Drug Consumption Rooms: Welfare State and Diversity in Social Acceptance in Denmark and in France

Abstract

Drug consumption rooms (DCRs) have the potential to have a positive impact on the opioid overdose crisis. DCRs could also potentially change the political environment for public health because they can affect the distribution of responsibility for harm reduction between the individual and society by collectivizing responsibility for harm reduction through welfare regimes.

The methodology is based on 2 case studies—1 in Copenhagen, Denmark, and 1 in Paris, France—about residents, people who inject drugs (PWID), and politicians’ experiences of DCRs involving semidirective interviews. Denmark has a long history of harm-reduction policy, and the implementation of DCRs in Copenhagen has happened through close collaboration between local authorities and the local community. France is far more centralized and paternalistic in terms of the distribution of authority and decision-making in welfare and drug policy.

Difficulties in cohabitation between local residents and PWID happened in both countries and can sometimes make public authorities hesitate to implement DCRs because of the NIMBY (“not in my backyard”) phenomenon. However, the Danish and French case studies show that DCRs have the potential to become an instrument for civic cohabitation as well as to contribute to the destigmatization and health of PWID. (Am J Public Health. 2022;112(S2):S159–S165. https://doi.org/10.2105/AJPH.2022.306808)

Drug consumption rooms (DCRs) are a proven efficacious public health approach to reducing HIV¹ and hepatitis infection via decreased syringe sharing and discarded syringes in public space^2,3 as well as to prevent overdose.^4–6 Thus, DCRs may be a suitable tool for fighting the dramatic opioid overdose crisis in North America. DCRs are already part of a comprehensive harm-reduction policy and, since the mid-1980s, have been widely implemented in Europe, Canada, and Australia in the context of the AIDS epidemic.⁷

Harm reduction is often reduced to technological and biomedical tools, such as opioid-agonist treatments, syringe access, naloxone, or drug-safety testing. However, harm reduction can also be considered as part of a broader social and political movement originating in “new public health,” part of a society-wide call to restructure social, political, and economic systems by actively involving affected individuals, in this case people who inject drugs (PWID).⁸ Furthermore, DCRs may also be understood as a political attempt to transform the risk environment^9–11 in which PWID use substances by creating more favorable social environments^12–14 and serving as refuges from drug-related street violence.^15,16 DCRs also provide a gateway to social and health services⁷ by facilitating dialogue, based on mutual trust, between care professionals and PWID regarding injection practices and harms.¹⁷

At a structural level, DCR implementation was made possible by implementation of policies that allow for approaches beyond repression.¹⁸ Therefore, DCRs are a preferred humanitarian approach in combination with welfare state projects.¹⁹ This implementation requires making DCRs compatible with national policies and for political representatives to be willing to promote harm reduction at local levels. In 2012 and 2016, respectively, Denmark and France followed the lead of other European countries and implemented DCRs to improve the social and political risk environments related to injection practices by addressing both social vulnerability of PWID and public order concerns of residents who reside in areas where injection drug use may occur in public spaces.

In welfare states, drug policies can differ by the degree to which such states collectivize versus individualize drug-related risks.^20,21 This in turn depends on whether drug-related harms are understood to be caused by individual behaviors or more fundamental societal problems, such as social inequality. Replacing individual responsibility for risk (in part) with collective responsibility for providing public health services to at-risk individuals is effective in improving both the health of PWID and the community^21,22 and might also be effective in addressing the opioid crisis affecting much of North America.²³

Denmark and France are 2 European welfare states with long histories of collectivizing risk. We present how this conceptual framework of collectivizing risk has influenced the decision-making process of implementation at local and national levels and has had an impact on the social acceptance of DCRs and cohabitation between residents and PWID in the different political and cultural contexts of Copenhagen, Denmark, and Paris, France. We use Benoit’s framework, which shows that how governments address drug-related risks is connected to how they address other forms of socioeconomic risks, such as illness or social precarity.²¹ We show how this conceptual framework of collectivizing risk has influenced the decision-making process of implementation at local and national levels, and how it has affected the social acceptance of DCRs and cohabitation between residents and PWIDs in 2 different political and cultural contexts.

