecting paraphernalia. Out of 47 responses,

55% had answered yes to having injected in public (i.e. on the streets), while 53% had

disclosed that had injected in a public facility, such as a toilet in a coffee shop. Many had

disclosed that they had overdosed within these environments, 35% and 40% respectively,

while many more, 83%, had responded yes to having witnessed injecting drug use either in

public or in a public facility. Despite these statistics, the minority, 28% responded yes to

ever having discarded injecting paraphernalia in public. However, drug litter is still visible in

various places in different towns and cities across Wales, evidenced by the pictures below

that were taken in Swansea.

Picture 1 + 2. Clear evidence of injecting drug use at the back of a house in Swansea city

centre

Such statistics and anecdotal information has led me to look at alternative provisions that

have been evidenced in helping deal with the various issues already mentioned.

Consequently, my interest in DCRs grew which in turn led me to conducting my Winston

Churchill Memorial Trust (WCMT) Fellowship on this topic.

4.2 Aim and Objectives of the fellowship

The overall aim of the fellowship was to gain a greater understanding around the process of

establishing a DCR and how this can then be applied to conducting such developments

within the harm reduction approach to substance misuse in Wales. The learning objectives

of my fellowship are as follows:

1. Learn from established DCRs with regards to the process of setting up a facility.

2. To analyse the effectiveness of DCRs in relation to reducing street drug use and

minimizing harm to users, communities and the economy.


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3. Discuss challenges posed in Wales and UK, and identify how the same or similar

obstacles were overcome by established DCRs.

4. Discuss and identify partnership development with key stakeholders that established

DCRs fostered in the development, and current delivery of, the facilities and transfer

this knowledge to those partnerships needed in Wales and the UK.

5. To formulate a strategic plan within the DCRs steering group in Wales based upon

the evidence gained from the Fellowship in accordance with the Welsh Government

Delivery Plan 2016 - 2018.

To obtain the relevant information I travelled to the following places to gain related

information in accordance to the objectives above:

Toronto, Victoria, Seattle and Calgary: At the time of visiting, these cities did not have an

operational DCR in place and were in the process of establishing such facilities. The aim of

visiting these cities was to learn about the processes they have gone through in relation to

working towards establishing a DCR including the partnerships developed to make it as

smooth a process as possible with the optimum potential to achieving their goals.

Vancouver, Copenhagen and Hamburg: All three cities have established DCRs already in

place. The main objective of visiting these cities was to learn about the operational side of

facilitating such a service, what model of DCR was in place and how they ensure the service

remains functional, sustainable and achieve its aim and objectives.

4.3 Recommendations

Following the conclusion of my Fellowship, the subsequent recommendations have been

made and will be discussed in more detail throughout the remainder of the report

1. The need of a DCR is to be significantly evidenced and if established, located in an

area where public substance misuse is already occurring.

2. To identify and develop partnerships with key stakeholders who have a vested

interest in health and social care.

3. To facilitate directed consultations with various stakeholders including local business

owners and residents.

4. To involve individuals who currently use established drug and alcohol services in the

planning of setting up DCRs.

5. Develop 5 key messages that are emphasised every time the subject of a DCR is

discussed with key stakeholders and the media.

6. Provide documents to key stakeholders and the public raising awareness about what

DCRs are and the aim and objectives of such facilities.

7. Provide accessible and rapid turnaround drug testing.

8. Develop a Welsh Good Samaritans Drug Overdose Act.

9. Establish multiple DCRs in Wales, ideally attached to established drug and alcohol

treatment services.


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5. Introduction - What are Drug Consumption Rooms?

Drug Consumption Rooms (DCRs) can go by multiple names including: Medically Supervised

Injecting Centres (MSIC); Supervised Injecting Facilities; Supervised Injecting Services;

Community Health Engagement Locations (CHELs); and what they intend to be called in

Wales, Enhanced Harm Reduction Centres (EHRCs). For the simplicity of this report, I will

only use the DCR terminology, that will encapsulate all the other names.

DCRs have been a part of the harm reduction movement within the substance use field

since the mid 1980’s with the first such facility opening in Bern, Switzerland in 1986. Of the

123 DCRs that are currently operational worldwide, the majority are based within Europe.

Australia and Canada are the hosts to DCRs outside of Europe. Closer to home, discussions

regarding establishing a DCR in both Dublin and Glasgow are ongoing.

Picture 3. Locations of DCRs throughout Europe. Source: European Monitoring Centre for

Drug and Drug Addiction (EMCDDA).

Within a DCR, people can use illicit drugs under the supervision of trained staff. The way

these drugs can be administered depends on the model of the DCR; some facilities only

allow injecting whereas others also provide areas for inhalation of substances. Different

services may be available at other DCRs, with further explanation in section 7.1 but all DCRs

provide clean equipment for people to administer their substances (e.g. needles, syringes,

cookers etc). Most DCRs also provide naloxone on site (legislation permitting).

The aim of DCRs are as follows:


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1. Reduce morbidity and mortality by providing a safe environment for more hygienic

use and by training clients in safer use.

2. Seek to reduce drug use in public and improve public amenity in areas surrounding

urban drug markets.

3. Promote access to social, health and drug treatment facilities.

4. Reduce the acute risks of disease transmission through unhygienic injecting, prevent

drug-related overdose deaths and connect high-risk drug users with addiction

treatment and other health and social services.

5. Contribute to a reduction in drug use in public places and the presence of discarded

needles and other related public order problems linked with open drug scenes.

Source: EMCDDA

6. Setting up a Drug Consumption Room

6.1 Needs analysis

It is vital that any potential DCRs to be established are based upon a significant level of

need. DCRs have been established due to various reasons such as high levels of street

injecting within a certain location; high levels of Blood Borne Virus (BBVs) transmissions

within injecting drug user (IDU) cohorts and rising drug-related deaths (DRDs).

Subsequently, before initiating action plans for the potential development of a DCR, the

reasoning behind such discussions need to be clear to all.

As already mentioned, DRDs have been on the rise in Wales for the last two years and

overall, these statistics are at their highest since records began throughout England and

Wales. It is also estimated that half of all people who inject drugs in Wales are Hepatitis C

(HCV) positive (Public Health England, 2015). These statistics in combination with visible

evidence of drug litter on the streets in various cities (picture 1 + 2), led to a consensus

between various professionals working within substance misuse and associated fields, that

there is a need for additional effective services to reduce these issues. One such option

discussed was the potential establishment of a DCR in Wales leading to the EHRC steering

group to be established. This group is committed to reducing the harms associated with

substance misuse and recognising that a DCR should be part of an overarching harm

reduction approach to substance misuse in Wales. The main aim of this group is to establish

whether there is a need for DCR provisions in Wales. The needs assessment (appendix 2),

developed by Katy Holloway (University of South Wales) for the EHRC steering group, has

identified an approach to examine the extent to which the issues need to be addressed

including: fatal and non-fatal overdoses; BBV rates; unsafe injecting practices; engagement

in treatment, health and welfare services; public drug use; publicly discarded injecting

equipment; relationships between drug agencies and local residents; stigma towards people

who inject drugs; and improving physical and personal safety of users.

