1. Social acceptance in a secure environment|
1.1 Non-judgemental approach in the DCRs
1.2 How staff forge relationships and trust in a hectic environment
1.3 Challenges in the DCRs—seeking normality in a hectic environment
2. Survival, health and well-being of DCR clients|
2.1 Prevention of overdoses
2.2 Physical health: hygiene, wound care and injection technique
2.3 Mental health: providing care and protection
3. Building bridges between DCRs and other sectors|
3.1 Drug treatment and the social sector
3.2 Referrals to the healthcare sector
Theme 1: social acceptance in a secure environment
In this section, we explore the manner by which members of the staff try to cultivate an environment of social acceptance inside the DCRs and how staff members forge relationships with DCR clients. We then examine the challenges experienced by both staff and clients in the interpretation and upholding of house rules.
Non-judgemental approach in the DCRs
DCRs constitute low-threshold harm reduction facilities. Their mission is not to rehabilitate their clients but rather to reduce potential harm, especially that which is caused by incorrect drug use and injection techniques. To fulfil this end, DCRs must ensure that DCR clients utilize the facilities appropriately and follow basic rules and guidelines. The DCR clients interviewed at all five participating DCRs unanimously reported that they felt safe and were treated respectfully in these facilities. For example, one DCR client stated, ‘it is a really nice place where I feel welcome’. The majority of DCR clients with whom we spoke expressed satisfaction with the DCRs. They stated that the DCRs provide a safe environment for injecting and smoking. DCR clients experienced the members of staff to be welcoming, and the clients felt encouraged to engage in conversation with staff about their life circumstances and their general well-being.
It feels like a ‘safe haven’ to come here … because I know that they have an agreement with the police not to hassle us. Because normally the police chase after us, so we aren’t safe anywhere. We didn’t choose to live like this; we are forced to do things, so it is nice to have a place that serves as a safe haven, a place where nice people welcome me and where they know me, and they know what is going on (DCR client, age 44).
The staff in DCRs tried to enable clients to maintain a degree of human dignity as well as enjoy a measure of safety. There are ‘safe zones’ around the DCRs, where local police do not confiscate the illicitly obtained drugs [28, 38]. As described above by the DCR client in the interview, the DCRs function as ‘safe havens’, provide clients with safety from theft from other clients and protect them from being pursued or hassled by the police.
DCRs endeavoured to safeguard the DCR clients’ sense of dignity and self-worth insofar as clients experienced acceptance and recognition by staff members. One client said: ‘They (staff) talk to us at eyelevel. You do not have to be embarrassed that you are a drug user here’.
When interviewed about the importance of DCRs, the members of staff agreed with this description. They explained how the introduction of these facilities has improved the well-being of the clients, creating a sense of dignity and preventing unnecessary deaths due to ODs. As one of the nurses said,
But there’s no doubt that for the drug users this is a really, really good step in the right direction. Before they used to shoot up outside in the cold, in staircases, or in playgrounds using water from puddles. They shared syringes and they lived miserable lives. For many years they have been crying out: ‘Give us a place now. Maybe I cannot help using drugs but give me a decent life and some dignity’…. It has been horrible for them. So I think that it means a lot to get off the streets, and to not be looked down on by other people. I believe that safety is very important. Many of them have overdosed or have seen their friends overdose. Many have lost friends in the drug scene. So in that sense I think it means the world to them (Staff member, RN, age 32)
As the nurse stated, DCR clients have felt exposed when injecting in public which might have led to feelings of being outsiders and stigmatized by society [30, 31]. Several of the clients recalled how life used to be before the opening of DCRs, with stressful situations in basement stairwells or in public spaces, where they risked disturbing others and were often chased away. However, when asked where they consume drugs when DCRs are closed, DCR clients replied that they still make use of their homes or public spaces such as toilets, parks and hotels.
How staff forge relationships and trust in a hectic environment
According to members of the staff, establishing relationships and building trust with DCR clients is a responsibility that is central to the effectual operation of DCRs. The staff’s priority is thus to gain the trust of the clients; once this is achieved, the staff focus on encouraging clients to seek support and assistance beyond the DCRs. From a field note:
The staff told me (the researcher) afterwards about Max; they noted that he has exhibited very violent behaviour. It has taken them a long time to be able to talk with him in the way they are able to do now. He has spoken with the staff about his upbringing; he was at multiple foster homes, and was repeatedly exposed to violence and abuse (Field note 21.03.14).
