Benefits and Barriers: A Rapid-Ethnographic Study on the Perspectives of Potential and Actual Clients of Athens’ Drug Consumption Room

Benefits and Barriers: A Rapid-Ethnographic Study on the Perspectives of Potential and Actual Clients of Athens’ Drug Consumption Room | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Benefits and Barriers: A Rapid-Ethnographic Study on the Perspectives of Potential and Actual Clients of Athens’ Drug Consumption Room Benjamin D. Scher, Nikolaos Poulopoulos, Christos Anastasiou, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6555632/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Jan, 2026 Read the published version in Harm Reduction Journal → Version 1 posted 9 You are reading this latest preprint version Abstract Background In April 2022, a new Drug Consumption Room (DCR) opened in Athens’ city centre. To date, no qualitative research has evaluated the operational strengths and weaknesses of the site from the viewpoint of DCR clients and people who use drugs locally in public settings and do not access the DCR. Methods Rapid-ethnographic fieldwork was conducted over a seven-week period. This comprised an initial five-week period of non-participant observation (≈200 hours) followed by a community consultation regarding the research design and question protocols. Qualitative data were then collected through five focus groups with 24 regular DCR clients and 25 street-based interviews with non-DCR clients who consume drugs in public settings. Results Regular DCR clients reported increased physical, structural, and emotional safety and increased connection with auxiliary health and social services and staff and peers. Those who did not use the facility could see potential benefits but noted several operational and contextual barriers. These results are presented through three themes (1) Safety, (2) Connection and (3) Barriers, each with several sub-themes. Conclusion Addressing DCR barriers could increase service access, reduce the presence and visibility of public drug use and improve public health outcomes for people who use drugs in Athens. Indeed, some of these barriers have been addressed since the research was conducted (eg., by expanding operating hours, increasing the number of staff with lived experience, offering on-site drug checking), illustrating the value of evaluating the efficacy of a DCR from the perspective of actual and potential clients. Introduction Athens experienced severe social and economic impacts from the 2010 global financial crisis (Panori & Psycharis, 2018). This led to a sharp increase in numbers of people living in poverty, urban homelessness, and rates of HIV (Arapoglou & Gounis, 2017; Syspa et al., 2015). Despite harm reduction interventions being scaled up during the HIV outbreak of 2011 (Flountzi et al., 2022), Athens continues to face challenges, including a new surge in HIV cases linked to difficulties in delivering HIV prevention, including a lack of needle and syringe coverage during the COVID-19 pandemic and limited urban social housing (Roussos et al., 2020; Sypsa et al., 2023). People experiencing homelessness in Athens also frequently face food and hygiene insecurity (Sypsa et al., 2020). In April 2022, a policy window shaped by the urgency of safeguarding vulnerable populations during the COVID-19 pandemic (Rigioni & Tammi, 2024), led to the expansion of several progressive drug and housing interventions, including: 1) the expansion of the city’s housing first programs, 2) the liberalization and expansion of national naloxone policy and 3) the opening of a drug consumption room (DCR). Nine years after the closure of Athens’ first DCR site (Harm Reduction International, 2022), and now with support from national and local level politicians (Southwell et al., 2022), OKANA, who operate and oversee most of Greece’s drug services, opened a DCR. In addition to overdose supervision and response, the site, called Steki 46, provides a range of on-site services as well as a robust off-site referral system for auxiliary health and social care programs. Like many DCRs globally (Shorter et al., 2023), the primary aims of Steki 46 are to prevent and intervene in overdoses, provide harm reduction advice, provide sterile equipment and offer on-site primary healthcare, mental health services and social services or refer off-site (see Methods for more information on the DCR). As secondary aims, the DCR also works to reduce public drug consumption and drug-related litter in the community (Kennedy et al., 2017). In Athens, the facility also acts as the hub for OKANA’s outreach team which operates across the city. The aim of this study was to conduct a rapid-ethnographic evaluation to provide immediate policy recommendations to OKANA on how to build on the strengths of the service and expand access. Most DCR evaluations rely on service user perspectives; here, we seek to expand understanding of the experiences and potential barriers faced by those who could benefit from the service yet do not access it (Urbanik & Greene, 2021). To develop a holistic understanding of Steki 46’s model of operation and service design, we captured a range of perspectives, including: 1) people who regularly attend the DCR, 2) people who use drugs locally who do not access the service and 3) DCR staff. In this paper, we analyse the perspectives of DCR users and DCR non-users. The perspectives of staff will be reported elsewhere. Methods Study Setting This study took place at the Athens DCR and in the immediately surrounding neighbourhoods. This DCR is a medicalised model, with on-site GP, nurses, psychologists, counsellors and social workers to offer wrap-around support. On the ground floor there are twelve injecting booths and an inhalation room with space for four people. The ground floor has a medical room for the on-site doctor, a kitchen, toilets, washing machines, showers and a courtyard garden for clients. On the second floor of the building there is a common room with board games, cards games, TVs, meeting rooms, a kitchen from which food is distributed to clients throughout the day, a cold-water station, a coffee machine, and offices for the on-site social workers, pro-bono legal workers, employment assistance staff. The third floor has more offices for the various professional staff and the fourth floor is the central hub and main office of the ‘streetwork’ outreach team who use the building as a base for outreach trips throughout the day, across the city. Observations and fieldwork occurred throughout the building, with client focus groups and staff interviews taking place on the second floor. Interviews with people who did not access the service but used drugs in public occurred in street-based settings. These interviews were conducted in three separate open-air drug scenes, in locations where the ‘streetwork’ team conducted their outreach activities. These tended to be alleyways and urban parks with a high