In March 2004, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) published a review of the evidence base for the introduction of consumptions rooms as part of a harm reduction strategy. 

Definition

Consumption rooms are protected places for the hygienic consumption of pre-obtained drugs in a non-judgemental environment and under the supervision of trained health and social care staff.  They comprise a highly specialised drugs service within a wider network of services for drug users. Consumption rooms are official services, funded from local or regional budgets or by voluntary organisations. They are distinct from illegal ‘shooting galleries’, which are run for profit by drug dealers, as well as from consumption facilities provided within the framework of drug prescription programmes, where drugs are supplied to users.

Rationale and objective

Dagmar Hedrich1 at the EMCDDA reviewed the available literature on consumption rooms. She reviewed 143 articles, written in several European languages, from published and grey literature. The overall rationale for consumption rooms is to reach and address the problems of specific, high-risk populations of drug users, especially injectors and those who consume in public. These groups have important healthcare needs that are often not met by other services, and pose problems for local communities that have not been solved through other responses by drug services, social services or law enforcement.

According to Hedrich’s review, the specific objectives of consumption rooms are:

• to establish contact with difficult to reach populations;
• to provide a safe and hygienic environment for drug consumption, and injecting drug use in particular;
• to reduce mortality and morbidity associated with drug use including overdose, as well as transmission of HIV, hepatitis, and bacterial infections;
• to promote other social, health and drug treatment services;
• to reduce public drug use and associated nuisance.  

Availability and house rules

The author reported that in Europe there are 62 consumption rooms located in 36 cities in four countries, namely, Switzerland, The Netherlands, Germany and Spain.  The first consumption room was opened in Berne, Switzerland in 1986.  In the early nineties, the first consumption rooms were opened in the Netherlands and Germany, while in 2000 the first was opened in Spain.  There are no consumption rooms in Ireland. 

In a consumption room, the use of drugs is supervised by staff, who also give advice on risks, educate clients about safer drug use techniques and provide emergency help in case of overdose or other adverse reactions.

General admission criteria are that clients are regular or dependent users of heroin or cocaine and over 18 years old. Occasional or first-time users are excluded. Access controls to consumption rooms are strict, and in many services personalised user cards are issued after formal registration. In some cases, the number of cards is limited to prevent overcrowding. Use of a facility is sometimes restricted to local residents to limit the influx of drug users from other cities.

House rules prohibit drug dealing and specify basic hygiene requirements and safety procedures. Consumption rooms do not advertise, and staff do not help clients inject.

On entry, staff ensure that potential service users meet the admission criteria and make them familiar with house rules. After receiving sterile equipment, clients can use the facility, usually for about 30 minutes (this period applies to facilities that are predominantly used by heroin injectors; cocaine injectors usually require less time). Inside the supervised consumption area, a staff member makes clients aware of health risks and dangerous modes of consumption, observes during consumption and provides safer use advice, for example, on injecting techniques. Other staff are available to provide immediate help in case of an emergency.  As most consumption rooms are integrated into wider drugs services, many clients also use other services available on site.

Risks and benefits 

According to the author, the expected benefits of consumption rooms are:

• decreased high-risk drug use;
• decreased morbidity and mortality among the target population;
• increased uptake of health and social care including drug treatment;
• reductions in public drug use and neighbourhood nuisance. 

Because consumption rooms target those who are not ready for treatment, a major function is to offer other survival-oriented services, including basic medical care, food, drinks, clothes and shelter. The rationale underlying this function is that drug users, as long as they cannot or do not want to stop drug use, should be enabled to survive in the hope that they may at some later stage be able to give up drug use.

The possible risks of these facilities are that their presence:

• encourages increased drug use;
• initiates new users;
• makes drug use more acceptable and comfortable thus delaying initiation to treatment;
• increases public order problems by attracting drug users and drug dealers from other areas. 

Effectiveness  

Several studies have examined the positive and negative effects of this intervention.  Hedrich reviewed the available literature on the effectiveness of consumption rooms and her summary findings are presented in order of the specific objectives of consumption rooms.  

Objective 1: Attract difficult to reach drug users

Consumption rooms reach their defined target population, including street users and older, long-term users who have never been in treatment. There is no evidence that they recruit drug users into injecting.

In order to achieve adequate coverage and high rates of regular use, it is necessary to provide sufficient capacity relative to the estimated size of the target population, to locate rooms on sites that are easily accessible and to ensure that opening hours are long enough to meet demand, especially in the evening. Rooms set up to facilitate drug-using sex workers also need to be appropriately situated and remain open in the evening and night.

