User perspectives on outreach opioid substitution treatment among street-entrenched people who use drugs in Denmark

Abstract

Background

The COVID-19 pandemic had many serious consequences for vulnerable populations, but it also gave rise to innovations and changes of established ways of providing services for such populations. In Copenhagen, Denmark outreach opioid agonist therapy (OAT) was such an innovation.

Methods

Based on qualitative interviews with 15 individuals who received outreach OAT this article describes this new service and presents OAT clients’ experiences of previous OAT and outreach OAT. Analytically the article draws on literature about people who use drugs’ experiences of barriers when wanting to access drug treatment and other services.

Results

The participants had experienced significant systemic and social barriers in relation to outreach OAT. Outreach OAT helped to minimize both types of barriers. It also created new opportunities for providing care because treatment took place in participants’ own environments.

Conclusion

Outreach OAT has the potential to minimize treatment barriers for some of the most vulnerable people who use drugs. It is however also important to review and possibly change system design, guidelines, and practices of the existing system to better accommodate the program to the needs of vulnerable people.

Keywords:

• Opioid agonist therapy
• vulnerable people who use drugs
• timely service

Introduction

Vulnerable populations were disproportionately exposed to and suffered from the consequences of COVID-19 (Collins, 2024). However, as has also been widely documented, in some contexts, the pandemic led to important innovations and improvements in social and health services for vulnerable people, including vulnerable people who use drugs. Studies have documented how COVID-19 and related restrictions led to innovations in harm reduction and opioid agonist therapy (OAT) to people who use drugs (Grebely et al., 2020; Harris et al., 2023; Krawczyk et al., 2021; McDonald et al., 2023; Nygaard-Christensen & Houborg, 2023; Otiashvili et al., 2022). In Denmark, a significant change of services to marginalized people who use drugs was the initiation of outreach OAT at the open drug scene at Vesterbro, a centrally located neighborhood in Copenhagen (Nygaard-Christensen & Houborg, 2023). Service providers’ call for more accessible OAT services to marginalized people who use drugs preceded the pandemic. Yet the broader incentive to reduce barriers occurred in the context of the pandemic lockdown when broader public health concerns and the need to curb transmission highlighted the need to keep people who use drugs off the streets and other high-risk environments. Within this ‘policy window’ (Kingdon, 1995; Ibid.), service providers pushed for rapid implementation of a service that would enable them to offer OAT in clients’ own environments – whether their own apartment, a street corner, or a shelter room – instead of a municipal drug treatment center. The outreach service enabled service providers to reach clients facing significant systemic and social barriers to access and sustain OAT. The outreach OAT offers is an illustrative example of how the pandemic ‘prompted an urgency to adapt and innovate’ (Grebely et al., 2020) when existing problems experienced by marginalized people who use drugs became linked to broader public health concerns. While a significant body of work has examined examples of such service innovation during lockdown, fewer studies have examined the long-term fate of initiatives beyond the impetus for innovation during the pandemic lockdown. Towards this aim, this paper focuses on outreach OAT as it was maintained and further developed after the COVID-19 lockdown had been abandoned. We do so with a particular focus on clients’ experiences with outreach OAT and their perspectives on its effects on barriers to OAT.

Background: Opioid substitution treatment in Denmark

Opioid agonist therapy was first implemented in Denmark during the early 1980s as a harm reduction and social inclusion measure for people with a long career of heroin use and several unsuccessful treatment attempts (Alkohol- og Narkotikarådet, 1984; Houborg, 2006). While HIV/AIDS sped up the process of OAT implementation (Ege, 1998; Houborg, 2006), OAT remained a high threshold service for people with a long career of heroin use. It involved compulsory urine tests and participation in social treatment as well as a zero-tolerance relapse policy where illegal drug use would lead to involuntary dismissal from treatment. Consequently, some opioid-dependent people would get private practicing doctors to prescribe methadone to them, leading to a de facto two-tier OAT system. As a response to this problem, from 1996, only doctors employed by drug treatment institutions or authorized by such institutions could prescribe drugs for OAT. This restriction of OAT access points increased barriers to OAT, leading the Advisory Council on Drug Issues (Narkotikarådet, 2000) to recommend the implementation of a lower-threshold OAT policy with less restrictive treatment guidelines from the National Board of Health and less restrictive treatment practices that would put an end to mandatory urine tests and participation in social treatment. It should also end the zero-tolerance relapse policy in many places (Houborg, 2006). Overall, such developments led to a gradual lowering of treatment thresholds in Denmark, albeit with local variations, because OAT is delegated to the 98 municipalities in the country. In 2008, it became a social right to be offered drug treatment by a municipality within 14 days after a client has applied, including OAT, if a medical assessment shows that the person is opioid dependent (Law on Social Service §101; Law on health care §142). In 2008, new legislation further made it possible for municipalities to offer OAT with heroin. Today, four municipalities offer such treatment, including the municipality of Copenhagen.

