ABSTRACT

Drug consumption rooms (DCR) aim to facilitate consumption in hygienic and safe conditions. However, users also consume drugs in public spaces and homes generating incremental risk for health. To strengthen our understanding of consumption practices, we conducted an ethnographic study in different consumption locations in Barcelona, including DCRs, public spaces, and homes. Focusing on consumption practices and narratives, we conducted participant observation and interviewed 16 DCR users. Our findings show that different consumption spaces allow users to experiment different types of pleasures. In addition, consumption in each type of location is associated with various types of harms, which are managed by users by self-regulating their practices. These aspects, therefore, must be taken into account to design harm reduction action aligned with users’ practices.

KEYWORDS:
Drug Users; Harm Reduction; Needle-Exchange Programs; Qualitative Research; Heroin Dependence; Cocaine; Spain

INTRODUCTION

Starting in the early 2000s, drug dependence attention departments reporting to public health agencies in Barcelona and in Catalonia have coordinated, planned, and put forward guidelines to strengthen network programs focused on harm reduction, targeted at drug users who resort to parenteral and pulmonary routes of administration.¹1. Bosque-Prous M, Brugal MT. Intervenciones de reducción de daños en usuarios de drogas: situación actual y recomendaciones. Gaceta Sanitaria. 2016;30(Supl 1):104-110. doi: 10.1016/j.gaceta.2016.04.020.^,22. Folch C, Lorente N, Majó X, Parés-Badell O, Roca X, Brugal T, Roux P, Carrieri P, Colom J, Casabona J, REDAN study group. Drug consumption rooms in Catalonia: A comprehensive evaluation of social, health and harm reduction benefits. International Journal of Drug Policy. 2018;62:24-29. doi: 10.1016/j.drugpo.2018.09.008. Specifically, needle-exchange programs (NEP) have increased, as spaces to supply needles and other elements for hygienic consumption involving parenteral and pulmonary routes, and to provide health and social services to users,³3. Clua R, Tenza G, Mingueza J. Guia de bones pràctiques en els programes d’intercanvi de xeringues. Barcelona: Agencia de Salut Publica de Catalunya; 2015. as well as methadone maintenance treatments (MMT), to decrease consumption of illegal opiates/opioids, to reduce incidence due to HIV and Hepatitis B and C infection, to reduce drug overdose deaths, to decrease criminal activities, and to improve users’ quality of life.⁴4. Dennis BB, Naji L, Bawor M, Bonner A, Varenbut M, Daiter J, Plater C, Pare G, Marsh DC, Worster A, Desai D, Samaan Z, Thabane L. The effectiveness of opioid substitution treatments for patients with opioid dependence: a systematic review and multiple treatment comparison protocol. Systematic Reviews. 2014;3:105. doi: 10.1186/2046-4053-3-105. Both programs have diversified, mainly in Barcelona metropolitan area, into pharmacies, mobile units, and centers dealing with medical care and follow-up monitoring of drug users, to improve drugs users’ access to these services and to have their needs covered.¹1. Bosque-Prous M, Brugal MT. Intervenciones de reducción de daños en usuarios de drogas: situación actual y recomendaciones. Gaceta Sanitaria. 2016;30(Supl 1):104-110. doi: 10.1016/j.gaceta.2016.04.020.

Furthermore, as an integral part of the harm reduction policy, drug consumption rooms (DCR) were set up as places to use substances submitted to supervision (heroin and cocaine), obtained from the illegal market, where users are guaranteed a hygienic place and material for consumption, the required supervision and professional assistance in case of overdose or other complications, and the promotion of healthy habits to shorten morbidity and mortality rates due to drug abuse.²2. Folch C, Lorente N, Majó X, Parés-Badell O, Roca X, Brugal T, Roux P, Carrieri P, Colom J, Casabona J, REDAN study group. Drug consumption rooms in Catalonia: A comprehensive evaluation of social, health and harm reduction benefits. International Journal of Drug Policy. 2018;62:24-29. doi: 10.1016/j.drugpo.2018.09.008.^,55. Potier C, Laprévote V, Dubois-Arber F, Cottencin O, Rolland B. Supervised injection services: what has been demonstrated?: A systematic literature review. Drug Alcohol Depend. 2014;145:48-68. doi: 10.1016/j.drugalcdep.2014.10.012.^,66. Hedrich D, Kerr T, Dubois-Arbe F. Drug consumption facilities in Europe and beyond. En: Rhodes T, Hedrich D. (eds.) Harm reduction: Evidence, impacts and challenges. Luxembourg: European Monitoring Centre for Drugs and Drug Addiction; 2010. p. 305-331.^,77. Noël L, Gagnon F, Bédard A, Dubé È. Avis sur la pertinence des services d’injection supervisée: analyse critique de la littérature. Québec: Institut national de santé publique du Québec; 2009.^,88. Clua R. Salas de consumo higiénico en España (2000-2013). Salud Colectiva. 2015;11(2):261-282. doi: 10.18294/sc.2015.688.^,99. Bertrand B. Salles de shoot? Un regard engagé en faveur de l’expérimentation de structures d’accueil avec possibilité de consommer à moindre risque des drogues. Paris: Books on Demand; 2010.⁾ Thanks to these DCRs, users are given the chance to receive social and health attention services, and they also have “Drop-in” zones to take care of their basic hygiene, eating, and rest needs.²2. Folch C, Lorente N, Majó X, Parés-Badell O, Roca X, Brugal T, Roux P, Carrieri P, Colom J, Casabona J, REDAN study group. Drug consumption rooms in Catalonia: A comprehensive evaluation of social, health and harm reduction benefits. International Journal of Drug Policy. 2018;62:24-29. doi: 10.1016/j.drugpo.2018.09.008.^,55. Potier C, Laprévote V, Dubois-Arber F, Cottencin O, Rolland B. Supervised injection services: what has been demonstrated?: A systematic literature review. Drug Alcohol Depend. 2014;145:48-68. doi: 10.1016/j.drugalcdep.2014.10.012.^,88. Clua R. Salas de consumo higiénico en España (2000-2013). Salud Colectiva. 2015;11(2):261-282. doi: 10.18294/sc.2015.688.⁾ Furthermore, these rooms are facilities that improve public policy interests, by reducing community conflicts, law violations due to drug abuse in public, and the number of needles and other paraphernalia left behind in public places.⁵5. Potier C, Laprévote V, Dubois-Arber F, Cottencin O, Rolland B. Supervised injection services: what has been demonstrated?: A systematic literature review. Drug Alcohol Depend. 2014;145:48-68. doi: 10.1016/j.drugalcdep.2014.10.012.^,88. Clua R. Salas de consumo higiénico en España (2000-2013). Salud Colectiva. 2015;11(2):261-282. doi: 10.18294/sc.2015.688.^,1010. Espelt A, Villalbí JR, Bosque-Prous M, Parés-Badell O, Mari-Dell’Olmo M, Brugal MT. The impact of harm reduction programs and police interventions on the number of syringes collected from public spaces: a time series analysis in Barcelona, 2004-2014. International Journal of Drug Policy. 2017;50:11-18. doi: 10.1016/j.drugpo.2017.07.033.^,1111. Vecino C, Villalbí JR, Guitart A, Espelt A, Bartroli M, Castellano Y, Brugal MT. Apertura de espacios de consumo higiénico y actuaciones policiales en zonas con fuerte tráfico de drogas: Evaluación mediante el recuento de las jeringas abandonadas en el espacio público. Adicciones. 2013;25(4):333-338. doi: 10.20882/adicciones.35.

