Thirteen family members living in a range of locations across Scotland were interviewed. While familial relationships included partners, siblings, and cousins, the majority were mothers, and 11 out of 13 interviewees were women. Data are presented in relation to four thematic categories: 1) awareness and knowledge of DCRs among family members; 2) facilitating use or gateways to recovery?; 3) missed opportunities and managing fear; and 4) stigma and DCRs as a paradigm shift.
Theme one: awareness and knowledge of DCRs among family members
Interviewees had varying levels of background knowledge about DCRs. A small number of participants (n = 3) were actively involved in campaigning for drug law reform and considered DCRs to be an essential service capable of reducing DRDs, as this participant highlights:
‘I would say quite aware, like more aware probably than the general member of the public because I’ve been campaigning for over ten years for drug law reform. So I’m not an expert but I’m someone who has you know looked into all of these things because of what happened to my [family member name]’ (Participant 1, woman, cousin, West Scotland).
Those participants who had a good level of background knowledge tended to be strong advocates for DCRs. Several other participants had become aware of DCRs because of their own family member’s experiences which motivated them to find out more:
‘I pay a lot of attention to drug policy in Scotland because of the way it impacts on my own and my son’s experience’ (Participant 3, woman, mother, North Scotland).
However, others were much less aware of DCRs and had very minimal background knowledge. In such instances, the researchers gave a brief outline of what a DCR is, and what it seeks to do. This, and the information provided on the participant information sheet, meant that knowledge became developed and/or worked through as a consequence of the interviews. Those who had limited detailed knowledge of DCRs were still relatively aware of media debates surrounding DCRs. Much of this awareness related to media coverage of the unsanctioned van that was operating in Glasgow at the time of the interviews:
‘On the news, ken [you know], as I’m saying, that them getting stopped by the police and I think there is one guy in particular that is doing it in [Glasgow] on a bus’ (Participant 2, woman, mother, East Scotland).
Some of those who were strongly in support of DCRs told us that they had not always felt this way:
‘I know my son and I know what he has struggled with and I know what he is still struggling with and I know that essentially he is a very good person. Who actually needs help. So any kind of attitude I may have had in the past about setting up DCRs has drastically changed because of my lived experience’ (Participant 13, woman, mother, location unknown).
Many family members could pinpoint moments or events where they had become supportive of DCRs. Several told us that listening to people with lived experiences similar to their loved one had contributed to a shift in perspective. Often this initiated a journey of learning in which they engaged with the issue in more depth through reading and wider research:
‘It was, as soon as I started educating myself, it was like a lightbulb moment, and the DCR, the idea of a DCR was just one you know of many things that I thought “Oh my golly, I can’t believe we don’t do this as a humane society” […] But it was just, it was literally just through reading about it and thinking… immediately thinking “why on earth are we not doing this?”’ (Participant 1, woman, cousin, West Scotland).
Several had engaged with international research evidence on drug policy, not only on DCRs but related to wider reforms:
‘I’ve just been reading and then sort of other countries were trying things, you know, so Canada and Portugal were looking at radically supporting users of needle-based drugs you know, to try and reduce the harm to them. I was like “Wow that’s amazing, that’s really interesting. Yes, why would we not want to keep everybody safe?”’ (Participant 8, woman, sibling, North Scotland).
As the preceding quotations highlight, exposure to (unidentified) sources that presented positive outcomes from DCRs encouraged some family members to become strong advocates for implementation. Participants did not discuss some of the gaps and uncertainties that characterise the scientific literature on DCRs, and which have been represented in some popular news-media reporting in the UK (see Atkinson et al., 2019), suggesting that reading may have been limited to a few sources or to confirm prior beliefs. For others, listening to personal narratives was the primary motivation towards active support. In summary, within our sample there was a breadth of understanding of the role and function of DCRs. Listening to the narratives of those with first-hand experience of DCRs was particularly influential in shaping views towards them.
Theme two: Facilitating use or gateways to recovery?
While prior research has not found evidence that DCRs encourage drug use, a small number of respondents expressed concerns that this might be a risk with regard to their loved ones . This point connects with some of the concerns expressed by family members protesting in San Francisco mentioned earlier in this paper:
‘I mean, one part of me says yes, I possibly would have encouraged her to do it, but also I may not have because I’m just enabling her to take drugs’ (Participant 10, woman, mother, East Scotland).
