Abstract
This article discusses the introduction of the safe drug consumption facility in Glasgow and considers some of its potential consequences. The authors acknowledge the benefits of such a facility, but propose that while it goes some way towards addressing issues such as overdose, it simultaneously raises two further, intertwined, problems, namely where the drugs to be consumed come from and how they are paid for. Legal supply and free provision of the specific substances to those in need are presented as possible solutions. This would have the almost immediate effect of reducing the flow of drug money to organised crime while concurrently negating the need for people who inject drugs (PWIDS) to resort to criminal activity in order to fund their habit. Advantages of this proposition are considered.
Keywords
Introduction
It has been documented that, in relation to substances and substance misuse, many policies developed specifically with the intention of prohibiting or suppressing use and disrupting supply often have quite unforeseen and negative effects (e.g., UNSR, 2024); such policies have ‘contributed directly and indirectly to lethal violence, communicable disease transmission, discrimination, forced displacement, unnecessary physical pain, and the undermining of people's right to health’ (Csete et al., 2016). Drug laws oftentimes have a limited effect as a deterrent and often exacerbate the situation by creating further, still more harmful circumstances (Adam and Raschzok 2017). The same laws also further victimise individuals and groups already highly stigmatised and disadvantaged (Turnbull, 2009).
In Scotland, as with many other parts of the United Kingdom, those from the most deprived areas are vastly overrepresented in drug related deaths figures, with 23 times more likely to die from a drugs overdose than those in the least deprived (McPhee et al., 2019). Unfortunately, since this study was carried out people from those areas are unlikely to see any change to this in the near future despite various attempts by Government and civic society to reduce the numbers of individuals losing their lives due to drug use, including the setting up of the now disbanded Scottish Drugs Death Taskforce. Indeed, Scottish Government figures for the first quarter of 2024 show a 7% increase in deaths from the same period in 2023 (Scottish Government, 2024). On top of this, it has also been shown that among all the nations that make up the United Kingdom, Scotland has the highest death rates among alcohol and drugs, as well as suicide with the most deprived areas, again, overrepresented (Walsh et al., 2021).
‘Big stick’ type approaches to people who use drugs (aggressive policing techniques and the potential threat of having children taken into care as two examples) are often counter-productive in outcomes and often result in further problems being created and are mostly targeted at those who are most vulnerable in society – those from the most disadvantaged socially and economically (Csete et al., 2016).
The proposed introduction of the Glasgow Safer Drug Consumption site (BBC Scotland, 2023; COPFS, 2023; Glasgow City HSCP, 2023) is therefore to be applauded as a triumph of pragmatism, and the authors offer well-deserved kudos to everyone involved in moving it forward. As a harm reduction intervention, sites such as this have been shown to be very effective in reducing drug-related harm anywhere they have been used (EMCDDA/C-EHRN, 2023; Potier et al., 2014; Tran et al., 2021). A reduction in the amount of litter and (more seriously) drug-related hazardous waste in the form of used injecting equipment and so forth that usually accompanies the introduction of these safe spaces is also to be welcomed. It has also been noted that facilities such as these significantly reduce the burden on the emergency services and the knock-on financial burden to the taxpayer (Khair et al., 2022; Potier et al., 2014; Tran et al., 2021). We have already highlighted the disproportionate impact of drug deaths on areas of multiple deprivation, so any financial gain through potentially reducing deaths and non-fatal overdose among this cohort will have not only a financial benefit but have a marked effect in health and social terms also. Safer injecting facilities also offer an opportunity for improved public health outcomes and greater collaboration between different agencies that will inevitably be involved in the running of such sites, which not only has economic benefits but much wider gains in improved health – and all the social benefits that can come with that (Houborg and Jauffret-Roustide, 2022).
The process has taken a long time (far longer, some would say, than it should have done) but it has been repeatedly held up due to concerns such as where such a facility would be sited, who would be eligible to use it and (more seriously) regarding provision of the substances to be consumed (EMCDDA/C-EHRN, 2023). There is currently no plan, for example, to provide the substances required (‘free’ or otherwise) at point of use within the consumption site, meaning that users of the facility would be obliged to attend with their substance of choice provided and paid for by themselves.
All of this, of course, created a problem for the police around whether or not to arrest individuals who may (or more pertinently, may not) have been users of the consumption site for possession of controlled Class A substances.