In Catalonia the first DCR was set up in 2001 within an “open drug use scene” for drug abuse located in a slum area in Barcelona, where most drug users in the city would gather.¹²12. Anoro M, Ilundain E, Santisteban O. Barcelona’s Safer Injection Facility-EVA: A Harm Reduction Program Lacking Official Support. Journal of Drug Issues. 2003;33(3):689-711. doi: 10.1177/002204260303300309. The demolition of this neighborhood, in 2004, caused the scattering of users across the city, which led municipal experts in charge to open new DCRs in different districts within the city, and to integrate them into drug dependence attention centers that were already operating, located near selling zones and drug consumption.¹1. Bosque-Prous M, Brugal MT. Intervenciones de reducción de daños en usuarios de drogas: situación actual y recomendaciones. Gaceta Sanitaria. 2016;30(Supl 1):104-110. doi: 10.1016/j.gaceta.2016.04.020.^,88. Clua R. Salas de consumo higiénico en España (2000-2013). Salud Colectiva. 2015;11(2):261-282. doi: 10.18294/sc.2015.688.⁾ At present, there are 13 DCRs in Catalonia, out of which 11 are incorporated into harm reduction centers while 2 are integrated into mobile units and, regarding drug consumption, 11 are destined for parenteral route consumption and two for pulmonary route administration.⁸8. Clua R. Salas de consumo higiénico en España (2000-2013). Salud Colectiva. 2015;11(2):261-282. doi: 10.18294/sc.2015.688.^,1313. Agència de Salut Pública de Catalunya. Informe anual 2017. Sistema d’informació sobre drogodependències a Catalunya. Barcelona: Generalitat de Catalunya; 2018.⁾ In the last report released in 2017 by the data system on drug dependence in Catalonia, the total number recorded for DCR users amounted to 3,176 while a total of 124,711 accounted for consumptions, out of which 112,777 were related to routes of parenteral administration, 8,466 to routes of pulmonary administration, and 3,468 to intranasal drug administration, with no records for drug overdose deaths.¹³13. Agència de Salut Pública de Catalunya. Informe anual 2017. Sistema d’informació sobre drogodependències a Catalunya. Barcelona: Generalitat de Catalunya; 2018.

More than 80% DCR users are male, and their ages range mainly from 30 to 40 years, more than 40% are immigrants, who present a prevalence of HIV exceeding 30%, 70% for HCV, and about 30% having HIV and HCV coinfection. In general, it is a population with low levels of education, low labor market linkage, and they carry out illegal activities as their source of income, which result in problems with the criminal justice system.²2. Folch C, Lorente N, Majó X, Parés-Badell O, Roca X, Brugal T, Roux P, Carrieri P, Colom J, Casabona J, REDAN study group. Drug consumption rooms in Catalonia: A comprehensive evaluation of social, health and harm reduction benefits. International Journal of Drug Policy. 2018;62:24-29. doi: 10.1016/j.drugpo.2018.09.008.^,88. Clua R. Salas de consumo higiénico en España (2000-2013). Salud Colectiva. 2015;11(2):261-282. doi: 10.18294/sc.2015.688.^,1414. Clua R. Estilos de vida de los usuarios de las salas de consumo higiénico de Barcelona. Health and Addictions, Salud y Drogas. 2018;18(2):79-89.^,1515. Folch C, Casabona J, Brugal MT, Majó X, Meroño M, Espelt A, González V. Perfil de los usuarios de drogas por vía parenteral que mantienen conductas de riesgo relacionadas con la inyección en Cataluña. Gaceta Sanitaria. 2012;26(1):37-44. In recent studies, differing features among users are noted, based on consumption intensity, health and social conditions, and adherence to DCRs. In one research study on the impact out of frequent attendance to DCRs in relation to drug consumption in public spaces, infection risks, drug overdose, and access to drug dependence attention services,²2. Folch C, Lorente N, Majó X, Parés-Badell O, Roca X, Brugal T, Roux P, Carrieri P, Colom J, Casabona J, REDAN study group. Drug consumption rooms in Catalonia: A comprehensive evaluation of social, health and harm reduction benefits. International Journal of Drug Policy. 2018;62:24-29. doi: 10.1016/j.drugpo.2018.09.008. it was found that 20% of drug users were “frequent” and had 61% lower chances for drug consumption in public spaces taking into account the risks involved. Consequently, they were six times more likely to discard used needles in safe places and they had twice the chance of having access to drug dependence attention services than attendees with “medium” and “low” frequency. Furthermore, the proportion of homeless participants was higher among “frequent” users than in those with “medium” and “low” frequency; therefore, as they did not have a safe place to take drugs, they would be more willing to use DCRs regularly. An ethnographic study provided evidence of different lifestyles among DCR users in Barcelona.¹⁴14. Clua R. Estilos de vida de los usuarios de las salas de consumo higiénico de Barcelona. Health and Addictions, Salud y Drogas. 2018;18(2):79-89.⁾ Among usual DCR goers, users with a severe consumption patterns were identified who would also take drugs in public spaces and homes, who had remarkable physical deterioration, and who did not accomplish drug abuse follow-ups. Other users had less severe consumption patterns, with strong adherence to DCRs, accomplishing health and social follow-ups. Among users that occasionally used DCRs, those attending the rooms for consumption in their daily routine stood out, with low adherence to drug dependence follow-ups, being characterized as not devoting their daily routine to consumption but dedicating time to their families, work or other activities, while there was another group of users with strong physical deterioration, undergoing drug abuse treatments, who attended DCRs on scheduled days to use drugs.

In this way, although evidence show that DCRs can contribute to improving users’ health and social conditions, consumption still occurs in clandestine and unhealthy public spaces and homes that play an important role in the ritualistic use of substances, where high risks and social and health harm are experienced. This fact heightens the need to understand, from the users’ perspective, those experiences and practices related to drug consumption, as well as self-care strategies¹⁶16. Haro JA. Cuidados profanos: una dimensión ambigua en la atención de la salud. En: Perdiguero E, Comelles J. (coord.). Medicina y cultura: estudios entre la antropología y la medicina. Barcelona: Bellaterra; 2000. p. 101-161. that are used in different consumption spaces. Delving into these aspects will allow us to comprehend the reasons and experiences concerning consumption in different settings, as well as users’ self-care in different situations, thus grasping key elements to design more effective harm reduction strategies. To this end, this article has adopted the model of “risk environments” developed by Rhodes,¹⁷17. Rhodes T. The ‘risk’ environment: A framework for understanding and reducing drug related harm. International Journal of Drug Policy. 2002;13:85-94. doi: 10.1016/S0955-3959(02)00007-5.^,1818. Rhodes T. Risk environments and drug harms: a social science for harm reduction approach. International Journal of Drug Policy. 2009;20(3):193-292. doi: 10.1016/j.drugpo.2008.10.003. whereby consumption harms are caused as a result of social, structural, but also political and economic factors, which create inequalities and vulnerabilities in the interactions among drug users and consumption settings. Following this approach, apart from giving priority to social determinants in health, special attention will be focused on managing prevention and consumption practices among drug users in different risk environments.¹⁷17. Rhodes T. The ‘risk’ environment: A framework for understanding and reducing drug related harm. International Journal of Drug Policy. 2002;13:85-94. doi: 10.1016/S0955-3959(02)00007-5.^,1818. Rhodes T. Risk environments and drug harms: a social science for harm reduction approach. International Journal of Drug Policy. 2009;20(3):193-292. doi: 10.1016/j.drugpo.2008.10.003.^,1919. Llort Suárez A. «Dime dónde consumes y te diré…»: Antropología sobre el uso y abuso de cocaína. Perifèria, Revista de Recerca i Formació en Antropologia. 2018;23(1):56-83.

