Denmark’s Harm Reduction Approach to Addiction is Working

“We are civilized users,” says Kjær. “It’s possible to be active in volunteer work and even political work while using. We get the respect we deserve, but it’s taken 22 years.”

Danish policies are working.

The opioid epidemic and the widespread acknowledgement of the failure of the War on Drugs has created an environment in the U.S. in which ideas previously considered radical are now being embraced by policymakers, government officials from federal to local levels, and the medical community. The search for ideas that help to prolong the lives of substance users is widening, but there are places that have already gone a long way towards providing the kind of social support and medical care designed to destigmatize substance use and provide users safer environments in which to use drugs, while hoping to connect them to services that can help them move towards recovery. Denmark is one such place. By understanding and treating substance use as a social and medical issue, as opposed to a dilemma for criminal justice intervention, Denmark serves as a model for approaching addiction that other countries, including the U.S., would be wise to explore. Nathan Kuik gives Fix readers a look… Dr. Richard Juman

There is an opiate problem in the United States. There is also an incarceration problem. But while many agree on this, there is little agreement concerning their solutions. Despite some improvement in harm reduction policy in the U.S., Denmark’s policy is steps ahead of even the most liberal of American policies. In addition to treatment and health care paid by the state, Denmark has a number of fix rooms, a drug users’ union, clean needle handouts (not just exchanges) and heroin clinics where individuals can receive a daily dose of injected heroin (including one that I live a block from in Copenhagen).

With the UN’s symbolic lip service to harm reduction on full display at April’s special session, it seems necessary for local and regional governments to start implementing rational and humane policies. As a mental health and substance use professional that has worked with youth using heroin, and as a recent transplant to Denmark, I’ve been thinking about what the U.S. might learn from the Danes.

Fix Rooms

In 2011, some private citizens in Copenhagen began an experiment to provide a room for users to safely administer their drugs. Purchasing a used German ambulance, the volunteers created an agile and mobile consumption room, avoiding laws that prevented the establishment of rooms in buildings for the same purpose. The project was successful—so successful that Copenhagen municipality took over the site’s management. The program has now grown to a total of seven injection and use rooms across Denmark, says Joachim Rasmussen, the head nurse for Fixelancen.

Rasmussen considers the consumption rooms necessary for the individuals he works with. “My perspective is as a health professional,” comments Rasmussen. “I want to cure and prevent illnesses, traumas, and injuries caused by this way of life. I can’t treat my patients and work with them on motivation if they are not breathing anymore because of overdose.” Each room is different, but they all provide a hygienic and monitored place for individuals to inject, snort, and even smoke drugs, depending on the room’s amenities. The rooms are unassuming, until you notice the used syringes, stacks of bloodied gauze in the garbage, and ultraviolet lights used for finding suitable veins.

Poul and Johny (last names withheld), both frequent users of the consumption rooms, feel the rooms have made noticeable changes in their lives. Poul, a bald 40-year-old who has been living on the streets for the last 20 of them, talked about the difference the rooms have made for him. “Before the rooms, you had to use on the street or go to a bathroom in Central Station. That’s not so fun, because there were needles and pumps everywhere, probably thousands of kilos. People that live here, of course they don’t like the children playing with needles. You don’t see people fixing on every street corner anymore.”

Johny, whose English was sparse and still needed to dab a spot of blood on the inside of his elbow from injecting, comes to the room for social interaction with the staff. “I like the people that work here, they are from normal life. I can talk with them,” says Johny. Poul agreed, saying, “It’s the people that are working that make the difference, because they have heart, they really care. I got more open after coming here. Maybe I see people in a different way. People do care.”

Commitment to Harm Reduction

In all of my discussions with Danish service professionals and users, the discussion around harm reduction felt more open than conversations I’ve had with their American counterparts. While working in the U.S., it often felt like harm reduction was something that could only be whispered in dark rooms, something other professionals have written about. But in Copenhagen, I could talk about it openly with users and service professionals who embrace it.

Ivan Christensen is the superintendent of an organization called Mændenes Hjem, a 24-hour service provider that offers temporary housing, medical and dental care, two drug consumption rooms, and a café for eating and socializing. “For us, harm reduction is trying to decrease the costs you experience living with addiction or in a vulnerable situation. That’s just it. It’s very important that the people have to choose their own way of life,” says Christensen.

Commitment to sobriety is often a requirement for treatment or other services in the U.S., but this is almost the opposite in Denmark. For example, the housing provided by Mændenes Hjem is only available to active users. “We wouldn’t take anyone into the housing here if they were not a user, because it’s not an environment for a nonuser,” says Sara Zankel, Mændenes Hjem's communication manager.

Relationship with Police

Many of the professionals I talked with also cited that the Danish police were more concerned about fighting the drug distributors than the users. The people doing social work talked positively about police, and Mændenes Hjem’s building even shares a block with a large police station. “We have strict definitions of what is police work, what is health work, and what is social work,” says Christensen. “We have a good relationship with police. The police and the municipality of Copenhagen have signed an agreement where people are allowed to possess for their own use.”

Rasmussen echoed this, saying, “Taking care of the drug abuse is an issue for health care and social care. It’s not an issue for the judges, prison guards, and police.”

