Except when they're good. Some can be both. I've recently been asked by a friend for a response to the suggestion that we import Swiss style "Shooting Galleries" to the U.K. for injecting heroin users. I have to start by admitting absolutely no expertise in this area, but some experience in caring for drug users working towards withdrawal trough the substitution of methadone or subutex for their heroin. I'm also a big fan of it personally** for its proven role in pain control.
So, all that said, what about these shooting galleries then?
The answer I'm afraid, is complicated. Taking it one step back for a moment what about injecting users then? What do we know, and what have we been taught to believe?
We know it's bad. It must be, after all it's against the law and has been like forever hasn't it? Well not quite, only really from about 1920, and only a "Controlled Drug" in Blighty from around 1971.
Well O.K. it must be really bad for your mental helath yes? Well perhaps, though probably a lot less so than amphetamines and later "mood enhancers". All the punters I've seen with drug induced psychoses have been using amphetamines.
But it kills people! Well yes, no arguing with that, but because of prohibition we have only the sketchiest guesstimates of how many heroin users there are, so we can't say how many as a percentage, though instinct suggests its likely fewer than either alcohol or nicotine do. Overdoses are dangerous, but speak more to the despair and lack of hope that many users experience, of which their drug use if but one symptom. Inadvertent overdoses have happened when uncut drugs have been supplied, so that instead of a 90% talc (or worse) 10% heroin dose users have ended up taking 100% pure junk. Every avoidable death is a tragedy so arguments over relative risk seem specious in that context, but it probably remains the case that of all the drugs we chose for "recreation" heroin is a long way off being the most harmful.
The reality is that prohibition has created a lot of the problems we face right now. Heroin is addicting. To feed a habit costs money, but to have a lifestyle acomodating heroin is likely to imply a level of chaos that precludes a high or regular income. Hence to feed the habit users either deal or steal. Then we catch them and lock them up with dozens (or hundreds) of other dealers and stealers, so they learn how to do it "better". To keep them sweet we turn a blind eye to their continued use in stir-- after all at least they're off the streets, and heroin won't make you violent...
Then there's the "once a user always a user" myth. We have a number of users who have successfully quit not just injecting, but all illicit drug use. The trick is to "normalize" their care so they can be seen in the surgery without all and sundry knowing what they are here for. With a good rapport, a clear prescribing policy, and a willingness to accept change we can make opiate use so boring that clients will glady turn their backs on it, sometimes just for a time, but sometimes for good. Attending our surgery and not a "drug service" is a door back into the mainstream for some and it's this as much as the methadone substitution that gives them the push to move on with their lives and break out of the loop.
So, shooting galeries then?
Well on the plus side we get controlled dosing, reliable and affordable supply, sterile technique to avoid the harm of unsafe injecting and even perhaps a way in to accessing services for may users who are at present excluded precisely because they are "choosing" to continue to inject which will rule them out of admission to the vast majority of rehab systems.
On the minus side we get state sponsored addiction, less pressure to end a demonstrably harmful habit and a system likely to be too rigid to allow the chaos that is the lot of many current injecting users.
Were it to be made to work it could do a lot of good. The U.K is not the C.H. any more than it is the U.S.A. and any attempt to import techniques from another culture needs a lot of thought, but it appears on balance to be an import worthy of consideration.
* time to revive the tradition of the Virtual Chocolate Hob Nob for the first correct attribution.
** but not "personally" obviously.