This perspective will allow us to understand risk management as the ability of objectivizing events with the aim of making them governable in several contexts, thus obtaining positive experiences for one’s own well-being.¹⁹19. Llort Suárez A. «Dime dónde consumes y te diré…»: Antropología sobre el uso y abuso de cocaína. Perifèria, Revista de Recerca i Formació en Antropologia. 2018;23(1):56-83.^,2020. Sepúlveda M, Romaní O. Conceptualización y políticas de la gestión del riesgo. En: Martínez Oró DP, Pallarés J, (eds.). De riesgos y placeres: manual para entender las drogas. Lleida: Milenio; 2013. p. 89-102.⁾ Through management, drug users take part in various consumption settings, by making decisions according to available material, social, and cultural conditions, which define their different lifestyles.¹⁴14. Clua R. Estilos de vida de los usuarios de las salas de consumo higiénico de Barcelona. Health and Addictions, Salud y Drogas. 2018;18(2):79-89. In varying ways, they acquire skills and practices to experience pleasures and protect themselves against potential harms deriving from drug abuse in certain situations.¹⁹19. Llort Suárez A. «Dime dónde consumes y te diré…»: Antropología sobre el uso y abuso de cocaína. Perifèria, Revista de Recerca i Formació en Antropologia. 2018;23(1):56-83.^,2121. Duff C. Towards a theory of drug use contexts: Space, embodiment and practice. Addiction Research and Theory. 2007;15(5):503-519. doi: 10.1080/16066350601165448.^,2222. Duff C. The pleasure in context. International Journal of Drug Policy. 2008;19(5):384-392. doi: 10.1016/j.drugpo.2007.07.003. In particular, they carry out activities in which risk is put at stake, as a process of mediation in decisions that may have positive consequences, in the form of pleasures, or negative consequences, in the form of harms.²⁰20. Sepúlveda M, Romaní O. Conceptualización y políticas de la gestión del riesgo. En: Martínez Oró DP, Pallarés J, (eds.). De riesgos y placeres: manual para entender las drogas. Lleida: Milenio; 2013. p. 89-102.^,2323. Martínez Oró DP, Pallarés J. Riesgos, daños y placeres. En: Martínez Oró DP, Pallarés J, (eds.). De riesgos y placeres: manual para entender las drogas. Lleida: Milenio; 2013. p. 23-36. Specifically, pleasures result from an optimal combination among such effects that are expected from substances, the physiological aspect, the ways of relating to one another, and attraction and engagement to the consumption setting.²²22. Duff C. The pleasure in context. International Journal of Drug Policy. 2008;19(5):384-392. doi: 10.1016/j.drugpo.2007.07.003.^,2424. Dilkes-Frayne E. Tracing the “event” of drug use: “Context” and the coproduction of a night out on MDMA. Contemporary Drug Problems. 2014;41(3):445-479. doi: 10.1177/009145091404100308. Harms are accepted among users as adverse consequences toward their health (transmission of blood borne infections, overdose, substance withdrawal syndrome, among others), as well as discrimination and stigmatization processes within prohibitionism.²⁵25. Martínez Oró DP, Romaní O. Els danys de les polítiques prohibicionistes en l’àmbit de les drogues. Quaderns-E. 2016;21(1):33-49.⁾ Following such an equation, danger acts as an unwanted effect that cannot be controlled by drug users, which can be handled by taking harm reduction actions.²⁰20. Sepúlveda M, Romaní O. Conceptualización y políticas de la gestión del riesgo. En: Martínez Oró DP, Pallarés J, (eds.). De riesgos y placeres: manual para entender las drogas. Lleida: Milenio; 2013. p. 89-102.^,2323. Martínez Oró DP, Pallarés J. Riesgos, daños y placeres. En: Martínez Oró DP, Pallarés J, (eds.). De riesgos y placeres: manual para entender las drogas. Lleida: Milenio; 2013. p. 23-36.

This article is just one part of a larger project entitled “Register for the room!: Socio-cultural epidemiology of drug abuse and evaluation of harm reduction policies in drug consumption rooms located in Barcelona” [“¡Apúntame a la sala!: Epidemiología sociocultural del consumo de drogas y evaluación de las políticas de reducción de daños en las salas de consumo higiénico de Barcelona.”]²⁶26. Clua R. ¡Apúntame a la sala!: Epidemiología sociocultural del consumo de drogas y evaluación de las políticas de reducción de daños en las salas de consumo higiénico de Barcelona. [Tesis Doctoral]. Departament d´Antropologia Social i Cultural de la UAB; 2016.⁾ Related to that research, two previous studies were conducted before this work, one on the “Lifestyles of drug consumption rooms´ users in Barcelona” [“Estilos de vida de los usuarios de las salas de consumo higiénico de Barcelona,”]¹⁴14. Clua R. Estilos de vida de los usuarios de las salas de consumo higiénico de Barcelona. Health and Addictions, Salud y Drogas. 2018;18(2):79-89.⁾ and another one on “Nursing care for cocaine withdrawal syndrome in users attending drug consumption rooms in Barcelona” [“Atención de enfermería del síndrome posconsumo de cocaína en usuarios de las salas de consumo higiénico de Barcelona.”]²⁷27. Clua R. Atención de enfermería del síndrome posconsumo de cocaína en usuarios de las salas de consumo higiénico de Barcelona. IV Congreso Virtual Internacional de Enfermería en Salud Mental [Internet]. 2018;4 [citado 10 may 2019]. Disponible en: Disponible en: http://psiqu.com/1-8944
http://psiqu.com/1-8944... ⁾ This article is based on the same sample of participants that took part in the larger project; however, the question, objectives, hypothesis, and methodology differ from the works already published.

The goal of this article is to analyze and compare consumption practices and narratives among drug users that use substances in homes, public spaces and DCRs. To achieve this, a micro analysis is carried out to delve into the dynamics ruling consumption in different settings, with the aim of identifying key aspects to modify social conditions and to promote community interventions that should reduce suffering and vulnerability among drug users undergoing social exclusion. In this way, our purpose was to better understand such pleasures that lead users to take drugs in a particular place and the harms sustained in the different situations, as well as self-care strategies applied by users to self-regulate risks in each case. The knowledge contributed by this analysis will be relevant to design harm reduction policies that will be better tailored to suit users’ needs.

METHODOLOGY

We conducted a qualitative study with an ethnographic approach, since it is a method that enables contact with reality and direct interaction with drug users in their daily routines.²⁸28. Bourgois P, Schonberg J. Righteous Dopefiend. Berkeley: University of California Press; 2009.^,2929. Carlson RG, Singer M, Stephens RC, Sterk CE. Reflections on 40 years of ethnographic drug abuse research: Implications for the future. Journal of Drug Issues. 2009;39(1):57-70. doi: 10.1177/002204260903900106.^,3030. Singer M. Anthropology and addiction: An historical review. Addiction. 2012;107(10):1747-1755. doi: 10.1111/j.1360-0443.2012.03879.x.^,3131. Romaní O. La epidemiología sociocultural en el campo de las drogas: contextos, sujetos y sustancias. En: Haro JA, (coord.). El planteamiento de una epidemiología sociocultural. Un diálogo en torno a su sentido, métodos y alcances. Buenos Aires: Lugar; 2010. p. 89-113. This approach made it possible to deeply understand drug users’ consumption narratives and practices, facilitating a contrast of information and observation on pleasures and harms that they experience as well as harm reduction methods that are part of different consumption spaces. This research was conducted between 2012 and 2016 in five drug abuse attention centers with DCRs in Barcelona (Table 1) and its surroundings (public spaces), located in three zones, with heavy drug dealing, which are visited by the highest number of drug users from this metropolitan area.