The municipality of Copenhagen has been at the forefront of the gradual lowering of treatment thresholds in Denmark. OAT in Copenhagen is offered at five different treatment institutions. The three main treatment institutions provide medical and social treatment, although social treatment is mainly provided at the client’s request. For many clients, OAT mainly involves medical treatment with occasional meetings with the doctors and their case managers. Copenhagen Municipality aims to offer ‘immediate treatment,’ whereby treatment commences as soon as possible after a person has applied for it, well within the 14-day deadline that the legislation stipulates. The start dose for methadone is set to 30 mg, which can be increased by 10 mg every second day until pharmacological stabilization. During the period of stabilization, the client must ingest the medicine at the treatment center and stay there for one hour to be observed to avoid overdoses. After a while, it is possible to get take-home doses for increasing periods of time, depending on treatment progress. If clients stay away from treatment for more than three days – if the substitution medicine is methadone – they need to start with the initial dose of 30 mg when they return and have the dose gradually increased to 10 mg every second day. We will return to this so-called ‘three-day rule’ below.

Introducing outreach OAT

In its current form, the outreach OAT service is carried out by a team that consists of a doctor, two social workers, and two nurses. Clients are referred to the team by different actors, including drug treatment centers, drop-in centers, homeless shelters, drug consumption rooms, and other outreach workers. On referral, a social worker initiates a meeting with the client and achieves their consent to access relevant medical and social files. After assessment, the outreach team decides whether the client fits the inclusion criteria, which stipulates that clients should be opioid dependent and have dropped out of treatment or experienced difficulties in accessing treatment. If that is the case, a social worker, a nurse, and a doctor will visit the client to begin treatment. Initially, treatment consists of increasing the dose to a maintenance level. During that time, one health staff will visit the client daily. The primary focus is on medical treatment for opioid use, including heroin, preferably with buprenorphine, which can be administered as pills or injections with sustained-release medication lasting for up to four weeks. Outreach OAT aims at pharmacological stabilization of the clients, after which they should refer them to another service. However, the duration of outreach OAT varies depending on available services and whether other things than medical maintenance treatment need to be sorted out before a referral can happen. By June 2023, 121 individuals had received outreach OAT, 108 of these had been referred to treatment in one of the municipality’s treatment institutions or elsewhere, including the prison services, and 21 individuals were undergoing treatment in June 2023.

Analytical framework: Opioid substitution treatment and street entrenchment

We draw on two bodies of literature to support our analysis of outreach OAT in Copenhagen, Denmark. Firstly, we draw on existing studies of opioid substitution treatment thresholds and barriers. Secondly, to develop our understanding of the social contexts in which outreach OAT is introduced, we build on studies of drug scene entrenchment for marginalized people who use drugs.