Not Without Challenges

The system is not free from criticisms, however. Anja Plesner Bloch, who is currently on methadone and has been in treatment 23 times, started her own organization called Users Academy to advocate for change. “You will always feel ashamed as a drug user,” says Plesner Bloch. “You are asking for help so many times. So it’s easy to make us go home and forget about it. We have guaranteed treatment in Denmark, but it doesn’t feel that way. I know they have to give treatment in 14 days, but when you don’t know your rights, they drag it out.”

An organization called Street Lawyers promotes knowledge of rights among users and advocates for user-informed policies, but despite some success, users say there is room to improve. One frequent complaint concerns perceived restrictions on opiate replacement therapy. “Heroin treatment could be so good,” claims Plesner Bloch, “but it is so bad. The injections are too close, and they force the users to take their night dose, rather than allowing them to take a dose home.”

Another challenge, at least for Copenhagen, has been a shift in use from heroin to cocaine, since the effect of the drug is different. Rasmussen remarked, “If you have a shot of heroin, it will last for five or six hours, and in the meantime, you are usually calm and relaxed. People taking the cocaine, they are not calm and relaxed. They are flying out of the room and being a nuisance to the neighbors. The cocaine has taken over the scene and that’s been a bigger nuisance for everyone.”

Christensen reports that upwards of 80% of the drug administrations in his organization’s rooms include cocaine. “If you are woken up by yelling persons for the fifth time that night, you are still annoyed. So it is important that you are allowed to complain about the yelling, and it doesn’t mean you aren’t tolerant or want all the drug users to go away,” says Zankel.

To accommodate its neighbors, Mændenes Hjem holds community meetings every six weeks for citizens to voice concerns, and the collaborative approach appears to be working. “We are listening to our neighbors,” says Michael Pedersen, Mændenes Hjem’s Head of Health. “One of the things that is defining our place, no matter who you are or how you look at things, you’re welcome here and we will talk to you. I view the neighbors in the same way. We meet and listen to them, and understand their point of view.”

User Involvement

It is a common assumption, at least in the U.S., that active users are unable to positively contribute to society. The Danish Users Union has been working for the last 22 years to change this. The Union’s president, Jørgen Kjær, who has used some type of opiate for 40 years and is currently on methadone, has worked to increase the influence of users on policy and opinion. The Union sponsors a syringe patrol, runs regular educational groups, coordinates needle handouts, acts as a daily drop-in center for active users, and houses a self-proclaimed “opiate museum.” It also hosted an international conference for 120 drug user-activists from 26 countries in 2008 to launch the International Network of People who Use Drugs (INPUD).

“We are civilized users,” says Kjær. “It’s possible to be active in volunteer work and even political work while using. We get the respect we deserve, but it’s taken 22 years.”

This type of involvement includes a number of challenges. “After working in this area for more than 17 years,” notes Christensen, “I have never seen an ethnic minority in a user’s organization.” Logistics are also a problem. “It’s very difficult for crack user to go to a conference in Greece, for instance,” says Christensen.

Change in the U.S.

Despite an unwavering federal stance in the War on Drugs, there is some evidence that things are shifting in the U.S. One such example is the Law Enforcement Assisted Diversion (LEAD) program that was started in Seattle in 2011. The people behind LEAD started it with the goal of providing police officers with an alternative to arrests. If a person is arrested for drug possession—and they are eligible for LEAD—they are given the option of going to the jail or making a “social contact” with a LEAD case manager. If they choose to make the social contact, and they follow through within 30 days, the drug charge is dropped.

“It’s not less policing, it’s not depolicing,” says LEAD program director Kris Nyrop. “It gives the police a tool they never had. If their only tool for addressing drug use is arrest, they’re going to use that tool. But if you give police officers another option that’s at least as effective as jail, they’ll leap at the opportunity.”

And early program evaluations suggest LEAD makes a difference. Studies from independent evaluators show a decrease in recidivism rates after two years, a significant drop in felony arrests for LEAD participants compared to a control group, and lower service costs for participants in LEAD. To date, LEAD has been launched by five other cities, is in its final stages in four more cities, and is being developed in another 10 cities, as reported by the LEAD National Support Bureau.

Besides the implementation of LEAD in municipalities across America, Nyrop cited another example in the change in sentiment towards harm reduction: a lifting of the federal ban for funding needle exchanges—at least for everything but the needles. However, some have been critical that it was only until white, middle-class Americans were affected by addiction that current policies were considered to be too focused on law enforcement. Nyrop agrees with this, but says the window of opportunity for implementing more harm reduction policies should still be utilized. “There is real awareness spreading that the criminal justice system is not an efficient way of dealing with addiction,” says Nyrop.

As a potential shift seems to happen across the U.S., situations like the one in Scott County, Indiana, and the difficulties many Americans face when trying to find adequate addiction care, perhaps the U.S. should heed Senator Bernie Sanders' pointing to Denmark when it comes to addiction policy. And as pressure mounts to discontinue the War on Drugs, the U.S. and much of the world would do well to learn something from Denmark’s current harm reduction strategies.

Nathan Kuik, MSW, LMHC, CDP, is a co-occurring therapist interested in psychotherapy, addiction, and harm reduction. He currently lives abroad in Copenhagen, Denmark, and works as remote consultant to Asian Counseling & Referral Service, a nonprofit in Seattle, Washington. You can follow him on Twitter @NathanKuik.