The UK has never had a drug consumption room. At least not officially. From August 2020, an unofficial one was run in Glasgow for around ten months by Peter Krykant. He invited people into the back of his makeshift ambulance, converted from a second-hand minibus, and gave them a safe space to inject cocaine and heroin. It is the closest the UK has come, despite having the highest rates of drug-related death in Europe.
Injecting drugs is a risky activity – even when it is done in the carefully controlled environment of a hospital, with high-quality pharmaceuticals, experienced healthcare professionals and single-use sterile equipment. Injecting heroin in a filthy public toilet, by yourself, with someone else’s needle, is often desperate. There is the risk of damage from the needle, infection from the re-used needle and syringe, and the fact that if it all goes wrong and you overdose, there is no one to help you. You’ll die, despite the fact there is an easily administered and highly effective antidote.
Drug-related death rates in England have been rising for a decade and now outstrip comparable tolls in Europe. The highest rates are across the north-east, while Blackpool in the north-west is a pocket of pain. Scotland, meanwhile, stands in a grim league of its own – the sick man of Europe, with 1,330 deaths related to drug misuse in 2021. Comparisons are complicated, but Scotland has about four times more deaths than the worst countries in Europe and, by some calculations, more than 20 times as many deaths as the EU average. It’s carnage.
Most of the risks are due to the illicit nature of drugs. There is no way of knowing the dose, no way of even knowing for sure if that brown substance is actually heroin, and you’ll only find out how potent it is when it is coursing through your veins. Heroin, in the form sold on the street, needs to be dissolved in water, usually with the help of a little acid. If you are living on the streets, or in a squat, water isn’t always easy to get and people use water from puddles, from toilet bowls, even their own saliva.
Botulism, tetanus and necrotising fasciitis are regularly seen in people injecting drugs in the UK. Any re-use of needles is hazardous. Needles blunt quickly with use – ask any hapless soul who has been repeatedly stabbed by a junior doctor as they try to get blood. Blunt needles cause even more damage, tearing fragile veins and leaving them liable to clotting. And used needles can harbour hepatitis B, hepatitis C or HIV. Often all three.
One man's mission
Krykant saw the urgent need to tackle the problem in Glasgow. He is an activist; not medically qualified but motivated by the insight from his own past experience of heroin addiction. Although his ambulance project was short-lived, it was effective. In less than a year, he supervised nearly 900 injections by 835 people and nine overdoses were tackled. No one died and lives were saved. On one occasion, he was arrested and charged under the Misuse of Drugs Act, but Scotland’s public prosecutor dropped the case.
His audacious, law-defying actions have galvanised activists. The push for drug consumption rooms is now at the leading edge of the drive for evidence-based harm-reduction interventions.
Any human activity which could harm us, and that we are unlikely to stop despite those harms, can usually be squinted at through a harm-reduction lens. As it relates to drug use or laws, this means any policy or programme that reduces the negative effects. The approach is grounded in evidence, and aims to improve conditions both for the individuals concerned and for society. So who could possibly object?
The chief opponents are those who believe that complete abstention and prohibition should be mandated. Arguably, peak abstention was reached in the 80s and 90s with the “Just Say No” advertising campaign championed in the United States by then-First Lady Nancy Reagan. But the prohibitionist “War on Drugs” continues to this day. And while there are those who don’t believe any drug use is acceptable, others have variable thresholds and levels of tolerance.
Drug consumption rooms are a case in point. The first was opened in Berne, Switzerland in 1986. They now exist in 16 countries around the world, with Greece, Iceland and Mexico recently joining well-established services in Germany, the Netherlands, Australia and Canada – and, of course, Switzerland. The UK is lagging behind the rest of the world. Yet the picture is complex, as Britain has embraced other harm-reduction strategies – such as needle exchanges and methadone programmes.
