How to overcome political and legal barriers to the implementation of a drug consumption room: an application of the policy agenda framework to the Belgian situation

Drug consumption rooms (DCRs) are legally sanctioned public health facilities that offer a hygienic environment where people can use pre-obtained drugs in a non-judgemental environment and under the supervision of trained staff [1‐3]. They constitute a highly specialised service within a range of services for people who use drugs (PWUD). DCRs are embedded in comprehensive local strategies in order to reach different individuals and fulfil the community needs that arise from illicit drug use [4‐7]. DCRs have been operating in Europe, Canada, and Australia for the last three decades. Since the first officially sanctioned facility opened in Berne in 1986, the number of DCRs has risen and has reached more than 90 today [3, 8, 9].

Although DCRs vary in operational procedures and design, their aims are oriented towards public health and safety objectives. In terms of public health, the overall rationale behind DCRs is one of reaching out to, and addressing the problems of, specific high-risk populations of PWUD, especially people who inject drugs and those who consume in public [3]. For this group, DCRs aim to reduce the risk of transmission of blood-borne infections, to reduce the likelihood of morbidity and mortality resulting from overdose, and to help PWUD avoid other harms associated with drug consumption under unhygienic or unsafe conditions [4, 5, 7, 10]. DCRs also aim to reach and maintain contact with socially marginalised groups and to facilitate access to health and social services, including addiction treatment programmes [11‐16]. In terms of public safety, DCRs aim to contribute to a reduction in drug use in public places and in the presence of discarded needles and other related public order problems linked with open drug scenes [7, 17].

A substantial body of evidence has accumulated over the past three decades to support the effectiveness of DCRs in achieving their primary health and public order objectives, and therefore supports their role within a continuum of services for PWUD [6, 7, 18]. With regards to legislation, the European Union described DCRs as an effective measure for risk and harm reduction in its 2017‐2020 Drug Action Plan [19], as did the International Narcotics Control Board (INCB) in 2016 [20]. An abundance of studies has also demonstrated that feared negative consequences of opening a DCR are not borne out by experience: DCRs do not increase drug use in their vicinity, nor do they encourage young people to initiate drug use [21, 22]. Despite the scientific evidence and international legislation supporting DCRs, there continue to be social and structural barriers to the implementation of this public health intervention in communities across the globe [23, 24]. Accordingly, the debate about implementing new DCRs remains high on the political agenda in a number of countries worldwide, including the United Kingdom and the United States [25‐30].

From a legal point of view, international conventions allow flexibility in the establishment of DCRs when national legislation specifically acknowledges that these facilities are part of a public heath, harm-reduction strategy [31]. In several countries, this international framework has been sufficient to permit the implementation of DCRs [32], as was the case in Switzerland in 1986 [33] and in Germany in the mid-1990s [30, 34]. However, other countries were of the opinion that the establishment of DCRs required change in their legislation. That was the case, for example, in France and Luxembourg. In particular, the French legislation was modified in order to allow DCRs in the framework of a medical experiment [35], while new legislation in Luxembourg explicitly excluded DCRs from the articles that punished drug possession and drug-use facilitation [31]. Such exceptions were also introduced in the Canadian legislation [36].

In Belgium, the implementation of DCRs conflicts with the Belgian federal Drug Law of 1921, which makes it a punishable offence to make a room available to facilitate the use of illegal drugs. Since the beginning of the 2000s, several associations of field professionals, local policymakers, and scientific organisations have pleaded for a modification of the law and supported the implementation of DCRs in Belgian cities [37‐40]. However, a political consensus has never been achieved on amending the law and allowing implementation. In addition, the Belgian policy system is highly fragmented and complex. While the penal and criminal law is under the responsibility of the federal, i.e. national authority, most prevention and health policy responsibilities have been devolved to the federated authorities (regions and communities), each of which has its own government and majority. It is unclear whether the establishment of DCRs comes under the authority of the federal or federated governments. Against all odds, however, a DCR opened in the city of Liège in September 2018, 1 month before local elections. Against that background, this study aims to assess the drivers that put DCR implementation on the political agenda until its effective implementation, and to look at how the adverse legal and political context was overcome.

We applied the policy agenda framework proposed by Shiffman and Smith [41] in order to organise the presentation of the key elements that favoured the implementation of a DCR in Liège. That framework was initially developed to analyse why some health initiatives receive priority from political leaders and others do not, i.e. the so-called policy agenda setting [42‐44]. Shiffman and Smith developed the framework for examining health policy initiatives on maternal mortality in developing countries. Since then, it has been applied to many other health policy fields, including chronic and non-communicable diseases, mental health, and drug policies [45‐48]. The framework proposes four categories of key factors: [1] the intrinsic characteristics of the issue, [2] the political context, [3] the power of the actors involved in the policy initiative, and [4] the power of the ideas used to describe the issue (i.e. policy formulation). According to Shiffman and Smith, initiatives are more likely to attract political support when they share specific features in all categories [41]. Firstly, regarding issue characteristics, a health policy initiative is more likely to attract political support when the issue is considered to be sufficiently severe to deserve attention. That severity, however, has to be balanced against other possible priorities that are deemed to be less severe. The importance of an issue is reinforced if credible indicators exist that show clearly both the issue’s severity and interventions that are deemed to be feasible and effective in tackling it. Secondly, the impact of the political context on agenda setting is mainly driven by policy windows, i.e. external conditions that are perceived as favourable for tackling the issue. A textbook example of a favourable policy window is the holding of elections, as they create a context for proposing and discussing new policy initiatives. Thirdly, the policy agenda setting is determined by the power of actors, i.e. the policy cohesion that derives from the existence of strong leadership, guiding institutions that could operate the initiative, and civil society mobilisation. Finally, “the power of ideas” considers the different ways in which actors involved with the issue understand and portray it [49]. Therefore, the power of ideas is based on the capacity of actors to formulate the issue and potential measures to tackle it in a way that makes it possible to achieve a consensus, both internal and external. Internal consensus refers to the level of agreement across stakeholders and the policy community on the definition and terms of the issue. External consensus is the extent to which a consensus is also achieved outside the stakeholder and policy community, e.g. in public opinion and the media. In this study, we have examined these characteristics in the context of the moves to open a DCR in Liège.

