- Final Report on Injecting Rooms in SwitzerlandBy Kate Dolan and Alex Wodak. Unpublished Manuscript, 26 July 1996.

Summary

This report describes injecting rooms in three Swiss cities (Zurich, Basel and Bern) based on a visit which took place in February 1996.

The first injecting room in Switzerland was established a decade ago with the intention of reducing the public nuisance caused by injecting in public areas (toilets, parks) and public health problems such as HIV transmission and overdose. Injecting rooms are now generally well accepted by the Swiss public although opposition had arisen initially when some injecting rooms were located in residential areas. Injecting rooms also operate in some Germany cities. Injecting rooms are planned for some Austrian cities. There are virtually no publications in English on injecting rooms.

The Centres visited differed in strictness of operation and many other organisational details but were similar in many respects. All have medically trained staff who supervise all injections on the premises and revive clients who have taken an overdose. Staff were able to control the number of clients who entered the premises and the actual room where injecting takes place. All Centres were well patronised and provided free injecting equipment and advice on injecting. No staff assisted IDUs to inject. At least 100 clients visit each Centre daily. Tens of thousands of injections have been supervised and thousands of abscesses treated annually. No overdose deaths have occurred in any Centre.

The main benefits of injecting rooms have been reduction of public nuisance and improvement of health in a very vulnerable and unhealthy group of IDUs. Injecting rooms have enabled the adoption of less hazardous injecting practices, reduced the number of overdose deaths, minimised the nuisance to the community of injecting in public places and probably reduced HIV transmission. The Centres are well tolerated in Swiss communities. Some IDUs have entered treatment as a result of attending injecting rooms. Legal problems surrounding the operation of injecting rooms have been overcome. Police work with the staff of injecting rooms.

The annual cost of running a centre was about $300,000. Behaviour of some IDUs has been problematic. The Centres, apart from the actual injecting rooms, were heavily polluted with cigarette smoke.

Injecting rooms are only needed in areas of cities with particular characteristics, such as frequent public injection. It is relatively easy to demonstrate success in reducing public injection. Evaluation is technically quite difficult. Staff believe that risk behaviour has been reduced because of interactions between IDUs and staff. It seems clear that the benefits of injecting rooms in Switzerland have outweighed the costs but the ratio of benefits to costs is not as dramatic as with, say, needle exchange or methadone maintenance

Introduction

This report describes a visit to injecting rooms in three Swiss cities (Zurich, Basel and Bern) in February 1996 and reports on discussions with health workers and researchers who have worked in or evaluated these injecting rooms in Switzerland (appendix a).

The main aims of operating injecting rooms in Switzerland are to reduce the public health risks and the public nuisance associated with drug injecting. These health risks include death from overdose and infection with blood borne viruses (HIV, HBV and HCV) from the shared use of injecting equipment. The Centres are also important points of contact for IDUs not in treatment. Medically trained staff are available at all times to resuscitate clients who experience a drug overdose on the premises.

The context within which these injecting room exist should be noted. Switzerland has implemented a number of innovative HIV prevention programs which have rarely been adopted elsewhere. Examples include `needle parks’ or open drug scenes where IDU buy, sell and use drugs, a trial of provision of heroin which includes current prisoners) and syringe exchange schemes for prisoners. Some of these initiatives have been more successful than others. The distinguishing characteristic of Swiss authorities is the acknowledgment that existing policies have been ineffective (and often counterproductive) and a preparedness to experiment to identify more effective measures. Switzerland has a surprising high number of IDUs. Because of housing shortages, they are very visible in the streets. HIV prevalence among IDUs was already high, up to 50 percent in some cities, when HIV /AIDS was first recognised. Switzerland now provides excellent needle exchange and methadone programs.

The first injecting room in Switzerland was established in Bern in 1986. Health workers had noticed IDUs had become marginalised from mainstream society and were being shunned from cafes and restaurants. These health workers proposed establishing a special cafe for IDUs which could also be used as a convenient point of contact with IDUs who did not utilise health services. IDUs then began injecting in these cafes. The workers soon realised that this provided an excellent opportunity to monitor and modify IDUs risk behaviour to reduce harms associated with injecting. Initially, some injecting rooms were placed in settings later found to be unsuitable. These rooms had to be relocated. Community opposition in Basel decreased after concerned residents attended an open day at the Centre. Another factor was the desire to reduce public nuisance resulting from IDUs injecting in parks and public toilets.