A history of harm reduction
The UK has a proud history of harm-reduction activism, which can be traced back to the response in the 1980s to the emerging threat of HIV. There were several projects across the country, but two cities featured notably: Edinburgh and Liverpool. In Edinburgh, Roy Robertson, a GP and now Professor of Addiction Medicine, was involved in research that tested for HIV in the stored blood samples of 164 people who were known to be injecting drugs. The results were published in 1986 in the British Medical Journal. Just over half were found to be HIV positive. An obvious relationship had been found between sharing injecting equipment and the spread of HIV.
This important research came at a time when community pharmacies were scaling back the provision of injecting equipment, apparently at the request of police who were also confiscating it. As a result, a tight-knit group of people were sharing syringes and needles – and, of course, the HIV virus. HIV was spiralling out of control and an urgent response was needed.
Around this time, the public health team in Liverpool had become convinced of the need to establish needle exchange schemes to tackle the problem. Liverpool was one of the first British cities to establish such a scheme. The police also stopped arresting people for carrying the paraphernalia needed to inject drugs.
This was a significant shift in approach: the need to stop the transmission of HIV had superseded the need to get people to stop using drugs. Methadone programmes were rolled out across the UK. In December 1986, the Secretary of State for Health and Social Services, Norman Fowler, announced money to bring people into addiction treatment and a nationwide pilot scheme of needle exchange. Harm reduction had come of age.
The harm-reduction approach can lead to a virtuous cycle. The establishment of needle and syringe exchanges around the world has led to further opportunities to reduce damage, for example by supplying materials to help with safe injecting. Those injecing heroin usually need to get their hands on some form of acid. Addicts will use any available acid, including household vinegar, to help it dissolve, resulting in highly acidic solutions that are agonising to inject and can cause devastating damage to veins. Citric acid and vitamin C (ascorbic acid), in the right quantity, are now supplied in needle and syringe exchanges.
Many exchanges will also supply disposable crack pipes. Cracked lips can bleed, and sharing crack pipes can lead to the transmission of hepatitis C, which is much more infectious than HIV. (In many parts of the UK, roughly half of people injecting drugs have been infected by the virus.)
Policy vs science
Harm reduction has been embraced in many parts of the world – which is unsurprising, given its alignment with human rights and the strong evidence base. But many countries still have limited access to these strategies. HIV remains a major problem. Fewer than one per cent of people who inject drugs are living in countries that meet the UN’s recommendations on coverage for clean needles and access to opioid substitution therapy. In Eastern and Southern Africa, nearly 22 per cent of people who inject drugs are living with HIV. Compare that with England, Wales and Northern Ireland, where about one per cent of people who inject drugs are living with the condition, even though they often have long histories of injecting.
But access isn’t the only barrier. Attitudes to harm reduction vary around the world, in different countries and cultural contexts, and have waxed and waned over time. Some countries are very relaxed about giving out clean needles and syringes but don’t think we should provide crack pipes. Others may be happy to give out crack pipes but will balk at opening drug consumption rooms.
We can see what happens when a country takes a generally hostile approach to harm reduction. Russia not only remains resolutely opposed to offering opiate substitution in their own country, they have also used their position at the UN Commission on Narcotic Drugs to block harm-reduction policy approaches at the international level. After the Russian annexation of Crimea in 2014-15 and its occupation of parts of the Donbas, all harm-reduction services were closed in those areas and opiate substitution therapy was stopped. Obviously, all medical services in Ukraine have been severely impacted by the Russian invasion in February 2022. While some HIV and harm-reduction services have reportedly been re-established in Lviv, the overall effect will be devastating.
Methadone has an evidence base that can scarcely be matched by any other medication. It’s a long-acting opioid, designed to level out the boom-bust of short-acting heroin. It stops people oscillating wildly between withdrawal and intoxication, bringing stability and the opportunity to break the addiction cycle.
However, it straddles – uncomfortably for some – a nebulous zone between harm reduction and abstinence. Some people who take it will swiftly stop taking all illicit opiates. For others, it simply reduces the amount of “gear” they need. Even in those latter cases, though, methadone still reduces the risk of death, of infection and of crime associated with drug use. It has appeared on the World Health Organisation’s list of essential medicines since 2005. Yet it may still be one of the most stigmatised medications on the planet. In 2022, there were just 87 countries in the world with at least one programme offering opiate substitution therapy.