Establishing trust with DCR clients can be challenging due to the typically brief periods of time that staff are able to spend with the clients. There was a continuous flow of clients entering and exiting the DCRs during the facilities’ busiest hours, which only allowed for very limited interactions with each individual. These time constraints posed a challenge because, as one nurse noted, establishing trust takes time:
First of all, it took more than a month before I was accepted, and after coming back from vacation they (DCR clients) realized that I was more than a temporary staff member, and they began to ask for me by my name. So you start to lend a hand or put your arm around someone’s shoulder and ask ‘How are you doing today?’ Or they watch you care for one of their friends, and they remember this. And gradually, the more I have helped, the easier it becomes to set limits, and they do as I tell them. And they realize that I am not always annoyed. So, really, you have to give, give and then you will be able to take a little bit (Staff member, RN, age 42)
Gaining acceptance and trust of DCR clients is thus a time-consuming endeavour. As remarked by the nurse in the quote above, members of the staff must be willing to give a great deal in order to establish relationships and to be able to make demands with clients, who as a consequence of a life with stigmatization and marginalization may feel inherently distrustful and guarded. To give and take in this quote emphasises the importance of reciprocity between the clients and the nurse, and this is necessary for developing relationships. To build relationships and engage in conversations seems to have better conditions in the smaller facilities as they are not as busy as the bigger DCRs.
Challenges in DCRs—seeking normality in a hectic environment
At times, both members of the staff and DCR clients experienced challenges. On the one hand, a number of clients criticized DCRs for being too noisy and conflict-ridden. In some cases, these factors deterred clients from utilizing the DCR, leading them to opt either for the mobile DCR or for the street. On the other hand, it is a balance to keep the DCRs as low-threshold facilities. Certain clients emphasised that the house rules ought to be respected and, if they are not, that the staff should impose sanctions on those failing to observe the rules. One female client said:
They often talk too loud and I think they could have a rule such as - if you shout, then you have to leave. Because many are here to consume coke and they want it to be quiet. And if they are shouting at one another then it kills the buzz. So I think if you can’t shut up, then you should leave (DCR client, female participant, age 48)
It was clearly challenging for members of staff to strike a balance between maintaining a safe and tranquil environment within the DCR, while at the same time reaching out to and restraining DCR clients who exhibited inflammatory and antagonistic behaviour. As one of the nurses put it:
I used to work in a psychiatric ward where there were rules, cleanliness and consistency. So, in my opinion, the rules here are a bit vague as to when individuals should be put under a temporary ban – some staff members are very tolerant while others are stricter. So this leaves room for disagreement, and it is confusing for the clients as well as for me as a staff member (Staff member, RN, age 42)
The nurse pointed out that the rules were difficult to administer as they were not clear and standardized thereby opening for potential conflicts. She requested that the rules were more standardized, which in her opinion would benefit the staff and clients alike. Several clients were in agreement. In one interview, a male client put it as follows:
We could use representatives - one for the smokers and one for the junkies. He could sort of say: “Hey, listen to the staff”, acting as a kind of authority figure (DCR client, male, age 60)
As the DCR client pointed out, a spokesperson could mediate between clients and staff and support the staff by encouraging that everyone respects the rules in order to make the room calm and safe for injecting or smoking. Some clients were very helpful and helped maintaining peace and tidying up after themselves and other clients.
Theme 2: survival, health and well-being of drug users
Preventing and treating overdoses is one of the most important aims of the DCRs. In this section, we start by exploring the informational and interventional strategies that members of staff employ to prevent ODs. We then focus on the general impact the DCRs have on promoting physical health, e.g. hygiene, wound care, injection techniques and mental health, e.g. providing care and protection.
Prevention of overdoses
The foremost goal of DCRs is to prevent ODs and deaths caused by ODs among DCR clients. During the course of our study, we observed that the DCR staff employ both informational and interventional strategies to achieve this goal.