OAT is an efficient treatment for opioid dependence and a harm reduction measure that can reduce illicit opioid use, crime, drug-related risk-behavior, morbidity, and mortality (Corsi et al., 2009; Fullerton et al., 2014; Gibson et al., 1999; Marsch, 1998). However, research has also shown a complex everyday reality behind the positive results shown by epidemiological research, where people who use drugs experience problems with getting into treatment or have negative experiences and ambivalent feelings about treatment (Jakobsen et al., 2021). Much of this literature concerns how people who use drugs experience the control measures involved in OAT. It has, for example, been shown how rules, regulations, and their local implementation can lead to feelings of disempowerment, stigmatization, humiliation, anger, and deprivation of agency and autonomy (Dahl, 2006 Fraser & Valentine, 2008; Valentine, 2007). On this background, OAT has also been described as an instrument of social control, surveillance, and disciplining of marginalized people who use drugs (Bourgois, 2000; Dahl, 2006 Fraser & Valentine, 2008; Harris & McElrath, 2012). In a Danish context, Jakobsen et al. (2021) describe the ambivalence and ‘trade-offs’ involved in accessing and staying in OAT where logistical, medico-bureaucratic, and social interactional factors affect experiences of OAT and how this affects clients’ willingness to enter or stay in treatment. Such literature underscores how treatment barriers and thresholds potentially reduce the positive benefits people might have from OAT (Stöver, 2011). To understand the factors that may prevent people who use drugs from accessing or benefitting from OAT, studies have sought to conceptualize the various barriers OAT clients experience. Kourounis et al. (2016) distinguish between different types of ‘treatment thresholds’: ‘treatment accessibility thresholds’ and ‘treatment design thresholds.’ The former relates to treatment access and includes the length of waiting lists, the flexibility of admission criteria, points of access, and the cost of treatment for the individual client. ‘Treatment design thresholds,’ on the other hand, relate to possibilities for treatment retention, including whether the design is one for all or individualized, medication options, and relapse policies - which may vary from zero-tolerance to approaches where relapse is expected and part of the treatment, drug administration, and adjuvant social treatment (Kourounis et al., 2016, 3). In addition to systemic thresholds, other studies have unpacked the social dimensions that may present treatment barriers. Thus, in a systematic review of OAT barriers from a client perspective, Hall et al. point to stigma and fear about family, friends, employers, health care professionals, police, and other people in general as ‘social stigma barriers to OAT’ (Hall et al. 2021, 9). This and other studies likewise point to geographical distance to treatment locations as a barrier.Social barriers may also relate to homelessness, poverty, violence, recent incarceration, and illegal employment (Ibid; Edland-Gryt and Skatvedt, 2013). Additional thresholds include the economic, social, and mental resources required to seek and receive help and maintain access to treatment, including competence thresholds that have to do with the ability to express yourself and, in general, appear in a way that shows that you are eligible for help and support, as well as overall trust in welfare and health systems as well as service providers (Edland-Gryt and Skatvedt, 2013). As a result of such barriers, people may choose to end OAT or find other ways of administering treatment (Richert & Johnson, 2015). This underscores the importance of understanding how OAT offers are embedded within and interact with the social worlds of clients. Toward that aim, we draw on studies that shed light on the social settings that characterize the everyday lives of people targeted by outreach OAT. These include people who have not benefited from existing treatment offers and who typically live in situations of unstable housing and extensive, prolonged opioid use, often referred to as drug scene ‘entrenchment.’ Existing studies have employed the term to refer to situations in which people are ‘…consumed by the daily project of survival ‘on the streets’’ in the context of homelessness, chronic poverty, involvement in harmful forms of drug use, and/or dangerous income generation activities’ (Fast et al., 2009, 2014; Knight et al., 2017). Such work adds to our understanding of how barriers such as geographical distance to OAT can, in practice, be a huge distance – even when comparatively short - for people thoroughly entrenched in local drug scenes where ‘taking care of business’ (Preble & Casey, 1969; Stephens, 1991) – generating money, buying, and using drugs – takes precedence. This further underscores the need to understand how different barriers intersect so that geographical and time-related barriers may mutually reinforce each other. As demonstrated by Andersen & Bengtson, ‘timely care’ in drug treatment ‘requires a synchronization of the rhythms of everyday lives’ and those of drug treatment providers (Andersen & Bengtsson 2019, p. 1529). Hughes (2007) adds a further dimension to time-space related barriers when she discusses the time and space horizons of drug dependence. Drug time related to the metabolization of drugs, the location of places to acquire drugs and places to get treatment as well as treatment services opening hours may not be in sync, creating a time and space related barrier. As we will explore in this article, outreach treatment seeks to bridge these two distinct environments described above – that of the clinical or institutional drug treatment setting and local drug scenes - by moving treatment out of the clinic and into the everyday environments navigated by marginalized people who use drugs. This shifts the treatment encounter to peoples’ home environments and/or the drug scenes where people are entrenched. Little research, however, has been carried out on how this shift is experienced from a client perspective. To add to such work, we examine experiences of the effects of outreach OAT on treatment barriers.

Methodology and data

The project builds on qualitative interviews with 15 people who use drugs who were enrolled in outreach substitution treatment at the time of the interview. These interviewees do not correspond with the 21 who were in treatment in June 2023, because interviews were done from October 2022 until January 2023. The interviewees were between 23 and 49 years old. The majority were in their forties. Nine were men, and six interviewees were women. Five had their own housing (rental apartment), one lived in his partner’s apartment, and eight lived at shelters at the time of the interview. Interviewees all had previous experience with OAT, and three of them had been in drug-free treatment. Half had received treatment more than four times previously, while the other half had received treatment four times or less. Thus, not all the interviewees had extensive treatment experience. However, all were highly entrenched in local drug scenes (Fast et al., 2009) and were viewed by service providers as particularly difficult to include in existing OAT offers (see Nygaard-Christensen & Houborg, 2023).