CDAF = Center for Drug Abuse Attention and Follow-up; NEP = Needle-Exchange Program; MMT = Methadone Maintenance Treatment; SAPS = Health and Social Attention and Prevention Services.

Recruitment of all the participants in this study was performed during the phase of familiarization with the different observation environments. A qualitative and theoretical sampling was generated.³³33. Martínez-Salgado C. El muestreo en investigación cualitativa: principios básicos y algunas controversias. Ciência & Saúde Coletiva. 2012;17(3):613-619. doi: 10.1590/S1413-81232012000300006.⁾ During field work a hundred of users who resort to parenteral and pulmonary drug administration were contacted, in a direct way and by means of the “snowball sampling technique,”³⁴34. Shaghaghi A, Bhopal RS, Sheikh A. Approaches to recruiting “Hard-To-Reach” populations into research: A review of the literature. Health Promotion Perspectives. 2011;1(2):86-94. doi: 10.5681/hpp.2011.009. through users and professionals, and we conducted formal interviews with 16 drug users. The sample of participants included 9 men, 5 women, and 2 transsexuals aged between 30 and 50 years, out of whom 6 were heroin users, three were cocaine dependents, while 7 used both substances; besides, 12 were parenteral drug users, 3 were parenteral and pulmonary drug users, and 1 was a pulmonary drug user. Regarding blood-borne transmission infections, 8 had HIV and HCV coinfection, 3 were infected with HCV, 1 with HIV, and 4 reported no infections. Out of the 16 participants, 11 were undergoing opiate substitution treatment.

Data was collected through participant observation and semi-structured interviews. Participant observation involves observation and participation establishing an engagement/separation relationship that is built following field work logics.³⁵35. Hammersley M, Atkinson P. Ethnography: principles in practice. Third edition. London: Routledge; 2007.⁾ To that end, we interacted with DCR users in the different areas of the facilities. For instance, observations were made and interaction with users was established during their nursing consultations, at the needle-exchange spots, and in consumption spaces; we attended overdose prevention workshops; we had conversations with users at the time they started consumption in the DCRs or when exchanging consumption material during the needle-exchange programs, and we got into contact with them in the “Drop-in” zones (rest areas), needle-exchange programs or DCRs to invite them to take part in interviews. In addition, observations were made in public spaces, near the DCRs, in order to learn about consumption practices and narratives of those users that do not always rely on these facilities. To achieve this, we accompanied outreach educators that are in charge of community intervention and visit consumption spaces for the collection of already used needles, observing consumption practices in public spaces (porches, open spaces, among others), and starting a conversation with drugs users. These sessions were registered on a daily field journal to describe facts, events, places, and individuals, as well as interpreting the researcher’s impressions and reflections.³⁶36. Emerson RM, Fretz R, Shaw LL. Writing ethnographic fieldnotes. Chicago: University of Chicago Press; 2011. The total number of sessions was 259, written up in 1,928 pages of the daily field journal.

Through semi-structured interviews³⁷37. DiCicco-Bloom B, Crabtree BF. The qualitative research interview. Medical Education. 2006;40(4):314-321. doi: 10.1111/j.1365-2929.2006.02418.x.^,3838. Jamshed S. Qualitative research method-interviewing and observation. Journal of Basic and Clinical Pharmacy. 2014;5(4):87-88. doi: 10.4103/0976-0105.141942.⁾ specific information was obtained on consumption practices, representations, and related narratives, in a relatively intimate context that users who resort to parenteral and pulmonary administration methods are not always willing to offer collectively, and this situation facilitated information to supplement already collected data through participant observation. For this purpose, a script was designed based on the data obtained through participant observation, in which narratives and representations related to pleasures and harms were explored, as well as self-care strategies among participants. During the interviews participants described pleasure as the benefits of drug abuse, the relationships that may be established, and the positive experiences in different contexts; harms, were identified as the dangers and adverse effects of drug consumption in certain situations; and self-care strategies, as the ways of reducing risks and harms.

Each interview was divided into three theme blocks that included deductive questions concerning drug abuse in different consumption spaces: (1) Drug abuse in dwelling houses, for example, “What are the dangers of consuming in homes?;” “What measures do you take to prevent an overdose?;” (2) Drug abuse in public spaces, for example, “What advantages can you mention about consuming on the streets?;” “If you face dangerous situations on the streets, what methods do you adopt to protect yourself?;” and (3) Drug abuse in DCRs, for example, “Why have you decided to attend a drug consumption room?;” “What are the benefits of using drugs in a consumption room?” All interviews were digitally recorded and transcribed verbatim for later analysis. Ethical aspects were taken into account regarding confidentiality and anonymity of the participants taking part in the research, replacing their real names with fictitious names.

A content analysis was performed regarding the collected materials. This analysis consisted in the interpretation, and objective and systematic comparison of data in terms of some common denominator.³⁹39. Bengtsson M. How to plan and perform a qualitative study using content analysis. NursingPlus Open. 2016;2:8-14. doi: 10.1016/j.npls.2016.01.001.⁾ Field notes and semi-structured interviews were encoded by elaborating an index of concepts with provisional information. These codes were organized and compared to obtain more precise codes by simplifying them. These codes facilitated the identification of descriptions and ideas that were classified into theme groups, generating categories that provided a theoretical explanation for the data with respect to the object of study. Credibility and validity of the analyzed data were incremented by means of a triangulation approach,⁴⁰40. Carter N, Bryant-Lukosius D, DiCenso A, Blythe J, Neville AJ. The use of triangulation in qualitative research. Oncology Nursing Forum. 2014;41(5):545-547. doi: 10.1188/14.ONF.545-547. articulating the data gathered by means of different techniques of data collection in various consumption spaces and with multiple drugs users.

All the interviewees signed an informed consent and a document with information about the purpose of the research and about the use of the collected data. These documents were approved by the Commission of Ethics at the Universitat Autònoma de Barcelona.

RESULTS

Following the approach proposed and based on the “risk environments” framework, results are based on the description of the different consumption settings, as described above. Data analysis based on this approach allows us to intertwine three major dimensions regarding the relationship between consumption and setting, which structure the development of every section discussed below: the first dimension is focused on positive and pleasurable aspects of consumption in a given environment; a second dimension, on the contrary, involves negative aspects and the harms of consumption in such a space; and, a third dimension comprises the analysis of self-care strategies applied by users to manage risks in each one of these consumption settings.

Using drugs in public spaces

Drug consumption in public spaces represents a type of practice involving high health and social risk. They are places with precarious hygienic conditions, allowing users to hide in house porches, abandoned buildings, and green areas near drug dealing spots. These spaces are chosen by users who consider that “using drugs on the streets is fabulous” as opposed to those that, on the contrary, see said practice as “dangerous,” thus opting for consumption in spaces considered to be safer, such as DCRs or homes. However, at times this possibility is not available, given that a lot of users are homeless or they cannot take drugs in DCRs, due to opening times (Table 1), or because they were kicked out from these facilities after serious violations of rules or causing episodes of violence toward other users or professionals. In these cases, users adopt safety measures to prevent consumption harms in public spaces.

