A Drug Consumption Room in the Spanish Basque country

A professional interest in substance misuse having no effect on local crime levels or areas for drug consumption are provided, coupled with a love of the people, culture, individual drug consumption. 4 alongside education around safe injecting. and language of Spain led me to investigate The Netherlands, Germany, Switzerland, It’s run by a multidisciplinary team of social ’s Sala de Consumo Supervisado or Canada, and Australia all have DCRs. And of workers, educators, nurses, and Drug Consumption Room (DCR) last course, so does Spain. A country which little psychologists. The service is open for February. more than 30 years ago was gripped in the 8 hours daily, every day of the year. Bilbao, capital of the Spanish Basque clutches of a fascist dictatorship now Outreach work is also provided for hard-to- Country (País Vasco) is Spain’s largest port. It supports one of the most progressive reach groups. These include women, young flanks the green and winding Rio Nirvión, a democracies in Europe. people, ethnic minorities, and groin or neck back drop of hills on both sides completes DCRs are distinct from consumption injectors. (Obviously, unsafe injecting is not the scene. The streets are clean, sunny, and services provided by programmes which allowed in the DCR). welcoming. The small 16th century shops prescribe and dispense opiates for Javi shows me the three different areas: and bars of the old town () buzz dependent users. 5 There are three such ‘La Sala de Inyección’ (Injection Room), ‘La with tourist activity. Bilbao, like many pilots in the UK. 6 However, we have no Sala de Inhalado’ (Smoking Room), and La European cities has undergone much consumption rooms. Why not? This is a Sala de Relax (which speaks for itself!). Here regeneration in recent years. The spectacular good question which an editorial in The clients talk to each other and staff about their and surreal Guggenheim Museum is its most Independent addressed succinctly. 7 current concerns, while enjoying free filter famous achievement. ‘El Gugg’, as its known Readers can guess at the answers. The coffee and smoking tobacco. (Staff do not to the locals, is a pleasant half hour riverside government’s stance persists despite a have the right to indulge in the latter walk from our hotel in Casco Viejo. recommendation from the highly respected activity!). Workshops on topics such as basic In common with many thriving European Joseph Rowntree Foundation that a number life support and overdose management are cities, Bilbao has a darker side. The of pilot rooms be introduced. 4 provided regularly. More involved projects revitalisation strategies tended to focus The coordinator of the DCR, Javi Rio have centred round exhibitions of the clients’ mainly on the physical regeneration of the Navarro, remembers the pre-Gugg era when art work and the production of a magazine city, while ignoring socioeconomic aspects. 1 the streets were dirtier and declining ‘La Calle de Todos ’ (Everybody’s Street). Social exclusion persists; directly below our industrial heritage was all the city had to Seventy to a hundred regular users come walk the riverside arches provide shelter for boast. He has clear memories of the through the salas each day. There will only the city’s homeless. Although País Vasco is overdose related deaths which were a be about one new contact. These have to the most prosperous of Spain’s autonomous feature of the ‘80s and ‘90s and modestly register, provide a medical history and sign a regions, the more disadvantaged informs me that there have been no such contract. This ensures they understand the neighbourhoods of Bilbao have fatalities since the sala opened. basic rules of the sala. unemployment levels at around 14%. This is Centrally situated in an area with high A major frustration felt by the workers is inevitably linked with the related social rates of drug use and dealing, the sala their inability to influence the purity of the issues of poor educational achievement, occupies two floors of a conspicuous early drugs, or even know what people are street crime, prostitution, poor health, and 20th century building on the edge of the injecting. What’s the solution? We debate drug misuse. Nirvión, which Javi describes as ‘our first the pros and cons of decriminalisation and Against this background, the Basque sky scraper’. heroin prescription for entrenched users. I government commissioned Médicos Del From inside the DCR, I look out of the imagine my patients being cared for and Mundo to provide the DCR, which opened in window and ask ‘How can anyone need to empowered in a place like this. It’s much 2003. 2 DCRs are defined as ‘protected use drugs with views like this?’ We smile, easier to educate about risk reduction and places for hygienic consumption of pre- knowing the question is naïve and safe injecting when you have the person and obtained drugs in a non-judgmental rhetorical. Javi shows me the staircases the goods in front of you. environment under the supervision of trained leading down to the river where drug-taking I visited the sala before the official opening staff’. 3 They have links with the wider used to be rife. He points upstream to time of 11.30 at Javi’s request. It would have network of drug services and have been where deals are done many been fascinating to see the sala in action. If I shown to enhance the uptake of medical times a day. I see a side to life to which the were a real investigative journalist I would care and reduce overdose related deaths. majority of tourists are oblivious. have hung around the side door later and They are likely to curb the transmission of The sala’s objectives are to reduce approached people as they left. But I had a blood borne viruses. DCRs reduce mortality and morbidity by minimising risk. family who wanted some time with me and, homelessness and social exclusion, while Access to needle exchange and hygienic ultimately I know what I would have heard;

