One size does not fit all: the necessity of local applicability

As described above, studies show that DCRs can save lives and improve drug users’ health, while having no direct negative effects on the neighbourhood. These outcomes, however, are highly dependent on the local applicability of the facilities; their viability and effectiveness depends on local contexts and circumstances. Indeed, DCRs—and harm reduction strategies more generally—are in no way universal solutions that can be implemented in any given local context. In order to maximize their effectiveness, studies emphasize the importance of adequately tailoring these interventions to the specific setting and needs of the community, rather than implementing them as ‘one size fits all’ solutions (EMCDDA, 2015a; Marlatt & Witkiewitz, 2010; Parker et al., 2012)—a tailored approach that equally applies to the more general community-level drug policy (EMCDDA, 2015a). As such, DCRs represent a local response based on local needs, closely linked to policy choices made by local stakeholders (EMCDDA, 2017c). DCRs’ design should thus be tailored to local setting in order to meet local needs and demand.

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Design considerations and related barriers for access

DCR utilisation—and hence its effectiveness—is influenced by the extent in which the facility is locally embedded. In other words, DCRs can only realise their full potential if those in need have access to the service. Access restrictions may limit the number of people who can benefit from a DCR’s services in two general ways.

Location, accessibility, coverage and capacity

First, the extent to which a DCR’s goals is achieved largely depends on ‘physical’ aspects such as their accessibility, opening hours, and capacity required to satisfy the demand of its target group (Semaan et al., 2011). Location-wise, DCRs may be situated in a centralized location, or rather decentralised (away from the city centre). Whereas having a DCR proximate to other services would increase the likelihood of PWUD using those services, this centralization option may also lead to a concentration of services in one specific area and thereby neglecting other neighbourhoods. Having a DCR centrally located (mostly in central neighbourhoods where PWUD congregate) would not only respond to the need for these services for PWUD in the area, but may also function as a public health response to a high volume of publicly discarded needles and syringes in certain neighbourhoods. On the other hand, whereas the decentralisation option has the advantage of geographically spreading services and de- stigmatizing specific areas, it may be less accessible for clients when located too far from central neighbourhoods or other services (Bardwell et al., 2017). Rather than having a fixed DCR located in one neighbourhood, mobile units may make the services accessible to PWUD throughout the city (see Dietze et al., 2012; McCann & Temenos, 2015)

Relatedly, (fixed) DCRs must be easily accessible to PWUD, irrespective of (de)centralization. For instance, evidence indicates that PWID are not generally willing to travel great distances to use a DCR (the intensity of drug withdrawal symptoms may influence whether they had time to travel to a facility; Bayoumi & Strike, 2012), and public transportation is often described as a barrier for many PWID (Petrar et al., 2007). In this latter study, in addition to travel distance, the two most common reasons for PWID limiting use of the facility were limited hours of operation and waiting times.

In terms of capacity and coverage, it is important for DCRs to be adequately resourced to cover the local needs of PWID. Adequate capacity and coverage are important because pilot and under- resourced projects often cannot sufficiently control local epidemics, meet local needs, or provide the resources needed for DCR to meet their goals. For example, nuisance and neighbourhood conflicts (following a concentration of DCR clients in front of the facility) may be more likely when capacity or location of the facility does not meet local needs and waiting times are long. Waiting times can be problematic for clients who are experiencing symptoms of withdrawal. At the busiest times, clients in

the Vancouver DCR may have to wait 15–30 minutes for a booth to become available, and almost 10% of clients leave while waiting (Small et al., 2011b). Only one in five clients would prefer to wait at the DCR than to inject outside sooner (Small et al., 2011a). Thus, sufficient capacity is required to satisfy the demand of the target population. In order to guarantee sufficient flux, and consequently reduce waiting times, the majority of DCRs limit the amount of time clients can use drug consumption booths in one sitting (typically 30–45 minutes).

