After decades of advocacy by civil society, the government finally approved the opening of the first drug consumption room in Slovenia. On this occasion we interviewed Katja Krajnc from the NGO Stigma, a leading harm reduction organisation in the country.
Drugreporter: Can you talk a bit about your own background? How and why did you choose to work in the field of harm reduction? What work do you do for the organisation?
Katja Krajnc: I think that in choosing this field, the work, in a way, chose me. Even when I was a student and occasionally passed by the drop-in centre of the NGO Stigma, I often envisioned working for this organisation. After completing my studies, I had the opportunity to be employed by the association, and I have stayed here ever since. In my opinion, working in the field of harm reduction is not for everyone. Anyone who takes a job in harm reduction must start from the belief that drug use is a matter of personal choice and a human right to bodily integrity. It is necessary to be aware, without moral judgments and a patronising attitude, that there are people who, for various reasons, cannot or do not want to stop taking drugs.
The NGO Stigma is one of the leading harm reduction organisations in Slovenia. What is the story of Stigma? When and why was it established?
That’s right. The Harm Reduction Association Stigma is the first organisation that began operating in the field of harm reduction in Slovenia. The NGO was founded in 1990, and through its collaboration in the project ‘Preventing AIDS through the organization of aid and self-help for drug users,’ we established a framework for harm reduction in Slovenia. During this period, drug use increased, reflected in a higher number of overdose deaths and more frequent responses to drug issues in the media. Initiatives by drug users began to emerge as a reaction to repressive policies and moralistic treatment. With these initiatives, they sought to assert the right to health care, soon followed by the right to protection against infectious diseases, and, ultimately, destigmatisation of their social role. Stigma was formed as a collaboration project between drug users and professionals, with the aim of reaching out to those drug users who were labelled as “hard to reach”.
The choice of the name Stigma is aimed at drawing attention to the problems of the marginalisation and exclusion of a population, which, due to its hidden nature and life on the social fringes, is even more exposed to risks and dangers resulting from drug use.
What kind of services do you provide to people who use drugs?
Our NGO has two drop-in centres where needle exchange takes place, which is the basic measure and starting point for all other harm reduction approaches. Unhindered access to sterile equipment is a preventive measure and at the same time provides access to the largest number of intravenous drug users. The program provides free sterile equipment such as insulin syringes, various needles and syringes, cookers or spoons with filters, condoms, needle disposal containers, and informational materials.
Returning used needles is part of the needle exchange program, but returning a used needle is not a condition for issuing a sterile one. In the drop-in centre, we also provide counselling and practical assistance. Counselling is initiated by users who have contacted us personally, by phone, or online, within the framework of the drop-in centre program or mobile needle exchange through outreach. We assist people who use drugs access various services, such as opioid agonist treatment, and support them to find housing and jobs.
In addition, we have an outreach program to contact drug users in the initial phase of their drug use and try to reduce the harm that drug use could cause them. Our outreach workers step out of offices and counselling rooms to meet drug users in their environment, providing them with sterile injection equipment, necessary information, and incentives to follow safety instructions in drug use. If a need for more targeted treatment arises during a conversation, the person is invited to visit the drop-in centre, where we continue to address their situation.
Do you provide any special services for women who use drugs?
We have a safe house for women drug users who are victims of violence, located at a secret location in Ljubljana. The program is intended for female users of illicit drugs experiencing violence. We accept users from all over Slovenia. We are the only such social welfare program in the country. The house can accommodate up to 8 women simultaneously, with the possibility of accommodating one more person in a crisis.
Our employees provide counselling and information by clearly identifying the problem, exploring possible solutions, and finding resources to resolve the situation. Users can stay in the safe house for up to 18 months, with the possibility of extension due to special circumstances. The program is implemented 24 hours a day at a secret location. The key importance of the program is to provide a safe space for women who use illicit drugs and are victims of violence.
Within the program, we also conduct individual and group counselling and accompany women to the Ig Prison sentence-serving institution. Through individual work, we create conditions in which women regain a sense of security and trust in people. The first contact is crucial when working with female users of illicit drugs, and this contact is established in the field, in the drop-in centre, or through counselling in the prison. The more complex the situation, the longer the path a woman must leave behind, and the longer the process of stabilising positive changes. With placement in the safe house, women are no longer physically threatened and are less exhausted.
What happens with them after they leave the safe house?
When women complete the safe house program, the housing problem mostly remains unresolved. We identified the need for long-term accommodation in the form of supportive housing, as users lack financial resources and a social network that would enable complete independence. Therefore, we upgraded the program with supportive apartments for more stable users. We started the supportive housing program in July 2016. This way, we can provide the necessary help, as well as comprehensive and individual assistance in overcoming specific social issues. The goal of the program upgrade is to enable women take more responsibility for their health, affairs, and lives in general. The long-term goal is stability, independence, and social inclusion.