One example of a best practice ‘needs analysis’ was compiled by Toronto and Ottawa

Supervised Consumption Assessment (TOSCA) Study in 2012. The TOSCA study identified

and examined key factors when considering establishing a DCR that used various methods


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to analyse the need including qualitative research methods to explore attitudes toward DCR

facilities; survey data to characterise the epidemiology of drug use and the health of people

who use drugs (PWUD); geographical analysis to determine the distribution drugs in various

locations; and mathematical modelling in the form of cost-effectiveness analysis to compare

the cost of an intervention with its potential benefits. Due to the rising fatalities associated

to substance use, in particular, opioids, Toronto Public Health published their Overdose

Action Plan in March 2017, which includes a 10-point overdose prevention and response

strategy. Within this is the establishment of DCRs as well as drug checking programs and on

demand treatment (Shepherd & Caldwell, 2017).

Three locations have been identified so far in Toronto: Toronto Public Health/The Works, South Riverdale Community Health Centre (SRCHC) and Parkdale Queen West Community Health Centre (PQWCHC). The Works coordinates 46 satellite agencies to deliver NSP, of which the SRCHC and PQWCHC are two of these. Between the three of them they account for 75% of all needle exchange transactions throughout the city. The Works, on average, see over 1000 client visits every month and last year provided 2.3million needle exchange transactions, a jump from the 800,000 in 2013. Intranasal naloxone, an opioid overdose antidote, is also available for people who use drugs as these locations. So not only is the trend of IDU seen to be increasing as well as the reported fatal OD, but the establishment of DCRs are seen the next progressive step within the harm reduction initiative within Canada’s largest city. At the backend of 2016, a coalition was set up in Alberta that included professionals from Safeworks, HIV Community Link, police force, municipality government, service users and the Medical Officer for Health, to name just a few. This group was set-up in response to growing trends associated with opioids, especially fentanyl, a potent opioid which resulted in a total of 19,000 ODs and 363 DRDs (associated only to fentanyl) throughout Alberta last year. In the first 6 months of 2017, there were a total of 246 DRDs associated with fentanyl, highlighting that this matter is only getting worse (Alberta Government, 2017). Calgary was the hotspot for these statistics resulting in a recent needs assessment carried out by the Alberta Coalition to recommend multiple DCRs, alternatively known as Supervised Consumption Services in the province, to be established in Calgary (Potkins, 2017). The needs assessment is similar to the one currently being conducted in Wales as well as other areas worldwide, whereby various individuals were consulted such as service users and asked how they would access such facilities; as well as data collected on ODs and STI infections; drug litter information; and emergency services data regarding attending drug-related emergencies to name just a few. Medicine Hat is located 3 hours away from Calgary but has also been recommended to be a location for a DCR. Medicine Hat boasts a population of 68,000 people, yet in 2016, 240,000 transactions were carried out via the HIV Community Link NSP alone. The city itself accounts for the highest rates of both ODs and HCV of which 97% of the latter are through IDU. Throughout the province, there were 263 new HIV infections of which 17% were a result of IDU. Such consequence from substance use has not only led to the recommendation of DCR facilities to be established but have since been given the go-ahead to become part of harm reduction services in the city (CP, Canadian Press, 2017).


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Most DCRs that have been recommended such as those in Toronto and Calgary, are for IDU only. Seattle have recommended a DCR that allows any type of drug use, including inhalation, nasal and oral, as well as injecting. In Seattle, the current DRD rates are 40 per 100,000 people and at present, despite having a population that is thirteen times less than New York City, Seattle is currently seeing higher levels of needle exchange transactions compared to its east-side counterparts. Another DCR has been recommended for outside of the city but still within King County.

6.2 Legality

The legal situation in relation to facilitating a DCR service is different in the UK to that of the

countries I visited during my Fellowship. In Canada, for a service to provide a DCR, they must

apply to the federal government for an exemption under Section 56 of the Controlled Drugs

and Substances Act (CDSA). Insite, the first DCR in North America, and other established

DCRs are not technically legal, however they are exempt under the CDSA.

There are no DCR’s in the United States of America (USA). Specific to Seattle (located in King

County, Washington), no changes to state or local law or any exemptions need to be applied

for, in order for the DCRs, or what they term Community Health Engagement Locations

(CHELs), to operate. King County’s Prosecuting Attorney, current Sheriff and Seattle’s mayor

are strong supporters of the establishment of such services. Health providers can also

survive a legal attack under state law if the service is in the best interest of the public to

achieve specific public health missions. One such example was the Washington Supreme

Court refusing to close an NSP, ordered by Spokane’s local prosecutor in 1989/90, due to

public health emergency regarding DRDs and BBVs. No court, including federal courts, have

ever weighed in on the legality of DCR’s, or decided whether they violate federal drug law.

The situation is different again in Denmark and Germany, where DCRs are legal

(Konsumraum 2011).

In the UK, the government has dismissed the call from its own advisory body, the Advisory

Council on the Misuse of Drugs, to consider introducing DCRs (Rhodes, 2017) stating they

have “no plans to allow drug consumption rooms, which [would break] laws whereby

possession of controlled drugs is illegal” (Wilkinson, 2014). However, a recent statement

from the government states ‘it is for local areas in the UK to consider, with those

responsible for law enforcement, how best to deliver services to meet their local population

needs’ (Rhodes, 2017). This opens the possibility of local services developing agreements

with Police and Crime Commissioners (PCC) to look at the feasibility of establishing such

services in their respective localities. Agreed protocols between the DCR and the PCC would

be necessary to protect individuals who would use the service from the risk of arrest and

prosecution for offenses under the Misuse of Drugs Act 1971.

6.3 Key partnerships

The main partnership that has been developed and sustained by all DCRs that I visited

during my Fellowship was that with the local police forces. The steering groups that have

been established in various cities examining the potential of establishing a DCR, have had


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representation from the police on board, if not had approval from the Chief of Police

themselves. Partnership between the potential DCR service and the police is vital during the

set-up process and facilitation of the harm reduction service. If the local police force is not

on board then establishing and facilitating such provisions could prove extremely difficult,

especially if a DCR is not legal or legally exempt. This could result in those providing and

accessing the DCR being arrested thus leading to a short-term provision only. Once a DCR is

established and the local police force are on board, then they can be a vital source to help

deal with any anti-social behaviour and high concentration of individuals within a given

location that could have adverse effects on the local community. The first DCR in North

America was Insite, which is based in Vancouver. Insite is based in the Downtown East Side

(DTES) of the city, where there is a high concentration of homeless and street drug users.

Such social issues were one of the main reasons as to why Insite was established in the DTES

in 2003, yet their relationship with the Vancouver Police Department has proved crucial in

dealing with any disturbances inside and out of the service. This then leaves the staff to get

on with supporting those who access Insite.

It is also vital to build relations with local residents and business owners. Many may disagree

with the development and establishment of a DCR in their local community as it may drive

house prices down and reduce custom to those businesses. Such recommendations when in

Toronto were made in relation to visiting all local businesses who are based close by to the

proposed location of the DCR, on a one-to-one basis to raise awareness about what the

services are and discuss what issues and solutions there could be to establishing such

provisions in the local community. One of the locations for a planned DCR in Toronto is at

Toronto Public Health in their harm reduction program, ‘The Works’, that facilitates a

needle exchange and Opioid Substitution Therapy (OST), and is located on the ground floor

of the head office for Toronto Public Health. The building itself is based in Yonge-Dundas

Square, one of the main tourist locations in the city, which also plays host to the media

headquarters and Nordstrom retail department. Within the surrounding area is Ryerson

University, a private school and St. Michael’s Hospital. Consequently, working alongside the

business and residence associations is vital to achieving the overall aim of establishing a DCR

in the area. Overall, it is critical to saturate the field of those who have a part to play in the

development of such a facility as well as those who have a keen interest in local healthcare.