Respondents were recruited with the assistance of the outreach OAT program employees. The program employees informed users about the project and asked if they were interested in participating. If the user was willing to participate the first author was contacted by a program employee and time and place for an interview was arranged. The first author or a student assistant would accompany a program employee to the place where the user lived and after the users had received their medicine one of the researchers would do the interview. All users that agreed to be interviewed were interviewed. Before the interviews were carried out the researchers achieved informed consent from the interviewees. Because initial contact was done by program employees, we are not able to compare users who agreed to be interviewed and who did not. This is a limitation of the study. The interviews were conducted in the apartments or shelters where the interviewees lived. Sometimes, the doctor or a nurse was present during the interview, catching up on case management on their computers while the interview took place. Interview questions focused on their drug use (types of drugs, drug market access, etc.), their everyday life, living situation and social networks, past experiences with drug treatment services, barriers they experienced in traditional OAT, their experiences with outreach OAT and how it affected barriers of accessing OAT. All interviews were recorded and transcribed verbatim. They lasted between thirty and fifty minutes and were conducted in Danish. The authors translated quotes used in the analysis to English. The first round of coding was done thematically (Braun & Clarke, 2012) by the first author, after which the first and the second author reviewed the coding and developed themes for further analysis. This further analysis was in part informed by the literature presented above. It was also informed by the first author’s previous research on the everyday lives and risk- and enabling environments of marginalized and street-entrenched people who use drugs in Copenhagen, including experiences with receiving OAT (Houborg et al., 2022; Jakobsen et al., 2021). Also informing the analysis was the authors’ research into COVID-19-related innovation of low-threshold services to marginalized people who use drugs during COVID-19 (Nygaard-Christensen & Houborg, 2023) and the impact of COVID-19 and related restrictions on local drug scenes (Nygaard-Christensen, 2024; Nygaard-Christensen & Søgaard, 2023).

The research project upon which this article was approved by the Data Protection Agency. Furthermore, the research has been conducted in compliance with the Danish code of conduct for research integrity.

Results

In the sections below, we will present interview participants’ experiences of OAT. We begin by accounting for the main themes in the interview responses to questions about their past experiences with OAT, with a particular focus on the barriers they had experienced. We will then account for their experiences of outreach OAT and its effects on these barriers.

System accessibility thresholds and barriers

Several interview participants mentioned mobility-related barriers as obstacles to entering and remaining in treatment. For them, distance to treatment centers constituted a significant barrier. A woman told us that her treatment ended when she was no longer able to go to the treatment center to pick up methadone because she had swollen legs. For her, administrative regulations combined with her somatic condition became an obstacle because she could not be offered a solution that would accommodate her condition:

U: I couldn’t get up there. Can you see how swollen I am?

I: Yes, I can see you are swollen.

U: I couldn’t get up there.

I: What did you do when you couldn’t get up there? Did you talk with them?

U: Yes, I talked with them, but they wouldn’t help me. […] They said that if I didn’t come to get my medicine myself, my treatment would be terminated.

For other participants, the experience of mobility difficulties was not purely a geographical obstacle. None of the interview participants would have to travel more than three-quarters of an hour to reach a treatment service. Instead, geographical obstacles intersected with other issues that made transport difficult. Thus, a 23-year-old woman who had begun treatment experienced difficulties in transporting herself to the treatment service, as this meant she had to use public transport while experiencing withdrawal symptoms. ‘It was too hard to have to transport myself out to [a neighborhood at the opposite end of the city where the drug treatment center was located], with withdrawal symptoms (…) and in the morning hours with everyone being on their way to work and school and you feel terrible.’

As a result, the woman dropped out of treatment—barriers relating to geographical distance further entangled with time-related barriers. Several interviewees emphasized time regulations as a significant barrier that they found it difficult to live up to. One interviewee said this: I have a daily rhythm that says no to it (man, 28 years). Others offered more elaborate accounts of why they found it difficult to comply with time-related regulations: I have PTSD as it is, and social anxiety and that sort of thing, from when I was deployed to Afghanistan (…) I have a hard time leaving at a specific time, to a specific place and that sort of thing, right? (…) It’s a kind of panic disorder (woman, 47 years). One interviewee explained how difficulties in keeping appointments were not limited to drug treatment but characterized other kinds of obligatory appointments as well. Asked what made it difficult for him to keep appointments, he responded:

I really don’t know. If I knew, I’d have done something about it. If I know that I need to go and collect money, for instance, I need to go and collect my social benefits, and then on the way over to the job center, I stop, and I just enter a kiosk, and I shut down. I don’t know what causes that. I have such a hard time showing up, and I have such a hard time adjusting (…) Sometimes I take a taxi, but then in the taxi, I get off right before (my stop) because (…) then I try to focus on something else, consciously, because I feel like the situation is too much. If it’s the center or just anything where I know it’s compulsory for me to attend. It is so bloody hard for me, and I wish I could work out what the hell it was because if I had the right tools, I would actually have solved the biggest of my problems (man, 31 years).