METHODS

Between 2014 and 2021, researchers from Copenhagen and Paris collected data on the implementation of DCRs by using ethnographic observations of open drug scenes—defined as situations where citizens are publicly confronted with drug use and drug dealing^24,25—and urban environments around DCRs, as well as semidirective interviews with stakeholders. In France, 156 semistructured interviews were conducted with the following stakeholders: residents (n = 53), addiction care or harm-reduction professionals (n = 20), police officers or security agents (n = 29), street cleaning professionals (n = 13), local politicians (n = 11), and PWID (n = 30). In Copenhagen, researchers conducted a quantitative survey among residents (n = 567), n = 33 semistructured interviews with residents, n = 10 semistructured interviews with professionals (social workers and police officers), and n = 24 semistructured interviews with PWID. PWID were recruited according to gender, age, social status, and living conditions. In both countries, residents were recruited according to the streets where they lived, with a focus on those most exposed to the drug scene, including diverse ages, genders, and having children or not. All interviews, in both Paris and Copenhagen, were conducted by one of the authors of this article or a trained research assistant. PWID received financial incentive for their participation.

Data Collection

For residents, interviews explored exposure to drug scenes (including syringes, drug use, and drug dealing) and the extent to which such exposure was considered a nuisance. Among local politicians, interviews explored the political decision-making process at local, national, and international levels and how they built alliances with different stakeholders. For PWID, interviews explored their experience with street-drug scenes including interactions with residents and police officers and their use and experience with DCRs.

We reviewed data from historical archives such as those of the Ministry of Health, city reports on processes that allowed the creation of DCRs, legal documents, and notes from meetings with residents and other stakeholders organized at the city level, which we systematically collected through searches of legislation databases and local and national governmental Web sites, for the 1990–2021 period for France and for the 1998–2020 period in Denmark.

Analysis

We coded all data (i.e., interviews, open-ended survey question responses, and archival materials) by using thematic analysis approach. We organized the data into themes for analysis based on both a priori themes (e.g., participants’ exposure to drug-related activities in their neighborhood, their experiences with the drug scene and the DCR, the coexistence of PWID and residents, the policy-making process for DCR creation) and those that emerged from the data (e.g., feeling abandoned by the state, social consciousness, ambivalence in relation to living near a drug scene). For semistructured interview data, we categorized full-text responses on attitudes toward the drug scene and DCRs into “positive,” “negative,” “neutral,” and “ambivalent.” Interviews were audio-recorded, transcribed, and analyzed with NVivo12 software (QSR International, Melbourne, Australia). Comparison between the French and Danish databases was made possible through the use of a similar interview guide and coding framework.

RESULTS

DCRs have been the subject of debate in Denmark since the early 1990s when Denmark experienced a dramatic increase in drug-related deaths, which remain high.²⁶ Despite an advisory committee recommending DCRs in 1998, the idea was repeatedly rejected by successive governments. In 2011, activists in Copenhagen established a mobile DCR to provide services to PWID and test at the courts whether DCRs could be illegal under Danish law as claimed by the government. However, before the legality of the mobile DCR could be tested, a newly elected center-left national government proposed legislation to establish DCRs as an inclusive harm-reduction policy in 2012 noting:

The government wants to put an end to marginalization, exclusion and unworthy living conditions and its ambition is to reduce the high mortality rate among addicts on the streets, among other places in Copenhagen, as well as the harms, problems and nuisance associated with drug abuse in the streets.²⁷

Confident in the findings from research studies demonstrating the efficacy of DCRs, Danish legislators approved DCRs as a permanent component of Danish drug policy without requesting any additional trials be conducted in Denmark. The City of Copenhagen took over the mobile DCR and established a permanent DCR in 2012 in a homeless shelter; another larger DCR was established in 2016 (Supplement 1, available as a supplement to the online version of this article at http://www.ajph.org). The city council determined the site for the DCR would be in the area of Vesterbro, which is the location of the largest open drug scene in Denmark and across the Nordic countries.²⁸ Furthermore, DCR legislation states that local police and the municipalities must define an area “in the immediate vicinity” of the DCR where police will neither enforce drug legislation on drug possession for personal use nor confiscate drugs from DCR users. This established the entire area of Inner Vesterbro, where the open drug scene is located, as a decriminalized area for users of the DCRs.²⁹