Dissemination of information regarding the strength of drugs in circulation
The informational strategy of DCRs consists of staff members gathering current information from DCR clients about the strength of the drugs in circulation, and subsequently, if they are aware of potent drugs circulating on the market, they warn clients. We observed that the staff were attentive as to which drugs were in circulation at any given time, as well as to how potent they were. If the staff observed or were informed by clients that drugs on the street were strong, they cautioned other clients and suggested reducing doses by half in order to prevent overdoses. One client who was visiting the DCR for the first time was given such a warning. The nursing aide informed him that the heroin might be very potent, and she advised him to start with a half dose. He later conveyed to the aide that he had become very ‘hit’, and he stayed at the DCR for some time until he felt less intoxicated. Another client had a suggestion to ameliorate the DCRs:
I know from Holland that they have quality places where you can have your drugs tested. It would be nice to have such a place here where the quality and the strength could be checked (DCR client, male, age 44).
The observational studies showed that the interventional strategy focuses on the consistent observation of clients in the DCR, so as to be in a position to detect whether any individual appears to be at risk of an OD. In cases of high opioid consumption, the staff upgraded their monitoring of the individual, talking to him or her, inquiring as to how the client was feeling, and advising him or her not to consume further doses for the time being.
As one nurse explained:
We wait with the naloxone administration until they become unconscious and don’t breathe because we know that we can help them in that case. That’s why we let them sit and chill. Maybe we stimulate them, talk to them, shake them, pain stimulate so they wake up and remember to breathe. (Staff member, RN, age 52)
Another nurse elaborated on the interventions:
If they saturate under 90 %, we give them a little oxygen under the nose and make sure that they breathe. Maybe we support their head and chin to secure airways. And we let them chill as long as their vital signs are OK. It is not so dramatic. In that way we do not ruin their fix and the rest of the day (with Naloxone) (Staff member, RN, age 32).
In severe cases in which clients experienced respiratory problems or became unconscious, the antidote naloxone was administered as instructions prescribe neutralize the effects of the opioid taken . Naloxone was unpopular among some of the clients as it dulls the high, and clients may experience opioid withdrawal symptoms when they come down from the high. The DCR staff did not always readily administer naloxone as they were aware that the half-life of naloxone is shorter than that of opioids, which means that the effect of the opioid may return after the client has left the DCR, and the client could potentially be at risk of an overdose once out of reach of the facility.
Cocaine overdoses seemed to be more complex to handle as clients, who use cocaine, exhibited different behavioural symptoms. Some had stereotypical repetitive behaviours where they were looking for things or had psychotic symptoms, for example, experiencing sensations. The behaviours lasted from minutes to hours where the staff observed closely, carefully monitoring the clients’ blood pressure and pulse, eventually treating them with acetylsalicylic acid and nitro-glycerine spray when deemed appropriate .
Cultivating a sense of security and preventing overdoses
The presence of trained personnel, ready to intervene should something go wrong, provides DCR clients with a sense of safety and the opportunity to feel at ease. Many clients have experienced overdose situations prior to the opening of the DCRs, so they are aware of the importance of consuming drugs in safe environments. One DCR client emphasised why he prefers to inject in the DCR:
If I get something too strong and risk an overdose, it is a safe place. They will always be there to help. And the equipment is sterile, so I don’t risk contracting staphylococci or Hepatitis C (DCR client, male, age 44)
Being in secure surroundings is important for the DCR clients both in relation to survival of an overdose and the prevention of infections. Another client witnessed an episode in the DCR, in which an intoxicated client entered the facility. The client commented on the episode:
It was very unpleasant today… there were two near overdoses, and then he talked about taking more drugs. Then I opened my mouth and said that he shouldn’t have more drugs because then they will kill you. You are not going to die in there (DCR client, female, age 48).
Many of the DCR clients had experienced overdose situations and had lost friends before DCRs opened, so they are aware that it is imperative to consume drugs in a protected environment.