This case report results from our involvement in the national feasibility study on DCR implementation in Belgium that was carried out a few months before the opening of the DCR in Liège. During that study, we carried out a series of qualitative interviews with relevant stakeholders (i.e. prosecutorial authorities, law enforcement, local policymakers, and health and social care professionals) as well as PWUD, in the five major cities of the country, including Liège. In addition, we followed up the events that occurred after the publication of the study report and we collected press releases regarding the topic of the potential DCR and subsequently the actual opening of a DCR. Finally, we had additional contacts with the Liège authorities and DCR providers, in order to appraise the context of the opening of the DCR.

Despite the lack of political consensus at the national level and the lack of a legal framework, a lack that might lead to instability and affect longer-term effectiveness, the DCR implementation in Liège has been successful. The four categories of Shiffman and Smith’s framework help to clarify how the local characteristics of the issue, the policy context, the power of actors, and formulation of policy on the issue contributed to this outcome. In the specific context of a long history of initiatives in relation to harm reduction in Liège, the implementation of the DCR was made possible, in the context of the local elections, by a consensus among local stakeholders (policymakers from the different parties, the public prosecutor’s office, law and enforcement professionals, health and social care professionals, and residents) and by a communication strategy that involved all these stakeholders and researchers. The local initiatives were feasible thanks to the commitment of the local authorities and the context of fragmentation and political deadlock at the national level.

The literature makes it clear that the lack of political consensus in national governments favouring the implementation of DCRs is mainly related to issues of morality, ideology, public acceptance, and negative media response and the associated political consequences [30, 78‐81]. The strategy in Liège, however, proved to be successful in overcoming barriers of that kind. What is more, the local political support for DCR implementation was, in this case, a factor of popularity in the context of the elections.

One key element for the opening of the DCR has probably been the local consensus of stakeholders (prosecutorial authorities, law enforcement professionals, local policymakers, health and social care professionals, and residents). This consensus was made possible by the visible increase in public safety issues related to drug use over the last decade in the city and by the past experience of harm-reduction interventions, i.e. the TADAM pilot project. Local stakeholders and the population all agreed that the TADAM experience had been beneficial and criticised its closure [31]. A second key element was the communication strategy and the consultation of local stakeholders, leading to their involvement throughout the process of implementing the DCR. The publication of the feasibility study, which recalled the evidence on DCRs, and the context of the local elections helped to create momentum. The Vancouver experience also made it clear that one element of success in the implementation of their DCR was the consultation and involvement of key stakeholders, including the residents, in the process of establishing the DCR [82]. Indeed, consulting local stakeholders makes it possible to establish collaboration and a dialogue on the resolution of issues and misunderstandings in relation to DCRs [82]. The emphasis on public nuisances (consumption in public spaces, discarded syringes, and drug-related crime) in the formulation of the policy issue may have contributed to the involvement of local stakeholders and residents. In the Netherlands, the majority of DCR managers explained that the primary rationale for founding a DCR was the reduction of public nuisances [83, 84]. In contrast, a policy formulation clearly presenting DCRs as a public health instrument has led to an internal consensus between policymakers at the level of the federated authorities.

Finally, the lack of political consensus at the national level left room for local leadership and autonomy for initiatives, in particular where there was a prior history of similar interventions. This kind of context has also been observed to an extent in France, for example. The case made by the Paris City Council for the opening of a DCR in 2010 and 2013 led to a compromise at the national level, with the French parliament adopting a new law that permitted DCRs as an experiment in 2016 [35, 85]. In Vancouver in 2003, the exemption granted by the then Canadian government, which allowed the opening of the DCR, followed the election of a new mayor in 2002, Larry Campbell, who had made the opening of a DCR in Vancouver a key part of his programme [36, 86]. However, this bottom-up development of initiatives requires local powers and autonomy, which do not exist in all countries. For example, one study observed that the absence of DCRs in the UK, even though some cities wanted to open them, may reflect the limited power and autonomy of local authorities as compared to other countries, such as Germany [30].

However, the Liège initiative remains unstable and the lack of an appropriate legal framework may weigh on its long-term effectiveness. It remains unclear whether the courts would interpret the article of the federal Drug Law that punishes the facilitation of a room for drug use in a way that would rule out DCRs. The outcome of any such case remains unknown. The development of Belgian drug policy is characterised by a bottom-up approach, in which innovative interventions have often been initiated at a local level [87] and have only later become part of a legal framework. This has been particularly the case for harm-reduction interventions such as opioid substitute treatments [88], syringe exchange [89], and the organisation of drug-addiction treatments in prisons [90]. These harm-reduction interventions had no legal framework or were even illegal when they were implemented, but they were legalised or regularised over time. This might also happen to DCRs in Belgium. Since the DCR was established in Liège, other Belgian cities, particularly in the French-speaking community, have developed plans for establishing their own DCRs in the near future, including Brussels, Charleroi, and Namur [91‐93]. In Charleroi, the city council came out in favour of the implementation of a DCR [93]. Finally, Brussels, which has its own regional government, approved a draft decree providing for the implementation of a DCR in the city during the next legislature as part of a broader, integrated regional drug policy [91, 94].