Overdose prevention centres in the UK

Abstract

In response to the drug related death crisis in the UK, more than 80 prominent medical, academic, and third sector organisations have called for the introduction of pilot overdose prevention centres (also called drug consumption rooms).1Faculty of Public HealthFPH lead cross-sector call to pilot overdose prevention centres in the UK.https://www.fph.org.uk/news-events/fph-news/fph-lead-cross-sector-call-to-pilot-overdose-prevention-centres-in-the-uk/Date: Dec 12, 2021Date accessed: January 17, 2022Google Scholar The government, however, has repeatedly indicated it has no plans to introduce them, and overdose prevention centres are not mentioned in it's 10-year drug strategy. Here, we question the arguments used to defend this position with relevance for other countries debating the introduction of overdose prevention centres. First, regarding the argument that there is insufficient evidence to show that overdose prevention centres are beneficial. These centres have been introduced in at least 14 countries across more than 130 sites (with an unsanctioned mobile site operating in Scotland between 2020–21).2Shorter GW Harris M McAuley A Trayner KMA Stevens A The UK's first (unsanctioned) overdose prevention site.PsyArXiv Preprints. 2021; (published online Dec 10.) (preprint).https://doi.org/10.31234/osf.io/5bqfuGoogle Scholar They provide a safe environment for the most vulnerable to use drugs under the supervision of trained professionals, who intervene in the event of an overdose; and an opportunity to provide evidence-based interventions, including naloxone, oxygen, psychosocial support, and needle and syringe programmes. Observational evidence shows fatal overdoses decreased in areas where overdose prevention centres were introduced alongside other beneficial outcomes, including reductions in self-reported high-risk injecting practices and increased engagement with drug treatment services.3European Monitoring Centre for Drugs and Drug AddictionDrug consumption rooms: an overview of provision and evidence.https://www.emcdda.europa.eu/system/files/publications/2734/POD_Drug%20consumption%20rooms.pdfDate: 2018Date accessed: January 17, 2022Google Scholar, 4Caulkins JP Pardo B Kilmer B Supervised consumption sites: a nuanced assessment of the causal evidence.Addiction. 2019; 114: 2109-2115Google Scholar There are no randomised controlled trials (RCTs) showing that overdose prevention centres reduce drug-related deaths.4Caulkins JP Pardo B Kilmer B Supervised consumption sites: a nuanced assessment of the causal evidence.Addiction. 2019; 114: 2109-2115Google Scholar As overdose prevention centres are complex community level interventions, and deaths are a relatively rare outcome, a fully powered RCT would be very large and expensive. Given the observational evidence in favour of overdose prevention centres and the clear understanding of the mechanisms by which they would prevent drug-related deaths, it is not justifiable to oppose their introduction until RCTs, which might never be conducted, are available. Many public health interventions have been introduced without RCTs when their mechanism of action is clearly understood. The inconsistent requirement for more rigorous evidence in the case of overdose prevention centres might relate to moral perceptions of illicit drug use. However, RCTs did not show the effectiveness of opioid agonist therapy to reduce mortality or blood borne virus transmission, which is recommended on the basis of observational evidence and clinical experience.5Platt L Minozzi S Reed J et al.Needle and syringe programmes and opioid substitution therapy for preventing HCV transmission among people who inject drugs: findings from a Cochrane Review and meta-analysis.Addiction. 2018; 113: 545-563Google Scholar Second, regarding the argument that overdose prevention centres condone illicit activities; it is important to note that these centres are a harm reduction intervention, meaning they aim to reduce the negative outcomes of a behaviour, without necessarily condoning or condemning that behaviour. There is no evidence overdose prevention centres are associated with increased initiation or frequency of drug use, whereas they can promote engagement with drug treatment services, which might support drug use cessation.3European Monitoring Centre for Drugs and Drug AddictionDrug consumption rooms: an overview of provision and evidence.https://www.emcdda.europa.eu/system/files/publications/2734/POD_Drug%20consumption%20rooms.pdfDate: 2018Date accessed: January 17, 2022Google Scholar Historically, other harm reduction interventions have been opposed on the basis of moral arguments that they condone drug use. In response to the 1980s HIV epidemic for example, the introduction of needle and syringe programmes in the UK was