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  • Writer's pictureChristie Roberts

Overdose Prevention Centres

Hello again! I'm back with more public health content, based off my first ever essay I wrote in my Masters programme.

DISCLAIMER- aspects of this post will be copied directly from an essay submitted to Oxford Brookes University as part of my MPH. Any similarity to this post will be flagged as plagiarism by systems such as TurnItIn. This essay was written in 2022 and most references have not been updated, so may not reflect most recent data.

This was such an interesting topic to research, and it was also shocking to see how harm reduction for people who use drugs (PWUD) seems to be lagging so far behind in the UK, despite having some of the highest rates of drug death in Europe. Substance use disorders (SUD) are an undeniable public health issue, yet are rarely prioritised. In my opinion, this is partly due to stigma and the complexity of the lives of people with SUD which can make it difficult to provide holistic care- SUD rarely occurs in isolation, threrfore it should not be treated in isolation.

Overdose prevention centres (OPCs) are also known as 'supervised injection sites' or 'drug consumption rooms' provide a safe and hygienic place for PWUD to inject drugs and have been described as a 'basic public health intervention' (Thompson, 2023). They have been successfully implemented in at least 13 countries worldwide since roughly 1986 (Department of Health and Human Services, 2021).

In my essay, I focused on the population of Blackpool due to the area displaying the highest rates of drug death in England, so have the most specific information for this city; however, it is a national problem and I will try to bring in other areas where I can. Many of the factors contributing to drug deaths and substance misuse in Blackpool can be extrapolated to other regions.

The current situation:

Since 2004, the United Kingdom has demonstrated the highest number of drug overdose deaths in Europe, with mortality increasing yearly. Most recent data reported deaths 2.5 times higher than the next worst affected country, however, there is limited data after 2017 due to the UK no longer being part of the European Union (European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), 2022). From 2006, around 50% of annual drug deaths in the UK have been due to opiates, and there have been no significant changes in mortality rates for opiates since 2014 (ONS, 2022).

Despite interventions seeking to provide harm reduction for people who use drugs (PWUD), morbidity and mortality due to overdose or physical and mental health outcomes remain a growing public health problem of great cost to the UK. Public Health England (PHE, 2017a) estimate an annual cost of substance misuse (excluding alcohol) of £10.7 billion, incorporating health and social care (H&SC), policing, and criminal justice systems. However, it has also been identified that for each £1 invested, there is a £4 return (PHE, 2018a). The resources saved through investment and preventative care can be used to generate improvements in H&SC, crime reduction, and holistically help patients and their families. These targets can be matched to the UN sustainable development goal to ‘ensure healthy lives and promote wellbeing for all at all ages’ (UN, 2022a, p10).

It is difficult to collect accurate data on substance use disorders (SUD) as patients may come from hard-to-reach communities, be unwilling to disclose their drug usage, or only be reflected in statistics if they are known to H&SC services. Therefore, statistics for PWUD are likely to be underestimations and subject to wide sampling variability (ONS, 2020).

A convergence of vulnerabilities increases susceptibility to drug misuse, which can be mapped to Dahlgren and Whitehead's 1991 'rainbow model' of the social determinants of health (PHE, 2017b). Exploration of these characteristics and circumstances allows a broader understanding of which factors are immutable or modifiable, and which are salutogenic or pathogenic (Dahlgren and Whitehead, 2021). As multiple factors intersect across different levels in SUD, lasting change cannot occur by acting on only one level: co-production from individuals to governments is required (Marmot et al., 2010).

Factors impacting on SUD:

Individual characteristics including age and sex are fixed, however, trends can be observed that allow for targeted intervention. Males have consistently higher rates of drug use than females, centred around 16-24 years old (Home Office, 2019; Substance Abuse and Mental Health Services Administration, 2020). Individuals reporting multiple adverse childhood events (ACE) have up to three times higher risk of drug usage in adulthood. ACE may be unavoidable for the child but are preventable or modifiable by caregivers (Houtepen et al., 2020).

Familial instability is a known risk for engaging in substance misuse, and many PWUD have experiences of being a looked-after-child (LAC). Blackpool has the highest number of LACs in England, at three times the national average, which may contribute to the area's high prevalence of PWUD (Marmot et al., 2010, JSNA Blackpool, 2022a). Conversely, stable parenting and attachment styles act protectively for preventing commencement of substance use, and maintaining abstinence if recovering from SUD (Ram, Whipple and Jason, 2016; Fosco et al., 2019).

