Unsafe injection practices are common among people who inject drugs [1]. Drug-related harms that are associated with these unsafe practices include overdose, endocarditis, and transmission of human immunodeficiency virus (HIV), hepatitis C virus (HCV) and a host of bacterial agents. The community is also at risk of contamination owing, for example, to unsafely discarded injection debris (e.g., needles and syringes) [2].
In some countries, supervised injection facilities have been set-up to curb risks associated with unsafe practices. The first one operated in Switzerland in 1986, as a public health initiative [3]. Following its success, it was replicated in many places in Switzerland: 14 facilities operated in 2019 [4]. The Netherlands followed the Swiss initiative, with 24 facilities operating in 2018 [5]. Other European countries then tested the idea. In Germany, for example, at least 24 facilities are now available in six federal states [6]. On a global scale, at least 78 legal facilities operated in 2018 [2].
Despite scientific evidence showing that supervised injection facilities reduce the number of overdose fatalities, reduce the prevalence of HIV and HCV among patrons, increase the number of individuals seeking treatment (e.g., detoxification services, opioid agonist products), and improve people’s quality of life in affected areas (e.g., by reducing instances of public injection and by reducing the quantity of drug-related litter in public parks), without being associated with an increase in criminality in the vicinity [7], opposition to them has been vocal [2, 8]. The main argument against their creation is morally grounded. Drug consumption is, according to these views, bad behavior; it must be punished and setting-up any kind of public structure in which drug use is tolerated sends the wrong message [8].
Public views regarding supervised injection facilities
In the face of this unshakeable opposition, researchers have conducted public opinion surveys to determine whether the strong opposition to supervised injection facilities reflects the views of the majority of citizens or is a rearguard action by a self-righteous minority. These studies were conducted in Canada, where a facility has operated in Vancouver since 1990, in Australia, before and after the setting-up of a facility in Sydney in 2000, and in the USA, where no facility was operating at the time of the surveys.
A survey conducted in 2009 in Ontario [9] found that, among 968 participants, (a) 31% agreed that supervised “injection facilities should be made available to injection drug users to encourage safer drug injection,” (b) 48% agreed that they “should be made available if it can be shown that they reduce overdose deaths or infectious disease among users,” or, “if they can increase drug users’ contact with health and social workers,” and (c) 56% agreed that they “should be made available if it can be shown that they reduce neighborhood problems related to injection drug use.” These figures were higher than those found 6 years before in a similar study using the same material [10]. However, they were lower when it was the acceptability of supervised smoking facilities (e.g., for smoking crack cocaine) that was being assessed [11]. A survey conducted in 2011 in British Colombia found a higher level of support among the general public. A large majority (76%) of the 2000 respondents supported harm reduction strategies for people who inject drugs. Females, younger participants and more educated participants were more supportive than males, older and less educated participants [12]. However, support was lower in rural areas of the province [13].
A survey conducted in Sydney in 2000 found that 68% of the 724 respondents living in an area long affected by drug dealing and public drug consumption agreed that a supervised injection facility should be set-up in their area. Two years after it was created, public support increased to 78% (of 747 respondents). In addition, fewer respondents reported witnessing public drug use or publicly discarded drug-related litter. There was no change in the percentage of those that reported having been offered illicit substances in the street [14].
Last, a survey conducted in 2013 in the United States [15] found that 60% of the 899 respondents agreed that “supervised injection facilities for current intravenous drug users (i.e., legally sanctioned and medically supervised facilities to consume drugs) should be made available through federal funds if it can be shown that they reduce overdose deaths or infectious disease among users.” Agreement was higher among older participants and among those with liberal political ideologies and non-punitive views towards drug addicts. However, another survey, conducted in 2017 [16], found very different results. Only 29% (18% of Republicans and 39% of Democrats) of 1004 participants supported the legalization of supervised injection facilities. A subsequent study [17] found that arguments used to oppose legalization, such as “Safe consumption sites should be illegal because funding should be spent instead on opioid use treatment and recovery” and “Safe consumption sites should be illegal because use of heroin and other opioids is illegal,” were supported by 58 and 56% of the 1004 participants, respectively. Moreover, all the arguments commonly used to support supervised injection facilities were only approved by a minority in each case. Even an argument, based on the available evidence, that demonstrated these facilities were effective in reducing fatal overdoses failed to convince a large majority (66%).