controversial. However, they became widely accepted as their important role in reducing blood borne virus transmission was recognised.6Stimson GV AIDS and injecting drug use in the United Kingdom, 1987–1993: the policy response and the prevention of the epidemic.Soc Sci Med. 1995; 41: 699-716Google Scholar Arguments that overdose prevention centres condone drug use are comparable to objections to needle and syringe programmes, which are no longer considered credible, while harm reduction approaches generally are promoted by the highest coordination forum of the UN.7UN Chief Executives Board for CoordinationUnited Nations system common position supporting the implementation of the international drug control policy through effective inter-agency collaboration.https://unsceb.org/sites/default/files/2021–01/2018%20Nov%20-%20UN%20system%20common%20position%20on%20drug%20policy.pdfDate: 2019Date accessed: January 17, 2022Google Scholar Thirdly, regarding the claim that a range of offences would be committed by overdose prevention centre providers; the liability of providers is subject to debate, in the UK at least. Although statutory protection would be preferable, local areas might consider overdose prevention centre pilots if local law enforcement agencies have agreed to facilitate their introduction.8Fortson R Setting up a drug consumption room – legal issues.http://www.rudifortson4law.co.uk/legaltexts/Rudi-Fortson-DCR-legal-issues-17thOct2017-v1.pdfDate: 2017Date accessed: January 17, 2022Google Scholar Internationally, overdose prevention centre providers have productive relationships with the police9Watson TM Bayoumi AM Hopkins S et al.Creating and sustaining cooperative relationships between supervised injection services and police: a qualitative interview study of international stakeholders.Int J Drug Policy. 2018; 61: 1-6Google Scholar and in the UK, there is support for their introduction from some police forces and police and crime commissioners.1Faculty of Public HealthFPH lead cross-sector call to pilot overdose prevention centres in the UK.https://www.fph.org.uk/news-events/fph-news/fph-lead-cross-sector-call-to-pilot-overdose-prevention-centres-in-the-uk/Date: Dec 12, 2021Date accessed: January 17, 2022Google Scholar Regardless, if a legal framework did preclude the provision of overdose prevention centres, without adequate justification, recognition of this should prompt changes to the legal framework, rather than opposition to the sites. Overdose prevention centres are not a so-called silver bullet to reduce drug-related deaths.10BBCDrug consumption rooms are a 'distraction' says UK minister.https://www.bbc.co.uk/news/uk-scotland-51644786Date: Feb 27, 2020Date accessed: February 5, 2022Google Scholar Their introduction would, however, be a reasonable incremental response to a drug-related death crisis, which would facilitate and enhance the effectiveness of other interventions. They are one component of a multifaceted toolkit, which could be suitable in areas with high rates of drug-related harm. Further research on overdose prevention centres is required to evaluate their impacts and cost-effectiveness. However, when facing the risk of serious harm, the precautionary principle compels us to not delay action while awaiting scientific certainty.11Fischer AJ Ghelardi G The precautionary principle, evidence-based medicine, and decision theory in public health evaluation.Front Public Health. 2016; 4: 107Google Scholar If considering an experimental and potentially dangerous treatment, the safest response would be to delay its introduction. Overdose prevention centres, in contrast, offer a new setting to deliver widely accepted and evaluated treatments, with no evidence they increase crime or drug use. The safest response to prevent harm is to support, and not oppose their introduction. GWS, MHa, and AH made donations towards operational costs for the Glasgow Safe Injecting Facility (<£330). MP works for the Transform Drug Policy Foundation, which received a grant from the Esmée Fairbairn Foundation, to support advocacy work related to overdose prevention centres. All other authors declare no competing interests. Opioid overdose crisis: time for a radical rethinkThe opioid epidemic is one of the worst public health disasters affecting the USA and Canada. Over the past two decades, nearly 600 000 people have died from an opioid overdose in these two countries, and an estimated 1·2 million people could die from opioid overdoses by 2029. The opioid crisis, which involves both prescribed opioids such as oxycodone and illicit drugs such as heroin, has reached new heights amid the pandemic. Against this backdrop, the Stanford–Lancet Commission on the opioid epidemic in North America, published on Feb 5, maps out an action plan to de-escalate the crisis. Full-Text PDF Open Access