Could you give us a brief outline of the history behind the idea of opening drug-consumption rooms in France?
Taking responsibility for different types of drug addiction and the risks they involve has been one of the key issues facing elected representatives for more than 20 years: it cannot be done without the support of city authorities. At present, installing automatic needle dispensers or opening a CAARUD (Centre d’Accueil et d’Accompagnement à la Réduction des Risques pour Usagers de Drogues, a support centre that seeks to minimise risks for drug users) is simply not possible without the agreement, if not the participation, of municipal authorities. Therefore, if city councils are not willing to cooperate, we cannot make progress.
Our association, Élus, Santé Publique et Territoires, has been working for a long time on the issue of risk reduction, and drug-consumption rooms in particular. In 2009, we joined forces with the FFSU (Forum Français pour la Sécurité Urbaine – French Forum for Urban Security), which is an association of local councillors with safety and security-related responsibilities. The complementary nature of our two associations seemed obvious to us, as drug-consumption rooms straddle the boundary between public health and public safety. We wanted to organise a national study day in order to capitalise upon experiences and provide training for elected officials. At the same time, the group known as the Collectif du 19 Mai (literally the "19th May Collective", comprising ASUD – Autosupport et Réduction des Risques parmi les Usagers de Drogues – Self-Support and Risk Reduction among Drug Users –, Fédération Addiction, Act Up-Paris, SAFE, Gaïa, SOS Drogue International and SOS Hépatites Paris) opened a "replica drug-consumption room" with the goal of stimulating debate. Following this event, Paris City Council made it clear that it wished to give this issue serious consideration, taking into account of the problems of "open practices", i.e. the consumption of hard drugs on the public highway. We agreed to meet to discuss the matter in more detail. The city council required training, discussion and research activities, and to see how other cities, faced with similar problems, have managed to respond to these issues. We proposed that we run a symposium for them, which took place over six months in total. We created a group for councillors interested in the subject, which brought together representatives from nine towns and cities in France (Paris, Saint-Denis, Nanterre, Marseille, Lille, Le Havre, Annemasse, Mulhouse and Bordeaux), all of which are confronted with the problems of street-based drug addiction, with highly desocialised users that healthcare centres and CAARUDs do not manage reach, and who accumulate a variety of risks (health-related, infection-related, social, legal, etc.).
We organised two days of hearings, during which 18 experts spoke, including the head of the French drug squad; the professor of medical ethics Emmanuel Hirsch; addiction specialist William Lowenstein; associations such as ASUD, the AFR (Association Française pour la Réduction des Risques, the French association for the reduction of risks connected with drug use) and ANITeA (Association Nationale des Intervenants en Toxicomanie et Addictologie, a national association of experts in the field of drug addiction and addictology); and Nicole Maestracci, the former president of the MILDT (Mission Interministérielle de Lutte Contre la Drogue et la Toxicomanie, the interministerial taskforce against drugs and drug addiction). Only the current president of the MILDT refused to speak in front of the councillors present.
This was followed by field visits to two drug-consumption rooms, in Bilbao and Geneva. Foreign experiments such as these have proved particularly instructive, especially when it comes to understanding how these facilities were set up in their respective cities. One of the things that surprised me most was that these rooms are located in the heart of the city centre and are clearly identified. It is, for example, impossible to miss the "Quai 9" premises in Geneva, located in a public square just a few metres away from the city’s main railway station. The building itself is a customised Portakabin-type structure, painted fluorescent apple green: there is no question of hiding it. In Bilbao, the room is located in an old railway building on the riverbanks in the heart of the city. One of the embankment roads had become a regular shoot-up spot, where drug addicts found themselves in full public view. There were many accidents, in particular drownings. Consequently, this place had a very negative reputation among the city’s residents. The drug-consumption room is today on the opposite bank of the river; it is integrated into the urban fabric, and the building in which it is located also accommodates other activities.
What is the best place for a drug-consumption room in the city?
It must be easily accessible and in a location where drug dealing and consumption is currently problematic for residents. If a room is opened in Paris, it must be fully integrated into the city’s urban fabric. Initially, local residents will oppose it, protest, sign petitions, and so forth. However, once it is up and running, nobody will want to see it closed: the initial reaction is always "no way", then "maybe, but not in my neighbourhood" and, finally, once the room is open and has proven its worth as both an urban feature and a social tool, residents acknowledge its importance. The same attitude is encountered among local councillors, whatever their political persuasion. In the beginning, they have reservations or are even downright hostile to the idea of drug-consumption rooms, but many of them recognise their value once they have visited similar facilities for themselves. The major obstacles are therefore ignorance and negative preconceptions. Other problems can also arise, however. For example, what other structures can – and indeed must – work in partnership with a drug-consumption room? What sort of relations need to be established with the police? How will minors and pregnant women be dealt with? In my view, it is advisable to answer these questions on a case-by-case basis: the experience in Bilbao was not the same as in Geneva, and it will necessarily be different for Paris and Marseille, too. Problems must be considered (and solutions found) locally, as drug-consumption rooms are above all carefully targeted tools: they cater to a specific population, at a particular stage in their lives, over a certain period of time.