Family members who reported concern about DCRs ‘enabling’ drug use were still supportive of implementation:
‘[…] almost all of us who are parents have engaged in enabling behaviour you know? Because we love our children, and nobody wants to see their child harming themselves even if they are an adult, so we have had to change our ways too and there is a whole education that needs to happen […] So family members need to be included in the DCR [debate], even if it’s just educating us about what it is, and what it means, and all of that is really important’ (Participant 6, woman, mother, East Scotland).
Several participants said that they believed that their loved ones had to reach ‘rock bottom’ before they would change. This term often relates to recovery concepts within the 12-step programme. While considered outdated by many critics within addiction research (e.g. ), the concept clearly had valence for a number of participants and framed their understanding of the role of DCRs in regard to experiences of addiction:
‘[…] one hears phrases such as reaching rock bottom before the person chooses to change, needs to reach the bottom. Needs to suffer so much pain to put their hands up and say “Oh please help”’ (Participant 9, man, relationship undisclosed, East Scotland).
Our data highlighted an underlying tension between harm reduction and abstinence-based recovery concepts which linked to this notion of ‘rock bottom’. These concerns were more prevalent among the participants who had low, or no, prior knowledge of DCRs. Most participants described DCRs as essential harm reduction, with many suggesting that, by the time a person required a DCR, they were likely to already be in a very difficult situation, akin to ‘rock bottom’:
‘I mean DCRs are really, equally as important, because once someone gets to using needles, they are seriously, you know, caught in the addiction. You know, they have reached the almost pinnacle of their addiction when they are willing to do that. Because injecting is not fun for anybody. Once someone has got to the point where they are willing to do that, they are really hooked and seriously need help’ (Participant 6, woman, mother, East Scotland).
As participant 6 outlines above, DCRs were also represented as a challenge to simplistic notions that ‘rock bottom’ was a singular and transformative event. Advocates for DCRs note that they help prevent the kind of catastrophic experiences that may be more likely to result in death than sudden transformation, though some participants saw DCRs as mitigating, rather than removing, those risks.
‘There is all different levels of rock bottom and I don’t think […] certainly someone coming into a safe consumption room is going to stop them reaching rock bottom, why are they there in the first place?’ (Participant 11, man, sibling, Central Scotland).
All family members believed that DCRs could provide a potential gateway to future recovery, although how this was conceptualised differed across the sample. For some this gateway involved creating an environment where people could inject more safely, while gradually establishing trusting relationships with non-judgemental staff. These family members believed that trusting relationships, in a predictable, stable environment, could help individuals move towards decisions to reduce drug use or seek further support:
‘If you go to a drug consumption room you are going to get suggestions and advice on where to seek treatment locally to where you live, to access the services, find out about actual recovery. Because there is (sic) thousands and thousands of drug users don’t realise that they can recover. And […] if you have never touched in with the services, or been part of anything, how would you know that you could recover?’ (Participant 4, woman, mother, East Scotland).
‘[…a DCR] lends itself to people being given just a bit of space to say “Actually I would want to do something different here….”. I think it’s the gap between what we say and what we do at a deeply compassionate level. It’s easier to blame and shame and stigmatise people, and see them as less than human, rather than see them as your son, daughter, niece, nephew, uncle, or whatever’ (Participant 3, woman, mother, North Scotland).
Although some participants saw DCRs as a gateway to recovery, the above quotations illustrate that others saw DCRs primarily as a type of enhanced harm reduction. Ultimately, whether framed in terms of ‘rock bottom’, or as an opportunity to encourage incremental change, family members who supported DCRs viewed them as a source of hope that, under their difficult circumstances, should be available as an option:
‘Hope, just absolute and utter hope, when he […] is living with you or she is living with you and she wakes up and she’s shaking and she is dreadful, you can say “Do you want me to take you, do you want me to take you to the consumption rooms […]?” So hope, that’s all you are left with in the end you know. Hope one day that they say, “I don’t want to live like this anymore”’ (Participant 7, woman, mother, North Scotland).
