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Training Guide

Alternatives to Public Injections

Frankfurt, Germany: Drug Consumption Rooms

Werner Schneider, former Drug Policy Coordinator for the City of Frankfurt in Germany, spoke about the success of their “Four Pillars” framework, which he helped pioneer. This Four Pillars approach sought to address public drug use and associated harms and to establish safer drug use as a legally sanctioned integrated part of local policy. The four pillars approach is a jointly applied city-wide drug strategy addressing Prevention, Treatment, Enforcement, and Harm Reduction.

In Frankfurt and a few other German cities, there were drop-in centers or “health rooms” operating in a legal grey area. These laid the groundwork for drug consumption rooms (DCRs), which would be operated as health-promoting services in drug and AIDS services organizations. To move into legally-approved health programs, it was critically important to gain the support of local public officials, which allowed Frankfurt to successfully overcome the initially strong opposition from the national government.

The first DCR in Germany was implemented in 1992, and three more were opened over the next few years. Today, DCRs comprise a major cornerstone of a comprehensive strategy that includes consumption rooms, three methadone treatment programs, 126 shelter beds, a large scale syringe access program, street outreach, and a laundry room. The DCRs operate from 6:00 am to 11:00 pm six days per week. Utilization is tracked through a computerized identification system with unique personal identification codes. Every visit to the DCR is registered, and participants are surveyed annually about their health and drug consumption. Preliminary debate about the establishment of a DCR revolved around concerns that it would attract more people who use drugs to the area, encourage young people to use drugs, and increase the overall rates of drug use. These concerns each proved to be unfounded, but are common across communities considering safer injection facilities, mirroring objections to syringe exchange programs and other harm reduction services. An abundance of evidence has consistently demonstrated that these objections are not borne out in experience.

“To move into legally-approved health programs, it was critically important to gain the support of local public officials.” 

“Drug consumption rooms have been effective in saving lives.” 

In Frankfurt, cooperation from the police was essential to the success of the DCR, according to Peter Frerichs. Frerichs served as the VicePresident of the Frankfurt Police Department in charge of law enforcement and coordination with harm reduction drug policy in the city at the time of the establishment of the DCRs. An initial problem they faced was that there was no latitude in the penal code to allow the police to exercise discretion on drug possession charges. To resolve this contradiction between law enforcement and public health, the Frankfurt mayor ordered all of the stakeholders to meet every week to coordinate efforts and develop solutions. These regular roundtable discussions led to the high court issuing a legal opinion that the DCR was a medical intervention, thus clarifying the role of law enforcement and providing the legal authority needed to move forward.

Since opening in 1992, the DCRs have documented 191,729 injections on site, and now average about 17,000 injections per month or 550 per day. Most of the uses are for heroin. In 2013, roughly half of the DCR participants were surveyed and consented to tests for HIV and hepatitis C. The survey found that more than 50% had a medical appointment in the prior month, 21% were homeless or living without stable housing, and 60% were unemployed. The seroprevalence rates were 3% for HIV and 41% for hepatitis C among those tested, which was down significantly from 8.6% for HIV and 61% for hepatitis C in 2004.

Between 2000 and 2013, DCR staff have provided on-site emergency first aid 3,180 times. No fatalities have occurred at the DCR, and the staff train participants in overdose prevention and the use of the opioid overdose reversal drug naloxone. Across the city, there has been an 80% reduction in overdose deaths.

The Frankfurt DCRs have two fundamental rules: no violence and no drug dealing (or sharing). DCR employees are also required to cooperate with the police when necessary.

Mr. Schneider summarized the following benefits of the DCRs:

1. DCRs have been very effective in saving lives;
2. Strong evidence suggests that DCRs help to reduce HIV and HCV infections;
3. DCRs can foster participant engagement in treatment and socialization;
4. DCRs reduced noise complaints and public safety concerns in the community without attracting young people or users from places outside of Frankfurt.

Sydney, Australia: Supervised Injection Facility 

Marianne Jauncey, MD, the medical director of the Sydney Medically Supervised Injecting Centre (MSIC), reported that the Australian SIF was the first to open outside of Europe and the first in the English-speaking world. The Sydney SIF is a single-site service that opened at a time of intense public and media scrutiny of overdose fatalities, drug-related crime, and police corruption. A very structured medical model was chosen as a way to gain legitimacy among the public and policymakers. Dr. Jauncey cited three key factors leading to the success of the SIF:

1. Changing state law to allow participants to self-administer drugs and possess controlled substances;
2. Securing the support of the local police;
3. Leadership by the faith community (the United Church is the licensed operator of the SIF).