The use of these facilities contributes to the resocialisation of the most excluded users. Drug addicts know that they have a place to go where they can consume safely without being continually forced to find a cellar, a stairwell or a secluded spot on the public highway, constantly at risk of being harassed by police. All the experiments and trials have shown that many users, even if they continue to take drugs, manage to achieve a level of social stability that often enables them to get back into employment.
How can drug-consumption rooms be successfully integrated into city life?
First and foremost, by talking about them. Throughout the course of our symposium, everyone who took part ended up rethinking their opinions. If politicians of all hues are able to change their views in this way, members of the public are surely able to do the same. Drug-taking exists, it’s a fact; instead of trying to deny it, we need to remove the "drama" surrounding these practices. These rooms improve the lives of drug users and have positive effects on the life of the surrounding community. In Bilbao, for instance, users of the facility help collect syringes and clean up the neighbourhood. And for local inhabitants, the room has become a useful resource centre. They know that, for much of the day, there is someone there who is available to provide assistance if necessary – for example, if a drug user is seen stumbling about under the influence of an illicit substance. Drug-consumption rooms are a vector for resocialisation and for the rehabilitation of users’ family, social and even professional lives. It is important to show that these facilities also provide added value, in particular for those who are most directly affected by their presence, namely local residents.
Choosing the right location for a new drug-consumption room is fundamental. If it is situated in a quiet neighbourhood, where people tend to consume on their own premises, without ever asking anything of anybody, the presence of such a facility will not have much of an impact. On the other hand, if it is located on Place Stalingrad or next to the Boulevard Périphérique ring road – two places in Paris where drug addiction is particularly visible – people will immediately start to notice that there are fewer users in the street, that there is less violence, and consequently that a truly positive change is under way.
What cities are committed to a process of opening drug-consumption rooms?
Paris City Council voted in favour of setting up a drug-consumption room as soon as "legally possible", even though it is not actually prohibited by law at present, despite a statement to the contrary made by the French Prime Minister last summer.
Marseille City Council set up a working group in July 2010, together with local associations, and is currently considering the most appropriate place to open a room and the partners that need to be mobilised. They have been committed to supervised drug-consumption facilities for a long time now.
A Bordeaux city councillor came with us to Geneva and clearly saw the benefits of opening a drug-consumption room, not least because he is a local councillor for the Sainte-Catherine district in the heart of Bordeaux, an area with a high concentration of drug users. The councillor concerned managed to convince the city’s mayor, Alain Juppé, to agree to further research and discussions into the subject. The mayor subsequently brought together all parties involved and rallied the support of the head of the Bayonne branch of Médecins du Monde, the organisation behind the drug-consumption room in Bilbao.
Similar approaches have been initiated in Le Havre and Annemasse. The case of Annemasse, a French town on the border with Switzerland, is somewhat unusual, as 20 % of the users of the Geneva drug-consumption room come from France. Is it therefore necessary to open a room in Annemasse, or should we simply let the Swiss continue to deal with this problem, even if only as a temporary solution? This is a question that also has resonance in the northern city of Lille, close to the Belgian border. In the inner Paris suburbs, the city of Saint-Denis is likely to open a drug-consumption room in conjunction with Paris City Council in the near future; however, nothing definite has been decided yet regarding the potential presence of two rooms so geographically close together. Nanterre, another inner Paris suburb, is currently considering the benefits of such a room, but in this case it is necessary to evaluate the needs and possible locations across the whole northern section of the Hauts-de-Seine département. Strasbourg and Toulouse have also made similar commitments.
In order for a drug-consumption room to provide clear benefits for everyone, I believe that it is above all necessary to identify those places where disturbances for the population and hardships for drug users are most concentrated. Anywhere where there are open practices, the question of supervised facilities should be raised in all seriousness. There are no theoretical answers, only pragmatic responses adapted to the individual context. The starting point for any project must be residents’ feelings and impressions; field visits are then necessary to establish which areas are most affected by problematic drug use.
What is the most realistic scale for this kind of operation?