“Using drugs on the streets is fabulous”

Users with severe consumption patterns are the ones that usually accomplish their practices in public spaces. In general, they are cocaine and heroin users who resort to parenteral routes administration and explain that consuming on the streets allows them to a more intense sensation in a relatively safe environment. These users go to places close to drug-dealing houses, such as porches, parks or other spaces where they can take shelter, for immediate consumption. They carry out ritualistic consumption practices with freedom only subject to their own decisions and the conditions available in the environments chosen by them. In these places, users turn up on their own or they are accompanied by other users to share money spent on substances, or they gang up with other groups in which they trust. As for cocaine users, they argue that, on the streets, their experience is quieter and it is a way to get more intense effects. On the streets drugs can be used with much more freedom and, when suffering paranoia, they report that consumption is less stressful than in a space enclosed by walls. Regarding heroin consumption, they argue that on the streets it is possible to experience pleasurable effects more intensely, avoiding impertinence and noises from people with whom they do not want to share their space.

“Using drugs on the streets is dangerous”

Users that describe using drugs in public spaces as “dangerous” are the ones that have less severe consumption patterns than the ones that prefer to use drugs on the streets. Regarding parenteral cocaine administration, users report that when they suffer “paranoia” it is difficult to keep calm and bear such effects in an unprotected environment. Among parenteral heroin users, they are aware of the likelihood of suffering a fatal overdose and having difficulty in receiving attention to avoid death. In both cases, they report that precarious hygiene conditions in public spaces may lead to infection or reinfection of HIV and/or hepatitis B virus (HBV) or hepatitis C virus (HCV). Among drug users who resort to pulmonary routes administration, although these risks are not contemplated, they report that it is difficult to perform this type of consumption in adverse weather conditions (wind, rain, among others), and that is why many prefer to take drugs in homes or DCRs.

Users who do not take drugs on the streets highlight that in these spaces one runs the risk of being seen by neighbors and passersby, and having law enforcement problems when being stopped by the police. Furthermore, users that accomplish consumptions on their own report the risk of suffering aggressions or extortions by other users.

Self-care strategies in public spaces

In order to avoid negative social consequences, users often look for a quiet place to take drugs with company and far away from their neighbors and passersby looks. If they are approached by the police, they try to give reasonable explanations why they are using drugs in public spaces. If the police draw up a record and take their drug doses, users often allege that it is for self-consumption to avoid punishment, and if the police insist on finding out where they bought such substances, they give fake information as a bargaining chip to prevent confiscation and protect the drug dealer’s identity.

In these spaces a number of self-care measures are adopted to reduce harms, given the impossibility of going to safer spaces. As regards prevention of infectious diseases, users try to make sure they have sterile material for preparation and drug abuse through parenteral routes administration. However, this is not always the case, and risk practices are also detected such as sharing needles and other paraphernalia for the preparation of the syringe among users. Regarding overdose episodes, users handle drug abuse by avoiding substances in quantities that cannot be tolerated and that may lead to an overdose or other adverse effects. On few occasions users informed that they take naloxone kits to be ready to act in case of heroin overdose; however, they often take mobile phones to call emergency services or they take heroin in nearby recreational areas where they can alert passersby or which are close to a DCR so they can resort to professionals. Among drug users who resort to pulmonary routes administration, in order to fight adverse weather conditions, they carry out their practices in sheltered places, such as inside vehicles or awnings.

Using drugs in homes

This type of consumption is carried out in private homes, squat houses, and flat floors where drugs are sold. In each of these spaces there are different features regarding consumption organization. Private homes are not so often attended by users given the very low percentage of individuals who live in these types of houses. In these cases, the consumption of these users is moderate, either on their own or in small groups, who describe these spaces as safe and intimate. Squat houses are more or less organized spaces attended by larger groups of drug users. In relation to floors where drugs are sold, there are differences in the types of dwellings among the different neighborhoods studied. In the city centre of Barcelona, there are floors with poor housing conditions exclusively organized for drug dealing and consumption, where small groups of users gather. In the suburbs or outlying neighborhoods, there are homes where spaces for domestic life are separated from spaces for drug dealing. In these types of houses, trusty users are only allowed for consumption, with no concentration of large groups. In general, users regard using drugs in houses as being “quieter” than consuming on the streets or in a DCR. On the contrary, other users report having experienced “troublesome” situations, which is why they look for safer spaces and, when need be, they adopt harm reduction measures.

“It is quiet to use drugs in homes”

Drug consumption in homes facilitates peaceful preparation and consumption, without being disturbed by other users and without having to obey DCR drug use rules. When compared to consumption in public spaces, drug users report that consuming in homes is a good way to avoid being seen by neighbors and the police, with no interruptions, without receiving recriminations, while being able to experience desired effects without setbacks. In general, users that take drugs in homes are those that have a severe level of consumption, mainly those who live in squat houses, or those that often take drugs in public spaces but attend drug-dealing houses, where consumption is allowed, located in neighborhoods with tight police control. In these spaces it is possible to use drugs secretly and to enjoy the effects of substances in small groups.

In the city of Barcelona there is only one DCR for pulmonary administration of drugs, which is not open 24 hours. Therefore, when they are closed or users buy substances in neighborhoods lacking these spaces, they must look for alternatives, like looking for homes for consumption. Furthermore, consumption in these spaces is a good way of avoiding adverse weather conditions and trouble with the police and passersby.

“It is troublesome to use drugs in homes”

There are health and social adverse consequences regarding drug consumption in homes. Heroin users resorting to parenteral routes administration report that in these spaces there is a risk of suffering an overdose, with no proper means to revert such an episode, especially if consumption is on your own or with individuals with little capacity for attention. When it comes to cocaine users, resorting to both pulmonary and parenteral routes administration, they report that there is a risk of suffering serious hallucinations and anxiety that are hard to be alleviated in these types of environments.

Users describe a number of issues depending on the type of home. In private homes shared with relatives or flat mates that are not drugs users, they report that being seen while consuming can cause cohabitation issues. In squat houses, similar situations take place, mainly when common spaces are not respected or consumption is carried out without observing any safety and hygiene measures. In drug-dealing floors, places where individuals stay for a short time, the biggest problem is when there are quarrels among users and dealers, or when police raids with multiple detentions occur.

Self-care strategies in homes

When decision is made to use drugs in a home, even knowing that there is a risk of suffering a heroin overdose or an adverse reaction to cocaine, all the participants describe a number of protection measures similar to the ones taken when consumption occurs on the streets. In general, they try to buy hygienic consumption material before getting or consuming drugs, and their space is organized with certain hygiene measures (having containers for disposing used needles disposal). To be on the safe side, they take drugs with the company of trusty people and they take mobile phones to be able to contact emergency services in case of an overdose. As for users living in private flats and squat houses, they try to use drugs during hours with no relatives and mates around that can reproach them for these types of practices, thus avoiding being seen and generating cohabitation uneasiness.

Using drugs in drug consumption rooms

DCRs are spaces to take drugs in a hygienic and safe way under the supervision of professionals. Users who go to a DCR report that “using drugs in drug consumption rooms is safe,” while users who do not opt for these spaces report that consumption is “annoying.” In these cases, they take measures so that going to DCRs becomes an advantageous experience.