Physical health: hygiene, wound care and injection techniques
Staff members also focused on monitoring hygiene and risk practices related to the transmission of infections among DCR clients, as this could prevent complications and reduce the risk of severe disease. Whenever possible, the staff encouraged good hygiene and hand washing. They made these suggestions gently, in such a way so as not to dismay or unnerve users. Staff members, particularly healthcare professionals, monitored DCR clients in order to detect any signs of infection. They advised the clients to seek medical assistance, and in severe cases, they either referred the clients to nearby health clinics or, if necessary, to specialized treatment and surgery at hospitals. One nurse said:
For some it might be difficult to understand but in my opinion there’s so much nursing here. For example, today I rinsed the eye of someone who had some alcohol thrown into the eye. It can be mental nursing - conversations. Staying and talking, listening and accepting, and setting boundaries. A little wound care, injecting techniques. People sometimes cut themselves or somebody cut them. So there is so much nursing if you know what to look for (Staff member, RN, age 42)
Although wound care is normally not offered in DCRs, the nurse indicated that the help offered involves many different aspects of nursing. Our observations revealed that nurses were able to intervene in a variety of ways. They invited the DCR clients to visit the local clinic to have their wounds treated. On one occasion, the nurse failed to persuade the client to visit the local clinic, so she contrived a makeshift bandage on the spot, right on the street in public view outside the DCR. Some clients sought medical assistance from DCR staff because they trusted them more than other health professionals. In one instance, a client with a deep ulcer on her hand, which came as a result of injecting cocaine incorrectly, was asked whether she had received any help from the staff. Her response was as follows:
The doctor is going to have a look at my fifth finger. The staff told me that the doctor at the clinic nearby could look at it. They wanted me to go to the hospital, but I refused because then the city administration and my GP will know about it, and I don’t want them to know. And they (the staff) helped me to get antibiotics, so I had two kinds of AB, and the wound has now become half the size. (DCR client, female, age 48)
Our observations in the DCRs indicated that staff members were attentive to the hygiene of clients. The members of staff encouraged DCR clients to use new needles at each skin penetration, and fortunately, this resource was unlimited. However, some clients had developed unsafe and unhygienic habits during their active years of drug use, and they often found it difficult to locate veins. Safe injection techniques are important skills in a harm reduction framework. For this reason, all DCRs are equipped with a vein scanner to locate veins for safer injecting practice in order to find suitable intravenous access. The members of staff suggested other drug intake methods if the DCR client could not find veins, such as taking the drug orally or intramuscularly. Still, most clients prefer to inject intravenously, and their long-established habits are frequently difficult to change.
Mental health: providing care and protection
It is widely acknowledged that people who use drugs experience a variety of mental health issues in addition to their addiction, yet not all have been diagnosed, and many do not receive relevant treatment. The members of staff in DCRs often functioned as aides and witnessed DCR clients who seemed to have mental health conditions. The staff supported and cared for clients whether the clients’ hallucinations and paranoia were due to drugs or the drugs were taken to mitigate the symptoms of their conditions. The following excerpt illustrates how caretaking was carried out in one DCR:
A tiny woman is cuddled up on the floor in the corner panting and looking panicky around in the DCR. She wants the window closed although it is around 30 °C in the room, apparently afraid that something threatening might come through the window. Both nurses are near her. One of the nurses helps her up from the floor. Her forehead is beaded with sweat, and one of the nurses asks her: “Can I dry your face?” She asks: “Can I do it myself?” The nurse hands a paper tissue moistened with cold water. The woman crawls down on the floor again; she obviously feels safer there (Field note 23.05.14).
In this case, two nurses cared for the woman by reassuring her that she was safe and secure, while offering her practical help, assessing and safeguarding her from other clients in the room. They were caring towards her and offering her assistance within the scope of the DCR. In another instance, the members of staff referred a psychotic client to the psychiatric emergency room (PER). In this case, a female regular client became increasingly aggressive, shouting at and admonishing those around her; she provoked conflict, expressed frustration and felt sick, and eventually the staff were not able to take responsibility for her security and health within the DCR. The members of staff organized for her to visit the PER once she had injected her drug, since she had psychiatric problems in addition to her addiction. The staff’s previous experiences with the client enabled them to assess her condition and determine that a referral to the PER would best protect the woman; she agreed to go to the PER, but the psychosis subsided and, within a few hours, she was discharged from the PER and returned to the DCR. This is one case of many, during the course of this study, in which the staff tried to provide assistance for mental health problems.