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stories of damaged lives, difficult childhoods, their hospitality and for allowing me some insight European Communities, 2004. shattered dreams. But, here in Bilbao, I was into the service. 4. Joseph Rowntree Foundation. The Report of the Independent Working Group on Drug Consumption Rooms. York: Joseph heartened to learn about a really radical Rowntree Foundation, 2006. service which supports and protects drug REFERENCES 5. Sheldon T. More than a quick fix. BMJ 2008; 336: 68 –69. 1. Nieto M. : marginalidad en el centro: Los users, offering the chance to improve futures guetos en Espana . San Francisco: marginalisation in the 6. Laurance J. Heroin: The solution? 2006, The Independent. town centre: ghettos in Spain. Madrid: Elpais.com, 2006. http://www.independent.co.uk/news/uk/crime/heroin-the- and heal the wounds of the past. solution-480734.html (accessed 9 Oct 2008). 2. Gutiérrez Estíbaliz B. Una Sala de Consumo Supervisado en Bilbao: Evolución y resultados tras dos años de 7. Anonymous. Editorial: an injection of reality. 2006, The Meg Thomas funcionamiento. A drug consumption room in Bilbao: Independent. http://www.independent.co.uk/opinion/ Progress and results after 3 years in operation. Report for leading-articles/leading-article-an-injection-of-reality- the Cadiz government. Cadiz: 2002. 480718.html (accessed 9 Oct 2008). Acknowledgements 3. Hedrich D, European Monitoring Centre for Drugs and Many thanks to the Médicos del Mundo team at Drug Addiction. European report on drug consumption the Sala de Consumo Supervisado, Bilbao for rooms. Luxembourg: Office for Official Publications of the DOI: 10.3399/bjgp08X342714 Down the rabbit hole

‘Down, down, down. Would the fall never most used word in America. Choice is a visiting neither is portrayed as bold by his come to an end?’ Just as Alice followed the value when the country is so flush that health loyalists and as thumbing his nose at the rest white rabbit, so have all of us gone down the plans, like brands of breakfast cereals, each of the world by everyone else. economic hole and we don’t know where it offer something different. But, cereal is Obama’s plan for universal coverage will end. The freefall that started in the US cereal to those who have no food. So when depends heavily on employer –funded and has affected everyone else comes from the ranks of those who have no choice insurance, uses tax relief for small the economic interdependency of the world because they have no insurance grow, businesses and covers the uninsured economy. That is not a bad thing. We all including millions from the celebrated middle through pools and expanding Medicaid. He share the planet. But, not only has the class, there may be greater hope for wants to create savings through managing unregulated greed of Wall Street indebted agreeing on the value of everyone being in drug costs and squeezing insurance my grandchildren, but it has also threatened this together. The tipping point toward a companies, the two most powerful health any serious talk about healthcare reform, yet system of universal coverage in the US may lobbies. McCain insists that market again. Health reform has dropped from the just be coming into view. competition will sort everything out and that major domestic concern of the public a year Barack Obama’s story is one of the most giving families tax breaks with which to buy ago to ranking down there with agricultural compelling and moving ones in America. But insurance will drive prices down. He is less policy as we head into the final weeks of the the homestretch of this exhausting political clear about the increasing numbers of election. Losing one’s retirement or house or circus known as the US Presidential election uninsured, however. His plan doesn’t paying for gas to drive to a job that may not continues to have him portrayed by his rivals mention them. And he proposes to deal with be there trumps paying the doctor. The as an ‘elitist’, rather than the mixed race son the issue of access to care by putting clinics healthcare crisis, of course, will be back and of a hardscrabble Midwestern family, raised in shopping malls. be more imposing after the realities of the by a single mother on the edge of poverty The deadline for this piece comes shortly financial meltdown becomes clear. who became the educated, community before the election. I don’t know the Opportunities for moving health reform grounded person that he is today. ‘Elitist’ outcome. A vote for progressive, thoughtful, may come out of this costly underwriting of means he speaks clearly and in full politics that DOES bring the Change We banks and investment firms. Even though sentences, he talks about social justice, Need may still be possible in this country. the large majority of Americans favour an equality and has an interesting, But we have been stupid before and may be overhaul of the system, policy theorists say it accomplished wife and children. His again. Look who we have in the White hasn’t happened because the middle class opponent has a stirring story and, because House. When Alice was leaving the Mad has not yet felt enough pain to risk change. he is 72 years old, a more complicated one. Hatter’s Tea Party and opened the gate into Now, as unemployed bankers, white collar John McCain endured things few of us the Garden of the Red Queen, she said workers, executives, financial advisors all can imagine as a POW and seemed ‘Now, I'll manage better this time.’ Whatever look at a life without health insurance and determined to use his experience to be a lurks on the other side of the next election in maybe even join laid off auto workers and different and less predictable public official. the US may be better. We can certainly hope undocumented immigrants at the free But in the past 6 months, he has become so. Another possibility is that we might all clinics, there is a higher likelihood of serious nothing but predictable, despite his lose our heads. talk about a basic level of care for everyone. protestations to the contrary. His willingness Universal health care is an economic issue to choose to run with someone whose entire John Frey that Americans disguise as a ‘values’ issue. international experience comprises living in a ‘Choice’ is second only to ‘change’ as the state between Russia and Canada and DOI: 10.3399/bjgp08X342723

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