Communities and networks have wide influences on the behaviours of those within them, both positively and negatively. Existing in a physically or psychologically unsafe environment means that drug use can more easily escalate to addiction (NHS, 2021). However, a supportive network free from stigma, which may include peer support, can help to mitigate risk, and promote recovery through promotion of psychological wellbeing and social support (National Treatment Agency for Substance Misuse (NTASM), 2014; Dekkers, Vos and Vanderplasschen, 2020).

Blackpool ranks as one of the most deprived localities based on English Indices of Deprivation, with high rates of income and employment deprivation and a lower than national life expectancy (MHCLG, 2019; Blackpool Council, 2022). There is a positive correlation between deprivation and SUD; the likelihood of admission to hospital secondary to illicit drug use was found to be five times higher in areas of high deprivation (NHSD, 2021) with associated higher rates of crime, homelessness, and overdose (NTASM, 2014; Ignaszewski, 2021). Since 2018, Blackpool has held the highest mortality rate from drug-associated deaths in England, alongside a prevalence of substance misuse 2.5 times higher than the national average (Marmot et al., 2010; Blackpool Council, 2022) which correlates with its deprivation status.

Unemployment in Blackpool is high, and the area has 130% lower gross weekly earnings than the average UK income (JSNA Blackpool, 2022b) with the greatest proportion of individuals on Universal Credit In the UK- 27.5% compared to a national average of 13.8%. Relative and actual poverty are known risk factors for substance misuse (Pear et al., 2019; Lancashire County Council, 2022).

In 2019, 45% of PWUD entering treatment programmes experienced insecure housing (PHE, 2020); homelessness and substance abuse are known to have a reciprocal relationship (Doran, Focele and Maguire, 2022). It is difficult to ascertain accurate statistics for rough sleepers in the area, but 36% of homeless people in Blackpool report drug use, compared to 5% of the wider homeless population (JSNA Blackpool, 2022c).

Higher educational attainment and school attendance are positively correlated with lower drug usage and greater health literacy (Schepis, Teter and McCabe, 2018). Unfortunately, educational attainment in Blackpool is significantly lower that national averages and it is likely that this contributes to SUD (GOV.UK, 2022; Blackpool Opportunity Area, n.d).

Mental illness acts as a significant factor in SUD- both drug use triggering mental illness, and mental illness triggering drug use. Despite 60% of people identifying comorbid mental health problems alongside substance misuse, 25% of this population receive no mental healthcare (PHE, 2020). Prolonged SUD can precipitate physical comorbidities and lead to blood borne viruses (BBV). These risks escalate when drug equipment is shared or reused and can lead to transmission of BBV (NTASM, 2014), with 90% of hepatitis C diagnosed in the UK attributed to injected drugs and numerous HIV clusters linked to shared injecting equipment (Bartle, 2019).

Substance use may begin as a conscious behaviour. However, there is a limited degree of choice and likelihood of change associated with disenfranchised and disadvantaged groups as they are heavily influenced by wider determinants (Dahlgren and Whitehead, 1991; Marmot, 2015). Some of the determinants, such as ACE and parenting styles, are immutable by the time SUD emerges. However, other factors remain modifiable. These include health education, access to mental and physical healthcare, social supports, and support for living and working conditions (Advisory Council on the Misuse of Drugs (ACMD), 2016).

Where we are now:

Current interventions in the UK are subject to economic and geographic variability. Although £780 million is ring-fenced until 2033 to provide support for PWUD, there is an element of infighting as these funds are associated with multiple departments including Work and Pensions; H&SC, and Levelling Up, Housing and Communities- whilst local authorities are asked to take responsibility for service provision (GOV.UK, 2022). A disjointed approach results in ‘postcode lotteries’ and ineffective care (Ford et al., 2021). This is despite integrated services being recommended by NICE (2019) to achieve maximum accessibility, sustainability and health equity (UN, 2022b).

School-based education acts as an upstream intervention, and a form of primary prevention. This forms part of an existing strategic plan to include substance misuse education through school curriculums and local specialist services. However, little information is provided about how this is delivered or assessed. A consistent message should be presented with relevant and accessible information for young people to prevent escalation into ongoing substance abuse, yet this may be hindered by low school attendance in Blackpool (Blackpool Council, 2022; Blackpool Opportunity Area, n.d).

Interventions on a secondary level, aimed at initial harm reduction, include access to naloxone- an emergency antidote for opioid overdoses (PHE, 2018b; Kisling and Das, 2022). Although available in over 100 local authorities in the UK, demonstrating equity of access, 40% of PWUD stated that they did not carry naloxone (Local Government Association (LGA), 2017; PHE, 2018b). This may be due to poor health literacy, lack of awareness, or lack of opportunity for naloxone provision, and likely contributes to the high UK mortality rate of opiates (WHO, 2021; DHSC, 2022; ONS, 2022).