6.3.1 Peer involvement

Peer involvement is crucial to the development of any substance use related service. Many

of the individuals I met with during my Fellowship advised me to ensure that not only are

the voices of those who currently use substances (whether in treatment or not) are heard

but also for those making the plans to always view the development of such services

through the eyes and feet of those that currently use substances as well as concerned

others. The development and establishment of services is required to fit the need of all and

not just the select few. This is vital to remember when deciding what model of DCR to

establish.


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6.4 Consultation

One of the key methods undertaken by those involved in planning and proposing a DCR at

‘The Works’ (in Toronto) was to facilitate direct consultations with the public, residents and

business owners nearby the service. Two consultation exercises were completed in at the

local town hall, facilitated by an external consultation organisation. The consultations were

split into two: Firstly, The Medical Officer of Health delivered a presentation on what DCRs

are, the reason for the locations and how they are to operate. The second part of the

consultation included facilitators asking the attendee’s questions such as: Discussions took

place in a directive manner by which the facilitators asked questions such as: Do you have

any concerns? What would mitigate these concerns? And what benefits do you see? The

focus was not on providing an open platform for discussions as to whether participants

thought it was a good idea.

SRCHC played a different tact in which they held multiple open days for the local public so

they could see first-hand what services are already available within the building but also

how the DCR will look and compliment the already established harm reduction service.

SRCHC worked closely with the Chair of the Business Improvement Association that helps to

build relations with local businesses.

Both organisations used social media to their advantage, which included key stakeholders

setting up their own Facebook pages to support the development of DCR in their area. All

information regarding DCRs, in the form of Frequently Asked Questions, were put on their

respective websites. The Works also did a question of the week with their service users. This

again was to allow service users a voice via an alternative route in relation to service

delivery and the establishment of the DCR. Such questions posed were what should the

opening times be and how would the ‘after injecting’ space look and work? Among many

other questions.

6.5 Media and key messages

The media have been key to getting the right messages out to the public in Dublin. Tony

Duffin (Ana Liffey Drug Project) struck up a positive relationship with the media in

conjunction with promoting their goals at every opportunity. In Toronto, the same occurred

thus using them to their advantage to inform people at the right level. Therefore, the use of

terminology is critical. Of those I met in Toronto, they all emphasised that the word ‘health’

is to be used throughout and that the word ‘safer’ was nowhere to be seen, in the context

of drug use within a DCR. No form of drug use is safe, leading to one of the reasons why this

behaviour is supervised within DCRs. They also ensured that any DRD reported in the media

was humanised in a way that whoever the victim was, they were someone’s brother, sister,

son, daughter, mother or father and in turn highlighting that the victim could still be alive if

a DCR was already established.


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It is fundamental that everyone in the process of evidencing the need or even establishing a

DCR (i.e. a steering group) is clear of the reasons behind these actions. Therefore, these

motivates need to be emphasised every time a member of the steering group engages with

a stakeholder or the media. Advice passed on by those I met with was to have key messages

that are mentioned within all discussions relating to DCRs. Such messages could include: The

DCR aims to reduced drug-related health risks and harms including fatal ODs, transmission

of BBVs and other infections; DCR aims to improve public safety and the community

environment by reducing public drug use and discarded drug using paraphernalia; DCR can

help with the use of public money being used more effectively by reducing costly criminal

justice system involvement and the burden on emergency services. These are just examples.

However, one thing that was advised not to do by the Seattle and King County Task Group,

who are working towards establishing two DCRs, was to advertise these facilities as a

gateway to treatment services. The reason behind this is that DCRs sometimes work

towards engaging the most vulnerable and marginalised section of our society and they may

not yet be ready to access more traditional treatment such as OST, or purely don’t want too.

Therefore, as many new DCRs are set up on a pilot basis, if you promote the service as a

gateway to treatment, there is a good possibility that this measure would fail to meet its

targets. Consequently, it could then be suggested that the service is a failure because of

potential low numbers referred on to treatment, despite the fact there could be less drug

litter and IDU on the streets, and less ambulance callouts. Consequently, such services could

be highlighted as providing the opportunity to access substance use treatment and other

services. From Seattle’s Heroin and Opioid Task Force perspectives, their approach to

winning over hearts and minds regarding DCRs is purely from a humane perspective, to keep

people alive.

6.6 Challenges and solutions

One major challenge in Wales is sourcing the monies that would fund such a service. While

the current EHRC and APoSM steering groups are yet to formally enquire about potential

funding streams, anecdotal discussions have taken place. Whereas in Canada, Denmark and

Germany, the DCRs are funded by their respective governments, whether it be municipal,

provincial or federal, no such luxury is available within Wales. At the time of visiting Seattle,

this was a major stumbling block too. However, the cost to run a DCR very much depends on

the model and the level of service provided. Annual budgets vary from service to service and

country to country. The Sproyterom DCR in Oslo, Norway has an annual budget of around

£1.5million compared to the annual budget of around £175,000 at AMOC in Amsterdam

(Otter, 2017). It is estimated The Works annual budget will be around CAD$700,000. In

Wales, the locations within the three cities have all but been identified yet the model for

each location needs to be determined before a cost-effectiveness analysis can be

undertaken to determine how much funding would be required to make such facilities

functional and sustainable. Services would be able to identify sources to fund this facility,

once the annual budget and costings is known.


17

Another issue that could potential face any group looking to establish a DCR is the political

buy-in. Substance use is a contentious matter within society with various beliefs on the

subject. Therefore, local assembly members (AM), members of parliament (MP) and PCC’s

have to be conscious of such opinions within their constitutions. If the perception in their

local area is a strong ‘no’ to the establishment of such facilities within that area, then it

could be likely the local AM, MP and/or PCC could be consistent with this stance due to not

being re-elected in the next election if they have a difference of opinion on the matter. It is

therefore worthwhile to look at some form of political cover to help sway the opinion of

those currently in a position of influence. Therefore, striking relations with civic leader

alliances such as former politicians, academics, former PCC’s and retired medical

professionals could help. For example, David Cameron, prior to becoming Prime Minister of

the UK, gave his support for the development of DCRs in a speech to parliament in 2002

(Helena, 2015). While getting the likes of David Cameron on board may unrealistic for some,

attaining the voice of similar personnel with the same views could provide back up for the

current AMs, MPs and PCC if they were to come out and be in favour of these evidence-

based facilities.

It is vital for society to be aware about what DCRs are. Media reporting from time to time

does not help in terms of their use of language such as ‘shooting galleries’ or ‘fix rooms’

(Siddique, 2017; BBC Wales News, 2017). Most DCRs that are currently operational are

much more than just places where people can go and consume substances. Different

models of DCRs will be discussed in the next section of this report, but the clear majority of

DCRs throughout the world have a wide array of additional services attached to them, from

washing facilities and a place to eat to access to medical professionals and treatment.