The drug market is changing and diversifying in Europe. How do you see the trends of drug use in Slovenia, and what do you experience among your clients?
At the association, we mainly work with users of opioids and cocaine, so we do not have a comprehensive overview of drug use in Slovenia. However, according to data from the National Institute of Public Health (NIJZ) Annual Report for 2022, the most popular illicit drugs in Slovenia are cannabis, cocaine, MDMA and amphetamine. According to the European Web Survey on Drug Use, 13% of adults reported using New Psychoactive Substances in the last 12 months.
Based on daily records since the beginning of the COVID epidemic, we have observed an increase in the number of illicit drug users both at the drop-in center and in the field. We assume there are several reasons for this. Firstly, in our opinion, the number of illicit drug users is increasing due to growing personal distress. Drug use can be unequivocally linked to social isolation, deterioration of physical and mental health, and loneliness, as drugs promise pleasure, enjoyment, a sense of well-being, euphoria, pain relief, and more.
Secondly, it can be concluded that there is an increase because Ljubljana has the most social welfare programs and services for users coming from smaller towns or rural areas, where drug users are more visible and consequently more stigmatized. I would also mention that the number of drug users is increasing due to the growing accessibility to drugs. Paradoxically, the current legislation on illicit drugs allows drugs to be more accessible to new drug users than decriminalisation would enable.
Slovenia is considered a country with a progressive drug policy, compared to most other countries in the region. As a professional who often attends international conferences, how do you feel? Are you more aligned to the Eastern or Western part of Europe in terms of drug policies?
Regarding drug policy, I can argue that we are closer to the West, although there is still a need for numerous improvements in Slovenia. In my opinion, drug policy still predominantly operates towards zero tolerance for drugs, and the field of harm reduction is under-resourced both financially and staff-wise. As a participant in international conferences, I notice that Slovenia lacks many programs considered effective and essential abroad, which respond to the specific needs of illicit drug users.
In Slovenia, we have adopted the fourth National Program on Illicit Drugs for the period 2023-2030, aiming to implement the stated vision that by 2050, programs will be established and upgraded to improve the health and social well-being of people, creating conditions for a health-friendly, dignified, inclusive, peaceful, and safe life for all residents of the Republic of Slovenia. The National Program is directed towards the development and strengthening of psychosocial treatment programs for drug users, therapeutic communities, and comprehensive recovery programs.
Of particular importance is reducing social exclusion among drug users and giving appropriate attention to particularly vulnerable groups, such as women drug users. The planned upgrade includes programs for drug users in prisons, continuation of measures, and support for programs aimed at reducing HIV and hepatitis B and C infections, as well as reducing the number of deaths from overdoses. State activities are also strengthened in the fight against organised crime, illicit drug trade, and other related forms of crime.
The struggle for drug consumption rooms (DCR) seems to be a never-ending story in Slovenia – as far as I know, the first idea to open one was presented in the 90s, almost 30 years ago. In 2015 we expected that the first DCR would be opened in a year, but it has never happened. Can you explain why it takes so long? What are the main barriers?
In 2013, the Governmental Commission for Drugs adopted a document, prepared by the National Institute for Public Health in cooperation with NGOs. This document determined theoretical and practical aspects of opening DCRs in Slovenia. After almost two-decades-long advocacy efforts and legal background setting, in 2015, the local NGO Stigma initiated the drug consumption room (DCR) pilot project in Ljubljana, funded for 18 months by the Ministry of Health.
Unfortunately, the opening never happened. Due to lack of financial resources, we decided to shorten the project’s duration to six months and hire only one medical staff. In February 2016, one month before the opening, the Ministry of health who granted the pilot in the first place, requested us to get the project checked at the National Medical Ethics Committee. The Committee received our project proposal the same month, but then needed two years to decide whether to approve or refuse the project, which would be ending in November 2016. In its decision, the Committee refused to issue an ethical permission, arguing that staff members of the DCR would “indirectly cooperate” in illegal activities.
In 2023, the Ministry of Health finally approved the opening of a supervised consumption room for two organizations – Stigma and Šent Nova Gorica. The NGO Šent Nova Gorica will open a supervised consumption room for sniffing, smoking, and injecting. At the Stigma association, initially, we plan to facilitate sniffing in the drop-in centre. As for the opening of a supervised consumption room where users can also smoke and sniff, we would need new facilities.
So now we hope the first DCRs will open in 2024 in Nova Gorica. Can you talk about this program, how it will work, what groups of drug users they would like to reach?
