Local characteristics of the issue

Until the 1960s, Liège, one of the largest industrial cities in Belgium, had thriving mining and steel industries [50, 51]. As happened in many other coal-based industrial areas, its industry declined from the end of the 1970s and the city experienced a socio-economic crisis, with increased poverty and unemployment in some neighbourhoods [52]. The socio-economic decline was accompanied by an increase in illicit drug consumption and trafficking [53]. In addition, it is usually considered that the geographical position of the city, near the Dutch city of Maastricht and the German city of Aachen, is strategic in terms of the illicit drug market [54]. In 2016, in the Walloon region (3.5 million inhabitants) in southern Belgium, the number of heroin users was estimated at 12,000, including 2500 people who inject drugs [55]. Although it is difficult to estimate the size of this hidden and marginalised population, several sources suggest that the size of the DCR target group in the inner city of Liège (200,000 inhabitants) is about 300 PWUD [56]. The geographic landscape of the local drug scene is not spread across the city but is concentrated in the downtown area near the train station, bus station, and shopping malls [31]. In 2013, between 352 and 470 people who inject drugs attended the syringe exchange counters [56]. In 2017, 134,500 syringes were distributed to 550 unique PWUD [56]. The Institute of Forensic Medicine of Liège recorded 35 cases of fatal intoxication by drug use between 2011 and 2013 [56]. The local police drew up 1745 reports related to narcotics in 2016, and 2197 in 2017 [56]. All these figures indicate that the public health and public safety issues related to drug use are becoming more severe.

Over recent years, the City of Liège has developed innovative interventions to tackle issues related to drug use. In 2011, the city supported a 2-year pilot intervention based on heroin-assisted treatment delivery in the form of a clinical randomised controlled trial, called the treatment assisted by diacetylmorphine (TADAM) project [39]. With the approval of the prosecutorial authorities and the “Federal Agency for Medicines and Health Products” (National Belgian medicine agency), in the context of a scientific medical experiment in line with UN drug conventions, a derogation from the federal Drug Law was granted, allowing the medical prescription of diacetylmorphine (heroin) and the availability of a room for its supervised consumption [57]. The pilot project was completed in 2013 and its evaluation showed positive outcomes for PWUD [39, 58]. The only caveat was the cost–benefit analysis, which showed that, compared to methadone maintenance treatment, diacetylmorphine treatment resulted in an annual extra cost per patient of almost €20,000, which was not offset by societal benefits [59]. The limitations of this analysis were, however, that it only involved a small sample of 74 PWUD randomised between the two groups, and its short follow-up period of 12 months. Authorities used this negative cost–benefit analysis and the absence of an amendment to the federal Drug Law to close down the pilot project and the facility [57, 59].

In the light of that experiment, the mayor of Liège undertook several initiatives to support the establishment of a DCR in the city. In particular, in 2014, he introduced a bill in the federal parliament to amend the federal Drug Law in order to permit the establishment of a DCR [60]. However, the bill never reached the level of consensus required. By the end of 2016, the drug policy department of the Belgian Ministry of Public Health published a working paper on DCRs in Belgium [61]. One of the seven conclusions of that paper was that “if one wishes to implement a DCR, a prior feasibility study is essential. In addition to the above-mentioned elements, the budget and legal aspects, including the issues regarding liability of the health care providers and the authorities in case of overdose, must be thoroughly examined” [61]. In 2017, the feasibility study was carried out in the five largest Belgian cities, including Liège [31]. The aims of this study were [1] to provide an up-to-date overview of the effectiveness of, models of, and barriers to DCRs worldwide, [2] to conduct an analysis of the legal framework for the implementation of a DCR in Belgium, [3] to conduct a qualitative feasibility study with stakeholders (i.e. policymakers, policy administration, law enforcement, criminal justice, drug treatment services, outreach services, and harm reduction services and social welfare services) and PWUD from each of the five Belgian cities, and [4] to formulate recommendations for the implementation of DCRs should they be deemed necessary. The full report of the feasibility study has been published elsewhere [31]. The Liège local authorities used this feasibility study in the development of their policy.

Political context

The feasibility study showed that most stakeholders in Liège (prosecutorial authorities, law and enforcement professionals, local policymakers, and health and social care professionals), as well as PWUD, agreed that implementing a DCR would be useful [31]. The earlier TADAM experiment was perceived as positive in terms of implementation in the neighbourhood, impact on public safety issues, and PWUD health and wellbeing by most stakeholders. The TADAM experiment also indicated the commitment of local authorities in relation to drug use issues in the city since the early 2000s (i.e. local policymakers and law enforcement). Indeed, when considering several technical options for the establishment of a DCR in their city, e.g. regarding opening hours, inclusion/exclusion criteria, and the type of personnel needed, all stakeholders interviewed in the feasibility study referred positively to the previous TADAM experience [31]. The publication of the national feasibility study in February 2018 [31] was used by the mayor of the city of Liège as an opportune political window to reignite the political debate on DCRs in the context of local elections. In the same period, press articles were published about the drug scene in the city of Liège (on the numbers of drug users and the prevalence of drug-related harm, consumption in public spaces, discarded syringes, and drug-related crime), as were articles commenting on the results of the feasibility study [54, 62]. Against that background, the mayor organised several meetings in the city to discuss both his political programme for the local elections and the results of the feasibility study [63, 64]. Several meetings were organised with the local prosecutorial authorities and the police in order to anticipate legal and security issues. Meetings also took place with residents, in order to discuss the potential effects of a DCR on the health and welfare of PWUD, as well as on public safety and nuisances related to drug use in the city centre, bearing in mind the earlier positive TADAM experience. These meetings were organised with the participation of different local policymakers, including from the opposition and, despite the electoral context, which might have favoured confrontation, a broad political consensus was reached across all the parties represented on the city council in support of the DCR [64].