I am convinced that these questions can only be dealt with at local level, because, without mayoral support, the opening of a drug-consumption room will never take place. Paris City Council’s decision was by no means a foregone conclusion, even with regard to the mayor’s decision. Reservations and questions cross party-political lines, hence the importance of informing councillors and inhabitants alike, by adopting as educational an approach as possible, with a view to reaching pragmatic and non-ideologically driven decisions. One of the objectives of our association (Élus, Santé Publique & Territoires), which brings together elected representatives of all affiliations, is to provide members with training in the various issues connected with health, drug addiction and risk reduction, all of which are challenging subjects. The training we provide is increasingly in demand.
When will these facilities appear in cities in France?
There is currently some debate within the French government on this matter, notably between the Prime Minister, who has described drug-consumption rooms as structures that are "neither useful, nor desirable" (ministerial statement of 11 August 2010), and two of his ministers, who say that such a measure should be trialled. INSERM also gave a favourable opinion in June 2010. A study by the Quebec ministry for health (November 2009) concluded that drug-consumption rooms are beneficial; furthermore, an evaluation of the drug-consumption room in Vancouver (September 2010) showed that this facility encourages users to turn to substitution therapy or even abstinence.
Two parliamentary committees have recently been created in France: one in the Senate and the other in the National Assembly. The president of the Senate, Gérard Larcher, who is familiar with the health issues involved, has taken the initiative and begun work with his colleague in the National Assembly, Bernard Accoyer. He believes it is high time that members of parliament were told about the realities surrounding drug-consumption rooms, and given all the facts they need to make an informed decision. These committees will perform the same activities as us, and hear from the same expert speakers. Logically, therefore, they should arrive at the same conclusion, and underscore the need for these rooms to be trialled in France. To me, this is inevitable.
We want to help speed up the work of these committees, and so have written to all their members in order to communicate our conclusions to them, as well as the proceedings of the symposium we organised. At present, the French law of 9 August 2004 (law no. 2004-806) states that everything must be done to reduce the risks associated with the injection of drugs. The French decree of 14 April 2004 defining the "Risk-reduction reference specifications" stipulates all activities that are prohibited, such as "testing" (i.e. checking product quality), but says nothing about drug-consumption rooms. It is therefore not formally illegal. Because the law itself does not prohibit the existence of the drug-consumption rooms, it therefore becomes difficult for certain political parties to stick to their party line. Paris City Council maintains that such rooms are not illegal; nevertheless, a city authority cannot realistically establish a drug-consumption room that the government and the interior ministry are opposed to, and which the health ministry refuses to fund…
However, there is another measure, which is currently being implemented under the aegis of Médecins du Monde in two CAARUDs: SIDA–Paroles (based in Colombes, Hauts-de-Seine) and Gaïa (based in Paris). This measure is known as ERRLI (Education for the Reduction of the Risks Linked to Injection), and essentially involves users coming in with a substance and injecting it in front of a health professional, who then instructs and advises them, and informs them of the relevant health-prevention issues. ERRLI is therefore a true risk-education measure that takes place in the presence of a real injection. It took three years to get the green light and funding from the ministry.
What is the difference between this measure and a drug-consumption room?
ERRLI concerns just one person at a time, and involves a significant degree of control and individual support for each user, whereas a drug-consumption room allows 10 or 12 people to consume their product simultaneously, under professional supervision at all times.
Conceptually and legally, the only difference between ERRLI and drug-consumption rooms is the number of users that may inject at any given time. The fact that ERRLI is authorised by the government confirms our analysis of the law. Indeed, the Prime Minister did not talk about prohibition with regard to drug-consumption rooms; he merely said that it was "neither useful, nor desirable".
Discussions and research surrounding the issue of drug-consumption rooms also reveal drug users’ relationships with the city, the way they use health and social services, why they remain in particular areas, and why they prefer to frequent certain places rather than others. Dealing locations provide one possible explanation, but by no means the only one. We know, for instance, that in the vicinity of SIDA–Paroles, there is less dealing than previously: it has not completely disappeared, but has moved elsewhere, perhaps at the request of SIDA–Paroles users themselves who do not wish to put the facility at risk.
All this collective thinking surrounding the issue of drug-consumption rooms makes it possible to ask questions that are more wide-ranging and which show that there are urban spaces so abandoned by public services and authorities that drug users appropriate them; drug addicts do not choose these locations at random. We believe it is important to put the users who live in these (often desolate) places in contact with professionals who can provide advice, support, a little human kindness and safety, and a temporary roof over their heads. Measures such as drug-consumption facilities can help, in however small a way, to make these aims a reality!