In need of a breakthrough
Here in the UK, we have a comprehensive methadone programme. Other substitution therapies are also available, including buprenorphine in various forms. But the vast majority of services now sit outside of the NHS and are provided by third sector organisations in a competitive commissioning model. And while we follow the science on some harm-reduction approaches, we reject others. There is no widespread availability of heroin-assisted treatment, despite the excellent evidence base for this approach. In fact, it was once the basis of the “British System”, in which heroin was prescribed by doctors up until the 1960s.
In some cases, we simply take our time to follow the science. One of the great harm-reduction stories in recent years has been the incredible progress in making naloxone, the “Lazarus drug”, available to all. Naloxone has been around since the 1960s, but it was only at the turn of the century that pilot schemes in the UK showed its real promise. Given as an injection or a nasal spray it can reverse an opioid overdose, bringing blue breathless bodies back to gasping life. It is given out to people who use drugs to use on each other and to families to save loved ones. In some parts of the UK, the police are now carrying it as well.
The harm-reduction philosophy can also be applied to party drugs. Education campaigns on how to safely take drugs like ecstasy or ketamine all fall under the umbrella. A crucial problem with all forms of illicit drug is the lack of standardisation. Dodgy pill factories churning out tablets in makeshift facilities don’t have stringent quality control. Charities such as The Loop attend festivals and other events where they check drugs. Festival-goers voluntarily provide samples of the products, such as ecstasy, that they have bought. The Loop then does a chemical analysis of the drug. Warnings can then be issued for dodgy or particularly high-strength batches. In a recent case, chloroquine (best known as an antimalarial drug, very toxic in overdose) was being sold as ketamine.
Harm reduction also has a role in legal drugs: “no-lo” alcohol drinks that reduce overall alcohol intakes fall into harm-reduction policies, as do e-cigarettes. There is still much to learn about vaping from a health perspective, but the current evidence suggests it is less harmful than smoking tobacco by an order of magnitude. The use of condoms is the prime example of where a harm-reduction intervention trumps an irrational and unrealistic insistence on abstinence.
Arguably, the biggest harm-reduction intervention would be to decriminalise or to legalise drugs. In a stroke, this would sweep away many of the associated harms. This is, perhaps, the reason why many are opposed to harm reduction, seeing it as decriminalisation by the backdoor. Yet, while many activists advocating for harm-reduction measures may well support decriminalisation policies, the quotidian work of reducing harm is well established, as this piece has described.
In some ways, the UK is a success story when it comes to harm reduction. We should recognise and celebrate that we have one of the lowest burdens in the world of HIV infection amongst people who inject drugs. But progress has stalled, even as the death toll from drug use continues to rise.
Lessons can be learned from the 1980s, when harm-reduction values were embedded in our current system. That period is an example of what philosopher William MacAskill calls a “malleable” moment from the past, where a certain plasticity in people’s thinking and a willingness to consider a different approach yielded significant results. Activists, healthcare and public health professionals came together with a government that didn’t get bogged down in ideological or intellectual cul-de-sacs. It was harm reduction writ large. Since then, some of our thinking has ossified again, but we know that breakthroughs are possible.
The UK needs a breakthrough when it comes to drug consumption rooms. The evidence is compelling, the moral imperative in the face of so many deaths irresistible. That’s surely why Krykant acted – his was a practical and compassionate response. Providing a safe place, with access to clean needles and drugs, is an act of simple humanity, offering one of the most stigmatised groups in society some dignity. Professionals and peers can help anyone who “goes over” and overdoses. They can help reduce drug deaths and the transmission of disease. There is also evidence that drug consumption rooms benefit the wider community, reducing ambulance call-outs and drug litter on the streets. The UK was once a leader in harm reduction. Today, we need to re-model our approach once again, to better our society and reflect the needs of people whose lives depend upon it.
This piece is from the New Humanist spring 2023 edition. Subscribe here.