density of people consuming drugs. These locations were all within 500m-2km radius of the DCR. Rapid-Ethnographic Approach This study used a rapid-ethnographic approach. Rapid-ethnography is defined by four distinctive characteristics (Vindrola-Padros, 2018): (1) the research must be carried out over a short, compressed or intensive period of time; (2) the research captures relevant social, cultural and behavioural qualitative data and is focused on human experiences, perspectives and practices; (3) the research engages with anthropological and other social science theories promoting reflexivity and (4) data must be collected from multiple sources (various stakeholders implicated in the topic of focus), using multiple modes of data collection and is triangulated during analysis. The strengths of this approach lie in its ability to produce research with a “nuanced understanding of lived experiences while prioritizing efforts to rapidly inform interventions and decisions that address urgent health and social issues” (Collins et al., 2020, p.384). Overview of Methods The methods of data collection were chosen specifically for their ability to rapidly observe and capture the ways in which clients as well as those who do not use the DCR, view and engage with the service. Data collection comprised seven weeks of fieldwork, including: 1) a community consultation, 2) five weeks (≈200 hours) of participant observation and fieldnotes within the DCR, 3) focus groups with regular clients, 4) informal street-based rapid-ethnographic interviews with people who do not use the service and 5) semi-structured interviews with staff and management (which will be reported elsewhere). Research Team and Partnerships This study was conducted as part of the doctoral work of ANONYMIZED, with fieldwork led by ANONYMIZED, a graduate student in addiction studies at the University of Athens and ANONYMIZED, project manager with the European Network of People Who Use Drugs and the Greece based Peer Network of Users of Psychoactive Substances. Both researchers are local to Athens and ANONYMIZED has a deep knowledge of the local community and environment. ANONYMIZED has lived and living experience of drug use and utilization of harm reduction and OST services in Athens and has worked as a peer researcher on several other related projects. ANONYMIZED, ANONYMIZED and ANONYMIZED supervised the project, supporting design and analysis off site, meeting regularly with the research team. Recruitment and Sampling Recruitment for focus groups was done through a combination of snowball and purposeful sampling (Naderifar et al., 2017). During the initial five weeks of participant observation ANONYMIZED immersed himself within the day-to-day operations of the DCR, on the ground floor and second floor (consumption and post-consumption spaces). During this period, he built rapport with clients and discussed the scope of the project and upcoming focus group dates with eligible participants. People who signed up were encouraged to discuss the study with eligible members of their peer network. Eligibility was defined as: 1) aged 18+ years 2) used the DCR regularly, 3) provided informed consent and 4) could speak Greek. Participants in the street-based interviews were approached by ANONYMIZED who introduced the project to them. Those who wished to take part would move to a private location. ANONYMIZED would then conduct the interview. Interview eligibility matched focus groups. Additionally, participants had to have experience of consuming drugs in local public and or/semi-public environments. Community Consultation, Data Collection and Compensation Following the five-week period of participant observation, ANONYMIZED led a consultation with six DCR clients. Here, the group discussed the research design and question protocols, and feedback was sought to develop the questions alongside the aims of the study, and to be trauma informed in line with best practice (Dickert & Sugarman, 2005). Rapid-ethnographic data collection was conducted over the final two-week period. Typically, in the morning we conducted a focus group and, in the afternoon, would accompany the ‘streetwork’ outreach team to conduct street-based interviews before returning to conduct 1-3 staff interviews. Multiple methods of qualitative data collection afforded triangulation of findings (Malina et al., 2011). Five focus groups were conducted which lasted 40-60 mins and contained four to six people per group (total n=24). Participants were aged 30-56 years (Mean=44; SD=6.4). One participant self-identified as Black, two preferred not to say, 22 self-identified as White. There were 7 females and 18 males, 9 were housed, 4 in temporary or emergency shelter accommodation and 11 self-identified as unhoused. The question protocol was semi-structured, and participants were asked questions related to their experiences using the DCR, their views on operational policies and if they would add to or change anything about the services on offer within the facility. These included questions such as: “How often and why do you come to the DCR?”, “How would you describe your relationship with staff?”, “Which services within the facility do you tend to use?” and “Has the DCR impacted your life beyond the immediate harm reduction benefits of consuming drugs whilst supervised?”. Participants were recruited from the DCR by ANONYMIZED and ANONYMIZED, who would then accompany them upstairs to the private meeting room. Once the team had the desired number of people, ANONYMIZED explained the scope of the project, assisted people in completing the consent forms and demographic questionnaires. NP then conducted each focus group and ensured that the session was audio recorded for subsequent transcription and translation. Snacks, coffee, and soft drinks were provided during the sessions. Ethnographic street-based interviews were conducted by ANONYMIZED, who took handwritten fieldnotes and wrote down verbatim quotes of importance. These quotes were then read back to participants at the end of interviews to make sure they accurately reflected the conversation. Interviews were semi-structured and followed a question protocol relating to their experiences of street-based drug use, their perceptions of the DCR and rationale for not using it. Questions included: “How would you describe your experiences of using drugs in locations like this?”, “Have you heard of the DCR, if so, what are your views on the facility?”, “Do you ever attend the facility, if not, why?”