Descriptions of the Centres and the injecting rooms

In Zurich, Centres with injecting rooms are funded by the Department of Welfare. Non government organisations operate injecting rooms in the other cities. The injecting rooms are housed within Centres which also contain a cafe, a counselling room and a clinic for primary medical care. The injecting rooms are discrete rooms within the Centres. These two terms `the Centre’ and `the injecting room’ will be used to distinguish between the two levels of intervention.

In Zurich, door-men are employed to manage the flow of clients into the Centre. They ensure that only residents of Zurich enter the Centre and also prevent clients from congregating outside.

The actual injecting rooms are small and have a `sterile ambience’. All injecting rooms contained two or three tables where clients sit to prepare and inject their drugs. The three rooms visited had spaces at tables for six, six and twelve clients to sit and inject. Injecting paraphernalia – such as needles and syringes, a candle, sterile water and spoons – were placed at each position at the tables where the clients sat. There were also paper towels, cotton pads, bandaids and rubbish bins nearby. The walls of the injecting room were tiled up to a height of approximately two metres. The tables tops were made of stainless steel which enabled the surfaces to be cleaned easily.

An overwhelming impression of all the Centres visited was the constant in and out movement of clients. Movement in and out of the injecting rooms was less common as IDUs generally stayed inside for up to half an hour. Once clients were inside the Centre, most appeared content to wait for their turn to inject. Many preferred to remain in the Centre for some time after injecting.

Access to the injecting rooms

In Zurich, clients were required to show evidence of residence in that city before entering the Centre. This restriction was imposed in response to the Centres being inundated with IDUs from other cities. Staff must verify that clients are at least 16 years old and have a history of injecting before they are allowed to use the injecting rooms. The order in which clients enter the injecting room was regulated by a queuing system in two cities. In Zurich, clients took a number and entered the injecting room when their number was called. In Basel, clients were required to sit in chairs forming a queue just outside the room. However, this system sometimes resulted in disputes about who was next in line as clients would often leave their seats. In Zurich, clients’ first names were recorded on a diagram which depicted where they were sitting in the room. This allowed staff to know who each client was in case of an overdose.

Most Centres had a maximum capacity limit. When this limit was reached, clients were only admitted when others left the Centre. In Bern, the door to the Centre was only opened every half hour for five to ten minutes. Clients could only enter or leave the Centre during this time. It would be almost impossible to enter the Centre, visit the injecting room, inject and leave the Centre within the brief period that the door was opened. This meant that clients had to remain in the Bern Centre for at least half an hour, making the Centre more crowded than perhaps it needed to be. The Centre in Bern originally provided clients with identity cards which had to be shown to gain entry. This system has been abandoned as clients tended to loose the cards.

Rules

In addition to rules which are common in most drug agencies (such as no violence or drug dealing), there were specific rules for the injecting rooms. Clients must wash their hands on entering the injecting room and clean their own place at the table after injecting. Clients were not allowed to smoke in the injecting rooms. Most Centres had a maximum time limit (30 or 60 minutes) that a client could spend in the injecting room. Clients are only allowed to prepare their own drugs in the injecting room. In some injecting rooms, clients were allowed only one injection per visit to the room. Staff were not permitted to help clients inject in any Centre. Breaking the rules resulted in clients being barred from the Centre for a few days or up to a few weeks depending on the nature of the infringement.

Staff and operation

All Centres had at least one staff member present in the injecting rooms at all times. This staff member changed every hour or so as extended periods in the injecting room were considered to be too taxing. All staff have been trained to resuscitate clients if they overdose, although one staff member had the prime responsibility for this duty.