In addition, accessibility in terms of hours of operation is equally important, suggesting that these services be readily available when needed. Few DCRs are open 24 hours a day, which leaves clients with some hours during the day during which they must find another place to inject, or inject publically (Petrar et al., 2007; Small et al., 2011a). Extended opening hours in the evening can attract specific target populations into the DCRs, such as sex workers.

Admission criteria

Second, it is important for DCRs to be low-threshold and low-barrier, but it is common for the facilities to establish eligibility criteria for use of services. Several admission criteria may limit access for several (minority) groups. For example, clients enrolled in OST are formally excluded from DCRs in Germany and Luxembourg (Schatz & Nougier, 2012). Elsewhere, considering the high prevalence of continued drug use among OST clients (Judson et al., 2010; Senbanjo et al., 2009), a pragmatic view is adopted that if clients enrolled in OST are going to use anyway, it is better if they do so in hygienic circumstances where there is also the opportunity for staff to engage with them.

Similarly, primarily to avoid attracting more drug users to the vicinity of the DCR, many Swiss and Dutch DCRs do not admit PWUD who are not resident in the local area (Schatz & Nougier, 2012). The downside of placing such a criterion is that it excludes non-local residents who may benefit from such a service, and vulnerable groups such as illegal immigrants and refugees. Other specific populations likely to be excluded include pregnant women, minors (or young people), novice injectors (i.e. individuals who intend to inject for the first time or who have only recently initiated injecting), and intoxicated clients.

As reported by Schäffer and colleagues (2014), the negative effects of admission criteria are illustrated by research in one German DCR. On 544 occasions, potential clients of the DCR were denied access for the following reasons: 150 times because clients were drunk or intoxicated; 109 times because people were in OST; four times because people were first-time or occasional users; two times because PWUD were under 18 years of age; and 250 times because they do not reside in the vicinity of the DCR. Analysis of 98 drug-related emergencies that happened in the vicinity of that DCR found a direct relationship between the reasons for excluding these potential clients and their exposure to risk

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when they decided to use drugs but without the safety net provided by the DCR. Thus, as barriers to access are created by well-intentioned (and sometimes legal) regulations, such admission criteria may restrict access to a vulnerable group of PWUD who would significantly benefit from DCR usage. After all, restricting access for specific groups in need undermines the low-threshold underpinning of DCRs.

Lastly, as discussed above, restrictions on type of substance (e.g., heroin only) and route of administration (e.g., injecting only) may exclude vulnerable groups of drug users, for example crack cocaine smokers, whom could significantly benefit from DCR usage (Voon et al., 2016).

Local needs and barriers for access

In short, several operational considerations (e.g., location, capacity, coverage, and admission criteria) may limit DCR accessibility and usage. If DCRs are to have an impact at community level, it is necessary to provide sufficient capacity relative to the estimated size of the target population, to locate rooms on sites that are easily accessible, and to ensure that opening hours are long enough to meet demand (Hedrich et al., 2010). All in all, since DCRs are a local solution to a local problem, such services should respond to the needs of their target group.

Box 5. The need to tailor a DCR to its local setting

A DCR represents a local response based on local needs, closely linked to policy choices made by local stakeholders. Indeed, DCRs are no ‘one size fits all’ interventions that can be implemented in any given local context—DCR utilisation and its effectiveness relies on local applicability and the extent in which the DCR is locally embedded. Based on the available services, needs of the community, and drug use patterns, there are several essential operational issues to consider when implementing a DCR, such as its location, capacity, coverage, opening hours, and eligibility criteria (i.e., target group). Inadequately tuning such elements to the local setting may limit the number of people who can benefit from a DCR, and consequently undermine the success of the facility. A DCR should furthermore be embedded into the wider local policy framework as part of a network of services aiming to reduce individual and social harms arising from problem drug use. Taken together, DCRs can only realise their full potential if the service is part of a continuum of local services for PWUD, and all those in need have access to the DCR.