. These interviews lasted between 5 and 15 minutes. To support anonymity, no names were taken and we only gathered gender information. Participants in the community consultation/focus groups received €15 reimbursement; those participating in a street-based interview received €10. Ethics Ethical approval for this study was granted by the ANONYMIZED on 11/03/2023 reference ANONYMIZED as well as internal ethical approval from OKANA. The approved, anonymised ethics protocol is hosted on the Open Science Framework (DOI ANONYMIZED). OKANA also provided logistical support through: 1) office space for focus groups, 2) snacks and drinks for clients during the sessions, 3) safeguarding support for street-based interviews. During focus groups and street-based interviews, staff were not present and could not hear what was being said. All participants gave written consent. It is also important to not that the overall ethical approach of this study was strongly informed by the authors varied prior research experience with similar populations as well as ANONYMIZED experience both as a member of and experience conducting research with this population group. Ethical questions and trade-offs were frequently considered by the research team in a way which specific to this particular study context and participant group. Data Analysis Data analysis comprised of the Braun & Clarke (2006) six stage reflexive thematic analysis, commencing with a process of familiarization with the data, whereby ANONYMIZED and ANONYMIZED read transcripts and fieldnotes, wrote analytic memos and collectively developed a thematic codebook to work systematically through the data, identifying relevant and meaningful information related to the research questions, as well as novel concepts inductively. These codes were then reviewed by ANONYMIZED, ANONYMIZED, ANONYMIZED and ANONYMIZED who refined and challenged the initial coding process until all the data were systematically organized into a final coding framework (Braun & Clarke, 2023). Results Following the coding of transcripts, three central themes emerged, each with several sub-themes related to the perceived and experienced benefits and barriers of the Athens DCR. Themes incorporate the views of both daily DCR service users and people who use drugs in public, street-based settings, or a combination of the two (see Table 1). Table 1: Themes and sub-themes of the views of people who use drugs (who do and do not use the Athens DCR) Theme Sub-Theme 1. Safety 1.1. Physical safety 1.2. Structural safety from police and criminalization 1.3 Safety from stigma and desire for privacy 2. Connection 2.1. Access to basic necessities 2.2. Built relationships in the DCR 3. Barriers 3.1. Stigma 3.2. Operational barriers 3.3. Physical barriers 1. Safety 1.1. Physical safety Participants regularly contrasted the environment of the DCR to that of the ‘piazzas’, the local term for open-air drug scenes. This comparison often centred around the physical safety afforded by the DCR, as highlighted by one participant who described the sense of relief experienced when accessing the service: “The benefits, well it is a breath of fresh air away from the road, from the piazza, it’s a safe place.” (Regular DCR Client, White, Male, 40-45 yrs, Housed) Expanding on this, another participant described how the DCR offers respite for people who use drugs and experience homelessness: “ It is a place that provides security. Many younger people without shelter cannot sleep at night. They run all night right and left and come here during the day, they use early [in the day] and many times after using you see them get sleepy. They're tired, they're finished, and you see them come over here and look to get a little sleep...in a sheltered space they know won't take away their things.” (Regular DCR Client 2, White, Male, 40-45 yrs, Unhoused) The ability to rest without fear of being robbed was seen as a significant benefit. This was reiterated by non-DCR users: “Over there, there is security, while out on the street there is none and you can be easily robbed.” (Non-DCR User, Interviewee 8, Male). Alongside providing a safe environment, the knowledge there would be a swift medical response to keep people alive during an overdose was commonly cited as a primary benefit and reason they attended the DCR: “You know that there are doctors here so there is no chance of you dying.” (Regular DCR Client, Black, Male, 45-50 yrs, Unhoused) “When something happens to me they [staff] are there to help me. [Even] just watching me, I feel safe.” (Regular DCR Client, White, Male, 35-40 yrs, Unhoused) The non-verbal reassurance provided by the presence of staff, even when no intervention was needed, was a vital aspect of participants’ sense of security and trust in staff. Safety was also discussed beyond that of physical safety, with this participant associating safety with the harm reduction equipment available within the DCR: “With the scanner I can see the veins that are to be punctured. This is very helpful.” (Non-DCR User, Interviewee 21, Male) Despite street-based interview participants not accessing the DCR, there was a general awareness and understanding of the ways in which the DCR would offer increased safety from overdose, theft, and injection-related harms. 1.2. Structural safety from police and criminalization For many, protection from police apprehension and the risk of criminalization was a key motivator for attending the DCR: “The fact that there is a place...where we will not be bothered by the Law is a good thing...it is a place where I can use without the constant fear of the police.” (Regular DCR Client, White, Female, 35-40 yrs, Housed) Supporting this statement, this participant described how the fear and anxiety of police harassment and rushing the injection process to avoid police detection lead to physical injuries. Such injuries are rare when an individual can take their time in the DCR: “The benefit is that you're not being chased by the police, the stress of use especially if it's intravenous and you see the cops in front,you can easily do something wrong, as I suffered. I put a pinch of sisha [methamphetamine] together and then saw the cops in front of me [and rushed]...I have had an abscess from that which is still slowly recovering.” (Regular DCR Client, White, Male, 35-40 yrs, Unhoused) Mistrust of the police also related to whether they would respond appropriately in the event of an overdose: “This is where the DCR is needed because when something happens inside, staff will...help you…if I’m outside, I don't know if the police will call the ambulance.” (Regular DCR Client, White, Male, 35-40 yrs, Temporary Shelter Accommodation) Police were perceived not to prioritize the health and safety of people who use drugs. This fear extended to various other aspects of criminalization such as arrest or processing through the courts, which would also have implications such as the confiscation of drugs, and potential withdrawal: “The security you get here is that you will not be taken to court, your fix will not be taken. You don't know how much I...do to get my dose, and then it just gets taken away.” (Regular DCR Client, White, Male, 50-55 yrs, Unhoused) In contrast, many expressed a sense of relief knowing they could use the DCR without fear of arrest or harassment, specifically contrasting interactions with police (and