The police – understandably – have sought advice and clarity on the matter, and this was finally forthcoming when the Lord Advocate (Scotland's most senior law officer) made the following statement: On the basis of the information I have been provided, I would be prepared to publish a prosecution policy that it would not be in the public interest to prosecute drug users for simple possession offences committed within a pilot safer drugs consumption facility. (COPFS, 2023)
However, given that under the new agreement underlined in the Lord Advocate's statement, this particular issue is potentially resolved, several others make an appearance, specifically the thorny and intertwined matters of where the drugs come from and how these are paid for: at which point in the chain of events between acquiring and using Substance X will the ‘turn a blind eye’ policy be initiated?
Will it be once the users are physically inside the facility, behind a closed door?
If so, then what would happen should they be stopped, searched and arrested before they get to the clinic?
Perhaps the blind eye will be turned from the point the user decides to attend the clinic in order to use? That would also work, but what would happen before that point? What happens when they actually purchase Substance X? Do the police turn a blind eye to an illegal money–drug transaction?
If we assume that they do, then what about when the users are raising the money to pay for Substance X? There is a very high likelihood that raising the money for purchasing illicit substances is going to involve criminality at some point and at some level, most likely in the form of sex work (Jeal et al., 2018), mugging, burglary or shoplifting (APCC, 2022; Pierce et al., 2017; Turnbull, 2019); do the police turn a blind eye to that as well? As has been demonstrated elsewhere, the link between drug use and crime is complex and multi-faceted (Hammersley, 2008). However, there is little doubt the two are inextricably linked and that some crime is committed by some users to support the considerable costs associated.
So, the money used to purchase Substance X is potentially raised by criminal involvement, and this has the inevitable knock-on effect of – for example – an increase in prices in shops (as a result of shoplifting), a rise in insurance premiums (in the case of burglary and car break-ins), traumatised mugging victims, an increase in sexually transmitted infections and/or BBV's (as a result of unprotected sex).
Substance X itself (let's assume that it is heroin, though we could really be talking about benzodiazepines or any of the highly potent synthetic variants) will inevitably be variable in terms of strength and content (EMCDDA, 2023), leading in part to the need for the facility in the first place (although, at time of writing, an application has been submitted to the U.K. Home Office for on-site drug testing to run in tandem with the DCR; STV, 2024). However, where does the money used to purchase the heroin then go? It is known that, at least until recently, around 84% of the opium used to produce heroin originates in Afghanistan (Victoria et al., 2021) indicating that at least some of the money will be funnelled into groups involved in serious organised crime and terrorist activities (Clark et al., 2021).
The thread that runs through non-medical heroin use from, at one end, low level crime all the way up to, at the other end, international terrorism makes a case for the supply and provision of heroin by the state for those who specifically require it. There are a number of countries where this has been trialled and demonstrated to work very well (McNair et al., 2023). Fair Trade arrangements could be made with opium farmers, effectively removing the cartels from the equation, however despite recent events in Afghanistan suggesting a move away from opium production, there remains significant Taliban involvement in the trade (Mahadevan et al., 2023).
What can be said, is that the street heroin trade is extremely volatile and rapidly changing. In a recent comment piece in The Lancet, it was stated that recent testing of street heroin has shown an increase in the use of nitazenes, which can be even more potent than fentanyl – etonitazene can be 10 times that of fentanyl, and up to 500 times as strong as heroin. Not only that, but nitazenes are increasingly found to have been cut into street benzodiazepines and some synthetic cannabis products, putting non-opioid users in equal danger (Holland et al., 2024: 71). Between 2022 and 2023, 25 drug-related deaths (DRDs) in Scotland had nitazenes present (RADAR, 2023), where they hadn’t been detected before. Does this reflect that fentanyl has been replaced by nitazenes in Scotland before fentanyl really took off?
Regarding the ‘blind eye’ policy itself, to a jaundiced eye, this might look like a very comfortable arrangement, providing a ‘get out of jail free’ card (actually, an ‘avoid going to jail’ card might be more accurate) for a group, many of whom fund their substance consumption by means of criminal activity (APCC, 2022; Pierce et al., 2017).
In these cash strapped times, a group perceived in all likelihood by many of the public at large as contributing very little to society and in return receiving preferential treatment from the police runs a risk of fuelling resentment and in turn further marginalising this already highly stigmatised group; some form of public education process may assuage this to some extent.
