Drug consumption rooms: Comparing times, spaces and actors in issues of social acceptability in French public debate

Abstract

Background

In October 2016, the first French drug consumption room (DCR) opened in Paris. We propose to examine the process through which this issue has been framed as a matter of public concern, after being ignored for almost 20 years. Our analysis of the controversy on DCRs investigates how public conversations on harm reduction evolve according to the time period (from the 1990s to the present), scale of discourse (local vs. national), and involved actors (politicians, professionals, local residents, and drug users).

Methodology

Our methodology includes analyses of media content: we reviewed 1735 articles published between 1990 and 2017. Our theoretical approach is in line with the sociology “des épreuves” derived from pragmatic sociology and controversy analysis. This approach goes beyond interactionism by attempting to place situations back into broader sociological realities. We also pay special attention to governance, a political lens that focuses on local aspects of negotiations and on the implication of a variety of actors.

Results

While the current debate on DCRs in France draws on constraints and resources already present in the harm reduction debate of the 1980s, it also repositions itself by avoiding moral argumentation and featuring less confrontation in the professional sphere. Today, we can see that the center of this tense debate has shifted from the professional sphere to the political and residential spheres. Most often, residents advance concerns that are not directly related to drug users themselves, but that derive from their apprehension of living in a displaced and stranded neighborhood. The public conversation leaves little room for drug users, even though they are the primary stakeholders of harm reduction and play a crucial role in DCR advocacy.

Conclusion

Our work reveals that the controversy about DCR is the product of complex interactions between different kinds of actors harm reduction professionals, political actors at the local and national levels, local residents, and drug users. Comparing different instances of public debate reveals the specific limitations and potentials for change in French drug policy.

Introduction

In October and November of 2016, two drug consumption rooms (DCR) opened in France, in Paris and Strasbourg. At the time of this inauguration, approximately one hundred rooms already existed worldwide. The first DCR officially opened in Berne, Switzerland in 1986; others were set up just after that in the neighboring countries of Germany and the Netherlands (de Jong & Weber 1999). Since then, another hundred rooms have opened in Europe, Canada, and Australia (Hedrich, Kerr, & Dubois-Arber, 2012; Woods, 2014).

Making DCRs available is in line with the principle of harm reduction, whose priority is to reduce risk related to drug use, and more specifically to reduce drug use in public spaces. Injecting drugs in public spaces harms drug users because these spaces do not provide the hygienic conditions necessary for safe injections (Bourgois, 1998; Rhodes et al., 2006). Besides, public drug use, in particular injections, is a source of public nuisance for local residents (Jauffret-Roustide, 2011). DCRs make it possible for drug users to carry out injections in a hygienic and safe setting and to avoid injecting in public spaces.

In order to better understand the roots of the DCR controversy in France and internationally, we must define the global political context in which DCRs have emerged, and particularly the harm reduction policies set up in the 1980s to prevent the spread of AIDS and hepatitis among drug users. According to its founding principles, harm reduction followed in the footsteps of the ‘70s and ‘80s movement for “new public health,” which valued individuals’ abilities and demanded that health policy take into account the needs of individuals (Rhodes, 2002; Berridge, 1999). This movement for new public health was part of a larger call to restructure social, political, and economic systems by actively involving affected individuals, in this case drug users (Keane, 2003).

Harm reduction strives to pay special attention to drug users’ lifestyles, so as to present them with adequate public health measures that are not dictated from the outside by the will or interest of professionals and politicians. Harm reduction works as an alternative to the dogma of abstinence as the only path available to users, and to the ideal of eradicating drugs from society at large. It promotes a sense of moderation instead of perfect abnegation (Ehrenberg, 1996).

DCRs are a representative application of the harm reduction approach. Absence of judgment towards drug use is at the heart of the ethical code of conduct of harm reduction professionals, especially in the case of DCRs, where professionals witness the usually private and intimate act of injection. Harm reduction operates a shift from moral judgment of drug use to judgment of the hygienic conditions and risk exposure of drug use (Jauffret-Roustide, 2016). DCRs apply this principle by attempting to transform the risk environment (Rhodes, 2002) in which drug users consume their substances.