The present study
The present study was conducted in France. In 2017, about 2% of young French adults (18–34 years) were using amphetamines (or derivatives), and about 3% were using cocaine. In addition, 1% had experimented with heroin at least once in their life. The number of high-risk opioid users was estimated at 210000 [18]. Syringe exchange programs were introduced in France in 1990 [19]; about 12,000,000 syringes were distributed in 2017. Maintenance treatments were made legal in 1993 [20] and the number of clients receiving opioid-substitution treatment was about 180,000 in 2017. Each year, however, about 350 drug users die from overdose [18].
The French government has been contemplating setting-up supervised injection facilities for a long time without been able to reach a political consensus on the subject [8, 21]. Despite opposition from the French Academy of Medicine, the French Academy of Pharmacy, the French National Authority for Health (Haute Autorité de Santé) and the National Council of the Order of Doctors (Conseil National de l’Ordre des Médecins) [22], a facility was finally established in Paris in 2016 and, later in the same year, a second was set-up in Strasbourg. To encourage their acceptance by the local authorities, these two facilities were called experimental facilities, even though such facilities have existed in neighboring countries for more than 20 years. Their maximum duration of operation was set at 6 years.
Although some published data on people’s views about supervised injection facilities was available at the time of this initiative, the findings were, as in the case of the surveys conducted in the US, seemingly contradictory. A survey conducted in 2010 found that, among the 2300 participants, 72% disagreed that “to prevent risks to health … heroin users should be provided with special premises and equipment where they can inject their drugs” [23]. Another survey conducted the same year found opposite results: 66% agreed that medicalized premises where drug users can inject their drugs in satisfactory hygienic conditions in order to limit the transmission of the AIDS and Hepatitis viruses (similar to those that exist in neighboring countries) should be created in France [21]. A third survey conducted the same year also found that a majority (53%) agreed that “places financed by the local councils where drug users can freely come with their drugs in order to take them under medical supervision and hygienic conditions” should be opened in France [21]. However, a fourth survey conducted in 2012 using this same question found that a majority (55%) opposed the idea [21].
As people’s views seem to oscillate notably as a function of the way questions are framed [21], the present study examined people’s positions regarding the setting-up, in their city, of supervised injection facilities that varied as a function of determined characteristics: (a) the kind of substance that users would be allowed to inject (e.g., only amphetamines), (b) the type of supervision staff (e.g., trained volunteers recruited by the municipality), and (c) the type of counselling provided (e.g., technical counselling about injection and hygiene). Three qualitatively different positions were expected: principled opposition, principled acceptance, and a flexible position that would take into account the characteristics of the proposed facility [24].
Firstly, as variable percentages of participants in all the studies on people’s opinions reviewed above always expressed their complete disagreement with harm reduction strategies, we expected that a sizable percentage of participants would express principled opposition. That is, they would oppose the setting-up of a facility, irrespective of its characteristics. Secondly, as there was always a small percentage of participants that expressed strong support in most studies reported above, irrespective of the characteristics considered, we expected that another segment of our sample would express principled acceptance. That is, they would agree with the setting-up of the facility, irrespective of its characteristics.
Thirdly, a flexible position was also expected, which we thought would be the majority position. The existence of this position was inferred from the variations observed in the percentage of participants who agreed or disagreed as a function of the formulation of the items in the surveys reported above. Namely, we expected that (a) when the facility involved physicians and nurses as supervisors, when their mission was to provide more than technical advice, and when only amphetamine consumption was allowed, a majority of people would agree with the setting-up of the facility, and (b) when the facility did not involve physicians or nurses as supervisors, when the supervisors’ role was not well defined, and when heroin consumption was also allowed, a majority of people would disagree with the setting-up of the facility.