“Using drugs in a drug consumption room is safe”

DCR users are often abusers resorting to parenteral routes administration, whose physical looks are deteriorated and who find it difficult to accomplish consumption practices in a satisfactory way in other spaces. These users report that in a DCR an overdose risk is lower and, if suffering an overdose, there are professionals that will supervise and give you assistance to prevent fatal cases. They have hygienic material for free and professionals help to accomplish consumption practices with less harm (search for shooting zones, vein canalization, among others). Among users who resort to pulmonary drug administration, they affirm that in a DCR they can use drugs in a satisfactory and quiet way, while having specific material for this practice. In all cases, users report that in a DCR they have spaces to rest after consumption and it is possible to ask for sanitary, social, and legal aid. They consider that when consuming drugs in a quiet and safe space, you can get optimal conditions to be able to enjoy the desired effects.

“Using drugs in drug consumption rooms is annoying”

Users that do not opt for DCRs insist that attending these spaces is annoying due to various reasons. The main limitation has to do with DCR rules. For instance, in most DCRs there is a time limit for preparation and consumption (30 minutes for parenteral route administration and 45 for pulmonary route administration), and after the permitted time for consumption users are not allowed to take drugs again until a 30 minutes’ interval has elapsed. To many users these regulations discourage consumption in DCRs, preferring other places. Other users report that, sometimes, there are problems when it comes to interacting with the professionals, in terms of strict fulfillment of the rules or extreme supervision, which makes it impossible to enjoy consumption according to users’ expectations. Some users report that professionals are constantly reproaching them for practices and behaviors experienced under the effects of substances. Among cocaine users the most common argument is that, inside a DCR, the effects of this substance are experienced in a negative way, feeling uncomfortable with themselves and toward other users and professionals.

Furthermore, when going to a DCR, there is a risk of getting into trouble with other users in various situations, such as receiving harassments and requests for an invitation, having discrepancies in dose partition when the costs have been shared, as well as being in an environment with noise and altercations. Another reason for not going to DCRs has to do with police routine controls in neighborhoods near these facilities. Users report that these types of practices suppose an access barrier, for fear of being identified or arrested if they have a search warrant and arrest order.

Self-care strategies in drug consumption rooms

As a result of different “annoying” situations, users take a number of measures when going to a DCR. In order to avoid crowds and waiting times, users attend harm reduction centers that are less busy, with a few consumption posts (Table 1), where it is possible to take drugs more peacefully, without crowds and with easy-to-make appointments to use the DCR. In order to avoid misunderstandings in the purchase of substances or to avoid requests for invitations from other users, efforts are made to apply strategies to drive improper users away, such as never offering drugs, never lending money or never sharing the costs to buy substances with people that are unreliable.

As for negative experiences related to drug effects, mainly cocaine users, the aim is to preserve tranquility inside DCR spaces, to stay there the minimum amount of time to later move to quieter, larger spaces, with fewer stimuli than those inside the facility, to experience the effects of this substance more intensely.

DISCUSSION

Despite the implementation of programs and interventions for harm reduction, drug users still keep having risk practices with adverse consequences for health, suffering discrimination and stigmatization within the framework of prohibitionist policies. This article expands knowledge about practices and narratives of users that use drugs in public spaces, homes and DCRs, which reveals elements to promote community actions on harm reduction. Apart from delving into the adverse consequences of drug abuse in different “risk environments” and in self-care strategies that are adopted in each case, by adding the notion of “pleasure” we are given information about what attracts users to use certain harm reduction programs and what innovations can be made to give better responses to users’ health and social needs. Below, a discussion is presented about pleasures and harms in the different consumption spaces under review and, in each case, proposals are made for a most effective intervention.

In public spaces the presence of individuals with lifestyles characterized by severe consumption patterns, with serious health and social problems is detected.¹⁴14. Clua R. Estilos de vida de los usuarios de las salas de consumo higiénico de Barcelona. Health and Addictions, Salud y Drogas. 2018;18(2):79-89.^,1919. Llort Suárez A. «Dime dónde consumes y te diré…»: Antropología sobre el uso y abuso de cocaína. Perifèria, Revista de Recerca i Formació en Antropologia. 2018;23(1):56-83. Although it is considered a “risk environment,” users keep on searching for their wellbeing through everyday rituals of drug abuse. Following Duff,²²22. Duff C. The pleasure in context. International Journal of Drug Policy. 2008;19(5):384-392. doi: 10.1016/j.drugpo.2007.07.003.⁾ pleasures on the streets happen in situations in which it is possible to prepare and use drugs in an environment that proves attractive. To this end, users look for hidden places where they can act with freedom, without being supervised and/or controlled, and where they can feel the effects of substances more intensely. This setting shapes the experience of drug users, who carry out accepted practices among peers that look for quiet and untroubled consumption, which is not possible in other places.¹⁹19. Llort Suárez A. «Dime dónde consumes y te diré…»: Antropología sobre el uso y abuso de cocaína. Perifèria, Revista de Recerca i Formació en Antropologia. 2018;23(1):56-83. In that way, drug consumption in places without being reprimanded and where they can have an intense sensorial experience of drug effects is definitively praised by users. These are key aspects in order to optimize the design and the rules applied by DCRs or other harm reduction programs.¹⁴14. Clua R. Estilos de vida de los usuarios de las salas de consumo higiénico de Barcelona. Health and Addictions, Salud y Drogas. 2018;18(2):79-89.^,4141. Duncan T, Duff C, Sebar B, Lee J. ‘Enjoying the kick’: Locating pleasure within the drug consumption room. International Journal of Drug Policy. 2017;49:92-101. doi: 10.1016/j.drugpo.2017.07.005.