In the DCR operated by the NGO Šent in Nova Gorica, the operation of the supervised consumption room program is planned to be integrated with the existing drop-in centre for users of illegal drugs. The space, where the centre operates and which is owned by the Municipality of Nova Gorica, is a standalone facility – a residential container consisting of interconnected modules. The Šent association has been using this space since 2006 for the drop-in centre. Over the years, it has proven suitable for providing harm reduction services due to its location on the outskirts of Nova Gorica, making it unobtrusive for residents. The city centre is 500 meters away, ensuring proximity for those in need.
The supervised consumption room program will follow international guidelines for such facilities. The facility will include a main area for drug use and rooms for individual counselling with users. The space for drug use will be divided into two: one for intravenous drug use and the other for users who prefer oral or nasal administration. The two areas will be separate, and the supervised consumption room will be used by one user at a time, with a session lasting between 20 to 60 minutes. Specific individual needs, such as difficulties with collapsed veins, will be taken into account, allowing for longer injection times. Each user will have access to sterile equipment for nasal, oral, and intravenous drug use, as well as other necessary accessories provided free of charge by the program.
Before using the supervised consumption room, the user, under the guidance of staff, must ensure personal hygiene. After use, the user will be required to clean the workspace, with cleaning supplies and a disposal area for infectious waste provided. The cleanliness and adequacy of the work areas must be monitored throughout the use, and staff should provide assistance when needed. The program will employ two professional staff members, a qualified healthcare professional, and a social care professional.
What about the other DCR in Ljubljana?
In Ljubljana, discussions regarding the opening of a supervised consumption room are still ongoing, and the issue of finding a suitable space for the program needs to be resolved. The initial plan is to facilitate a safe space for sniffing only. Additionally, the employment of a registered nurse to work in the safe space for sniffing is foreseen. Simultaneously, discussions will take place with relevant ministries and the municipality to expand the program to include smoking and injecting. Despite challenges, the organisations remain optimistic.
Slovenia also has a drug checking service (DCS). Can you talk more about this? How widely accessible and available is it?
Drug checking in Slovenia originates from the drug-related death of young girl at a festival in city of Celje in 2001. The ecstasy pill which was suspected to have contributed to fatal health complications, was provided to DrogArt by drug users, and with collaboration of national forensic laboratory (NFL). It was the first drug not connected to police seizures to be analysed.
In 2006, DrogArt joined the national focal point for the Early Warning System, contributing data from outreach work to the system and warning users about the emergence of dangerous substances in the Slovenian drug market. Over the next 10 years, there was slow development, with the introduction of a basic drug-checking method involving colour reagents and, with suspicious reactions or effects, laboratory testing with only qualitative analysis in collaboration with the NFL was provided to users. Users would drop off the sample in DrogArt’s info point, where brief counselling was provided. After the info point was closed, a police officer would make an anonymous seizure and take a sample to the NFL. The results were sent back to DrogArt, up to two months. The excessive time lag, coupled with the fear of loss, was the principal reason discouraging users from using the service.
Is drug checking accessible in all parts of the country?
In 2016, DrogArt participated in the I-SEE project, where new NGO info points became available across Slovenia for users to drop their drug samples, thus increasing the availability of DCS. With further DrogArt advocacy for DCS in Slovenia, and with support from the Ministry of health, additional funds were made available, enabling collaboration with the National Laboratory of Health, Environment and Food (NLZOH). This is coupled with the employment of professional chemist since the beginning of 2018. PWUDs in Slovenia can now submit their drug samples to one of nine collection points across the country, and receive qualitative and quantitative results in 3-10 days, depending on the day of sample submission, anonymously and free of charge. NLZOH use the most accurate methods (e.g., HPLC-DAD, GC-MS, FTIR) for drug checking, ensuring highly reliable results. With admission of sample, users receive tailored harm reduction advice or counselling and the same happens when the results are provided. Results can be communicated through e-mail, telephone, or in person at the location where sample was submitted.
Mental health of harm reduction staff is an issue in many countries. What is it that keeps you motivated to work with people who use drugs? How do you prevent burning out?
Working in the field of harm reduction undoubtedly presents a challenge for maintaining the mental health of employees. I believe that too little attention is given to preserving the mental health of employees. In my opinion, free psychosocial or psychotherapeutic support should be provided. The possibility of using psychotherapy should be systematically arranged for all employees in such organisations, financed by the relevant ministries. As part of our employment, we have monthly supervision, but I believe that is not sufficient. For all other forms of assistance, employees participate at their own expense and initiative. Some of us also have one or more hobbies to try to alleviate our own stress and overwhelm. It is crucial that the employees understand and support each other well and supports.
Thank you very much for the interview!