other community members) to those they experienced with staff: “There you feel safe from the residents and from the police. There I can ask about medical problems and they treat us like human beings.” (Non-DCR User, Interviewee 15, Female) 1.3. Safety from Stigma and Desire for Privacy There was agreement from regular clients that by ensuring privacy, the DCR provided emotional safety from stigma; there is respect and dignity not often experienced in public settings and everyday encounters with the public. Contrasting the privacy offered within the service, this participant described feelings of shame and emotional discomfort experienced when using drugs in public settings: “For me I come here [because] I don't like to use on the street. I don't want everyone who passes by to see me.” (Regular DCR Client, Black, Male, 45-50 yrs, Unhoused) Participants described the relief of not using in public and particularly how the DCR helped reduce the visibility of drug use in public, particularly around children: “Children now don't have to see me. I…come and do it [use drugs] here because otherwise I do it on the sidewalk. Imagine being with your child...and explaining to them what that is, having that bad conversation.” (Regular DCR Client, White, Male, 45-50 yrs, Temporary Shelter Accommodation) “I come here in the morning hours more. Why? Because I'm on the street and homeless I can't sit out on the step, because the police are pushing me away, the shops are kicking me of their steps...especially now with tourists. In the morning, when the whole world is out and about kicking me out...I'm ashamed, so I see this place as a shelter to hang out, to take some time to myself and drink some coffee. (Regular DCR Client, White, Male, 40-45 yrs, Unhoused) These dual perspectives, where participants reflected both on their personal relief of no longer using in public spaces and exposed to ill-treatment from the public, and the broader benefits for the community in the reduction of public drug use, demonstrates how the DCR generates important benefits for the whole community, in particular shielding others (eg., children) from visible drug use. 2. Connection 2.1. Access to basic necessities When asked what they valued at Steki 46, service users highlighted the tangible benefits to their daily lives through access to auxiliary services, food, hygiene facilities and others which provide basic necessities: “It is the clean space, medical care and toilets, because I am homeless [and] the main problem is [accessing] toilets. The bathroom, the washing machine…the supervision of the doctor is a bonus on top of that. It all helps immensely. Also, the referrals to the hospital, to legal aid…they all help.” (Regular DCR Client, White, Male, N/A yrs, Temporary Shelter Accommodation) Many who participated in focus groups were either in situations of homelessness and/or severe financial precarity. In this context, the provision of regular snacks, sandwiches, coffee, and other donated meals was an essential resource: “This is a very big help. Coffee for example…finances are difficult, [this] is what will make the most difference to the people outside. Some days when I am broke, it really helps me to come and eat a cheese pie…lunch food not just snacks.” (Regular DCR Client, White, Male, 40-45 yrs, Housed) For individuals without a stable income, items like coffee or a sandwich made a meaningful impact. For individuals with pre-existing health conditions such as diabetes, access to food at the DCR was both a convenience and a necessity for their well-being. One participant reflected on how the staff ensured he received this support: “[I am diabetic], when my blood sugar drops they give me something sweet. They make sure I…stay safe. I really like that. The people here help immensely…I am pleased to be a member here.” (Regular DCR Client, White, Male, N/A yrs, Temporary Shelter Accommodation) These essential provisions contributed to service users’ perception of care and belonging within the DCR, highlighted by this participants description of themselves as a ‘member’, a term encompassing a sense of belonging to the service. Whilst many began by describing the immediate, practical benefits of these auxiliary services, their accounts frequently expanded to encompass the more formal, institutionalized care they were able to access through support by DCR staff: “For so many years I couldn't cut down, but the guys that work here helped me. They also encouraged me into a treatment program....this place has made me realise that I can really make an effort to escape this life.” (Regular DCR Client, White, Male, 40-45 yrs, Unhoused) DCR staff supported participants’ personal efforts toward change, particularly in relation to drug treatment. Previously dismissed as unattainable or unappealing by many clients, the DCR was a place where the idea of recovery, or at least reducing or making healthier choices around their drug use, became a tangible goal. 2.2. Building relationships in the DCR Many participants described the positive social connections created in the facility. Field notes captured how only half an hour from when the DCR would open in the morning, the second-floor lounge was nearly always busy with clients watching TV, playing cards, and Tavli (Greek backgammon) with staff and clients having coffee and cigarettes on the balconies. Engaging in activities with peers and staff had positive effects, including alleviating boredom, described as a common trigger for substance use: “Here you will find other people to socialize with...do other things that fill up your time because many times you drink or use drugs out of boredom.” (Regular DCR Client, White, Male, 50-55 yrs, Housed) Many regular attendees also described positive relationships with staff in the context of them connecting clients to services as well as the care and respect they exemplified when working with clients: “In the beginning, I wondered about why it exists, but there happened to be a girl, a member of staff, who showed great interest [in me] …She helped me to deal with anything I needed, from benefits to whether I was interested in going into a detox program.” (Regular DCR Client, White, Male, 30-35 yrs, Unhoused) The ability of staff members to guide clients through complex service systems, whether related to benefits, healthcare, detox or drug treatment programs, was a frequent theme in participants' accounts. The positive impact of these interactions is further described by this participant: “I got my ID through the DCR with the social worker, she was very helpful. She is much more helpful than if I would have gone alone to the office…that’s another good thing…when there is someone in front of you who...sees that you know someone [a member of staff], everybody behaves a lot differently. Because they are very...discriminatory towards us in hospitals…we are not taken seriously.” (Regular DCR Client, White, Male, 50-55 yrs, Housed) This description of staff advocacy underscores the critical role played by staff in addressing the broader social inequalities that affect clients’ ability to access wider health and social services. Participants described how staff with lived experience were particularly effective in communicating with clients and addressing their needs: “The staff are very flexible, there are also ex-users and this plays a big role. They understand us even better and are very flexible with us and polite.” (Regular DCR Client, White, Male, 40-45 yrs, Housed) Supportive staff played an important role in clients' ability to access services, feel respected in potentially hostile environments, and establish a sense of trust with the facility. For many, these positive relationships were central to their continued engagement. 