Theme 3: building bridges between DCRs and other sectors
DCRs are expected to build bridges to other health institutions . DCR members of staff are in daily contact with DCR clients and are thereby in a position to both motivate and assist clients, e.g. seek treatment for somatic or psychiatric conditions or to take steps towards commencing drug treatment. Despite the fact that clients visit DCRs anonymously, the staff often managed to successfully establish relationships with clients and to acquire information regarding, e.g. how to motivate particular clients to seek treatment, the clients’ housing situations and their social conditions. In our study, we observed and spoke with DCR clients and staff about forging links to drug treatment centres, the social sector and the health sector.
Drug treatment and the social sector
DCRs are low-threshold facilities, and providing referrals to drug treatment is not the primary mission of the staff. Many of DCR clients in our sample were in opioid substitution therapy, either with methadone, heroin or subutex, and the drugs taken in the DCRs might be considered extraneous abuse. However, we observed that staff attempted to assist those clients who were motivated to undergo drug treatment by contacting treatment centres or by connecting these clients with social workers on outreach who could initiate treatment on the spot if the individual was so inclined. The members of staff reported that social workers were able to provide contact with acute treatment facilities. The main ways in which members of staff encourage clients to seek treatment was through regular conversations, continuous encouragement and nudges.
We were talking about Tai (a female DCR client). I hope that we (the DCR staff) have helped to push her in the right direction, although she wasn’t hospitalized through us … But I hope that we have planted some small seeds here. Sometimes we are the ones that believe in them, and say: “Well, you can do it, you can easily do it. If you don’t succeed this time, then next time.”- and we are here if they relapse (Staff member, nursing aide, age 28).
This nursing aide described the approach through which members of staff try to nudge clients whenever the opportunity arises, in order to motivate and encourage them to commence treatment programmes. She used the analogy of planting seeds when discussing the motivational conversations that took place. It was clearly of concern to the members of staff that they instil in DCR clients a sense of the importance of treating addiction and also that, if the clients relapsed, this was not regarded as a failure, and the members of staff would be there to pick up where they left off and would continue helping.
When asked whether a dialogue may push a client towards treatment, one nurse answered:
Yes, certainly. One thing is that when they are sitting around talking, they share many different personal problems. But otherwise, as nurses we try to guide the conversation in the right direction, or we focus on the possibilities instead of the limitations, and we look at their strengths rather than their weaknesses. And if they have an idea that seems to be very, very good for them, then we try to stick to it and find out whether we can help them further. For example, if they want to enter into treatment or care or whatever they want, we try in every possible way to refer them, or we contact the social workers or whoever can help them in the given situation (Staff member, RN, age 32)
This excerpt shows that the tasks of the staff in DCRs are multi-faceted: pulling the right strings, pushing in the right direction and expressing a positive attitude towards the clients. Some DCR clients had complex problems to deal with, and as some DCRs had social workers on staff, they were able to help clients with socioeconomic problems such as bills, pension and housing. In some cases, social workers did outreach in the DCRs or members of staff referred clients to social workers at nearby health clinics or to public defenders.
Referrals to the healthcare sector
People who use drugs often contract skin infections due to unhygienic and incorrect injection techniques. To manage wounds, infections and so on, the staff referred DCR clients to health clinics. However, some clients neglected their own health and postponed treatment, where other clients showed more motivation by attending the DCRs in order to protect their health.
One nurse, for instance, pointed out that sometimes DCR clients were not interested in or too busy to seek treatment. She noted that it would be beneficial if staff were authorized to treat wounds on the spot in the DCRs, because at times, they noticed clients ignoring large wounds and other chronic conditions. Staff also referred clients to their general practitioners, but it is uncertain to what extent DCR clients followed up on these referrals. One of the nurses described the dilemma: ‘I have many good relationships but it is not possible to find out if the bridge building was successful. Because when the client leaves I can’t pursue him (Staff member, social educator, age 42).
Because making appointments is not necessary in order to receive medical attention at health clinics, they are easier for clients to frequent, and they function as outreach centres for the most vulnerable. Most referrals made in DCRs were to health clinics in proximity of the facility, but sometimes referrals to emergency rooms were necessary.