These examples illustrate that several interviewees were unable to conform to the established treatment system and, for this reason, were hesitant to enter existing OAT treatment offers or ended up dropping out. For several of our interviewees, systemic and social barriers further overlapped as geographical and time-related barriers sometimes led to confrontations with the staff. This was the case for a couple in their forties we interviewed. They found arriving at the center on time difficult and often showed up at the last minute. This generated comments from staff members who came up with a nickname for the couple, as recounted by the man:

We’ve really struggled with the drug treatment center; I mean for showing up late and getting into arguments and… (…) We have to be there between 9 am and 1 pm on this and that day, and then they’re open Thursdays in the evening. I mean, we are addicts. If we get there 1 minute too late, they’ll be ready and locking the door. We are the homecoming committee. That’s what they call us; that’s what we’ve been called up there, ‘now the ‘homecoming committee’ is coming; now it’s time for us to go home’ because we arrive two minutes to six. That’s how it is; that’s the reputation we’ve gotten up there (man, 44).

This, in turn, ignited the couple’s existing resistance to the established drug treatment system. As these examples illustrate, geographical distance is a very individual experience and may seem insurmountable even for those living comparatively short distances from a drug treatment center.

System design thresholds and barriers

Our interviewees described four overall ‘system design thresholds’ they experienced regarding access to OAT. This included a choice of substitution medicine, dosing, take-home arrangements, and not the least, the ‘three-day rule.’ Regulations are directed by national and local guidelines but are implemented by the professionals at OAT centers based on their professional assessments. Because how system design elements are implemented can profoundly impact clients’ everyday lives, they frequently lead to discussions and conflicts between clients and staff and among professionals. For instance, social workers and health professionals may have different client assessments and how rules and guidelines should be interpreted (see also Houborg et al., 2022) . In our small interview sample, seven out of fifteen participants mentioned the ‘three-day rule’ as a factor that complicated their access to OAT. As mentioned above, the three-day rule is activated when a client has not collected methadone within three days of an appointment to do so. The effects of ‘falling for the three-day rule,’ as interview participants described it, have an immediate and significant impact on clients’ lives. Failure to comply with the three-day rule will return the client to an initial ‘start-up’ dose of 30 mg, which can only be raised by 10 mg every second day . The client will have to meet at a center every day during this time. For this reason, some people involved in OAT are constantly anxious about failing to comply with the three-day rule. One of the interviewees who found it difficult to conform to scheduled meetings and pick up medicine had a large consumption of drugs besides his medicine. Being anxious about violating the three-day-rule, he tried to work out a schedule for picking up medicine that would minimize this risk:

I tried this smart idea because it is difficult for me to show up. I figured out that if I got medicine on Tuesdays and Fridays, then it is Saturday, Sunday, Monday, and then Tuesday, and if I miss Tuesday, then I have got Wednesday, Thursday, and Friday, then I have got three days. If it were Thursday, I would only have one day, Friday, and then I would fall for the three-day rule. (man, 31 years old)

However, despite this plan, his treatment was ended due to the three-day rule, as he forgot an appointment. Another interview participant told us how the three-day rule was administered due to a bureaucratic error: They were supposed to phone in the prescription to the pharmacy, and that hasn’t been done, so my treatment was terminated because I didn’t get my medication that weekend (man, 48 years old). This, in combination with ongoing conflicts with other clients he would meet at the drug treatment center, meant that he stopped OAT altogether: The reason I don’t come to the [drug treatment center] any longer is because I have some conflicts with some of the people that go there, and that’s the reason I’ve had to stop going there. He further explained how ‘falling out of treatment’ had a significant negative impact on his life because he now had to procure money for illegal drugs:

Also, in this situation, where I fell out [of treatment] because of the three-day rule because they hadn’t called in the medication, and I was discharged entirely. I’d just started getting in touch with my daughter again and had to go home and take care of her for a week when I fell out due to this three-day rule, so that means that suddenly I have to get 1.500 DKK or something like that in order to stay well while I have to be with my daughter for a week (man, 42 years old).

Another interview participant reflected on the negative effects of the three-day rule. In his view, failing to comply with the three-day-rule should be seen as a sign that something is wrong:

No, what you can say is that, in the end, when it’s decidedly the most difficult, that’s when you need treatment the most, and that’s when it starts to go a bit wrong; when they just say… fuck it all up for you, all of the shit, right, and actually make the whole thing worse (man, 38 years old).

