“People are always against harm reduction programs at first. But once they see the results, their views change.” – Frederick Bernard, Liege Chief Commissioner of Police
My first visit to a safe consumption site (SCS), where people use illicit drugs under professional supervision, felt like a strange dream. On a tepid June day, I sat in a circular room decked with Star Wars posters in Liege, Belgium, drinking bitter coffee from a tiny plastic cup and listening to two Belgian police chiefs discuss the country’s first SCS, which had opened next to the police station nine months earlier. To my right, Liege Chief Commissioner Frederick Bernard praised the program for successfully removing illicit drug use from public spaces in Liege.
When I asked in halting French if the city had experienced pushback from other police or citizens about the site—especially considering that SCSs are illegal in Belgium—the commissioner waved his hand, saying, “People are always against harm reduction programs at first. But once they see the results, their views change.”
After our introductory meeting, Commissioner Bernard escorted a visiting police chief and me to the SCS, which was located on a pedestrian street near several restaurants and boutiques. Dominique Delhauteur, coordinator of TADAM, a private foundation that oversees the SCS, and a staff nurse met us at the door and welcomed us to a waiting area inside what looked like an old airplane hangar.
Using Illicit Drugs, with Supervision
A bald man with a long, forked beard and suspenders, it was hard to imagine that Delhauteur was once Belgium’s defense secretary. During our tour he recounted his bizarre journey from Parliament to coordinator of an illegal drug consumption site. Called Saf ti (a play on the word ‘safety’), the site had opened in September 2018.
“The city wanted to open a safe consumption room and they designated [TADAM] to open it,” explained Delhauteur, adding that mayor of Liege had been under pressure to do something about the open drug markets in Liege. “We were not put off by the illegality,” he adds, because local police supported the project from the beginning.
Currently, over 100 legal SCSs operate in 12 countries around the world, primarily Canada, Australia, and parts of Europe. Also called drug consumption rooms or supervised injection facilities, SCSs allow people to use drugs under the supervision of trained staff.
In order to prevent the spread of HIV, hepatitis C and other infections, SCSs offer sterile equipment for smoking or injecting drugs and provide education around safer use techniques. To prevent deaths, staff responds to overdoses and other emergencies. Most programs also offer wraparound services such as referrals to housing, healthcare, employment, and drug treatment programs. SCSs do not provide illicit drugs and forbid users to sell or share them onsite.
SCSs operate on a harm reduction model, which seeks to reduce the negative consequences of problematic drug use, such as death and disease, while at the same time recognizing that drug use is a part of our world. Harm reduction is a pragmatic approach to a complex problem, like providing condoms and safe sex education rather than pursuing the more elusive goal of abstinence for all people at all times.
Do Supervised Consumption Facilities Encourage Drug Use?
Opponents of SCSs argue that they encourage drug use—the same criticism often levied against other harm reduction programs such a syringe exchange or naloxone access. But although research on SCS outcomes is difficult (largely due to the ethical dilemma of creating a control group without access to SCSs and the difficulty of measuring illicit behaviors), existing reports point to positive outcomes for SCS users.
A 2014 review of 75 studies on SCSs around the world reported that the programs reduce drug use in public spaces, lower overdose rates, increase access to safer injection conditions (which can decrease infection and disease) and link users to healthcare. Other studies have reported lower overdose mortality, fewer ambulance calls, and a decrease in HIV infections among SCS participants.
A study published in Lancet on Insite, the first SCS in Vancouver, Canada, found a 35% decrease in overdose rates in the area immediately surrounding Insite (compared to a 9% decrease in the rest of the city). A study published in Addiction in 2007 reported that Insite users were 30% more likely to access drug treatment than non-participants. The study found no evidence that Insite increased or encouraged drug use.
How It Works
Saf ti – Liege, Belgium
During my tour of Saf ti in Liege, I was already aware of the benefits of SCSs (and their limitations, namely, that positive effects only extend to the site’s immediate area). But I wanted to see how the facilities actually worked.
Saf ti has only three rules: users must be 18 or older, they cannot sell or share drugs in the facility or surrounding area, and they must have a history of illicit drug use prior to their first visit. The program is open seven days a week at varying times and receives 50 or more visits per day, with some users returning several times a day. (To protect users’ privacy, our visit occurred outside operating hours.) Medical care for abscesses, burns (from smoking hot pipes), infections, or other complications is also available.
“We have a team of seven nurses, three social work educators, and two general practitioners who visit twice a week,” said Delhauter. “If someone asks for help, we listen and we help.”
After showing us the checkup room, which looked like any doctor’s office, Delhauteur led our little crew to the actual consumption area. Here, staff provides users with a tray containing sterile supplies for injecting (a syringe, a spoon, sterile water, alcohol wipes, and a filter to separate solid drugs from liquid after heating) or smoking (a pipe and a smoking filter). Heroin and cocaine are the primary drugs consumed at this site, with most heroin smoked and most cocaine injected (the reverse of drug trends in the U.S. and many other parts of Europe).
The injection room stands to the right of the supply counter. Several steel tables and chairs furnish the room, which is equipped with bright yellow biohazard containers to dispose of used injection materials.
Along one wall of the room, rows of tiny plastic drawers house multi-colored tourniquets, which are used to tie off the arm before injecting. Each tourniquet is labeled with the name of its owner so that it can be reused.
The smoking area stands to the left of the supply counter. The 12 steel smoking stalls resemble mini phone booths equipped with stools, tables for preparing drugs, and massive air vents to suck up smoke and sterilize the room. To facilitate cleaning and sterilization, every surface in the consumption area is metal.