However, consumption in public spaces carries a high risk of transmission of blood borne diseases (HIV and hepatitis B virus and hepatitis C virus), and suffering an overdose or adverse reactions related to drug abuse. These places are far away from those attended by users of more visible drugs, who administer drugs through parenteral or pulmonary routes, considered to be stigmatizing practices, which are the “scapegoat” of those that opt for standard consumption practices, and who describe users that take drugs on the streets as troublesome and difficult to control.⁴²42. Martínez Oró DP. Sin pasarse de la raya. La normalización de los consumos de drogas. Barcelona: Bellaterra; 2015. Consequently, users take drugs in hidden and unhealthy places, where they accomplish risk practices and suffer health harms, as noted above.¹⁹19. Llort Suárez A. «Dime dónde consumes y te diré…»: Antropología sobre el uso y abuso de cocaína. Perifèria, Revista de Recerca i Formació en Antropologia. 2018;23(1):56-83. Therefore, it is necessary to strengthen and diversify needle-exchange programs to reduce reusing practices of used consumption material and to promote larger dissemination of preventive messages in connection with hygienic and safe consumption through workshops on overdose prevention and attention, as noted in previous publications.¹1. Bosque-Prous M, Brugal MT. Intervenciones de reducción de daños en usuarios de drogas: situación actual y recomendaciones. Gaceta Sanitaria. 2016;30(Supl 1):104-110. doi: 10.1016/j.gaceta.2016.04.020.^,1414. Clua R. Estilos de vida de los usuarios de las salas de consumo higiénico de Barcelona. Health and Addictions, Salud y Drogas. 2018;18(2):79-89.^,1515. Folch C, Casabona J, Brugal MT, Majó X, Meroño M, Espelt A, González V. Perfil de los usuarios de drogas por vía parenteral que mantienen conductas de riesgo relacionadas con la inyección en Cataluña. Gaceta Sanitaria. 2012;26(1):37-44.^,1919. Llort Suárez A. «Dime dónde consumes y te diré…»: Antropología sobre el uso y abuso de cocaína. Perifèria, Revista de Recerca i Formació en Antropologia. 2018;23(1):56-83.^,4343. Sarasa-Renedo A, Espelt A, Folch C, Vecino C, Majó X, Castellano Y, Casabona J, Brugal MT, Redan Study Group. Overdose prevention in injecting opioid users: the role of substance abuse treatment and training programs. Gaceta Sanitaria. 2014;28(2):146-54. doi: 10.1016/j.gaceta.2013.10.012. Furthermore, if important changes are not introduced in present-day drug policies, it will be necessary to take actions to reduce vulnerability among individuals that use drugs in public spaces. A fundamental change would be a political reform to clear the way toward decriminalization, as has been the case in Portugal since 2001, which may favor a more pragmatic and humanitarian intervention scheme regarding drug users.⁴⁴44. Domoslawski A. Drug policy in Portugal: The benefits of decriminalizing drug use. Warsaw: Open Society Foundations; 2011. An urgent need is police participation in the development of a propitious social environment for harm reduction, as recommended in other publications.¹⁷17. Rhodes T. The ‘risk’ environment: A framework for understanding and reducing drug related harm. International Journal of Drug Policy. 2002;13:85-94. doi: 10.1016/S0955-3959(02)00007-5.^,4545. Bardwell G, Strike C, Altenberg J, Barnaby L, Kerr T. Implementation contexts and the impact of policing on access to supervised consumption services in Toronto, Canada: a qualitative comparative analysis. Harm Reduct J. 2019;16(1):30.^,4646. Shaw A, Lazarus L, Pantalone T, LeBlanc S, Lin D, Stanley D, Chepesiuk C, Patel S, Tyndall M. Risk environments facing potential users of a supervised injection site in Ottawa, Canada. Harm Reduction Journal. 2015;12:49.

Homes are considered peaceful and intimate spaces, where it is possible to obtain pleasurable experiences. Users narrate various pleasures that vary according to lifestyles¹⁴14. Clua R. Estilos de vida de los usuarios de las salas de consumo higiénico de Barcelona. Health and Addictions, Salud y Drogas. 2018;18(2):79-89.⁾ and different types of homes available for consumption. More or less organized domestic consumption spaces are detected, where cautious and safe consumption is possible, such as family dwellings and some drug dealing floors where trusty users are allowed to take drugs. People with less severe consumption patterns and that have less serious physical and cognitive deterioration attend these places as opposed to users that attend DCRs, they take drugs in public spaces or less organized homes. They do not need supervision during consumption and they try to hide signs revealing their abuser profiles.¹⁴14. Clua R. Estilos de vida de los usuarios de las salas de consumo higiénico de Barcelona. Health and Addictions, Salud y Drogas. 2018;18(2):79-89.^,1919. Llort Suárez A. «Dime dónde consumes y te diré…»: Antropología sobre el uso y abuso de cocaína. Perifèria, Revista de Recerca i Formació en Antropologia. 2018;23(1):56-83.⁾ There, they experience the desired effects, with the possibility of consuming in peace, establishing good relationships among users. On drug floors managed by dealers, who are marginalized drug users, and in not much organized squat houses, many times with an abandoned aspect, users with more severe consumption patterns and with worse health and social conditions turn up as opposed to the previously described spaces. However, grotesque practices in these environments do not escape the logic of pleasure.⁴⁷47. Moore D. Erasing pleasure from public discourse on illicit drugs: On the creation and reproduction of an absence. International Journal of Drug Policy. 2008;19(5):353-358. doi: 10.1016/j.drugpo.2007.07.004. In these types of houses it is easy to buy drugs and it is possible to have collective experiences and to get more intense consumption effects, apart from avoiding insults in public spaces and adverse weather conditions. Furthermore, it is considered an alternative to DCRs, where they feel controlled and where pleasurable experiences are not guaranteed. In addition, they are not reluctant to take harm reduction measures either, by getting clean needles and containers to discard used material.

The greatest health problem related to drug consumption in homes has to do with opioid overdoses. As evidenced in a report on drug abuse in the city of Barcelona, 73% of overdose-related deaths happen in homes and 75% are due to heroin consumption, which shows a growing prevalence of these two substances,⁴⁸48. Brugal MT, Guitart AM, Espelt A, (eds.). Pla d’Acció sobre Drogues de Barcelona 2013-16. Barcelona: Agència de Salut Pública de Barcelona; 2013. although over the last years there has been a decrease in deaths related to opioid overdose, which coincides with a larger coverage of overdose prevention workshops among users.⁴⁹49. Espelt A, Major X, Parés-Badell O, Carvajal S, Gasulla L, Bosque-Prous M, Brugal, MT. Implementation of Systematic Programs of Overdose Training at Drug Treatment and Prevention Centres in Catalonia, 2008-2013. En: Dichtl A, Stöver H (eds.). Naloxon - Überlebenshilfe im Drogennotfall. Frankfurt: Fachhochschulverlag; 2015. p. 83-95. Therefore, in order to maintain and decrease fatal overdoses it is necessary to continue reinforcing these types of workshops.⁴³43. Sarasa-Renedo A, Espelt A, Folch C, Vecino C, Majó X, Castellano Y, Casabona J, Brugal MT, Redan Study Group. Overdose prevention in injecting opioid users: the role of substance abuse treatment and training programs. Gaceta Sanitaria. 2014;28(2):146-54. doi: 10.1016/j.gaceta.2013.10.012. Moreover, to increase coverage, interventions are recommended based on education among peers as well as the realization of workshops on safe and hygienic consumption in squat houses or other possible spaces, with access through users taken from harm reduction services,⁵⁰50. Holloway K, Hills R, May T. Fatal and non-fatal overdose among opiate users in South Wales: A qualitative study of peer responses. The International Journal on Drug Policy. 2018;56:56-63. doi: 10.1016/j.drugpo.2018.03.007.^,5151. Latkin CA, Gicquelais RE, Clyde C, Dayton L, Davey-Rothwell M, German D, Falade-Nwulia S, Saleem H, Fingerhood M, Tobin K. Stigma and drug use settings as correlates of self-reported, non-fatal overdose among people who use drugs in Baltimore, Maryland. International Journal of Drug Policy. 2019;68:86-92. doi: 10.1016/j.drugpo.2019.03.012. which should be able to act as health agents and to contribute greater credibility in preventive messages.