As suggested above, one obvious solution here would be the legal provision of the particular substance as this would immediately remove the criminal involvement aspect from the loop. Provision of heroin along with care is indeed an expensive process, but the indirect savings made because of a greatly reduced burden on the Health Service and Social Care as well as on law enforcement and prison (Blanken et al., 2010a, 2010b; Dijkgraaf et al., 2005) are significant and offset the initial expense in the longer term. Heroin prescribing is not necessarily in contravention of the Misuse of Drugs Act (1971), so why not take the extra step and avoid some of the obvious pitfalls mentioned above? A licence can be obtained from the U.K. Home Office. However, a decriminalisation of all drugs possessions of certain amounts would at least be a marked progress.
In the absence of these legal changes, drug testing on-site may at least detect the more harmful additives such as nitazenes, and prevent even more potential DRDs (Maghsoudi et al., 2022). Indeed, there has been an application made very recently, perhaps anticipating one problem identified in this article, for such a facility to detect dangerous adulterants in the drugs brought on to the premises (Glasgow City Council, 2024).
Discussion and conclusion
With the introduction of supervised provision of free heroin (which is presently not illegal in the United Kingdom, but requires Home Office licencing) we would expect to see a rapid and quite dramatic reduction in drug-related crime overall, as well as reduction in drug related deaths. This stage would also have an immediate impact upon those involved in the trafficking and supply of heroin at all levels.
As an aside to this point, we predict that heroin dealers would notice an immediate fall in their client base and therefore a dramatic reduction in their income. It is perhaps unrealistic to assume that dealers would go completely out of business, as there would still be the ‘non-problematic’, occasional heroin use market to be catered for. However, the evidence such as it is (e.g., Shewan and Dalgarno, 2005; Shewan et al., 1998) would indicate that use of this type is very much a specialist or niche market and therefore, in theory, the availability of illicit heroin would decline and become a rarity in the same way raw opium is currently. Let us not forget that the target population for the DCR is the most disadvantaged and marginalised of all those who use and inject drugs.
Further, many children of problem users would be less likely to be present while their parent(s) used the drug, as under the proposed system the constant use of heroin in the home environment would be obviated; the children of problem users would benefit from not having to witness their parent(s) using heroin, a constant flow of strangers in the house nor much of the low-level criminality associated with problematic opiate use as the need to commit crime (or sell personal belongings) in order to purchase heroin would – in theory at least – no longer exist.
There would be a number of benefits to individual users. For many of them, their day can be reduced to a mundane routine of generating funds for heroin → buying heroin → using heroin (‘stealing, scoring, using’) and this, so one argument goes, prevents these individuals from doing anything ‘constructive’.
In the longer term, it would be hoped that those using the heroin provision service would eventually decide to take the steps towards treatment/reduction and ultimately cessation. However, while the provision of heroin is not seen by the authors as a permanent situation or a life choice, it is understood that there may be some for whom cessation or even reduction of use will be highly problematic. These will by necessity need to be considered on a case-by-case basis.
Long-term reductions in funding for treatment services across the United Kingdom has been apparent for many years (Holland et al., 2024; McPhee et al., 2019) and should be factored into any discussion such as this. By increasing funding across the United Kingdom, Devolved and Local governments, through health services, criminal justice services and third sector organisations we will see reductions in crime, needless criminal records, and health and social harms.
While the drug consumption room in Glasgow therefore has to be welcomed, it also introduces some legal difficulties. As we have stated, the ‘agreement’ for police to ignore particular areas of the Misuse of Drugs Act (1971) through the Lord Advocate's statement is tentative at best as has been illustrated by the years long political wrangling that led to it. The alternatives – decriminalisation, legalisation and regulation have been discussed before (Dalgarno et al., 2021), however in the absence of a more thorough, and less politicised debate, we will be forever faced with the current position being subject to changes – or scrapped altogether – on political whims. The opportunity to have that debate is here.
As has been stated, Scotland has not fared well economically and socially compared with other nations of the United Kingdom and has consistently had more per-capita drug deaths also. Not only is the DCR necessary from a harm reduction perspective, it presents an opportunity to begin to redress this imbalance and improve the health outcomes for those most in need. It also provides the potential for a much-needed evidence base to roll out the facilities to other parts of Scotland – and in the rest of the United Kingdom.
It is a welcome step forward, but in our view is only part of the solution. The job is not quite done, not in the absence of serious considerations of decriminalisation of drug possession – which can be done on a devolved basis – and a rational debate on the future of the Misuse of Drugs Act (1971) itself.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