In summary, while some family members had concerns that DCRs might sustain drug use, they remained supportive. Some family members felt that DCRs could help facilitate future (abstinent) recovery, whereas others saw DCRs as a harm reduction intervention. Across the sample, the important role of DCRs in promoting safety was recognised.
Theme three: missed opportunities and managing fear
Many participants expressed the view that DCRs could address some of the current gaps in the service system in Scotland. The first gap identified was a general lack of attractive services for people who inject drugs; ones that they believed would accept them and help them on their terms with less judgement. Almost all family members gave examples of situations where their loved ones had decided to seek help, but found services were not available or appropriate for their particular needs, for example, where waiting lists were unduly long, or accessing services where individuals felt they were not listened to or did not have their problems validated. One participant explained this as follows:
‘My [family member] had spoken many times over the years about him getting help and he actually had tried. He reached out to someone through the NHS [National Health Service], but then it just wasn’t facilitated very well so he then just continued what he was doing because he couldn’t get the help that he needed. So I would feel that [a DCR] would help those people’ (Participant 12, woman, partner, East Scotland).
Most participants broadly defined ‘treatment’. For many, the term treatment was taken to mean a person-centred intervention that would address underlying drivers for drug use. Several participants spoke of having been offered only one option, such as opioid replacement therapy, and felt that this had not aligned with their family member’s needs. Many suggested that a DCR could offer a valuable space where people could build trust in staff, and where there may be greater opportunities to explore diverse forms of ‘treatment’ or support:
‘Guidance and training, story sharing, events, education, all the things that happen in treatment, and by overcoming isolation and motivation to change, all these things that help and perhaps allow people […] to think about talking about the original causation’ (Participant 9, man, relationship undisclosed, East Scotland).
Several participants described a need for a person-centred, holistic approach to drug use and expressed the view that a DCR could provide this by being accessible and giving space to interpret and respond to emerging needs. Some participants discussed this in general terms, whereas others focused on specific gaps in the existing system:
‘There is no help for, not a lot of help out there […] it’s really difficult to get […] the help, and I know I’m not the only person because when I used to go along to my groups we used to talk about that’ (Participant 2, woman, mother, East Scotland).
In terms of accessibility, many interviewees highlighted the importance of DCRs being located in geographic areas of high need where people could use the service on a flexible, drop-in basis. Several felt that DCRs would help to overcome the difficulty of navigating a wide range of services:
‘There have been multiple times when my partner has gone to the GP […] they never tried to help or tried to you know give him information about programmes or anything you know, so I think I feel like just from my experience in Scotland there is sort of a gap […] it doesn’t feel that there are that many services out there and it doesn’t feel like many people know about them’ (Participant 12, woman, partner, East Scotland).
Several participants expressed that a DCR could provide a valuable, informal route into treatment and support that could potentially feel less daunting to those with drug-related problems who may have faced stigma in the past when attempting to access services. Several participants described the barriers their family members had faced when trying to access services:
‘So the first port of call for me was [his] local GP, and there was just a massive waiting list for rehabilitation and also, at that point, early on in his drug career, he wasn’t a problem. He wasn’t a problematic user, therefore didn’t fall into categories in order to get support. […] Looking back as an adult now I think “well that’s ridiculous, if somebody comes to you early doors that surely is an entry point to prevent further decline, or involvement or addiction, you know?” And now when I look back I think, and it’s one of the big things that kind of sticks with me, I think “gosh, if that had been different. My whole life could have been different if that had been different”’ (Participant 8, woman, sibling, North Scotland).
The above participant and several others suggested that having been refused support or interventions multiple times due to not meeting criteria, or there not being relevant interventions available in the area, could have the cumulative effect of causing people to distrust services and become unwilling to reach out again. A DCR was described as a way to overcome this:
‘I think there just is as many levels as possible, as many access points to treatment, support, information, the better and sometimes even just sitting in a doctor’s surgery is too much and a DCR, a drug consumption room, would be a much more informal way of accessing very formal support which doesn’t feel like you are entering a system or the system as it sometimes feels for drug users’ (Participant 8, woman, sibling, North Scotland).