DCRs are attended by drug users with severe consumption patterns that present physical and cognitive deterioration, and that resort to harm reduction strategies for self-care ⁽²2. Folch C, Lorente N, Majó X, Parés-Badell O, Roca X, Brugal T, Roux P, Carrieri P, Colom J, Casabona J, REDAN study group. Drug consumption rooms in Catalonia: A comprehensive evaluation of social, health and harm reduction benefits. International Journal of Drug Policy. 2018;62:24-29. doi: 10.1016/j.drugpo.2018.09.008.^,1414. Clua R. Estilos de vida de los usuarios de las salas de consumo higiénico de Barcelona. Health and Addictions, Salud y Drogas. 2018;18(2):79-89.⁾ Users with stronger adhesion are those that respond positively to the objectives of these facilities, that conceive DCRs as spaces for hygienic and safe consumption, a place where they can meet their health and social needs, and avoid social dangers involved in consumption in public spaces and homes, like violence among users and police surveillance, as explained in other studies based on users’ experiences.⁴¹41. Duncan T, Duff C, Sebar B, Lee J. ‘Enjoying the kick’: Locating pleasure within the drug consumption room. International Journal of Drug Policy. 2017;49:92-101. doi: 10.1016/j.drugpo.2017.07.005.^,5252. Jozaghi E, Andresen MM. Should North America’s first and only supervised injection facility (InSite) be expanded in British Columbia, Canada? Harm Reduction Journal. 2013;10:1. doi: 10.1186/1477-7517-10-1.^,5353. Small W, Moore D, Shoveller J, Wood E, Kerr T. Perceptions of risk and safety within injection settings: Injection drug users’ reasons for attending a supervised injecting facility in Vancouver, Canada. Health, Risk & Society. 2012;14(4):307-24. doi: 10.1080/13698575.2012.680950. But the bond does not occur under the instinct of embracing the DCR’s objectives and pursuing drug abuse harm reduction. Users attend those DCRs where it is possible to obtain the desired consumption effects, offering a quiet and reassurance environment on the part of the professionals. In said situations, users express that they do not feel stigmatized, creating a strong bond and engagement with these facilities, as concluded in one study conducted in a DCR in Germany.⁴¹41. Duncan T, Duff C, Sebar B, Lee J. ‘Enjoying the kick’: Locating pleasure within the drug consumption room. International Journal of Drug Policy. 2017;49:92-101. doi: 10.1016/j.drugpo.2017.07.005. Therefore, in DCRs it is possible to use drugs in hygienic and safe conditions, and to experience pleasures that encourage to avoid risk environments, and these arguments are significant to continue protecting these facilities as spaces to reduce harms and to mitigate vulnerability among drug users.

On the contrary, users narrate negative experiences in DCRs where it is not possible to enjoy the effects of substances and they have difficulty feeling recognized or free, to name but a few aspects, which amount to access barriers in connection with these facilities. It is evidenced that a lot of users prefer to take drugs on the streets or other spaces to avoid waiting times, mainly in busy DCRs, as well as having to obey prevailing drug use rules, as detected in studies conducted in DCRs in Canada.⁴⁵45. Bardwell G, Strike C, Altenberg J, Barnaby L, Kerr T. Implementation contexts and the impact of policing on access to supervised consumption services in Toronto, Canada: a qualitative comparative analysis. Harm Reduct J. 2019;16(1):30.^,5252. Jozaghi E, Andresen MM. Should North America’s first and only supervised injection facility (InSite) be expanded in British Columbia, Canada? Harm Reduction Journal. 2013;10:1. doi: 10.1186/1477-7517-10-1.^,5353. Small W, Moore D, Shoveller J, Wood E, Kerr T. Perceptions of risk and safety within injection settings: Injection drug users’ reasons for attending a supervised injecting facility in Vancouver, Canada. Health, Risk & Society. 2012;14(4):307-24. doi: 10.1080/13698575.2012.680950. In order to improve this aspect, more flexible drug use rules in DCR are advisable, so decision making in consumption practices as well as the idiosyncrasies regarding the diversity of users are respected.⁸8. Clua R. Salas de consumo higiénico en España (2000-2013). Salud Colectiva. 2015;11(2):261-282. doi: 10.18294/sc.2015.688.^,1212. Anoro M, Ilundain E, Santisteban O. Barcelona’s Safer Injection Facility-EVA: A Harm Reduction Program Lacking Official Support. Journal of Drug Issues. 2003;33(3):689-711. doi: 10.1177/002204260303300309.^,1414. Clua R. Estilos de vida de los usuarios de las salas de consumo higiénico de Barcelona. Health and Addictions, Salud y Drogas. 2018;18(2):79-89.^,5353. Small W, Moore D, Shoveller J, Wood E, Kerr T. Perceptions of risk and safety within injection settings: Injection drug users’ reasons for attending a supervised injecting facility in Vancouver, Canada. Health, Risk & Society. 2012;14(4):307-24. doi: 10.1080/13698575.2012.680950. Another detected barrier is that DCRs are not sufficiently adapted for cocaine users, since many report that they are annoying places to have an enjoyable consumption experience and, as a consequence, they prefer to use drugs in public spaces or other places. This aspect shows the need to design DCRs for cocaine consumption with a wider perspective, functionality and free of elements that alter users’ perception, as recommended in previous research studies.²⁷27. Clua R. Atención de enfermería del síndrome posconsumo de cocaína en usuarios de las salas de consumo higiénico de Barcelona. IV Congreso Virtual Internacional de Enfermería en Salud Mental [Internet]. 2018;4 [citado 10 may 2019]. Disponible en: Disponible en: http://psiqu.com/1-8944
http://psiqu.com/1-8944... ^,5454. Delàs J, Priore AG, Pigem A, Aguas M. Síndrome posconsumo de cocaína inyectada a partir de las observaciones en una sala de consumo supervisada. Medicina Clínica. 2008;130(1):35. doi: 10.1157/13114543.^,5555. Roncero C, Martínez-Luna N, Daigre C, Grau-López L, Gonzalvo B, Pérez-Pazos J, Casas M. Psychotic symptoms of cocaine self-injectors in a harm reduction program. Substance Abuse. 2013;34(2):118-121. doi: 10.1080/08897077.2012.691446. In turn, in the city of Barcelona, there is only one space to administer drugs through pulmonary routes, which implies a limitation for those users that buy drugs in neighborhoods that do not have DCRs adapted to this type of consumption; therefore, it is advisable to open more spaces for pulmonary consumption, as recommended in previous works.⁸8. Clua R. Salas de consumo higiénico en España (2000-2013). Salud Colectiva. 2015;11(2):261-282. doi: 10.18294/sc.2015.688.^,5454. Delàs J, Priore AG, Pigem A, Aguas M. Síndrome posconsumo de cocaína inyectada a partir de las observaciones en una sala de consumo supervisada. Medicina Clínica. 2008;130(1):35. doi: 10.1157/13114543.^,5656. Delàs J, Adán E, Díaz O, Aguas M, Pons M, Fuertes R. Smoked cocaine in socially-depressed areas. Harm Reduction Journal. 2010;7:27. doi: 10.1186/1477-7517-7-27.

This study faced several limitations that should be considered. One of them was the impossibility of accomplishing observations in homes, from which data could have been collected to delve into drug users’ experiences in these spaces. This limitation was partially overcome by the realization of semi-structured interviews in which users were asked questions on this aspect. However, it is recommended to conduct ethnographic research studies on consumption in homes in order to reflect on the design of strategies for the approach of harm reduction programs in these spaces. Furthermore, some flaws were detected in the design and rules applied by DCRs, which are considered access barriers when it comes to these facilities, whose analysis was insufficient, thus investigation in oncoming works is required. Despite these slants, this research has clarified the necessary elements for orientating policies of risk and harm reduction regarding drug consumption.

In conclusion, the comparison of practices and narratives of users that take drugs in public spaces, homes and DCRs provides information about pleasures and harms that they experience and about self-care strategies that they use in different consumption spaces. By focusing on the harms suffered by users and how they self-regulate their consumption practices in the different “risk environments,” we were able to learn about the impact of harm reduction programs and to reflect about how to strengthen promotional health strategies. But, by adding the notion of “pleasure” we have delved into positive consumption experiences in different places and what attracts drug users to rely on certain harm reduction programs. These aspects should be taken into account to design plans and to promote innovative community actions at a micro level to deal with harm and risk reduction that should be better tailored to users’ health and social needs.

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