3. Barriers 3.1. Stigma For some, the formality of the DCR, combined with concerns about being judged, deterred them, as noted by this participant: “They feel more at home in the piazza. They feel like they are being mocked or feel a bit uncomfortable [in the DCR].” (Regular DCR Client, White, Male, 35-40 yrs, Unhoused) For individuals who feel more at ease in the less regulated space of the piazza, the transition to the DCR, which can appear more clinical or formal, may exacerbate feelings of alienation: “I consider the space like a dentist’s office...that doesn't work for me.” (Non-DCR user, Interviewee 9, Male). This participant for instance who now attends the service regularly, recalled how “What was difficult...was actually showing the drugs at first”. (Regular DCR Client, White, Male, 35-40 yrs, Unhoused) The act of presenting drugs for consumption in a supervised setting can evoke vulnerability and anxiety, as people using the facility may fear judgment from staff or peers; and it diverges from street-based practices where drugs are hidden. This sentiment was corroborated by a participant who highlighted the sense of isolation, combined with feelings of apprehension about entering an unfamiliar space without peer support: “I don't know anyone there and I don't feel comfortable going alone.” (Non-DCR User, Interviewee 3, Male). 3.2. Operational barriers The overarching system of surveillance in the DCR, though for the purpose of reducing and responding to risk (e.g., overdose response), was acknowledged by many through comments such as: “in the DCR there is surveillance” (Non-DCR User, Interviewee 3, Male) and created discomfort for some people. A concern voiced by several participants was the feeling of being watched, either by staff or through cameras when using drugs: “There is the fear that there are cameras watching me there, I would like there to not be any.” (Non-DCR User, Interviewee 23, Male) This system of surveillance and risk reduction extended to specific moments within the intake and consumption process. For example, people who did not use the service cited the length of time from arrival at the facility to when you can consume drugs as a significant barrier. These experiences were again framed within the context of the unpleasant experiences of withdrawal: “I have been once and only once. It is a time-consuming process. When I'm...going through withdrawals or very high I don't feel like spending it [time] there.” (Non-DCR User, Interviewee 18, Male) The need for immediate relief, and time for the structured intake process to occur was described as a clear barrier to service engagement. Attendees valued the medical care provision, however, for some, the time spent checking in with a doctor each time they wished to use the site was additionally a barrier: “When you are sick, you don’t have the time to do paperwork, to see a doctor or any of those things, you don’t have time for that.” (Non-DCR User, Interviewee 6, Female) The waiting was particularly challenging when experiencing intense withdrawal symptoms as some clients presenting to the service experienced. While medical oversight is a core feature of the DCR, these experiences highlight how it may not serve the immediate needs of their client group. There was also some identified differences in the DCR compared to the street: “Not everyone can fit into one mold, workers can't understand users. I…enter and they ask me what substance I have on me. I often use with my friends by doing small transactions but inside they don’t let us do any transactions or share. It is very different to how we would use on the street.” (Non-DCR User, Interviewee 12, Male) “In the DCR there are many limits, there is surveillance, documents that you have to fill out. While on the street there are no limits, no rules” (Non-DCR User, Interviewee 3, Male) These participants explain how the DCR environment did not mirror socially driven consumption practices, habits, or rituals that people were able to practice in other environments, particularly in relation to sharing or exchanging drugs, a sentiment echoed by others who found that restrictions around mutual aid, such as being able to inject or assist a friend during consumption, was a reason for service avoidance: “I've went when it first opened. Often the ones who don’t want to go, it's because here in the square or on the street there is more help. There [the DCR]...your friend cannot inject you, while here...people can do things like that.” (Non-DCR User, Interviewee 19, Female) Beyond these social dynamics of drug use, certain higher-risk injection practices were not permitted, resulting in continued use within public environments where such injecting practices were not controlled or managed: “Over there, it is forbidden to shoot in the neck or the artery. One may not want to go there because it is forbidden.” (Non-DCR User, Interviewee 10, Female) One final and notable operational barrier which was discussed was the service restriction for people who were in opioid substitution treatment programs (OST). This was observed during the ethnographic fieldwork and noted by this participant: “Many users do not come because...if you are in an OST program you cannot come to use.” (Regular DCR Client, White, Male, 50-55 yrs, Unhoused) Someone who uses drugs in public settings explained they are now disqualified from accessing the DCR despite having built important relationships with members of staff: “The staff there are like my family looking after me. But since i'm in a substitution program I can't go there...it's forbidden.” (Non-DCR User, Interviewee 20, Male) The sense of disconnection experienced by this participant highlights how important the social aspect of the DCR can be for individuals who may otherwise be socially marginalised. 