In France, the debate about DCRs began in 2010 when harm-reduction activists, local politicians, and drug user activist groups developed alliances advocating “safer environments for PWIDs” as a “public issue.”³⁰ That same year, the French National Institutes of Health and Medical Research published an expert consensus report highlighting the benefits of DCRs and recommending government support for testing their efficacy in France.³¹ The French Prime Minister during this period, from the right-conservative party, refused to implement DCRs, arguing that “they are neither useful nor desirable.”³² However, the mayor of Paris’s 10th arrondissement (district) highlighted his willingness to create one:

For its part, the municipal team of the 10th arrondissement is also committed to the opening of a DCR in the district, in the Gare du Nord area, convinced that this facility might provide solutions to the safety and public health problems that arise there.³³

Despite national opposition, the mayor of the 10th arrondissement of Paris sought a pragmatic solution to open drug scenes (Supplement 2, available as a supplement to the online version of this article at http://www.ajph.org, quote 1) and envisioned DCRs as a possible effective “answer.” With a new left-social-democrat government elected in 2012, a lengthy legislative process was initiated to establish DCRs by creating a “tolerance zone” that would allow PWID to use such facilities and, importantly, to protect professionals working in DCRs from criminal prosecution. In 2016, after meeting national and local regulations, the French government agreed to the establishment of DCRs but stipulated that they would be a 6-year experiment in 2 cities: Paris and Strasbourg³⁰ (Supplement 1). The decision to categorize this as an experiment rather than a permanent measure is indicative of the French government’s dual goals at a national level: on the one hand to protect vulnerable PWID but on the other hand to not appear to favor decriminalization of drug use.³⁴ Contrary to the Danish experience, the French government was not convinced that existing scientific literature was sufficient to implement DCRs as a permanent measure. Rather, the government requested a specific French survey that lasts 6 years (from 2014 to 2021) to assess DCRs in the French context, with a specific focus on social acceptance among Parisian residents in the neighborhood of the DCR.

Immediately after the official creation of a DCR in Paris, a social movement of residents initially called “Against a shooting room in a residential area” and later known as “Lariboisière Gare du Nord Residents,” was created, gaining high visibility in the public debate because of press coverage.³⁰ Indeed, these residents were critical of the impact of DCRs, despite not being publicly opposed to DCRs as a public health measure or harm-reduction approach. They specified that they were only opposed to it being located in a residential area. Their discourse nevertheless reveals their reluctance to share urban spaces with PWID, as well as their fears and rejection of this social group (Supplement 2, quote 2).

Interactions between PWID and residents can be violent. Some residents expressed feelings of insecurity, attributing them to PWID behaviors. But, as several PWID reported during the interviews, violence can also stem from the residents themselves triggered by the DCR’s presence. Some users stated that they experience emotional violence from the residents’ stigmatizing words toward them on a daily basis. They also argued that it was crucial to deconstruct the stereotypes associated with drug use and to show that the “drug addicts” could have been their “children or grandchildren” (Supplement 2, quote 3).

Indeed, stigmatizing terms such as “psychopath,” “delirium,” or “ravaged” are often used by some residents opposed to DCRs who belong to the Lariboisière Gare du Nord Residents collective to describe and stigmatize PWID. The emphasis on arguments such as “they don’t respect the rules” places the responsibility for the degradation of the neighborhood on PWID, and some residents vocally demanded some form of compensation from the state. Indeed, residents who opposed DCRs also claimed that they felt abandoned by city and state authorities and that they lived in a neglected and deteriorating area. They stated that the welfare state needed to prioritize residents instead of “favoring” the protection of PWID, in the name of “democracy” (Supplement 2, quote 4).

After the Parisian DCR opened, another social movement, which brought together 3 different residents’ groups (Action Barbès, Parents DCR75, and Stalingrad Free Area),³⁰ supported the idea that implementation of the DCR was a way to collectivize the management of risks that improved the health and well-being of PWID as well as the daily lives as residents. Interviews with members of this social movement point to the belief that implementation of DCRs in this residential area also protected residents by enhancing the sense of security in their neighborhood. People from the Parents DCR75 movement felt protected because they could call harm-reduction providers who work at the DCRs when a problem with PWID occurred in their district (Supplement 2, quotes 5 and 6).