The Sydney MSIC began as a pilot program in 2001. The MSIC operates as part of a comprehensive array of complementary syringe access services in over 400 pharmacies, 360 syringe access programs, and several syringe vending machines across Sydney. The Sydney MSIC utilizes a highly structured clinical model that provides services in a friendly, non-judgmental way to about 700-750 people a month. The service supervises roughly 170-200 injections per day on the site. For the majority of participants the drug of choice is heroin, but recently the SIF has observed an increase in people injecting prescription opioids.

A secondary benefit of the Sydney MSIC is the ability to provide “real-time” drug market monitoring data that can be utilized by public health professionals, academic researchers and law enforcement so they do not have to rely exclusively on traditional public health data surveillance, which has a two year lag in reporting. This real-time drug market surveillance can identify trends in overdose outbreaks, drug types, and purity to inform community education and rapidly adjust public health strategies.

The Sydney MSIC is funded by government asset forfeiture funds. The utilization of ‘proceeds of crime’ to fund the Sydney SIF has been beneficial in countering criticism from fiscal conservatives and critics of using government funds on public health and harm reduction for people who inject drugs. For the first nine years of operation, the Sydney MSIC operated as a pilot program. Legislation was enacted in 2010 which authorized the program on a permanent basis. Dr. Jauncey highlighted current discussions about whether to integrate the SIF into existing medical services or to remain as single- site program.

Dr. Jauncey stressed that the Sydney MSIC emerged as a local solution to a local problem. The success of the facility is due to the support of key champions, including strong allies in medicine and academia. The MSIC’s continued survival as a pilot program at every election cycle was contingent upon the support of the local community and neighborhood businesses, support which has continued to increase over the years. In a large public opinion survey undertaken in 2014, 55% of the general public supported the SIF. Federal government acceptance of the SIF was initially slow, but acknowledgement has developed over time. The former Premier of the Australian state of New South Wales recently cited the Sydney MSIC as one of his proudest achievements.

“The success of the facility is due to the support of key champions, including strong allies in medicine and academia.”

Tony Trimingham became involved in drug policy reform in 2000 and was an instrumental advocate for the Sydney SIF. Trimingham is the founder of Family Drug Support (FDS), a non-profit organization that helps and assists the families of people who use drugs at problematic levels.

Mr. Trimingham lost his son Damien to a heroin overdose in 1997, two years after his son had started using heroin. Speaking as a parent, he suggested that harm reduction advocates partner with families who have been affected by fatal drug overdoses and other drug-related harms, including drug policy harms. This partnership, according to Mr. Trimingham, can help win “hearts and minds” by articulating the burden of living with the stigma and shame surrounding drug use, and can assist with counteracting opposition to SIFs and other harm reduction services. Mr. Trimingham spoke of the pain he lives with now, 18 years later, which comes from imagining what we could have done to reduce the stigma and demonization of people who use drugs and the thousands of lives that could have been saved from overdose.

Vancouver, Canada: Supervised Injecting Facility 

Insite is a supervised injection facility operating in the Downtown Eastside of Vancouver; an area with a high concentration of socio-economic issues, including homelessness, income inequality and unemployment, and public drug use. The SIF opened at a time when many people were dying of HIV/AIDS and overdoses. The organizers of Insite were motivated to address these public health challenges through a campaign to combat discrimination and demonization of people who use drugs. Insite’s director, Liz Evans, explained that the facility emphasized providing good medical care, establishing a safe and sterile environment, and fostering self-care and autonomy. The facility opened in 2003, providing an indoor space and sterile injecting equipment for people to use, along with counseling and linkage to housing and drug treatment. From the very beginning, academic researchers measured and evaluated all aspects of the services provided.

Insite’s organizers consulted international experts, adopted Germany’s Four Pillars framework, and extensively engaged local stakeholders, including those in the prevention and drug-free communities and law enforcement. The campaign organizers viewed law enforcement as potential allies, and gained their support by enlisting supportive police from other jurisdictions to engage Vancouver’s Chief of Police. The success of those meetings resulted in the Police Chief writing a letter supporting harm reduction as a public health intervention.