Saf ti is clean, sterile, and professional, though I would hardly describe it as comfortable or inviting. Its purpose, of course, is to reduce health harms associated with illicit drug use, but it is also designed to conceal drug use from the public. The facility is hidden in plain sight on a busy street where passersby on their way to nearby shops and cafes would never guess that inside that unmarked warehouse, dozens of people take illegal drugs each day.
Quai 9 – Geneva, Switzerland
The Liege SCS was the first that I visited during a six-week drug policy tour through central Europe. The second facility, Quai 9 in Geneva, Switzerland, had a whole different personality.
If Saf ti hides in plain sight, Quai 9 makes no effort to hide at all. The building, a garish lime-green box, rises out of a concrete parking lot next to Geneva’s busiest train station. The setup to Quai 9 is similar to Saf ti. Before using the consumption rooms, participants enter a waiting area for intake. Quai 9’s waiting room resembles a coffee shop, except that in addition to espresso (served in tiny ceramic teacups), the shelves behind the expansive counter offer sterile drug use supplies, brochures on HIV and hepatitis C prevention, biohazard containers, and other resources. The room has tables and chairs and a medical office to the side where people can visit a nurse or doctor.
The Quai 9 consumption room is painted the same blinding green as the outside of the building. Several injection stations are equipped with biohazard containers for waste disposal and bottles of disinfectant for cleaning each station after use. In a smaller room cordoned off by a glass wall, users can sit at a metal table to smoke their drugs.
Quai 9 receives an average of 120 visits per day, 365 days a year. It opened in 2001 in response to a rash of infections and overdoses among Switzerland’s heroin user population. Like the rest of Europe and the United States, Switzerland experienced rapid growth in heroin use during the 1970s, accompanied by increases in overdose deaths and HIV transmission through needle sharing.
At first, Switzerland responded like the rest of the world, engaging law enforcement in harsh crackdowns on users and dealers. In the ensuing years, overdose deaths quadrupled from about 100 per year in the late 1970s to nearly 400 per year in the early 1990s. AIDS deaths related to injection drug use skyrocketed as well, from a handful per year in the early 1980s to a peak of 350 in 1994.
After Switzerland Implemented Harm Reduction Programs, Drug-Related Deaths Declined Sharply
But beginning in the late 1980s, Switzerland adopted a different approach to drug use, seeking to manage the harms rather than attempt to eliminate drugs altogether, which was proving impossible. The first SCS opened in Berne, Switzerland in 1986. In 1994, the Swiss also pioneered heroin-assisted treatment clinics, where heavily dependent users could receive prescription heroin under medical supervision, therefore reducing the user’s contact with the underground economy and associated crime. Since the implementation of these programs and harm reduction techniques, Switzerland has seen a 64% decline in drug-related deaths. The percentage of new HIV cases originating from injection drug use also plummeted from 50.7% during the 1990s to 2% in 2014.
Switzerland’s results could serve as a blueprint for drug policy in other countries, including the United States. In fact, in 2017 the American Medical Association threw their weight behind SCS, issuing a statement announcing the group had “voted to support the development of pilot facilities where people who use intravenous drugs can inject self-provided drugs under medical supervision.”
Plans to open SCSs are underway in several U.S. cities, though numerous roadblocks remain. In 2017, the Seattle City Council committed $1.3 million to open a site, while surrounding King County pledged $1 million towards the project. But Seattle’s new U.S. Attorney, who took office in April 2019, has vowed to block efforts.
Jesse Rawlins, Project Manager for the Public Defender Association, which is leading the SCS campaign, says that the Association is “rolling supervised consumption work into a larger local campaign focused on engagement and care for drug users.”
In 2018 New York City Mayor Bill DeBlasio put forth a pilot plan to open four SCSs, but the sites are still awaiting approval from the state Department of Health.
In May 2019, backed by a broad coalition of public and private sector stakeholders, a bill authorizing SCSs in San Francisco passed the California state Assembly. In January it will attempt to move through the Senate.
“We’ve done a lot of organizing and educating in San Francisco, and SCS has broad support here, but we continue to face frustrating delays, most recently the decision to hold the state legislation until next year,” says Laura Thomas of the San Francisco AIDS Foundation. “We know these delays are measured in lives lost and we’re looking for other ways to provide these services to keep people alive and get syringes off the streets.”
Safe Consumption Sites in the U.S. Face Opposition
In Philadelphia, a non-profit called Safehouse is suing the federal government for the right to open an SCS. The group enjoys support from local elected officials, including the mayor and the District Attorney, but federal prosecutors are gearing up for a court battle. Evidentiary hearings for U.S. v Safehouse are set for August 2019. The court’s decision may determine the future of SCS efforts across the nation.
“We have consistently maintained that overdose prevention, including supervised consumption, is a legal medical practice and not prohibited by federal law,” says Ronda Goldfein, Executive Director of the AIDS Law Project of Pennsylvania. “A win in Philadelphia will diminish the fear of criminal and civil liability and will encourage other communities to push forward with efforts to save lives.”
U.S. resistance to SCS echoes the pushback from Europeans, Canadians and Australians when they first considered the programs. The fear that harm reduction will encourage drug use remains ingrained in the national psyche despite science that contradicts these claims. But during times of crisis, people often become willing to set fears aside and try new solutions. Europe implemented harm reduction programs at the peak of drug and HIV epidemics. The U.S. is currently facing a historic overdose crisis. Harm reduction programs once considered politically impossible are launching all over the country. If trends continue, legal safe consumption rooms might be in the U.S. sooner than we think.
Peter Muyshondt, Dominique Delhauteur, Marylene Tommaso, and Tessie Castillo