How to design a drug consumption room
A recent study reviewed key features to consider when designing a drug consumption room. From chill-out rooms to existential crises, Rob Calder picks out the shiny parts.
Original research article: Stakeholder preferences for supervised consumption site design, staff, and ancillary services: A scoping review of feasibility studies. By David T Kryszajtys and colleagues. Published in Drug and Alcohol Dependence (2022).
We at the SSA have written quite a lot about drug consumption rooms recently. It’s not just us, drug consumption rooms (also called supervised injection facilities, or supervised consumption sites – although there are differences) do tend to generate debate (1 2); not all of it reasoned or calm. Last week, drug consumption rooms were in the headlines again after the US Justice Department said that it would evaluate, rather than just oppose, these sites. This representing a dramatic shift from its previous stance that used laws designed in the 1980s for so-called ‘crack houses’ to try and prevent any drug consumption rooms from being opened.
These debates are often based on emotions rather than on a sober review of the evidence. Last year, the UK prime minister said he was “instinctively opposed” to drug consumption rooms, as if one’s instincts were proof enough.
And so, the latest piece of research on drug consumption rooms is a relief. Partly because it provides a well-earned break from polemics, and partly because it gets into the detail. It gets past the notion that there is a single thing called a drug consumption room, and looks at how facilities can differ. It describes how they can improve and how providers can accommodate the needs of people who use them as well as the needs of local communities and stakeholders.
The authors did not focus on whether supervised consumption sites are effective (well, not directly anyway); rather, this was a scoping review of feasibility studies. And it is in this feasibility element that the fun really starts.
The feasibility long-grass
If I’m honest, my heart sinks when I hear “Yes, I agree, but shall we conduct a feasibility study first?”. It’s an annoyingly effective way of taking the fun out of almost anything. Quite often, it is also used as shorthand for “shall we kick this into the long-grass?”. I do sometimes worry about how many things lurk in the long-grass.
The Canadian government, however, requires a feasibility study for every planned drug consumption room, which doesn’t seem to have particularly prevented them from opening. Most importantly, that now means that there are a lot of feasibility studies and a lot of data. As a result, most of the data reviewed in this study by Kryszajtys and colleagues are from Canada. Within this wealth of information are details about what it takes to make supervised consumption sites work better.
Location, location, location
First, location is important. Some people who use drugs wanted sites within other healthcare services, like a clinic within a hospital. This benefits from having other healthcare services nearby. But, because people are people, other people said they preferred standalone models that were away from hospital settings. This is already tricky.
Second, location is (still) important. A provider needs to place drug consumption rooms near to areas of need, and this might mean commissioning several of them. In a couple of qualitative reports, people using drug consumption rooms said they were unlikely to travel more than 20 minutes to get to a site. You need to look at walking journeys, bus routes, and in some cases taxi provision.
Which brings us to location. Or mobile units. People who use drugs rated these pretty highly because of their anonymity, flexibility and because they could be accessed locally. But the flip side is that mobile units tended to have less capacity to meet a wide range of needs. They also tended to provide less supervision. Some stakeholders thought that mobile units made fewer onward referrals. Which conveniently brings us to…
A staff or a signpost?
“Herein lies the conflict. People using the service want to minimise the risks of drug use whereas the people commissioning the service want to ‘sell’ treatment.”
Here you have a split between people who use drugs and other stakeholders. People who use drugs preferred drug consumption rooms to be run by nursing staff. They rated counsellors and psychologists too, but mainly preferred nursing staff. People who used drug consumption rooms really appreciated nurses’ clinical knowledge around injecting and its associated risks.
By contrast, commissioners would prefer drug consumption rooms to be run by people who are good at making onward referrals. And herein lies the conflict. The people using the service want to minimise the risks of drug use whereas the people commissioning the service want to ‘sell’ treatment. It’s a simplification of the reality, things are never so clear cut, but you get the point.
Thankfully, this is not an uncommon issue. When buying clothes, I want someone to help me find the right size, colour and to prevent me getting it (too) wrong. The shop owner, however, wants that same person to guide me towards buying several items, a coat, a subscription, another damned loyalty card.
Of course, buying a t-shirt is different from accessing a drug consumption room (see our information pages if you are still confused). But the point is, that this is not an insurmountable conflict, people can have dual roles in which they meet multiple and contrasting needs. This study showed that it’s really important to understand what these needs are when designing, planning and staffing drug consumption rooms.
There were further notes on peer mentors, outreach workers, youth workers, indigenous people, trauma-informed care and culturally-relevant services. It’s all worth a read.
More things to consider when designing drug consumption rooms
- A mix of cubicles (for privacy) and open tables to accommodate differences in drug use
- Chill-out rooms
- Minimal queues for people who might be experiencing symptoms of drug withdrawal
- Night-time, and 24/7 opening hours
- On site showers, naloxone, laundry, signposting, blood-borne virus testing, free food etc.
- Wheelchair access
- Women-only hours and services
Feasibility in existential crisis?
Where drug consumption rooms are provided, they can be effective (although detailed analyses of the research can quickly become complicated), but drug consumption rooms are often opposed, delayed and are rarely provided. To risk stating the obvious, where they are not provided, they cannot be effective.
One could argue that the biggest barrier to drug consumption rooms effectiveness is in their lack of provision. It is in their lack of existence. Alongside staff and layout, this study reports on what it takes to get drug consumption rooms implemented. Addressing this existential crisis could dramatically improve their effectiveness.
Researchers predominantly examine how well an intervention works. In real-world settings, however, the difference between an intervention being provided and not being provided can be the first limiting factor on effectiveness. You might have the most effective treatment imaginable, but if it is forever languishing in the long-grass then you don’t have an effective treatment. Instead, you have a good idea – and there are more than enough of those around.
This is probably a good point to note that the Home Affairs Select Committee on drugs policy (2002), the Independent Working Group on Drug Consumption Rooms (2006) and the Advisory Council on the Misuse of Drugs (2016) have all previously concluded that the UK should trial drug consumption rooms. There are, however, no approved drug consumption rooms in the UK and they remain very rare.
Drug consumption rooms can only be effective if they exist. Because of this, assessing the feasibility of drug consumption rooms is not merely an adjunct to research, it is central to finding better ways to improve the lives of people who use drugs.
by Rob Calder
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