Although some determinants are being addressed, fatal and non-fatal overdoses have continually risen since 2013 (PHE, 2018b). In 2019/20, UK hospital admissions secondary to drug poisoning were 9% higher than 2012/13 (NHSD, 2021) indicating that existing interventions to reduce drug-related harm are not effective or are inaccessible to the target population. Additionally, stigmatisation and criminalisation of drug use may fuel harm by failing to recognise social environments and determinants that influence drug usage (NHS Health Scotland, 2013).

Alternative interventions include overdose prevention centres (OPCs). These are facilities where PWUD can consume their own drugs under supervision by medically trained staff, who will intervene in emergencies (EMCDDA, 2018). This may include basic life support and administration of naloxone, and has led to eradication of fatal overdoses within OPCs, and a reduction in overdoses in surrounding areas (Caulkins, Pardo and Kilmer, 2019; Holland et al., 2022). OPCs have operated for over 30 years internationally, with an overall aim of harm reduction, consisting of reducing morbidity and mortality, minimisation of unsafe injecting practices, and facilitating connection with H&SC services (EMCDDA, 2018; Bartle, 2019).

The success of OPCs can be attributed to many factors, including their ability to engage with marginalised and hard-to-reach communities (Bartle, 2019) and provision of an integrated service, adopting a ‘making every contact count’ approach (NHSE, 2016). OPCs can ‘enhance the effectiveness of other interventions’ (Holland et al., 2022, p.197) that are provided alongside harm reduction. Taking this holistic stance can prevent over-medicalisation of SUD, with acknowledgement of wider determinants influencing drug use.

An advantage of OPCs is the ability to engage PWUD at many stages of readiness for behaviour change, making it more accessible to the target population. Readiness for change may be influenced through OPC inputs that act on modifiable determinants of health, and ‘the ability to reach and maintain contact with high-risk drug users who are not ready or willing to quit drug use’ (EMCDDA, 2018, p.6) will still provide vital harm reduction. OPCs are evidence-based and known to improve a range of outcomes and encourage behaviour change towards health-protective activities. Until drug-related harms are addressed on a upstream level to prevent SUD and address the ’causes of the causes’ (Marmot, 2015, p.45) meaning socioeconomic disparities and wider health determinants contributing to SUD, people will continue to use drugs. Therefore, the focus should remain on harm reduction whilst acknowledging that people have free will and may have mental capacity to choose to use drugs, potentially with no intention of changing this behaviour (Clark and Grana, 2022). Ethical obligations exist to safeguard vulnerable populations and mitigate risks as far as possible to maximise health whilst maintaining autonomy (Ortmann et al., 2016). This includes making drug use safer where possible through introduction of OPCs.

Actions undertaken within OPCs are supportive rather than restrictive, as centres recognise the dangers of injecting drugs, the barriers to accessing treatment and the difficulty in achieving abstinence from substances (ACMD, 2016). Generally, accessing support may be hindered by fear of arrest and contribute to a decrease in health-seeking behaviour alongside higher risk substance use (Home Affairs Committee, 2022).

OPCs work towards mitigating risks from drug use. On an immediate level, harm reduction is achieved by the presence staff who can manage overdoses. Other interventions are provided that act directly on modifiable determinants contributing to SUD in a holistic manner by opening a door to other services and resources, including education to improve health literacy, and information about social services that can address homelessness, income insecurity, and unemployment. Information about BBV is provided alongside practical supports like needle and syringe exchange (NSE) and screening programmes. It is difficult to quantify the impact of OPCs on rates of BBV due to multiple confounding factors, but efforts such as NSE are known to be cost-saving and life-saving for reducing BBV (Belackova et al., 2019; NICE, 2019) and are associated with self-reported safer injecting practice and safer equipment disposal (EMCDDA, 2018).

The legal situation:

Legality remains a challenge, with the major limiter of establishing OPCs in the UK being the UK government. Despite numerous UK bodies recommending the intervention, and successful implementation in other countries, current UK legislature precludes development of OPCs under the Misuse of Drugs Act 1971. The UK government has maintained that providers of OPCs would be liable to prosecution (Holland et al., 2022). In other countries, there has been negotiation with local law enforcement to prevent arrests for drug possession for people using the service in select circumstances (Bartle, 2019). To date, at least three UK police and crime commissioners have approached the government in support of OPCs, to provide reassurance related to managing policing issues (Bartle, 2019).