As summed up by the man, the three-day rule had the contradictory effect of distancing those who were the most in need of help from the drug treatment system. Another participant felt that he could not go to his treatment center because he had conflicts with other users, like the man mentioned above: The reason I don’t come to the [drug treatment center] any longer is because I have some conflicts with some of the people that go there, and that’s the reason I’ve had to stop going there (man, 42 years). Often, a drug scene develops around a treatment center. This can mean that users fear going there because they risk getting ‘rolled’ (Houborg et al., 2022) or have ongoing conflicts or strained relations with other users. It can also be experienced as a problem for users who try to end their drug use but risk being tempted by other users - and dealers – selling drugs near the centers: When you get it offered as soon as you go in and out of the door, or you get asked if you want to sell the medicine. That puts a pressure on you, right? (kvinde, 43 år).

Acknowledging this was part of the rationale behind the outreach OAT service, but also behind an older service where staff from the municipal drug treatment system has assessment interviews at the drug scene in low-threshold service, including one of the drug consumption rooms. The latter service also involved accompanying people to a drug treatment service. The thoughts behind it are that even a short geographical distance can be a huge distance for someone who is thoroughly entrenched in a drug scene.

Perspectives on outreach OAT

We will now look at how the interviewees described their experiences of outreach OAT. We will focus on geographical, logistical, and social barriers because these seem to have been the most important for the interviewees.

Effects on geographical and time-related barriers

As described above, traveling to a drug treatment center posed a barrier for several of the respondents. A man who lived in a shelter described how lack of sleep, worsened by the fact that he could not lock his room, made it difficult for him to get out of bed in time to make it to the treatment center. He told us the following about his experiences with the outreach OAT:

Well, I think it’s been awesome; I mean, it’s just that kind of additional stress that is removed by making sure that… I mean, here, I can almost sleep too long and get taken by surprise and have pills stuffed in my mouth, so to speak. I mean (…) because before you’re even quite awake, it’s ten o’clock, and I have to be in [another part of town] at 11 am, have to make a phone call out there, and then you’re in [the other part of town] at… ‘we’re closed unfortunately (…) so you can’t get anything, you can go home again’ (man, 38 years old).

Like others, he also described drug effects and withdrawal symptoms as obstacles to going to the treatment center. The stress associated with withdrawal symptoms either led him to spend time seeking out drugs in the immediate environment of the shelter rather than going to the drug treatment center or made him apathetic:

You wake up nice and quiet, and you feel more like getting out of bed because you know that you don’t have to get up to the stress [about seeking out drugs]. Sometimes, it is just easier to stay in bed, not do anything, and just feel like hell. Things just move backward. [Now the team comes] and put pills in your mouth, so you are covered…

Other interview participants described how the beneficial effects of outreach OAT had on the difficulties they experienced when using public transport when having withdrawal symptoms or while being intoxicated:

Yes, dammit, it suits me fine that I don’t have to go out somewhere too (…) Then you have to be there at 9 am or after 1 pm, but then you have to sit [on the bus] with all those normal people, or who aren’t on drugs, and it’s just the most embarrassing thing, I think (…). You have to sit with them, and people can see that you are all fucked up on crack and… I think it is humiliating. So, I think it is good that they come [home to me] (woman, 43 years old).

As the quote illustrates, having OAT administered in her home environment impacted both time and geographic barriers as well as the stigmatizing experience of traveling to the drug treatment center.

Most participants recounted the positive effects of the increased flexibility of outreach OAT. An exception was one participant who found it particularly difficult to comply with appointments and meetings and dropped out of outreach OAT when he failed to be present at the shelter where he resided when the OAT team came to administer his medication.

Finally, the opportunity for outreach treatment decreased the time people had to wait to begin drug treatment. As mentioned above, municipalities must offer treatment within two weeks after a person has requested it. Yet although municipalities strive to offer ‘immediate treatment,’ this is not always available in practice, as if a client is thought to have taken opioids. Meeting clients in their own environment in the morning, before they had consumed illegal drugs, meant that this obstacle would be removed. In another interview, a woman who talked at length about her lack of trust in the established OAT system described her surprise at the speed with which she and her partner could begin treatment in the outreach service:

So we got up there [to the drug treatment center] 14 days ago, and we come into the doctor; it’s a new doctor I talk with up there who says that there’s some kind of another offer if we want to do that, and that was this offer. But not a damn thing will come out of it, and we know that. So we dropped it and didn’t count on there being anything. And then they write to me on the Friday that he could come home to me and increase my dose’, if we wanted that. We thought it was bullshit, man; I mean, we thought it was bullshit. (…) and then they just stood there already, on the Monday, I think (woman, 43).

As the quote further illustrates, past negative experiences with OAT services impacted clients’ expectations of new treatment offers. In the following, we look closer at the effects of outreach OAT on the social barriers to treatment.