Subsequently, raising awareness of what DCRs are; their aim and objectives; what services

are available to people who access such facilities; and how it is operates within guidelines

and protocols is vital to dispelling any misconceptions. Therefore, providing literature and

going out and talking to the local community as well as disseminating this information via

the media is one place to start to overcome this challenge.

One major challenge that the Heroin and Opioid Task force in Seattle and King County has

encountered is a citizen’s initiative (I-27) in the form of a signatory petition to ban the

development of DCRs in the county. The I-27 DCR opponents collected over 70,000

signatures in an attempt to ensure the establishment of DCRs did not go ahead, of which

qualified for the topic to be on the next ballot. Despite many people being ‘for’ the

establishment of a DCR, the consensus is that those who signed the I-27 initiative do not

want the facility ‘in their back yard’. Also, opponents of DCR’s don’t want their taxes being

spent on drug users. Supporters of DCR’s successfully challenged I-27 in court. King County

Superior Court Judge Veronica Alicea-Galvan ruled that I-27 violated state law because it

“interferes with the duties and obligations of the (Health) Board and County Council”

(Springer, 2017) and ordered that it not appear on the ballot. But this is one challenge to be

wary of in both Wales and the UK thus having a plan of action to overcome this is vital.

Current DCRs including ‘Ragazza e.V.’ in Hamburg and ‘Skyen’ in Copenhagen face regular

challenges posed by their neighbours. The former frequently come up against many who are


18

not in favour of the service they provide. Skyen sees a significant amount of drug dealing

around the service which can also affect community relations. However, partnership work

with the police is one solution to building and sustaining relations between the respective

DCR’s and their neighbours. Many DCRs also employ outreach workers, who not only work

with the local community but also help deal with any anti-social behaviour around the

facility as well as encourage those who use drugs on the street to access the DCR. Skyen, for

example, attend multi-agency meetings every six weeks, that include representation from

the police and local residents. Ragazza e.V. also continue to keep consultations as frequent

as possible with their neighbours and ensure communication lines are continually kept open

by holding open days, whereby individuals from the local community can visit the project to

see for themselves what happens within the service and gain a better perspective on the

aim and objectives of the provision.

One other challenge is ensuring accessibility to the DCR once established. Many may not

access already established drug and alcohol services due to a variety of reasons. One of

these is due to the stigma attached to accessing such provisions. Therefore, it is vital to

ensure that the terminology is correct when talking about anything to do with substance

use. Also, it is about engaging with those who do not currently access treatment facilities

and working with them as a way of looking at solutions to breaking down these barriers.

Despite Insite (DCR in Vancouver) seeing 10,862 visits in August 2017 (Vancouver Coastal

Health, 2017), there were still 113 suspected OD deaths in the same period in British

Columbia, of which 88.5% occurred inside, including private residence. An additional 11%

occurred outside in vehicles, streets and parks (British Columbia Coroners Services, 2017).

The people I talked to who continue to use substances on the streets and not in DCRs like

Insite, said that they prefer to use on the streets or on their own. A recent survey conducted

by Drugaid Cymru, found that some people who are current IDU’s would not access a DCR if

established in their area because they would rather use at home. Such risky behaviour

provides the optimum scenario for a fatal OD. Consequently, more work has to be done

with those who currently use substances and to encourage them to access DCRs, which is

what happened at Insite. It was the current drug using community that encouraged people

to move from using on the street to using in the DCR.

7. Operations

7.1 Different models of a Drug Consumption Room

There are three different DCR models that are currently in operation: Specialised;

Integrated; and Mobile. Specialised DCRs provide a limited amount of services and the main

provision that is provided is a consumption room whereby people can take substances.

Many DCRs throughout the world operate via an integrated model whereby the

consumption room is usually an addition to existing services, or has been developed in line

with other services. For example, at the ‘Staying Alive’ project in Hamburg, people can use

the consumption rooms, but also access shower facilities, hot meals as well as a doctor

twice a week. The Skyen DCR is part of Maendenes Hjem (translates to the ‘Men’s Room’)

project that boasts not only separate departments for housing and health, including access


19

to dentists and nurses, but also the opportunity to work in the kitchen as a way of gaining

employability skills such as those associated to catering. Due to the amount of service

available, Maendenes Hjem employ up to 200 staff. Skyen now provide a drug testing

service three times a week, whereby people accessing the service can get their drugs

checked resulting in the potential user of that substance becoming more aware of what is in

the substance in question allowing for the professional to provide appropriate harm

reduction information. Similar services are now available at Insite in Vancouver.

The third DCR model is a mobile facility. This tends to be in the form of a van or bus that has

been converted to provide booths and a needle exchange. These tend to be in operation

where the need is not so big for a static DCR to be established, but also within rural areas, so

the van can move to different locations to meet the need of individuals who may not be

able to access other services that could be in a nearby town or city. Safeworks in Calgary, as

well as The Works in Toronto, provide a daily mobile unit service whereby they go to other

communities away from their static base and deliver a needle exchange transaction service,

as way as other forms of support including dispensing naloxone. It could be argued that if

there is a need for the current mobile unit service, then there is a need for a mobile DCR

facilitated by those services in the future.

Picture 4. Mobile DCR unit (Bus EPA) in Barcelona. This mobile unit provides 2 injecting

booths, a medical bed, needle exchange provision and the dispensing of naloxone.

There are also multiple DCRs that are based within hospital facilities. CAS Val d’Hebron in

Barcelona is one of many DCRs that operate within Catalonia. Forty-five members of staff

are employed within this centre with professions extending from social workers, social

educators and nurses to GP’s, psychologists and psychiatrists. Like other DCRs, additional

services are available too such as access to diversionary activities for those that engage with

the DCR. However, many individuals who IDU may not access such provisions due to the

clinical nature of the service. Therefore, it is vital for those that would potentially access a


20

DCR and PWUD to be consulted with regarding the set-up of a DCR and whether certain

aspects would put them off engaging with such a service.

Ragazza e.V. was the world’s first women-only DCR. It is held in such high regard as a

service, that other DCRs have followed suit, such as ‘Sister Space’ in Vancouver (Atira, 2017).

Hamburg is well known for sex work thus resulted in the establishment of Ragazza e.V. in

1992, to meet the need of women who are both drug users and sex workers. Within Ragazza

e.V. women can gain access to sleeping facilities (limited times throughout the week); food;

clothing; washing facilities; medical care; counselling; support; access to legal advice; as well

as clean paraphernalia and the use of the consumption room. No males are allowed to

access the facility, however since November 2017, transgender individuals can access the

service.

7.2 Location

Getting the location of a DCR right, is crucial. Despite the challenges faced by the Heroin and

Opioid Task Force in Seattle with regards to the ‘not in my backyard’ stance by local

residents, the setup of these facilities will only be in areas where drug use and drug-related

issues are already occurring. Insite was established in the DTES of Vancouver back in 2003

and signs of drug use and homelessness is highly visible in the area. However, these social

issues were already present before Insite was established. Anecdotal information shows

that people would only travel a maximum of 1 mile from where they currently reside, pick

up their drugs and/ or use their drugs, to a DCR. Therefore, it is vital to ensure that the

location of the DCR meets the need of that area and PWUD.