Development of OPCs has been championed by the Faculty of Public Health who cite further support from the House of Commons Health and Social Care Committee on Drug Policy, the Advisory Council on the Misuse of Drugs, the Scottish Drug Deaths Taskforce, and the Independent Working Group on Drug Consumption Rooms. The issue was further discussed at the 2022 RCN Congress.

Crucially, in 2019, the Chief Executive Board for the United Nations (which represents 31 UN agencies) unanimously announced their support for the decriminalisation of drug use, adding a call for

"changes in laws, policies and practices that threaten the health and human rights of people"

Objections may arise from stakeholders, such as people living in the areas around OPCs, on the basis of safety or ethical concern. However, observational evidence has shown no association between presence of OPCs and crime rates (Caulkins, Pardo and Kilmer, 2019) and similarly, no evidence has demonstrated that OPCs encourage or facilitate drug use, but instead improves rates of PWUD accessing treatment options (Holland et al., 2022). Additionally, NSE programmes lead to a decrease in discarded used syringes in public spaces, making it safer for both PWUD and others living locally (Bartle, 2019).

Where we are heading:

Calls to action for harm reduction in Blackpool continue, particularly following the tragic death of two men just hours apart earlier this year, and this also directly speaks to the importance of access to naloxone, and targeted support for people experiencing homelessness.

One service aimed at getting people off heroin was proposed in 2019 in Glasgow, described as 'Heroin Assisted Treatment' (Glasgow City Council, 2019). In this setting, patients who inject heroin (who miust already be known to the Homeless Addiction Team, and whose addiction persists following conventional care such as methadone and residential rehabilitation services) will attend the centre twice a day, 7 days a week, to recieve injectable diamorphone for injection. The injections will be supervised, and when ready, patients will move onto oral treatments. It is also said that holistic assessments will be undertaken of social, legal and psychological needs and that physical healtcare can also be accessed on site. (I'm not 100% clear whether this pilot actually got off the ground, as I can't find any literature relating to it since it was announced)

Also in Glasgow, an unsanctioned OPC operated from September 2020 to May 2021. This was organised by Peter Krykant (who has lived experience with drug use and homelessness, and now works with Cranstoun), and run out the back of a disused ambulance.

894 injections were supervised, and 9 successful overdose interventions were performed (7 for opioids, 2 for cocaine). This shows that, even with a service running without legal backing or funding, and operated by volunteers and activists, harm reduction can be achieved to reduce deaths from drugs. Paul Sweeney, MSP for Labour, volunteered with the unsanctioned OPC and said:

"Some people will take drugs. We might not agree with that, we might think it's an unhealthy, unsafe thing to do, but it's a simple reality of life that that happens. So we might as well face up to it and try and death with it in as safe a way as possible"

There are currently no plans for opening an overdose prevention centre in England. However, pivotal progress has been made in both Scotland and Northern Ireland for legally opening OPCs.

The Lord Advocate (Scotland's chief legal officer) has recently accounced that she would be

"prepared to publish a prosecution policy that it would not be in the public interest to prosecute drugs users for simple possession offences committed within a pilot safer drugs consumption facility"

This is massive progress, as currently the Misuse of Drugs Act is the key barrier to establishing OPCs, and this statement from the Lord Advocate represents a critical step in beginning a pilot for an OPC in Glasgow which is proposed to be opened in summer 2024 (Cook, 2023). Plans for a space in which drugs could be smoked have been dropped from the proposal due to logistical issues, but a safe place for drug inkection will be provided with trained staff

There are now calls for similar pilots in Dundee and Edinburugh- a scoping feasibility study is being conducted in Edinburugh, with backing from the City Chamber, and a call for an OPC to be estabished in Dundee has backing from 28 MSPs (Cranstoun, 2023). It feels like a positive step that political will is being strengthened to address this public health crisis.

In Northern Ireland, Belfast city councillors have supported a motion to establish OPCs, however, legal changes would be required before this can become a reality. Establishment of OPCs have previously been supprted by the Chief Medical Officer for Northern Ireland (Bonner, 2023) but there are no concrete moves being made by the Stormont to change laws around prosecution for drug possession offences.

I think it's clear to see that a novel approach to preventing drug deaths and harm from drug use is required. OPCs have worked effectively and safely internationally for years, and it may be the time to take their best practice and apply it to the UK to address the spiralling morbidity and mortality amongst PWUD.

Love, Christie x


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