PWID also described how DCRs served as a safe space for them to “relax” when they were otherwise in “emotional distress.” The narratives of PWID also show how DCRs serve as a safe space for “socializing” where “the staff can manage tensions between users” (Supplement 2, quote 7). It is interesting to note that public health literature always describes DCRs as “safe” places in the “hygiene” sense, while PWID have a broader view of safe that includes social, psychological, and emotional aspects of safety.

Creating a safe space for PWID is also considered beneficial to residents from this second social movement because it reduces occurrence of injection practices in public spaces and the number of syringes discarded in the streets.³ These residents employed both sanitary and moral reasoning to argue that DCRs are not only safe places for injecting but also humanitarian areas safe from the judgment and stigmatization of PWID (Supplement 2, quote 8). These residents were also sensitive to the importance of “cohabitating” with PWID in urban areas. The coexistence of various social groups (residents mixing with marginalized and vulnerable people) that share the same geographical space is a crucial argument in the advocacy for DCR dissemination (Supplement 2, quote 9).

Ethnographic data indicate that residents on both sides have expectations that the welfare state will create safer environments for them. For DCR opponents, there is the perception that the welfare state should focus primarily on residents who are contributing to society and who “pay (their) taxes just like everyone else” instead of focusing on marginalized people “who don’t respect the rules” (Supplement 2, quotes 2 and 4). For DCR advocates, intervention by the welfare state that allows DCR implementation is beneficial both for residents and for PWID (Supplement 2, quotes 5 and 6). The COVID-19 pandemic exacerbated these tensions, with DCR opponents expressing anger that PWID were allowed to be in public spaces while residents were under lockdown (Supplement 2, quote 10). Conversely, some residents were concerned that, during lockdown, homeless PWID would have no safe spaces for sheltering (Supplement 2, quote 11).

In Copenhagen, although there was little opposition to DCRs, opinions differed as to what would be the suitable location. The minority who opposed to DCRs argued that it should be located away from residential areas. Others, specifically social workers, health professionals, and activists, believed that the DCR needed to be located in or close to the drug scene, meaning that it needed to be in a densely populated neighborhood. A survey of PWID in the area found that the average distance PWID were willing to travel away from the drug scene to use a DCR was 500 meters. Based on the totality of the evidence, DCRs were established in locales close to residential buildings as well as commercial areas.²⁹

Upon implementation, residents of Vesterbro expressed different attitudes, including supportive, ambivalent, negative, and neutral, toward these facilities.^35,36 Some reasons for supporting DCRs included reduction in drug dealing, drug use, and drug-related paraphernalia in the area (Supplement 3, available as a supplement to the online version of this article at http://www.ajph.org, quotes 1 and 2). In addition, some residents who lived in buildings located on the streets closest to the DCRs experienced these issues more acutely (Supplement 3, quotes 3 and 4). This is an indication of how DCRs have changed the geography of the drug scene, with DCRs and surrounding areas becoming new places for drug dealing and drug use when DCRs were closed or there was a queue.³⁵ Among the minority opposed to DCRs, a common sentiment was that people who were part of the drug scene did not live in Vesterbro, and DCRs should therefore be located where PWID live (Vesterbro, a former working-class neighborhood, has been thoroughly gentrified since the 1990s, and most of today’s residents are middle or upper-middle class³⁷; Supplement 3, quote 5).

Those expressing ambivalence, on the one hand, wanted PWID to have access to harm-reduction services, but, on the other hand, they were concerned about the increased exposure to drug dealing, drug use, and discarded syringes, even though many also acknowledged that the DCR had reduced exposure. These residents represent a central dilemma in the creation of effective drug use‒related policy: how to negotiate the relationship between public health aims and perceived issues of public order (Supplement 3, quote 6). When experiencing this ambivalence, most of the residents wanted to prioritize public health for PWID, but they also wanted the authorities to develop solutions to the different forms of nuisance they experienced.