However, it could be that a DCR is established in an area that is surrounded by housing,

parks, businesses and even schools. Vestebro, in Copenhagen, is understood to be the party

scene of Denmark’s capital but over the last 40 years has been the victim to public drug use

and dealing. In was decided in 2012 that Skyen would be established, and then later ‘H17’

(in 2016), the world’s biggest DCR due to its floor space, to help deal with the social drug-

related issues. This is despite the area being surrounded by up-market restaurants, schools

and residential properties. The St. Peter AIDS Foundation, a service dedicated to those

diagnosed with HIV and/or AIDS produced a video in support for DCRs in Toronto

highlighting the location of their service that includes a DCR (Dr. Peter AIDS Foundation,

2016).

7.3 Staffing

Staffing levels depend upon the choice of model to operate. Many DCRs operate a medically

supervised service whereby nurses are present within the consumption room. As part of

their exemption to operate, a nurse must be present within the injecting room in Insite at all

times. In all the DCRs I visited during the Fellowship, apart from the ‘Staying Alive’ service,

nurses were always on site during opening hours of the facility. The Staying Alive service,


21

due to funding reasons, do not employ any medical staff to oversee the consumption room.

Therefore, this facility is not a medically supervised service.

Of the DCRs I visited, the following amount of staff on a single shift were as follows:

Insite: 10 members of staff with a minimum of 4 nurses.

Skyen: 4 members of staff (including medical professionals).

H17: 4-6 members of staff (including medical professionals).

Staying Alive: 4 members of staff (plus students).

Ragazza e.V.: 4 members of staff (including a nurse). All staff employed at Ragazza e.V. are

female.

In both DCRs in Hamburg, doctors also provided a clinic, twice a week in Staying Alive and

once a week at Ragazza e.V. These clinics help meet the need of any medical treatment such

as OST but also BBV and STI testing as well fortnightly access to a gynaecologist at the

Ragazza e.V. project.

7.4 Administration of substances

In order for people to consume their substance of choice in a DCR, they must first acquire

that drug before entering the service. No DCRs supply individuals with substances. As with

any country, the drug of choice varies from one location to another, and this could have

potential impact upon what service is offered within the DCR.

Insite, in Vancouver, offer up to 13 booths whereby people can inject substances. However,

no facilities are available for people in inhale drugs, such as smoking crack cocaine, or other

forms of administration. Whereby in both DCRs in Hamburg and Copenhagen, the services

offer the space to inject as well as a separate inhalation room.

The Heroin and Opioid Task Force in Seattle have recommended any type of drug use

including injecting; inhalation; oral and nasal. This purely based on the need and the

potential type of drug use undertaken by those who will access the facility once opened.

In all DCRs, they offer clean equipment to consume substances. Despite injecting

paraphernalia being constant from one DCR to another, other forms of harm reduction vary

from one place to another depending on the service offered. For example, the Staying Alive

project and Ragazza e.V, both based in Hamburg, offer inhalation rooms however they do

not offer sterile pipes for people to smoke substances such as crack cocaine. Legislation

dictates that naloxone is not available on site in these DCRs. Compare that to the H17 DCR

in Copenhagen, that provide crack cocaine users with baking soda and ammonia (chemicals

used during the cooking up process of making crack cocaine). The dispensing of such

chemicals is based upon need but also the fact that previous to this harm reduction

initiative, people who use crack cocaine would carry large bottles of ammonia around with

them, and was frequently used as a weapon against other people in violent situations. This


22

resulted in services like H17 providing these chemicals to prevent such horrific accidents

happening in the community.

Picture 5. The DCR in Ragazza e.V. There is space for 4 people to inject as well as a separate

inhalation room for up to 6 people. This set up is seen as good practice as the individual

supervising those consuming substances in this room can overlook both rooms at the same

time.

7.5 Opening times

The opening times of different DCRs is again based upon need but also funding criteria. Prior

to 2016, Skyen was the only DCR operational in Copenhagen and was open 23 hours a day.

However, since the opening of H17, a few blocks away from Skyen, the latter now operates

within limited hours (07.15 till 22.00) for seven days a week. This is due to funding only

being available for one service to provide a night time facility and that has since been

awarded to H17. The Staying Alive project is open Monday to Friday, 12.00 till 19.00.

The opening times of Insite are also based on limited hours, usually 09.00 till 03.00 seven

days a week. However, most individuals who are in receipt of social payments, receive this

money once a month, on a Wednesday, alternatively known as ‘cheque week’. For this

week, from Tuesday night through till Friday night, Insite is open 24 hours a day. This is due

to the demand upon the service but also that may individuals will spend a large proportion

of their social payment on substances and therefore the service has been proactive in

ensuring that it is open during a time when high-risk behaviour is occurring. Issues like this

are worth bearing in mind when discussing and deciding upon opening times.


23

Picture 6 (left) the front of Insite highlighting the opening times of the service. Picture 7

(right) the inside of Insite’s injecting room. There are a total of 13 booths, all of which have

mirrors, to not only help those using the booths, but also so the staff, who predominantly

base themselves at the raised nurses station, see over the individuals shoulders and see what

they are doing and if they are ok. Picture 7 is courtousy of http://vanmag.com/city/what-an-

increase-in-fentanyl-related-deaths-means-for-insite/.

7.6 Accessing a Drug Consumption Room

The advice given by all of those I met with during my Fellowship was to ensure that access

to a DCR is kept as low threshold as possible. The most amount of information any DCR

attained from an individual accessing the service was their name (real or alias) and what

substances they were planning on using. The advice given was generally that asking too

many questions at the point of entry could put people off from accessing the service. Such

information was requested in the waiting area of the DCRs, before entering the

consumption room. Once in the consumption room (picture 7 above), the staff would note

who is sitting where and would know what substance is being administered, therefore

allowing them to react appropriately in the case of an OD. In all the DCRs, time is limited in

terms of how long people can stay in the consumption room. On average, time allowed in

the consumption room was from 30 – 45 minutes depending on the amount of people

waiting outside to access the facility. Most DCRs then offer an after-consumption room

whereby people can chill out and even get some food and drink. The aim of this is to ensure

people continue to be monitored for a short period after consuming substances.

Rules also differ from one DCR to another. In Skyen and Insite, minors are not allowed to

access the DCR and if they do enter, the appropriate action will be undertaken such as

safeguarding procedures. Such rules can also apply to pregnant females, however, Ragazza

http://vanmag.com/city/what-an-increase-in-fentanyl-related-deaths-means-for-insite/

http://vanmag.com/city/what-an-increase-in-fentanyl-related-deaths-means-for-insite/


24

e.V. allows this cohort of individuals to access the DCR. Within Barcelona, both cohorts are

allowed to access the DCR facilities, as the belief is that if they are not allowed to access the

DCR, then they will still consume substances but in more risky environments such as on their

own or on the streets.

It is then vital to ensure that such rules and regulations are put in place and that legislation

regarding safeguarding is adhered to, just as it is in relation to these two cohorts of

individuals accessing current drug and alcohol services in Wales.

In all the DCRs, staff can help with the process of injecting of drugs. However, this support

ends at administering the substance. Staff can help individuals find a vein especially if it is

someone with mobility issues or is inexperienced in that practice.

It is worthy to note that all DCRs provide a needle exchange and that policies again differ

regarding how much paraphernalia is given out and whether individuals can bring their own

equipment in to the DCR or they have to use the equipment provided once inside the DCR.