3.3. Physical barriers Despite the many benefits which framed beliefs around why people attend or should attend the DCR, several physical barriers were described. Distance was perceived as an important factor which may dissuade people from attending: “I, [live] by Victoria square which is ten minutes away, but for someone who lives far away I don’t think they will come to the DCR. So it would be good if more existed.” (Regular DCR Client, White, Female, 45-50 yrs, Unhoused) For individuals interviewed in public settings, the urgency and necessity to alleviate the withdrawal symptoms of drug dependence was often cited as the primary reason for not being able to commute long distances once they were possession of substances: “If I am sick [from withdrawal], I use in the first place that I can find…if I am sick I will use anywhere...500m seems like 500km when you are sick” (Non-DCR User, Interviewee 6, Female) Additionally, regular attendees identified a lack of awareness amongst the local population of people who use drugs as a barrier to the service. Participants explained that beyond simply knowing about the service, people needed to be given a better understanding of exactly what takes place at the DCR and assurances they would be comfortable in that environment: “A lot don't even know about it, they might have heard it as an idea, but they haven't come to see for themselves. It would be great if one day staff came to pick them up to take them…or [came] to show them pictures of the DCR at the piazza. They should invite them...they are suspicious and don’t dare to take the step to come over here and see.” (Regular DCR Client, White, Female, 40-45 yrs, Housed) “When you are homeless, you generally have a lot of phobias, that's why people can be suspicious. Especially to give one’s name, for it to be written down, even during intake people may wonder, why do they want to see the drugs I have?” (White, Male, 45-50 yrs, Temporary Shelter Accommodation) These reflections underscore the notion that simply having a service available is not enough; active outreach is necessary to break down the barriers of suspicion and unfamiliarity. When we interviewed people in public settings, these sentiments were echoed: “Many people don't know about it. Some may think that the police are cooperating and there may be a check if you go to this place.” (Non-DCR User, Interviewee 16, Male) The recurring theme of safety, both physical and emotional, emerges here, once again emphasizing the need for the DCR to communicate how the service will treat them with dignity, respect and ensure anonymity. Discussion The overarching narrative from this study was that the Athens DCR is helping achieve the stated objectives of responding to overdose and connecting more people to on-site and referred auxiliary, health, social and drug treatment services. However, there remains a visible community who uses drugs in the public spaces (Hadjikou et al., 2021). People who regularly attended the DCR, many of whom experienced housing and financial insecurity and substance dependence, experienced positive outcomes echoed in the international literature (Levengood et al., 2023; Shorter et al., 2023; Yoon et al., 2022). Regular clients also spoke to potential barriers that may prevent others from accessing the service – opinions supported by the experiences and perceptions of people who used drugs in public settings. These non-DCR users also spoke to additional barriers that regular service attendees had not mentioned. Despite this, non-DCR users had an awareness of the positive outcomes associated with DCR attendance. If the identified physical and operational barriers related to specific policies and design features of the Athens DCR can be adapted to meet the needs of the population currently not accessing the site, there is an evidenced desire from local non-DCR users to access the service. The results from this study align with the positive outcomes described in existing qualitative evaluations of fixed-site DCRs cited above. Firstly, the primary aim of the DCR is to supervise drug use and manage overdose risks before, during and after the consumption event – in essence, keep people safe (Shorter et al, 2023). This perceived feeling of safety, particularly around ‘staying alive’ (Stevens et al., 2024; Keemink et al., 2025) was discussed at length by participants and demonstrates an interest and motivation of clients to manage their health, echoed in the existing literature (Ali et al., 2023; Levengood et al., 2021; Marshall et al., 2011; Potier et al., 2014; Shorter et al., 2023). Clients’ conception of ‘safety’ goes far beyond the traditional public health metrics used to define safety; instead citing a broader conceptualization of the term in relation to environments and situations in which structural violence manifests: protection from police and criminalization and safety as refuge from the stigma experienced within public consumption environments. This eliminates the need to rush the injection process, hide out in unsanitary and secluded drug consumption environments, and safeguards against the threat of physical violence, and stigma all reoccurring themes within qualitative studies of urban drug scenes (Degenhardt et al., 2023; Ickowicz et al., 2017; Levitt et al., 2020; Parkin & Coomber, 2009; Trayner et al., 2020; Rhodes et al., 2006, 2007, 2009; Southwell et al., 2022; Vallence et al., 2018). Food insecurity and a lack of access to basic hygiene facilities is a significant issue for people experiencing homelessness or vulnerable housing situations in Athens (Arapoglou et al., 2021; Arapoglou & Gounis, 2015; Stamouli et al., 2024). Our participants describe how the DCR bridges this gap in service provision by providing food, showers, washing machines, and toilets; and how elsewhere these needs are not met. The value placed on the provision of these services speaks to the level of need that exists regarding people's most immediate needs of safety, food, hygiene, housing – all unrelated to their drug use. Thinking about the concept of intersectionality and in particular the intersectional risk environment (Collins et al., 2019), many of the clients of this facility experience intersecting forms of vulnerability (eg., food insecurity, homelessness, mental and physical health issues, etc). Athens’ DCR is an example of how harm reduction services can successfully act as an engagement point for people who may not otherwise access auxiliary health and housing services, and as such is an inclusion health intervention (Scher et al., 2024). For those who do progress from the DCR into treatment whether abstinence or opioid substitution therapies and who lose access to the DCR, it is unclear where they would access this support. The second floor of the building, where clients can move onto once they have finished in the consumption space supports and facilitates increased feelings of socialization and belonging. Here, individuals relax with peers without the risks or fears that arise within the public environments. Such environments support broader behaviour change and wellbeing (Foreman-Mackey et al., 2019; Shorter, 2023; Stevens et al., 2024). Finally, participants spoke to reductions in public drug use which they saw and attributed to