DCRs were also seen as potentially easing pressure felt by families. Family members reported that, while they were constantly fearful about their loved one’s wellbeing, they could not always be their only source of support:
‘Most families like myself spend most of the time trying to figure out how to work with the person we love. There is just this fine line all the time [of] holding them with love, and offering support and help, and then having to practice tough love, and then just worrying about them all the time, about whether they are safe, what they are doing and where are they going, and are they getting drugs that are contaminated […]. And then if they are injecting or sharing needles, you know, and diseases, it’s just an ongoing nightmare of worry and concern. I think [a DCR] would create […] lower those anxiety levels for sure, for families and friends of the person who is using’ (Participant 6, woman, mother, East Scotland).
Asked about the potential impact of a DCR on their own lives, one family member commented:
‘Oh God, I think it would be massive, you know? I think the threshold of anxiety and fear that people live with when they have a family member misusing drugs is, is poorly understood. My son has been misusing drugs for seven, eight years now, and it’s really just in the last year that things have improved. So I have spent eight, nine years wondering where he is, is he alive? Not fully understanding the depth of his difficulties because we had to do a lot of work on our relationship anyway. And I think that is really poorly understood. And also the impact on his sister has been massive’ (Participant 3, woman, mother, North Scotland).
Another family member described how a DCR could have alleviated fears about her daughter during a time where she was injecting in public places:
‘They were all sharing needles and hitting each other up and oh my God it was just absolutely hellish […] whereas if there was a place like that at the time […] I would have been definitely more relaxed, definitely. I would have been able to put [my head on] my pillow at night and maybe not worry so much’ (Participant 5, woman, mother, West Scotland).
In summary, family members emphasised perceived inadequacies in current provision for people who use drugs, giving examples of long waiting times for support, and negative interactions with healthcare staff when support was able to be accessed. Family members saw DCRs as both filling gaps in current provision and establishing links between people who use drugs and access to other services such as housing.
Theme four: stigma and DCRs as a paradigm shift
For interviewees, stigma was fundamental to the harms experienced by people who used drugs. Stigma was seen as impacting at both an individual level—by pushing individuals and their supporters away from sources of help, and at the ‘macro’ level of policy—such as delays to strategic implementation of DCRs in Scotland. Many interviewees described the impact of stigma on loved ones who had previously tried to access services. Some reported that their loved ones mistrusted addiction, treatment, and health services, and did not want to be drawn into ‘the system’ where they might be judged. For many participants, DCRs represented a first step towards a new approach to reducing stigma:
‘So (a) first of all, yes I think it would reduce the deaths. And I think it would also make people feel we are being paid attention to. We are not having to sneak away like rats into a corner to do this. We are being given a place. We are being acknowledged as people with a problem. And that is the first step in changing people’s attitude about recovery and wanting to get into recovery. As long as addicts see the establishment as anti-them, then recovery will become more threatening for them and more difficult. Surely recovery is what we want at the end of the day?’ (Participant 13, woman, mother, location unknown).
Family members also connected the stigma associated with drug use to barriers in establishing DCRs. There was significant frustration about the lack of political progress towards implementation:
‘They [Scottish Government] are way behind and there is (sic) loads of other countries that are having them. The drug figure deaths are so much lower than what the UK and Scotland are, so to me it’s common sense, it’s like I cannae [cannot] see why we shouldn’t be doing it. I really don’t see why we shouldn’t be doing it’ (Participant 4, woman, mother, North Scotland).
For one participant, stigma was the only explanation for what they felt should be a simple political decision:
‘To me it seems really, really straightforward. And so argue that the other way then: “So you want to keep drugs in the hands of criminals. You want it to be illegal and dangerous because? Could you please explain to me why that is our policy?” […] I have not heard anything, “well it’s for this very good reason that we want to keep people dying from drugs, thank you.” So why would we not flip that on its head then and be like well “why don’t we try and stop people dying from drugs?” and a really good place to start would be decriminalising use. Allowing safe consumption. Allowing access to extra services. Not making them feel like crap because they are users. Providing everything that they need in order to possibly change their life’ (Participant 6, woman, mother, East Scotland).
For many participants, the value of drug consumption rooms went beyond the individual outcomes. Rather, they viewed the introduction of DCRs as symbolic of a paradigm shift towards a health-based approach to drug problems more broadly:
‘By creating these drug consumption rooms what we are really saying is, “we have an issue as a society. And it’s our responsibility to look after these people.” And that is a big mind set shift’ (Participant 8, woman, sibling, North Scotland).