All protocols are in place to dispose of drug paraphernalia.

7.7 Operational policies

There are a wide variety of policies and protocols to be aware of when designing and

developing plans to establish a DCR. Below is a list of policies that are already in place in a

variety of DCRs as well as within recommended guidelines for the set of up future DCRs:

Administration procedures.

Child Protection, Protection of Vulnerable Adults and Safeguarding.

Clinical governance.

Confidentiality.

Death protocol.

Disposal of substances.

Distribution and disposal of injecting equipment.

Drug consumption.

Eligibility.

Exclusion from service.

Management of certain behaviours.

Memoranda of Understanding.

Needle stick injury.

Overdose action and response.

Participant code of conduct.

Safer injecting including protocols around groin and neck injecting.

Service delivery.

Use of other facilities such as toilets.


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8. Effectiveness of Drug Consumption Rooms

The evidence of the effectiveness of DCRs in achieving their aim and objectives, is

overwhelming. Since the introduction of the first DCR in 1986, many people have OD within

these facilities, however not a single incident has been a fatal OD. It asks the question then

about how many lives would have been saved in Wales and throughout the UK had DCRs

been operational for the last few years.

When I first entered Insite, I was greeted by an individual experiencing an OD and

subsequently being given medical attention. Within an hour of the Staying Alive project

opening its doors the day I visited, one opiate user OD and was taken to hospital. If these

facilities were not available, it is possible those lives could have been lost. In August 2017,

there were a total of 127 OD at Insite, all of which were non-fatal (Vancouver Coastal

Health, 2017). One individual I spoke with who accessed the facility explained the reasons

behind this was because “it is clean, no-one bothers me, I am not judged, it is safe and I am

surrounded by people who care”.

Many research papers have explored the effectiveness of DCRs and have resulted in the

following findings:

DCRs attract some of the most marginalised and vulnerable PWUD; promotes safer

injecting conditions; enhanced the access to primary health care; and reduced the

overdose frequency (Potier, Laprevote, Dubois-Arber, Cottencin & Roland, 2014).

DCRs have a positive impact on both health and well-being of those that use the

facility as well as the wider community (Schatz & Nougier, 2012).

35% decrease in the number of fatal OD in Vancouver (Marshall, Milloy, Wood,

Montaner & Kerr, 2011).

68% reduction in ambulance callouts related to OD during the operating hours of the

DCR in Sydney (Salmon, Van Beck, Amin, Kaldor & Maher, 2010).

No increase in drug trafficking, crime or violence around the area of DCRs since

becoming operational (Hedrich, Kerr & Dubois-Arber, 2010; Milloy & Wood, 2009).

Reduction in IDU in public spaces and drug litter in these areas (Potier et al., 2014).

Many individuals I met during my Fellowship highlighted that the DCRs in the specific

locations had improved the nearby public spaces such as a lack of drug taking thus

paraphernalia discarded on the streets. However, as mentioned regarding witnessing the

ODs at Insite and Staying Alive respectively, these DCRs do as what the Heroin and Opioid

Task Force in Seattle are promoting them as: they help keep people alive and give them

another opportunity to achieve the goals they wish to in both their drug use but also their

life.


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9. Miscellaneous learning from the Fellowship

9.1 Dealing with the fentanyl crisis in Canada

At present, North America is amidst an opioid epidemic. Illicit drug overdoses in Canada are

constantly rising, with British Columbia bearing the brunt. One of the main reasons behind

the current crisis, is a substance known as fentanyl. Many media reports and research

papers describe fentanyl as being 100 times more lethal than pharmacological morphine. To

put in layman’s terms, it is an extremely toxic substance of which the smallest of doses

could lead to death.

Graph 1. An illustration of the rising DRDs over the last 10 years in British Columbia. Source:

British Columbia Coroners Service

On 14th April 2016, a Public Health Emergency was declared in British Columbia in response

to the opioid overdose crisis. In the first five months of 2017, fentanyl was detected,

whether alone or in combination with other drugs, in 78% of all illicit drug related deaths

(British Columbia Coroners Service). A Fentanyl Urine Screen Study (Amlani, McKee, Khamis,

Raghukumar, Tsang & Buxton, 2015) analysed 242 samples taken from 17 harm reduction

sites throughout British Columbia. Seventy participants tested positive for fentanyl,

however nearly three quarters of these individuals reported not having used fentanyl in the

last three days. This is a pivotal insight into use of the drug, as a considerable proportion of

fentanyl used within the province is potentially unintentional. This leads to great concern

among users, peers and professionals as unintentional use provides the optimal scenario for

an overdose.

The British Columbia Centre for Disease Control (BCCDC) has responded to this crisis by

coordinating a range of harm reduction initiatives within the province. BCCDC provide up to

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4650899/pdf/12954_2015_Article_88.pdf


27

476 distribution sites with naloxone, the opioid overdose antidote, and drug paraphernalia

including clean injecting and smoking equipment. All emergency services carry naloxone,

and are willing to administer it. British Columbia rolled out their take home naloxone

program in 2012 and since then, over 10,000 kits have been used to reverse an OD. Over

half of those 10,000 kits were used in the first six months of 2017. This may be due to a

variety of reasons, from more naloxone needed to reverse a fentanyl overdose, more

people in contact with services or just that there are just more overdoses occurring.

DTES Vancouver is where the current visible epidemic is concentrated and many Overdose

Prevention Sites (OPS) were opened after the Minister of Health called for their

establishment, in response to the increasing amount of 911 overdose calls and subsequent

fatalities on the streets of Vancouver. OPS’s can be described as pop up consumption

rooms, set up on a temporary basis, without legal exemption, to help deal with the

increasing number of overdoses, and consequently reduce the number of fatal episodes.

Multiple OPS’s are currently operational with all providing spaces to inject drugs, with one

OPS also providing an inhalation space. The Maple OPS at 117 East Hastings Street also

deliver a “Spikes on Bikes” initiative, providing clean injecting equipment, naloxone and a

witness service to those who use substances on the streets. Vancouver Area Network of

Drug Users (VANDU), an organisation whose board of trustees consists of former and

current drug users, not only provides a 6-booth supervised injecting room but also provide

daily support groups, including one for people who consume illegal alcohol or alcohol from

untraditional sources, such as hand sanitisers.

Picture 8. Vancouver Area Network of Drug Users (VANDU) has a long history of activism

fighting for the rights of those who previously or currently use drugs.

OPS’s are just one of many responses to this epidemic in Vancouver, as well as in other cities

across Canada. At present, there are a total of 20 OPS’ operationally throughout Canada.

Other responses within British Columbia include heroin assisted treatment via the

http://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/office-of-the-provincial-health-officer/overdose-response-progress-update-jan2017.pdf

http://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/office-of-the-provincial-health-officer/overdose-response-progress-update-jan2017.pdf

http://towardtheheart.com/naloxone/ops

http://towardtheheart.com/naloxone/ops


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Providence Crosstown Clinic, the only facility to offer such services in North America.

Another is the ‘bad dope’ initiative, whereby people can report overdoses that show

unusual symptoms via text. This information would then be passed on to Vancouver Coastal

Health staff immediately, and they in turn will warn various individuals about potentially

contaminated drugs (Vancouver Coastal Health, 2017).