Reducing social barriers

Shifting OAT from the frame of drug treatment center settings to clients’ home environments had additional positive effects, as described by research participants. Above, we have seen how strained relations with other users and relations with the staff an obstacle for some interviewees had been. One interview participant stopped going to his treatment center because he had conflicts with other users, and a couple walked away from treatment, after all, they got into a dispute with a doctor about medicine. Being met in their own environment, often in their own homes, meant that their experience of OAT could be undisturbed by the presence of other people who use drugs. It also meant that some of the things related to procedures for treatment start-up and dosing could be more flexible and less unpleasant. For example, being observed for one hour to prevent overdose was not described as unpleasant when it happened in one’s own environment. Quite the contrary, several interviewees described the time spent with a team member from the outreach OAT as a new, more pleasant way of interacting with treatment professionals. In some of the interviews, the users talked about how being met in their own homes, where the outreach staff would stay for one hour to observe the effects of the medicine, would create a new way of interacting. As mentioned earlier in Danish OAT today, social treatment is not a requirement. This makes it possible for people to have their medical treatment, which benefits some because they do not want social workers involved in their lives. But for others, it can be a problem because it means that they must express a wish or a need for social treatment if they want it so the most marginalized users risk going without social treatment. Several participants described how having OAT administered in their home environment positively affected this barrier. One interviewee described the difference between interacting with staff at a treatment center in the following way:

They talk with us, like ‘How are you’ and blah, blah, blah, you know, superficial. They don’t really go into the person. I think that is bad. (…) Like looking at the person and kind of assessing where they are at, if they are doing fine. Because we (users) tend to say, ‘Well, I am fine’ when we feel like shit. (woman 49 years old).

She further described the contrasting experience of interacting with the outreach team:

They are nice. They take care of us. They ask how we are, and even if we say that we are fine, they ‘go into us,’ come… They are just… The doctor is fantastic; he listens to what we say and takes it seriously. (…) It is not superficial. You can talk with them about what you really want from your treatment, what you really want if you want to go on, or if you want to try something else. (woman 49 years old).

Arguably, this shift, described by several research participants, owed less to staff than to shifting the treatment setting to their home environment. A man who had been able to tend to his OAT treatment at a center told us that he was experiencing a difficult time, possibly a depression. For this reason, he found it difficult to go to the treatment center and had been referred to the outreach team. He explained that being met in his home created new opportunities to talk about his situation with treatment staff:

Also, the thing that they come home to you (…) Also because I’m in a tough period of time lately, so it’s a big help that they bother showing up and delivering my medicine and that you can just have a chat if something is up (man, 48)

Such conversations allowed service providers to act on other pressing needs. The medical staff could refer to the social workers in the team, and the team members could also make contact and collaborate with social workers and health care professionals from other services. Following the team when we went to do the interviews, we saw several examples of this. In one case, a woman who had mental health problems wanted to be transferred from the shelter where she lived to another shelter because her current shelter had many active drug users and an unruly atmosphere. We observed how the outreach team members collaborated with the shelter staff to set up a meeting with the authorities that should make the referral to another shelter and prepare the woman for the meeting.

Limitations

The results of the research presented here have some limitations that must be mentioned. First, recruitment of interviewees was not done directly by the researchers, but via the program employees. This can have introduced a bias in the results because certain types of informants may have been contacted to hear if they wanted to participate in an interview. In our discussions with the program employees this has not been mentioned. Rather, practical, and logistical issues concerning when and where to do interviews seemed to be most important. Secondly, during some of the interviews program employees were present during the interview, in other cases the program employees were present somewhere else in the apartment of the interviewees, and sometimes program employees would also leave during the interview and return later. This could also introduce a source of bias in the interviews.