Some participants described having experienced stigma due to having a family member with drug-related problems. For example, one participant pointed out that, while she campaigns publicly for both DCRs and drug policy reform, another close family member feels unable to do so due to stigma. This participant, alongside others, perceived the introduction of DCRs as being capable of addressing multiple forms of stigma, and making it easier for families to gain community understanding of the challenges commonly experienced by people who use drugs. In this way, stigma was perceived to be a barrier to DCR introduction; yet should DCR introduction be possible, participants felt that the stigma of drug use could be minimised:
‘First and foremost, it’s keeping individuals safe who have got problematic drug use. You know, that is actually like a very small percentage of the people that actually use drugs you know daily, legal and illegal. So, you know, these people are really desperate, they are at such a low point, they are the most vulnerable people in society and it’s just I think symbolically […], it shows that we care as a society. You know, it’s just one step to showing that we should treat people who are in pain you know, which is generally what it is, with more compassion. […] I would hope that you know Scotland could lead the way in this, and send a signal to the rest of the UK about how things could be done in a more humane society’ (Participant 1, woman, cousin, West Scotland).
DCRs were widely viewed as marking a step towards a less enforcement-oriented response to drug use, by prioritising harm reduction over criminal sanctions. Several participants drew parallels between drug policies and policies directed to other behavioural issues, such as unhealthy eating or alcohol use. They expressed frustration that DCRs remained controversial, partly because drug dependence was often viewed as a moral issue rather than a matter of health. By contrast, it was argued that failure to implement life-saving interventions for conditions such as cancer would not be publicly acceptable:
You wouldn’t have somebody with cancer going to accident and emergency, [they] wouldn’t be sent away to find some chemotherapy or something. They would be given treatment’ (Participant 13, woman, mother, location unknown).
Regardless of how far participants supported more general drug policy reform, there was a shared sense that DCRs represented one aspect of a wider change in the way drug harms, and policy responses, were framed: away from a focus on enforcement and eradication of supply, towards principles of safety, prevention, protection, and the recognition of trauma:
‘It’s about creating a safe space really isn’t it, so if we have a premise that drug treatment service should be about creating safety. And its experience of safety which sits at the heart of trauma-informed approaches and responses, then why aren’t we also thinking about the other environments […]. Why aren’t we creating whole system responses that have a DCR alongside the police using their disruption and distraction, alongside people providing therapeutic support and input?’ (Participant 3, woman, mother, North Scotland).
The language and terminology surrounding drug consumption rooms were seen as significant with regard to stigmatisation. Many felt that the term ‘drug consumption room’ could exacerbate stigma and potentially inflame relations with local communities. One family member thought the term ‘consumption’ could create the impression that a facility was being funded merely for the consumption of illicit substances. By contrast, another felt that adding the word ‘supervised’ risked implying that the person required surveillance and was, therefore, a problematic person. Several suggested that the term ‘drug’ could detract from the service aims by focusing on drugs rather than harm reduction, safety, or support. When presented with various options, such as ‘safer consumption sites’, ‘safer injection sites’, and ‘overdose prevention centres’, many stated that ‘overdose prevention centre’ was the least stigmatising name. Two family members suggested that the service should simply be called ‘hope’, since that was what it represented to family members, people who use drugs, and local communities.
However, others felt that what mattered most was clarity about the service function itself:
‘It’s not about making it look better. It’s about [saying] “a spade is a spade, a drug is a drug”. It’s what it is. Be honest about it’ (Participant 4, woman, mother, East Scotland).
In summary, family members believed that DCRs could provide a useful addition to the range of services that could be implemented to prevent and reduce DRDs and other harms. Although some level of prior activism was apparent, most family members appeared to have learned about the intervention through media reporting including reporting related to the activities of an unsanctioned mobile DCR that was active at the time of data collection. Some disagreement was evident with respect to the role that DCRs could play in recovery from drug problems but, in general, participants believed that the intervention could, or could have, helped their own family members, and that implementation in Scotland would symbolise a more supportive approach to responding to people experiencing drug-related harm which they welcomed.