9.2 Good Samaritan Drug Overdose Act

One other response to the opioid crisis in Canada has been a national one, with the passing

of the Good Samaritan Drug Overdose Act 2017. This law has been introduced to reduce the

amount of people not calling the emergency services when at the scene of an overdose, due

to fear of being arrested. Under this law, anyone at the scene of an overdose cannot be

charged with possession of an illegal substance and would not be charged for breach of

probation or parole relating to drug possession. Such laws are currently in place in various

states within USA, including Washington, yet are vacant within UK legislation. Many service

users openly disclose not calling 999 in the event of an overdose, because of the anxiety of

police presence (Holloway & Hills, 2017).

10. Recommendations

My Fellowship has allowed me to gather an incredible amount of information about the

process of setting up DCRs and how to implement them within substance misuse services

and the community, I have also learned other forms of good practice, such as responding to

the threat of Fentanyl, which is a current cause for concern within the UK. Based upon my

learning from my Fellowship, I have made the following recommendations of which I believe

could help ease the process of establishing a DCR in Wales as well as help deal with other

social drug-related issues.

1. The need of a DCR is to be significantly evidenced and if established, located in an

area where public substance misuse is already apparent. It is vital that the need for

a DCR is evidenced, which then puts those proposing the establishment of such

facilities in a stronger position to argue the need for a DCR within their locality. The

EHRC steering group is currently undertaking a needs analysis within the 3 cities that

have been identified as a possible location for a DCR in Wales.

2. To identify and develop partnerships with key stakeholders who have a vested

interest in health and social care. Such stakeholders include the police force,

political personnel, business associations and resident forums. All DCRs that I visited

had very strong links and partnership working with their respective police forces. The

establishment of a DCR can help the emergency services in relation to a reduction in

demand upon their time and their services, as well as other key stakeholders

including a reduction in public drug use, drug-related crime within that area, and less

drug litter discarded within the community. It is therefore advised to saturate the

market in relation to partnership development.

https://www.canada.ca/en/health-canada/news/2017/05/good_samaritan_drugoverdoseactbecomeslawincanada.html

http://stopoverdose.org/section/good-samaritan-law/

http://stopoverdose.org/section/good-samaritan-law/


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3. To facilitate directed consultations with various stakeholders. It is important to

raise awareness of the benefits of a DCR to the local businesses and residents yet

consider their concerns but at the same time encourage them to explore solutions to

those issues they present. An honest and open relationship with all stakeholders is

key. Such consultations could be done via events with a structured process as well as

one-to-one meetings, online consultations or telephone conversations.

4. To involve individuals who currently use established drug and alcohol services in

the planning of setting up DCRs. Nothing about us, without us, is a motto that is

pivotal when looking to establish a DCR. Those who use substances and have

experience of accessing services, know what works for them and what doesn’t so it is

vital to ensure their voices are heard throughout the development of such a service.

5. Develop key messages that are emphasised every time the subject of a DCR is

discussed with key stakeholders and the media. Such terminology should always be

used including ‘health’ and ‘supervised’ as well as having clear messages that need

to be put across. These could include evidence-based facts as well as how a DCR can

help, not only those who may access the facility, but the community where it is

located.

6. Provide documents to key stakeholders and the public raising awareness about

what DCRs are and the aim and objectives of such facilities. Such documents should

be made freely available on certain websites and via other platforms such as social

media. Documents explaining what DCRs are and frequently asked questions should

be produced and disseminated.

7. Provide accessible and rapid turnaround drug testing. Although not hugely

discussed in this report, drug testing is one vital way to ensure that those who use

substances are provided as much harm reduction information as possible and

ultimately can make more informed decisions regarding their drug use. Best practice

can be seen within the UK via The Loop, whom provide drug testing at various UK

festivals.

8. Develop a Welsh Good Samaritans Drug Overdose Act. This could help reduce the

number of individuals within an overdose scenario not calling the emergency

services due to fear of being arrested. The development of such legislation could

help save more lives and reduce the number of fatal overdoses in Wales.

9. Establish multiple DCRs in Wales, ideally attached to established drug and alcohol

treatment services. I recommend that DCRs become part of the harm reduction

approach to substance use in Wales, in line with current service delivery

frameworks. It is hoped this report, along with other research documents, will help

with the development of DCRs as an additional way to help reduce DRDs in Wales as

well as improve public safety in relation to substance use.


30

11. References

Alberta Government, 2017. Opioid reports. Retrieved from https://www.alberta.ca/opioid-

reports.aspx.

Amlani, A., McKee, G., Khamis, N., Raghukumar, G., Tsang, E. & Buxton, J. A. 2015. Why the

FUSS (Fentanyl Urine Screen Study)? A cross-sectional survey to characterize an emerging

threat to people who use drugs in British Columbia, Canada. Harm Reduction Journal, 12:

54.

Atira, 2017. SisterSpace – shared using rooms. Retrieved from

https://www.atira.bc.ca/sisterspace-shared-using-rooms.

Bayoumi, A. M., Strike, C., Jairam, J., et al. 2012. Report of the Toronto and Ottawa

supervised consumption assessment study. St. Michael's Hospital and the Dalla Lana School

of Public Health, University of Toronto, Toronto; 2012.

BBC Wales News. 2017 September 18. North Wales drug fix room pilot moves forward.

Retrieved from http://www.bbc.co.uk/news/uk-wales-41267538.

British Columbia Coroners Service. 2017 October 12. Illicit drug overdose deaths in BC

January 1, 2017 – August 31, 2017. Retrieved from

https://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/death-

investigation/statistical/illicit-drug.pdf.

CP, The Canadian Press. 2017 October 27. Safe Injecting Site Approved For Calgary’s Sheldon

Chumir; Temporary Site Opens Soon. Retrieved from http://calgaryherald.com/news/local-

news/safe-injection-site-approved-for-calgarys-sheldon-chumir-temporary-site-opens-soon.

Dr. Peter AIDS Foundation. 2016. Community support for supervised consumption services.

Retrieved from http://www.drpeter.org/dr-peter-centre/knowledge-transfer/community-

support-for-sis/.

European Monitoring Centre for Drugs and Drug Addiction. Drug consumption rooms: an

overview of provision and evidence. European Monitoring Centre for Drugs and Drug

Addiction, Lisbon; 2015.

Hedrich, D., Kerr, T. & Dubois-Arber, F. 2010. Chap 11: drug consumption facilities in Europe

and beyond. In: Rhodes, T. & Hedrich, D. (eds.) EMCDDA monographs harm reduction:

evidence, impacts and challenges. Luxembourg: European Monitoring Centre for Drugs and

Addiction.

Helena, 2015 October 5. David Cameron in favour of supervised injection facilities,

prescribing heroin….. Before he was PM. Retrieved from

https://www.release.org.uk/blog/david-cameron-favour-supervised-injection-facilities-

prescribing-heroin-%E2%80%A6-he-was-pm.