the presence and availability of the DCR. These perceptions of Athens’ DCR contribute to an important evidence base highlighting the tangible benefits to individuals and wider communities of implementing such facilities in communities where there are substantial numbers of people who use drugs. As noted by Urbanik and Greene (2021), barriers to DCR utilization are contextually specific and therefore site-specific research is imperative in order for individual services to adapt to increase access. Given the multiple benefits of the Athens DCR, asserted by regular attendees, it is equally important to highlight the perceived barriers of people who could benefit from the service, yet who do not. In our interviews with non-DCR users, many of the stated barriers were contextual, however, others were very much a product of policies typical in medicalized DCRs. Other studies have examined such barriers through several theoretical frameworks (Urbanik & Greene., 2021; Ivsins et al., 2023; Xavier et al., 2021), however in this paper we group them under the categories of: 1) operational barriers, and 2) physical barriers. For each barrier, we make recommendations which could lead to greater use of the DCR. A primary barrier to people accessing the DCR was the distance of the service from Athens’ ‘piazzas’. Many explained that beyond consuming drugs with peers in these locations, crucially, people are often unable or unwilling to commute long distances to the DCR. Mobile DCR units which go out to these existing drug scenes could be effective (Shorter et al., 2022; 2023). DCR attendees suggested there may be a lack of awareness regarding the operational policies of the DCR amongst the wider population of people who use drugs. DCR non-attendees expressed that this lack of information made them feel apprehensive about attending. More direct outreach campaigns, preferably led by peers would help expanded local knowledge around the DCR, make people feel more at ease and expand access. This phenomenon has been reported in other harm reduction settings where individuals knew that a facility had been opened but had limited knowledge or understanding of the specific practices that occurred within it (Beck et al., 2024; Paquette et al., 2018; Shorter et al., 2023). Several people, both who attended the DCR and did not, perceived self and actual stigma as a barrier. Individuals expressed apprehension around attending as they were unsure how they would be treated by staff or how they would feel being around professional, non-peer staff members. Recent research examining the perceptions of staff from drug services in Athens, has suggested that there does exist a level of stigma towards people who use drugs (Temenos et al., 2024). Whilst this may not be the case for staff in Athens’ DCR, peer workers as active members of the staff team to welcome new clients is an evidence-based method of making both the intake and general service of a DCR a less intimidating or stigmatizing experience (Ivsins et al., 2023; Kennedy et al., 2019; Pijl et al., 2021). Interviewees cited the fear or being recorded or watched over during the consumption process as a barrier. This finding has been noted elsewhere and has led to DCRs being theorized as sites of governmentality (Fischer, 2004; Scher, 2019, 2020), where under the biomedical guise of harm reduction, behaviour is monitored and guided towards specific consumption practices. Indeed, the DCR’s emphasis on safety may deter individuals who equate privacy with freedom. Whilst supervision and surveillance is the central component to keeping people safe within supervised consumption facilities, making small adaptations to DCR policies, such as having a peer worker do the frontline supervision, with clinical staff in the background to intervene should an overdose occur, could make individuals feel more relaxed (Kennedy et al., 2019; McNeil et al., 2014). Also, better advertising that people’s personal information and details of service attendance (frequency, substance consumed, etc) will not be passed on to other health and social care agencies may also have a positive impact on service uptake. As noted by Urbanik & Greene (2021), the emphasis on risk reduction within DCRs, may be at odds with the needs for people who could benefit from the service. Issues arise when the environment and permitted practices within DCRs do not reflect the positive elements of socialization, pleasure or consumption ritual obtained or performed outside facilities (Clua-Garcia, 2020; Duncan et al., 2017, 2021). Non-DCR users specifically cited the extended time to arrive at the site, fill in paperwork, meet with the doctor and then access the consumption space as a deterrent, again specifically within the context of experiencing withdrawals. Where possible, policies could be reviewed related to the mandatory check to acknowledge withdrawal whilst maintaining operational licences. Where efficiencies are possible, this will avoid unwanted situations in the DCR where individuals leave and consume drugs in public or isolated locations with risks to the individual and the public. Several other restrictions around the consumption process existed, for example: no sharing of drugs, no assisted injecting, no sharing of booths. Whilst these restrictions are typical of more medicalized DCRs and have been reported widely in other global contexts (Cassie et al., 2022; Ivsins et al., 2023; Urbanik & Greene, 2021; Xavier et al., 2021), participants in Athens cited such policies as factors dissuading access. For example, during the intake process which took place upon each use of the service, the doctor would ask what and how much an individual was about the consume. A ‘harm reduction conversation’ would ensue. Here the doctor would sometimes recommend the person take less than planned or split their dose into smaller batches. Although this was not mentioned during interviews with people who use drugs, it was described during staff interviews. These conversations and the power dynamics in these conversations are unlike those which could occur on the street and could dissuade people already apprehensive around the DCR experience. Finally, several individuals reported as they were enrolled in OST programs, a key evidence-based harm reduction tool, they could not access the facility. Whilst the purpose of OAT is to support individuals in achieving their treatment goals (Nosyk et al., 2011; O’Connor et al., 2021) and reduce overdose risk by halting their consumption of drugs from the illicit market, this restriction also meant that an important support system of socialization and auxiliary services was cut off from this client group. Additionally, the subsequent inability of these clients to access the DCR when enrolled may lead some individuals to use in riskier, unsupervised settings, undermining harm reduction objectives of the service. Amending this policy could be considered to expand access to the