Compared to her European neighbors, France was very late in implementing harm reduction measures and opening DCRs. We attribute this delay to the predominance of the doctrine of drug use as a moral vice. Public officials who adhere to this mode of thinking are reluctant to understand drug use as a health issue (Jauffret-Roustide, Pedrono, & Beltzer, 2013; Bergeron, 1999). Although injecting drug use was identified as a political issue in France after the student protests of May 1968, the first two relevant public health measures – legalization of syringe sales in 1987 followed by access to opioid substitution treatment in 1996–only occurred after AIDS had become a public health crisis (Jauffret-Roustide, 2009). It was only in 2006 that France officially adopted harm reduction as a principle of public health. France still features repressive drug legislation (drug use is punishable by law), and members of parliament regularly contest harm reduction because they perceive it as a form of promotion of drug use (Jauffret-Roustide et al., 2013). In conservative contexts like these, DCRs lie at the radical end of harm reduction policy (Lloyd, Stöver, Zurhold, & Hunt, 2016), and have acquired a strong symbolic value in that they dedicate spaces to drug use in countries like France that continue to repress consumption.

The international scientific literature has proven that DCRs are an effective mode of action for purposes of both public health and public safety (Potier, Laprevote, Dubois-Arber, Cottencin, & Rolland, 2014). Various studies have confirmed that DCRs diminish the rate of overdoses (Marshall, Milloy, Wood, Montaner, & Kerr, 2011; Salmon, van Beek, Amin, Kaldor, & Maher, 2010), curb equipment sharing practices (Bravo et al., 2009; Kerr, 2005), and incite the most financially and socially distressed users to seek healthcare (Debeck, 2011; Wood, Zhang, & Montaner, 2006). Some studies have also suggested that DCRs may improve public peace in local neighborhoods by reducing the number of found syringes (Wood et al., 2004) and instances of drug use in public spaces (Petrar et al., 2007). DCRs are most often set up in cities where “open scene” drug use exists, i.e., where drug users gather in groups to inject in public spaces. Injections performed in public can cause nuisance to local residents by exposing them to violent images (a drug user injecting on the street, on a stoop, in a staircase, or on a parking lot). Such images generate a feeling of unease among residents and come to disturb their sense of safety in daily life (Jauffret-Roustide, 2011). As DCRs revive residents' fears of drug addict invasions and politician's unease with the potential endorsement of drug use, DCRs are not an obvious measure to implement from the point of view of social acceptability.

Beyond health risks, public drug use exposes users to social and moral opprobrium. They can experience the shame and fear of being observed by residents while injecting or of being apprehended by police (Bourgois, 1998). Despite the rooms' twin goals of improving health and public peace, the great majority of international research literature focuses exclusively on the health outcomes of DCRs using an epidemiological approach. It pays much less attention to the DCRs' effects on public peace or to issues of social acceptability (De Vel-Palumbo, Matthew-Simmons, Shanahan, & Ritter, 2013; Houborg & Asmussen, 2014). Furthermore, few articles focus on debates or controversies generated around DCRs in countries where they have or have not been set up (Hathaway & Tousaw 2008; Kerr, Mitra, Kennedy, & Mc Neil, 2017; Kolla et al., 2017; Lloyd et al., 2016; Strike et al., 2014; Strike, Watson, Kolla, Penn, & Bayoumi, 2015; Wood, Kerr, Tyndall, & Montaner, 2008) and the articles that do exist are mainly based on local residents and public opinion (Cruz, Patra, Fischer, Rehm, & Kalousek, 2007; Jauffret-Roustide et al., 2013; Salmon, Thein, Kimber, Kaldor, & Maher, 2007; Thein, Kimber, Maher, Mac Donald, & Kaldor, 2008). Finally, very few articles have focused on the way DCR controversies have been staged in public debate through an analysis of the printed press (Hayle 2015).

In this paper, we propose to examine, first, the conditions that have triggered debate on DCRs in France by placing these debates in a local and national context through an analysis of the printed press over the last thirty years. We also wish to analyze the process through which this issue turned into a matter of public concern, after it was ignored for almost 20 years. In order to understand France's delay in adopting a public health policy of harm reduction, and in order to grasp the meaning of individuals' hesitations and criticisms, we will give a brief timeline of the debate's major historical developments. Then, we will analyze the way this debate has evolved into a controversy at the heart of the political, professional, local residents' and drug users’ spheres of existence. Our analysis of the controversy on DCRs will investigate the way public conversations on harm reduction evolve according to the time period (from the 1990s to the present), scale of discourse (local vs. national), and involved actors (politicians, professionals, local residents, and drug users).