Holloway K. & Hills, R. 2017. A qualitative study of fatal and non0fatal overdose among

opiate users in South Wales. University of South Wales. Welsh Government. 2017.

https://www.alberta.ca/opioid-reports.aspx

https://www.alberta.ca/opioid-reports.aspx

https://www.atira.bc.ca/sisterspace-shared-using-rooms

http://www.bbc.co.uk/news/uk-wales-41267538

https://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/death-investigation/statistical/illicit-drug.pdf

https://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/death-investigation/statistical/illicit-drug.pdf

http://www.drpeter.org/dr-peter-centre/knowledge-transfer/community-support-for-sis/

http://www.drpeter.org/dr-peter-centre/knowledge-transfer/community-support-for-sis/

https://www.release.org.uk/blog/david-cameron-favour-supervised-injection-facilities-prescribing-heroin-%E2%80%A6-he-was-pm

https://www.release.org.uk/blog/david-cameron-favour-supervised-injection-facilities-prescribing-heroin-%E2%80%A6-he-was-pm


31

Konsumraum, A, K. 2011. Drug consumption rooms in Germany. A situational assessment.

Deutsche AIDS-Hilfe.

Marshall, B., Milloy, M., Wood, E., Montaner, J. & Kerr, T. 2011. Reduction in overdose

mortality after the opening of North America’s first medically supervised safer injecting

facility: a retrospective population-based study. Lancet, 377.

Milloy, M. J. & Wood, E. 2009. Emerging role of supervised injecting facilities in human

immunodeficiency virus prevention. Addiction, 104, 620-1.

Morgan, G. & Smith, J. 2016. Harm Reduction Database Wales: Take Home Naloxone 2015-

2016. Substance Misuse Programme, Public Health Wales.

Potier, C., Laprévote, V., Dubois-Arber, F., Cottencin, O. & Rolland, B. 2014. Supervised

injection services: What has been demonstrated? A systematic literature review. Drug and

Alcohol Dependence, 145, 48-68.

Potkins, M. 2017 April 7. Calgary leads Alberta with 25 fentanyl related deaths in first six

weeks of 2017. Retrieved from http://calgaryherald.com/news/local-news/calgary-leads-

alberta-with-25-fentanyl-related-deaths-in-first-six-weeks-of-2017.

Public Health England. 2015. Hepatitis C in the UK: 2015 report p15, 28 July 2015. In

Hepatitis C in Wales: Perspectives, Challenges and Solutions.

Office for National Statistics, 2017. Deaths Related to Drug Poisoning, England and Wales

https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/death

s/datasets/deathsrelatedtodrugpoisoningenglandandwalesreferencetable.

Otter, D. L. 2017. Lessons from Abroad: What the United States Can Learn from European

Drug Consumption Rooms. University of Washington.

Rhodes, D. 2017 July 26. Drug consumption rooms ruled out by government. Retrieved from

http://www.bbc.co.uk/news/uk-england-40674453.

Salmon, A. M., Van Beek, I., Amin, J., Kaldor, J. & Maher, L. 2010. The impact of a supervised

injecting facility on ambulance call-outs in Sydney, Australia. Addiction, 105, 676-83.

Schatz, M. & Nougier, M. 2012. Drug consumption rooms: Evidence and practice. In: IDPC

(ed.). London: IDPC.

Shepherd, S. & Caldwell, J. 2017. Toronto Overdose Action Plan: Prevention & Response.

Toronto Public Health.

Siddique, H. 2017 March 5. Durham police wil give addicts heroin to inject in ‘shooting

galleries’. Retrieved from https://www.theguardian.com/society/2017/mar/05/durham-

police-heroin-addicts-treatment-shooting-galleries.

Springer, D. 2017 October 19. Washington state judge rules in favour of supervised injection

sites. Retrieved from http://www.foxnews.com/politics/2017/10/18/washington-state-

judge-rules-in-favor-supervised-injection-sites.html.

http://calgaryherald.com/news/local-news/calgary-leads-alberta-with-25-fentanyl-related-deaths-in-first-six-weeks-of-2017

http://calgaryherald.com/news/local-news/calgary-leads-alberta-with-25-fentanyl-related-deaths-in-first-six-weeks-of-2017

https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/deathsrelatedtodrugpoisoningenglandandwalesreferencetable

https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/deathsrelatedtodrugpoisoningenglandandwalesreferencetable

http://www.bbc.co.uk/news/uk-england-40674453

https://www.theguardian.com/society/2017/mar/05/durham-police-heroin-addicts-treatment-shooting-galleries

https://www.theguardian.com/society/2017/mar/05/durham-police-heroin-addicts-treatment-shooting-galleries

http://www.foxnews.com/politics/2017/10/18/washington-state-judge-rules-in-favor-supervised-injection-sites.html

http://www.foxnews.com/politics/2017/10/18/washington-state-judge-rules-in-favor-supervised-injection-sites.html


32

Wilkinson, P. 2014. Appendix 3 – Update on Drug Consumption Room Feasibility Working

Group. Public Health, Brighton and Hove City Council.

Vancouver Coastal Health. 2017 July 14. New alert system starts for bad dope. Retrieved

from http://www.vch.ca/about-us/news/new-alert-system-starts-for-bad-dope.

Vancouver Coastal Health. 2017 September 18. Overdose statistics – August 2017. Retrieved

from http://www.vch.ca/about-us/news/overdose-statistics-august-2017.

http://www.vch.ca/about-us/news/new-alert-system-starts-for-bad-dope

http://www.vch.ca/about-us/news/overdose-statistics-august-2017


33

12. Appendix

Thank you for agreeing to complete this questionnaire regarding injecting drug use

behaviour and Enhanced Harm Reduction Centre’s (also known as Drug Consumption

Rooms). The information you will provide will be both anonymous and confidential. Your

participation within this survey is critical for Drugaid Cymru and relevant groups to gather

information regarding the potential need for a EHRC to help minimise the impact of both

blood borne virus transmission as well as Drug-Related-Deaths, among many other issues.

Appendix 1. Enhanced Harm Reduction Centres questionnaire that was complete by

(insert number) to give an overview of injecting behaviour and perceptions around DCRs

from a service user perspective.

1. Where do you live? SWANSEA (or surrounding area) MERTHYR (or surrounding area)

2. Have you previously or do you currently inject drugs YES NO

3. Have you ever tested positive for a Blood Borne Virus (e.g. Hepatitis B/C or HIV

YES NO

4. Have you ever shared any injecting equipment with another rrrrrrrrrperson

YES NO

5. Have you ever used unclean or old injecting equipment YES NO

6. Have you ever injected in public (i.e. on the streets/ someone’s back yard a. If YES – have you ever been hassled by anyone while injecting in public (e.g. by a passer-by)? b. If YES (to Q6) - Have you ever overdosed in public?

YES YES YES

NO NO NO

7. Have you ever injected in a public facility (e.g. toilet in a coffee shop? a. If YES – Have you have overdosed while injecting in a public facility?

YES YES

NO NO

8. Have you ever discarded injecting equipment in public (i.e. left injecting equipment on the streets)?

YES NO

9. Have you ever witnessed anyone injecting either in public or in a public facility?

YES NO

10. Have you ever witnessed an overdose in public or a public facility?

YES NO

11. Have you ever injected on your own within your residence?

YES NO

12. Do you know what Drug Consumption Rooms (DCRs) are? a. If YES – Please describe what your understanding of a DCR is?

YES NO

13. Do you feel DCRs should be established in your area?

YES NO

14. Would you access a DCR if one was established in your area? a. If YES – why? b. If NO – why not?

YES NO

Appendix 2. Enhanced Harm Reduction Needs Analysis – Data Collection Guide developed by Katy Holloway.

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