The power of actors

Fragmentation of policy responsibilities is one of the key features of the Belgian policy system [65, 66]. In particular, health policy responsibilities are shared within a complex system of different policy authorities: the federal (national) authority and several levels of federated authorities (regions and communities, whose territories overlap in some cases). A single health policy decision usually requires the agreement of at least two different authorities. By contrast, public safety is mainly the responsibility of the federal authorities, although local authorities have extensive autonomy for local initiatives. As a result, decision-making usually involves lengthy negotiation processes between diverse stakeholder groups and authorities, and decisions are driven by a high level of corporatism, with each segment aiming to protect its particular interests [66]. In addition, the Belgian policy system is characterised by a lack of cohesion, by multiple, sometimes competing, guiding institutions, and by weak overall leadership [67]. At the same time, this kind of system also leaves extensive room and autonomy for local initiatives and local leadership.

During the 2014–2019 legislature, no consensus was reached on new drug policy initiatives at the federal level [68]. This meant that there was no support for DCRs or for an amendment to the Drug Law from the federal government during the legislature. The Belgian federal government is usually formed by coalitions made up of different parties. Although some of the parties were not opposed to DCRs and were keen to consider the scientific evidence on their effectiveness, some other parties made their reluctance clear. Traditionally, when there is no consensus among members of the government on social issues, no decision is made [66], leading to a political deadlock. The situation, however, left room for local authority initiatives. Several local policy stakeholders pleaded for change, in particular regarding the possibility of implementing DCRs and other harm-reduction initiatives, particularly in the French-speaking community [69,70,71]. In the city of Liège, the local authorities had, since 2003, been developing a local drug policy plan that emphasised the need for a DCR in the city [72, 73]. In addition, the mayor had publicly taken the lead on a policy that favoured the opening of a DCR.

The power of ideas

The key policy formulation regarding DCRs is related to their ambiguous position between the penal and public health domains. Within the federal structure of the Belgian state, the Belgian Drug Law (1921), which is a penal law, is under the responsibility of the federal, i.e. national authorities, while the main responsibility for health policy, including prevention and harm reduction, is regional. After taking note of the lack of political willingness to amend the penal law at the federal level, the mayor of Liège obtained the support of the Walloon regional authority in the form of a resolution acknowledging that DCRs are an effective tool for harm reduction [74, 75]. As a result, an institutional debate took place about the potential conflict of policy responsibilities between the regions and the federal authorities. Some policymakers in the Brussels region also proposed regional regulation of harm-reduction interventions, including DCRs, arguing that health was a regional competence [76]. A formulation of policy on the issue that clearly presented DCRs as an instrument for public health led to an internal consensus among French-speaking stakeholders (in Brussels and Wallonia). This policy formulation helped to block possible counter-initiatives against the implementation of the DCR, e.g. from the federal authorities. Interestingly, however, the external consensus, i.e. involving the local stakeholders and residents, was achieved by emphasising the benefits of a DCR in terms of tackling public safety nuisances. Local authorities were successful in presenting the policy issue and intervention using both the public health and public safety frameworks.

The establishment of the DCR

Taking into account all the elements analysed within the four categories of Shiffman and Smith’s framework, the outcome was the opening of a DCR in Liège in September 2018, 1 month before the local elections, despite the adverse legal and federal policy framework. The DCR is funded by the city authorities and the Walloon region and is coordinated by the TADAM foundation that had managed the previous diacetylmorphine-assisted treatment project. The DCR was established in the same premises, which already had the appropriate infrastructure, including eight injection booths and one room for drug smoking for twelve PWUD. These premises are located in the downtown area, close to the local drug scene. Before the opening of the DCR, a consultation with local stakeholders was organised in order to validate the different operating criteria for the DCR (PWUD admission criteria, intake procedure, registration procedure, opening hours, house rules and regulations, and staff required), based on the previous TADAM experience and the results of the feasibility study [31, 56]. The public prosecutor’s office published a note explaining that it would not initiate prosecution against the DCR, its staff, or its users, although it would decide, depending on the circumstances, whether to prosecute the institution in the event of a complaint from a third party (public or civil party) [77]. During the week before the opening, the residents of the area were invited to visit the room and the press reported positively on the event [63]. Incidentally, the mayor was re-elected in October 2018.

As previously explained, the DCR’s target public was estimated at 300 PWUD [56]. Preliminary data gathered by the DCR providers stated that after 3 months, the DCR had reached 72% (216 PWUD) of its estimated target public, and 121% (363 PWUD) after 6 months, without any major medical or legal incident. Over the first 6 months, the average number of daily visitors was 35 (range 4–78). Of all registered visits (N = 6292), drugs were injected on 42% of visits and inhaled on 55%. The main drugs consumed were heroin (74% of visits) and cocaine (20% of visits). In addition, 44 PWUD have changed their route of administration from injection to inhalation. Two overdose events were adequately managed; these required resuscitation by the DCR staff and evacuation to an emergency department, without severe consequences.