Given the nature of the target population, it is vital that the ‘house style’ encourages rather than deters potential clients. This implies that staff need to be sympathetic and non-judgemental towards problematic, marginalised and sometimes difficult clients, yet at the same time be clear and consistent about admission criteria and house rules. 

Objective 2: Provide a safer injecting environment 

Consumption rooms achieve the immediate objective of providing a safe place for lower risk, more hygienic drug consumption without increasing the levels of drug use or risky patterns of consumption.

Health education at consumption rooms encourages sustainable changes in risk-taking behaviour by some clients and contributes to reducing drug-related health damage among a difficult to reach target group. 

Objective 3: Decrease the incidence of infection associated with drug use 

No conclusions can be drawn about the direct impact on infectious disease incidence owing to a lack of studies and methodological problems associated with isolating the effect of consumption rooms. 

Objective 4: Decrease incidence of drug-related deaths 

Where coverage is adequate, consumption rooms may make a contribution to reducing drug-related deaths at a city level. 

Objective 5: Increase access to social, health and drug treatment services 

Consumption rooms clearly increase access to drug services and health and social care. In so doing, they promote the social inclusion of a group of extremely marginalised problem drug users.

Besides supervision of drug consumption, a range of other services is usually delivered on site. Low-threshold medical care and psychosocial counselling services are especially well used and contribute to the stabilisation of and improvement in the somatic and psychological health of service users.

Consumption rooms make referrals to further services, including drug treatment. For frequent attenders, in particular, the rooms act as a link to the wider system of care. Only a small proportion of clients use the facilities for drug consumption purposes only. The majority at some point make use of other medical, counselling and treatment services.

It is possible that some clients become partly dependent on the services provided through consumption rooms. This is a fairly common observation in many services dealing with marginalised and problematic client groups. There is, however, little evidence to suggest that consumption rooms delay treatment seeking for problem drug use by clients through making drug use more ‘comfortable’.

The question of whether consumption rooms conflict with treatment goals, in particular whether they should allow clients in oral methadone treatment to use the rooms for injection, is dealt with in different ways. For example, in Germany, methadone clients are excluded from most consumption rooms; on the other hand, Switzerland takes the pragmatic view that if methadone clients are going to inject anyway it is better that they do so in safe and hygienic circumstances.

Objective 6: Reduce public drug use and associated nuisance

Consumption rooms can reduce the level of drug use in public. The extent to which this is achieved depends on their accessibility, opening hours and capacity to accommodate drug consumption that would otherwise occur in public.

The location of consumption rooms needs to be compatible with the needs of drug users, but also to take account of the needs and expectations of local residents. A reduction in the number of public consumptions can contribute to improvements in the neighbourhood by helping to reduce public nuisance associated with open drug scenes. However, facilities near illicit drug markets are not able to solve wider nuisance problems that result from these markets.

Police actions against drug markets and drug scenes in other neighbourhoods may sometimes increase public order problems near consumption rooms. This implies that, if rooms are to contribute to reducing public nuisance rather than be blamed for aggravating it, there needs to be consultation not only with local residents but also with police, so that action to discourage open drug scenes does not at the same time deter drug users from making use of the facilities.

Consumption rooms have greater impact where there is a political consensus that they are part of a comprehensive local strategy to respond to drug-use-related problems that acknowledges public and individual health objectives as well as the need to maintain an acceptable situation with regard to order and safety in the community.

There is no evidence that the operation of consumption rooms leads to more acquisitive crime. 

There is small-scale drug dealing in the vicinity of many services, which is not surprising given their location.

Conclusions

According to the author, the evidence suggests that the benefits of consumption rooms can outweigh the risks. It is important to set this in the wider context of problem drug use and of responses to it, and to be modest in claiming what consumption rooms can or cannot achieve. In particular, it is unrealistic to expect that they can:

• prevent all public drug use;
• persuade all clients to reduce risky drug use or enter treatment;
• in themselves be the major factor in reducing morbidity and mortality;
• solve wider problems of drug markets and drug dealing. 

The author states that the evidence suggests that consumption rooms can only be effective, if they are:

• established within the wider framework of a public policy and network of services that aim to reduce individual and social harms arising from problem drug use;
• based on consensus and active co-operation between key local actors, especially health workers, police, local authorities and local communities;
• seen for what they are – specific services aiming to reduce problems of health and social harm involving specific high-risk populations of problematic drug users and addressing needs that other responses have failed to meet. 

This article provides a basic overview of the evidence in relation to the provision of consumption rooms.  It is recommended, as a first step, that individuals or organisations considering introducing such facilities read the complete review-document.  

·         1. Hedrich D  (2004) European report on consumption rooms. Lisbon: EMCDDA.

This report is available on the EMCDDA website at: http://www.emcdda.europa.eu/