In interviews with residents and PWID, it was clear that, despite the physical proximity, there was a large social gap between PWID and residents.³⁶ Social interactions between PWID and residents were limited and only occurred as a consequence of being in the same location (Supplement 3, quotes 7 and 8). Strategies residents employed to avoid interacting with PWID included using back entrances to buildings, crossing the street, and avoiding eye contact with people they suspected of belonging to the drug scene. These tactics contributed to reproducing a social distance between PWID and residents. Several of the residents expressed annoyance about having to behave in these ways, but others were more pragmatic about it.

Although many residents encountered aspects of the drug scene on a daily basis, only a small minority advocated removing PWID or DCRs from the area. Negative attitudes toward PWID and DCRs were again related to PWID not living in the area or that PWID were attracted to the area because of the availability of services (Supplement 3, quote 5). The majority of the residents, however, even though they demonstrated greater reluctance in engaging in informal inclusion by interacting with PWID, argued that the need for vulnerable PWID to be protected and to have access to DCRs took precedence over their unease (Supplement 3, quote 9).

PWID were particularly concerned about children witnessing drug use in public spaces, feeling that the DCRs provided a legal place to use drugs without any risk of exposing the public to their activity (Supplement 3, quote 10). Because it was away from the public eye, the DCR provided a less stressful and, therefore, safer place to use drugs (Supplement 3, quote 11). From the perspective of at least some PWID, a DCR is an opportunity to avoid being a nuisance to other people and to avoid feelings of stigmatization when using drugs in public.

DISCUSSION

Denmark and France have both implemented DCRs within welfare regimes that share commonalities and differences in their approaches to distributing social rights and benefits for PWID. Drug policy, and harm-reduction policy in particular, should also be seen as matters of local policy.³⁸ Specific drug policies are framed not just by national policy but also by local drug issues and how they are articulated by local stakeholders. For example, the establishment of DCRs in Copenhagen was the result of a commitment to and involvement of both public and private stakeholders at the local level, with an emphasis on the social rehabilitation of PWID and their rights.³⁹ In France, DCRs were first envisioned as a public health approach to protecting PWID from infectious diseases with less attention being paid to their social rehabilitation³⁴ because of a prohibitionist model that still considers PWID as deviants. Local mobilization efforts provided the starting point for implementing DCRs through strong alliances between Parisian politicians and harm-reduction activists.

In Denmark, responsibility for welfare and health policy, including harm-reduction policy, is delegated to local authorities. This means that an institutional framework exists for involving local stakeholders in the drafting of local harm-reduction policies, such as the creation of DCRs. However, France is a much more a centralized state, which means that few institutional structures and traditions exist for involving local stakeholders even in the implementation of local harm-reduction policy. Finally, Danish drug policy is often described as “liberal” with regard to drug policy implementation, whereas French drug policy is considered to be more paternalistic and repressive.

With the introduction of DCRs through public initiative in both Denmark and France, the state is partially taking responsibility for managing risks associated with drug use in public spaces. In both countries, DCRs should be considered not only a public health approach to prevent drug use‒associated harms but also an approach that defines a particular relationship between PWID, residents, and the state. As we have seen, the involvement of local stakeholders can play an important role in the acceptability and legitimacy of DCRs. This comparative study shows that harm-reduction policies are influenced by the political and institutional history of the particular contexts in which they are developed and implemented. The involvement of local stakeholders is likely to play an important role in this. The willingness of welfare states to implement DCRs is a complex process that is not only embedded with a humanitarian approach but is also a decision based on public order imperatives.

Because of political resistance, and despite the scientific evidence, some countries are still reluctant to implement DCRs at a federal level. The French and Danish examples show that DCRs can be created in very different drug policy contexts ranging from tolerance to repression, as long as the state is considered to be responsible for the protection of all citizens, including PWID. Difficulties in colocation with local residents can sometimes make public authorities hesitate to implement DCRs because of the NIMBY phenomenon.⁴⁰ However, our comparative research demonstrates that DCRs have the potential to become an instrument for civic collaboration, for the destigmatization of PWID, and for improving the well-being of PWID and residents in urban areas.