Most Centres opened for approximately seven hours a day. Some Centres are closed for one or two days a week. Centres usually operated at full capacity. In cities with a number of Centres, operating times were staggered to increase the number of hours per day that IDUs could inject safely. Some Centres have allocated specific times for female injectors to inject drugs. There were usually three or four staff on each shift. In Basel the Centre was initially closed on Sundays. Demand has been as high that the Centre is now open every day. Doctors were employed on a sessional basis to visit the Centre for a few hours a week. The cafe areas were filled with cigarette smoke. The Centres preferred to employ smokers as these conditions are often difficult for non smokers. One Centre had a light indicating when the toilet was occupied. The toilets could be opened from the outside in case of an overdose. Some Centres had direct phone lines to the police and ambulance service.

In the event of an overdose

When a client collapses, the worker in the injecting room calls another worker to assist. A small bottle of oxygen is taken to the client and administered via a face mask and simple resuscitation bag until the client regains consciousness. If the client was unable to resume breathing within ten minutes, an ambulance is called. Naloxone, a narcotic antagonist, is not used to revive clients in any Centre.

Clientele

Most IDUs in Switzerland inject a cocktail of cocaine and heroin. There are an estimated 6,000 IDUs in Zurich and 2,000 in Basel. Most clients have had hepatitis. Clients were generally older than the average IDU, although one Centre did have a predominantly younger clientele.

Other Services

A safe injecting environment is just one of several services offered by the Centres. Counselling, referral, free soup, tea and coffee and cheap fruit and vegetables were provided in the Centres. In Zurich, clients volunteered to work in the cafe and to collect discarded syringes in the vicinity of the Centre. So many clients volunteer to help that work is allocated by a lottery system.

Research into injecting rooms

Research evaluation of the injecting rooms includes monitoring the number of needles and syringes distributed and returned, number of injections, overdoses, abscesses and the number of times an ambulance has been called. Approximately 100 clients a day visit the Centres in Zurich and Basel. In three centres in Zurich, there were an estimated 68,000 injections, 3,000 abscesses treated, 22 clients resuscitated and ten calls for an ambulance to attend in a one year period.

A comparison of clients surveyed in Bern in 1990 and 1995 was undertaken. Clients were mainly (70%) males and aged about 30 years. Most (73%) had a history of imprisonment. The mean age clients started injecting was 19 years. There had been a significant increase in the proportion of clients reporting that their first injection occurred with a sterile needle and syringe over the study period. Reuse of injecting equipment decreased significantly during the study. Self reported HIV positive status was 12 and 16 percent in 1990 and 1995 respectively. There has been a strong resistance to testing IDUs for research purposes in Switzerland. Therefore, most HIV data are based on self report.

The main reasons given for attending injecting rooms in 1995 were: to inject in peace (86%), to obtain free injecting equipment (33%) and because medical attention was available. Approximately half of the clients reported injecting several times a day. There have been no deaths in any injecting rooms in Switzerland to date. Workers in Basel believe that the number of deaths due to overdose in the community has decreased as a result of injecting rooms. In Bern, workers believe they have made the injecting ritual less dangerous by moving clients from 2 ml to 1 ml syringes which carry less risk of blood borne infection.

According to the Report “Evaluation der Gassenzimmer I, II, und III in Basel”, injecting rooms have provided drug users with hygienic and controlled conditions, prevented infection through the provision of sterile syringes, needles and condoms and gave access to medical care and opportunities for intervention with possible emergencies such as overdoses. The demonstration project was overwhelmingly welcomed by all key parties: the evaluation team called for the continuance of the strategy, so as to provide a stable environment for Basel IDUs.

Injecting equipment

Three different methods were used to distribute injecting equipment in the three cities visited. In Zurich, staff provided equipment to clients as they entered the injecting room and there was a strong emphasis on exchange. In Bern, clients were provided with a free syringe and charged a small fee for additional syringes. Clients in Basel helped themselves to injecting equipment from a dispensing tray on the wall. No Centres provided butterfly infusion sets. Only one Centre provided 5 and 10 ml syringes which clients use for the injection of methadone syrup. One brand of syringes available in Switzerland has detachable filters that are removed after drugs are drawn into the syringe. Samples of these syringes were obtained.

Conclusions

Experience over the years suggest that injecting rooms have probably not been as successful as syringe exchange or methadone programs in reducing HIV infection, but the benefits clearly outweigh the costs. Injecting rooms seem very likely to continue in Switzerland. Injecting rooms only seem to be needed under particular circumstances and in certain locations.

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