Initially, there was strong opposition to the facility from providers of abstinence-based drug treatment, but engagement turned them into allies over time as they recognized Insite’s role in referring participants to their treatment programs.

Alongside providing harm reduction and Housing First services, Insite also sought to address stigma and promote the human rights of people who had been demonized by the media and labelled as a nuisance by the local community. Ms. Evans noted a shift in media narratives toward a more sympathetic portrayal of people who use drugs, which she credited in helping to broaden public support and ultimately securing political approval.

Canadian Senator Larry Campbell, former Mayor of Vancouver, added that Insite built upon the syringe access initiatives already in place across the city. Campbell also attributed the success of the SIF campaign to the adoption of Germany’s Four Pillars model through ongoing community stakeholders meetings.

The Vancouver SIF engaged the scientific community from the very beginning in order to evaluate all aspects of the program. Thomas Kerr, PhD and colleagues at the British Columbia Centre for Excellence, oversaw the evaluations of Insite’s implementation and the publication of over 40 peer- reviewed studies of Insite. The research of Dr. Kerr and colleagues addressed questions about the impact on participants’ health, utilization of hospital and treatment services, public disorder, drug use in the community, and a cost-benefit analysis:

1. Insite users were much more likely to engage in safe injecting and less likely to share injecting equipment;
2. There was a 35% reduction in fatal overdoses in the area around the program, compared to only a 9% reduction in the rest of Vancouver;
3. Frequent Insite users lived within three blocks of the program, and did not come from outside the community to use the facility;
4. A survey of more than 1,000 participants showed that Insite referred 18% to detox and other longer-term drug treatment programs;
5. Relations with police improved; 17% participants surveyed said the police helped them get to Insite;
6. Insite was estimated to save $14 million over 10 years in health care costs.

Even with local community support and a strong record of successful outcomes, Insite was vulnerable to political changes in the federal government and had to fight against closure in court for a number of years. In 2011, a unanimous Canadian Supreme Court ruling in favor of Insite ended the struggle and allowed them to remain open. Today, Insite’s organizers are seeking to expand SIFs to other cities and integrate SIFs into medical clinics. Dr. Kerr and his team recently evaluated the integration of a SIF within an adult day treatment and residential program for people living with HIV.

“Initially, there was strong opposition to the facility from providers of abstinence-based treatment, but engagement turned them into allies over time as they recognized Insite’s role in referring participants to their treatment programs.” 

Research on Interim Initiatives

Alex H. Kral, PhD reported on a proof of concept study he conducted at a community-based program in the United States that modified a bathroom to accommodate safer drug consumption and then shifted to opening a supervised injecting room (SIR). The aim was to evaluate the programs and compare the benefits and challenges in how each model operated.

The initial safer use bathroom was adapted from an existing single use bathroom with modifications made to allow for a private space suitable for injection. The bottom of the bathroom door was cut out, and a trained member of staff was present outside the bathroom in case of overdose, but supervision was otherwise limited. There was a waiting list for use of the room.

The SIR was in a separate room at the agency with four stainless steel stations at which people could inject, along with a resting room. All stations were supervised by staff. Only injecting was permitted; inhalation/smoking was not allowed due to a lack of ventilation. Those utilizing the room had to be invited by the staff and were limited to about 50 people.

During its six months of operation, the safer use bathroom was used 1,246 times. Subsequently the SIR has been used 997 times in its first year of operations. Since implementation, there have been over 2,200 injections in total, with no overdoses, police visits, nor other adverse incidents. Most users were men, 75% of whom reported homelessness. The majority of participants reported using heroin, but some prescription opioid injection was also reported. Participants averaged 90 injections per month.

Staff participating in the study had been rigorously trained prior to commencement, and held weekly meetings throughout the duration of the trial. The participants were trained in self-care, overdose prevention, and safety awareness. Dr. Kral emphasized that study’s success was due to the commitment of staff, despite significant challenges and constraints. The safer use bathroom model created more stress for staff, did not allow for full supervision of injections, and did not help reduce stigma associated with drug use. The illegal status of SIR prevented licensed personnel (physicians and nurses) from working there, while also limiting access to funding and opportunities to establish formal linkages to health care and social services.