Discussion

Several conclusions follow from the findings presented above. The informants described several barriers that made it difficult for them to access and sustain OAT. The barriers were systemic, social, and affective, and they sometimes intersected to make OAT participation difficult for the informants. The barriers included mobility constraints, which could quite literally involve being unable to transport oneself to a treatment offer because of physical mobility problems. However, mobility barriers could also involve subjectively experiencing the distance to a treatment offer as difficult to manage, sometimes because of experiences of stigmatization when using public transport while having withdrawal symptoms. Another mobility barrier involved drug scene entrenchment where the need to ‘take care of business’ (Preble & Casey, 1969) – generating money, buying, and using drugs – does not leave many resources to access treatment. These findings are in line with the research literature. Some studies show that geographical distance can affect treatment adherence, although this mostly concerns treatment uptake in rural settings (Amiri et al., 2018; Pijl et al., 2022). However, the research literature has also shown how being entrenched in a drug scene and, more generally, living a marginalized existence can make survival and management of such a life the main priority (Coumans et al., 2006; Fast et al., 2009). Related to some of these mobility barriers were time-related barriers. Entrenchment in a drug scene, being caught in a need to ‘take care of business’ (Grapendaal & Nelen, 1995; Preble & Casey, 1969), waking up with withdrawal symptoms and need to procure drugs or being able to get out of bed, being awake at night and sleeping during the day, etc. could make synchronization with treatment offers’ opening hours difficult. But time-related barriers could also be related to mental health and cognitive challenges, including anxiety triggered by having to keep appointments with a treatment offer and ‘distractions’ leading to clients forgetting an appointment. Such challenges became barriers when intersecting with systemic dimensions such as opening hours and medical regulations such as ‘the three-day rule.’ Invoking the concepts introduced earlier, outreach OAT cannot be said to reduce ‘treatment accessibility thresholds’ (Kourounis et al., 2016) because it is more restrictive than standard OAT as clients need to be referred by another treatment offer, health service, or social service and admission is dependent on the assessment of the treatment team. With regards to ‘treatment design thresholds,’ on the other hand, outreach OAT is less restrictive by being less difficult for clients to adhere to than standard OAT. Outreach OAT also minimizes or removes social barriers related to meeting other people who use drugs at treatment institutions and hence distancing oneself from drug scenes. More generally, outreach OAT can be seen to contribute to changing important time-space dimensions of OAT, increasing the possibility of synchronizing treatment with the rhythms of the clients’ everyday lives (Andersen & Bengtsson, 2019). As further argued by Hughes, time horizons are ‘fundamentally spatialized’ so that people who use drugs may experience needs relating to time and place as ‘diametrically opposed to those underpinning service location and provision’ (Hughes 2007, 686). In Copenhagen, as elsewhere, treatment services are typically located further away from clients’ everyday lives than places to buy and use drugs, which may impact decisions on whether to seek out as well as remain in substitution treatment. This is, however, only partly true because shelters, where some of the clients live, are, in many cases, active drug scenes. However, we also saw that for some ‘street-entrenched’ (Fast et al. 2009) clients, the loosening of admission and treatment regulations offered in the outreach service could still be insufficient to sustain their OAT treatment.

Apart from better synchronization of treatment and reducing treatment accessibility and design thresholds, outreach OAT can also be seen to reduce important social barriers that can occur when receiving treatment in a treatment institution. By visiting clients and performing treatment in their own environment, a more flexible treatment became possible regarding the rules that regulate OAT in Denmark. In outreach OAT, stabilization could be done faster because the outreach treatment professionals would stay one hour daily in the clients’ environments when the dose was increased. Relatedly, it also removed intersecting systemic, social, and affective barriers by creating a treatment space where the clients felt less controlled and disempowered and more on equal terms because the treatment staff visited them in their own environment. Treatment in the clients’ own environment can also be seen to improve possibilities to enact care. Thus, both in the informants’ accounts and through our observations when visiting the informants with the treatment professionals it was clear that the one-on-one relationship in the informants’ homes opened for some of the essential dimensions of care. This included attention to more general needs and the clients’ living conditions other than OAT, taking responsibility for acting in relation to such needs, and reciprocal responsiveness between caregiver and care-receiver (Tronto, 1998). In recent years, a debate has arisen about the role of social care in harm reduction in addition to its public health dimensions. It can be argued that paying attention to how ‘spaces of care’ (Conradson, 2003) can be made would be an important part of such efforts, and outreach OST or other outreach services could play a role in this.

Conclusion

COVID-19 created an urgent need to recruit and keep people who use drugs in OAT because it was a way not only to treat drug dependence but also to prevent the spread of the virus. Against this background, many places have seen innovation in how OAT is provided, innovations that have reduced barriers to access and remain in treatment (Krawczyk et al., 2021). In Copenhagen, this involved establishing outreach OAT at the open drug scene, something that NGOs and professionals had been working towards for some time but which COVID-19 suddenly made possible. Experiences from implementing outreach OAT indicate that it can reduce some barriers to accessing and remaining in OAT. As we have shown in this article, this involves the reduction of systemic, social, and affective barriers, that is, barriers related to system design, social interaction, and the feelings and emotions that treatment and treatment institutions can invoke. Of particular importance is how outreach OAT has shown a way to reduce systemic barriers caused by treatment design, such as the location of treatment settings, opening hours, and rules and guidelines governing medical treatment. Moreover, outreach OAT has shown that it is possible to provide treatment for people who are entrenched in drug scenes and experience existing system designs as significant barriers. Outreach OAT may not be the only way to reduce barriers related to system accessibility and system design barriers. Changing existing treatment offers and guidelines and establishing new, more flexible treatment offers and guidelines could also contribute. However, we also see a role in outreach to OAT, particularly for the most marginalized people who use drugs.

Disclosure statement

The authors report there are no competing interests to declare.

Additional information

Funding

No funding was received.