DCR and auxiliary health and welfare services. Policy implications A significant proportion of non-DCR users understood the ways in which the DCR could benefit them - by reducing overdose risk, safeguarding them from physical and structural violence common on the street, increasing their access to auxiliary services and offering privacy during the consumption process. With this awareness in mind, we believe that implementing the recommended changes to DCR policies could effectively reduce the current barriers described in this paper. Not only will this allow more people to benefit from the DCR, but it will also decrease the prevalence of public drug use currently present within Athens’ city centre (Hadjikou et al., 2021). Limitations We explore participant perspectives at a specific point in time (May/June 2023). It is important to note that views may change, especially given the service has adapted certain policies, such as expanding their operating hours, increasing the number of DCR staff with lived experience, increased numbers of mobile DCRs in Athens and on-site drug checking services, all which may have increased access to the site and altered client perspectives. Transcripts were translated from Greek to English. Although this was to a professional standard, there may be some nuance and context which was lost in how people communicated. Our findings may also subject to selection bias, with participants potentially holding different perspectives to individuals who declined to be interviewed or could not be reached (Collier et al., 2004). This limitation is important to consider, as it may affect the diversity of viewpoints captured in our study. Finally, the views of people who access services are context specific and highly localized, our findings may not represent the realities of other communities in which DCRs are implemented and future research should look to assess benefits and barriers in other contexts as a way of adapting local DCR policies. Conclusion This study highlights both the current successes and limitations of Athens’ DCR. Whilst the facility is undoubtedly preventing and responding to overdoses, providing essential health and social care services and reducing the impacts of structural violence for those who experience homelessness or who would otherwise consume substances in public settings, there remains a substantial number of people who do not access the site who use drugs in public settings. These participants identified physical and operational barriers, such as restrictive consumption practices and the timeliness of the intake and consumption process as factors which discouraged them from accessing the DCR. Addressing these barriers through more flexible policies, expanded outreach and communication of the DCR and integrating peer workers could increase service access. More broadly, adapting these policies to be more reactive to the needs of local people who use drugs could reduce the presence and visibility of street-based drug use and improve public health outcomes for people who use drugs in Athens. Declarations Author Contribution BDS conceptualised the study and wrote the ethics application. NP, CA and BDS conducted the fieldwork, data collection and data analysis. BDS wrote the first draft and all co-authors assisted with comments and editing. BWC, DHK and GWS oversaw the study as doctoral supervisors. Acknowledgement We would like to acknowledge the Society for the Study of Addiction for funding this research through their doctoral studentship program. Data Availability The approved and anonymised ethics protocol is hosted on the Open Science Framework (https://osf.io/vs4at). Data is available from authors upon reasonable request. References Ali, F., Russell, C., Kaura, A., Leslie, P., Bayoumi, A. M., Hopkins, S., & Wells, S. (2023). Client experiences using a new supervised consumption service in Sudbury, Ontario: A qualitative study. PLOS ONE, 18(10), e0292862. https://doi.org/10.1371/journal.pone.0292862 Arapoglou, V; Karadimitriou, N; Maloutas, T; Sayas, J; (2021) Multiple Deprivation in Athens: a legacy of persisting and deepening spatial divisions. (GreeSE papers: Hellenic Observatory Discussion Papers on Greece and Southeast Europe 157). Hellenic Observatory, The London School of Economics and Political Science: London, UK. 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Food insecurity among people who inject drugs in Athens, Greece: a study in the context of ARISTOTLE programme. Public Health Nutrition . 2021;24(5):813-818. doi:10.1017/S1368980020004309 Sypsa, V., Paraskevis, D., Malliori, M., Nikolopoulos, G. K., Panopoulos, A., Kantzanou, M., Katsoulidou, A., Psichogiou, M., Fotiou, A., Pharris, A., Van De Laar, M., Wiessing, L., Jarlais, D. D., Friedman, S. R., & Hatzakis, A. (2015). Homelessness and Other Risk Factors for HIV Infection in the Current Outbreak Among Injection Drug Users in Athens, Greece. American Journal of Public Health, 105(1), 196–204. https://doi.org/10.2105/AJPH.2013.301656 Sypsa, V., Roussos, S., Tsirogianni, E., Tsiara, C., Paraskeva, D., Chrysanthidis, T., Chatzidimitriou, D., Papadimitriou, E., Paraskevis, D., Goulis, I., Kalamitsis, G., & Hatzakis, A. (2023). A new outbreak of HIV infection among people who inject drugs during the COVID-19 pandemic in Greece. International Journal of Drug Policy, 117, 104073. https://doi.org/10.1016/j.drugpo.2023.104073 Temenos, C., Koutlou, A., Kyriakidou, S., & Galanaki, S. (2024). Assessing stigma: Health and social worker regard towards working with people using illicit drugs in Athens, Greece. Harm Reduction Journal, 21(1), 175. https://doi.org/10.1186/s12954-024-01091-x Trayner, K. M. A., McAuley, A., Palmateer, N. E., Goldberg, D. J., Shepherd, S. J., Gunson, R. N., Tweed, E. J., Priyadarshi, S., Milosevic, C., & Hutchinson, S. J. (2020). Increased risk of HIV and other drug-related harms associated with injecting in public places: National bio-behavioural survey of people who inject drugs. International Journal of Drug Policy, 77, 102663. https://doi.org/10.1016/j.drugpo.2020.102663 Urbanik, M.-M., & Greene, C. (2021). Operational and contextual barriers to accessing supervised consumption services in two Canadian cities. International Journal of Drug Policy, 88, 102991. https://doi.org/10.1016/j.drugpo.2020.102991 Vallance, K., Pauly, B., Wallace, B., Chow, C., Perkin, K., Martin, G., Zhao, J., & Stockwell, T. (2018). Factors associated with public injection and nonfatal overdose among people who inject drugs in street-based settings. Drugs: Education, Prevention and Policy, 25(1), 38–46. https://doi.org/10.1080/09687637.2017.1351524 Vindrola-Padros, C. (2021). Rapid ethnographies: A practical guide. Cambridge University press. Xavier, J., Rudzinski, K., Guta, A., Carusone, S. C., & Strike, C. (2021). Rules and Eligibility Criteria for Supervised Consumption Services Feasibility Studies – A Scoping Review. International Journal of Drug Policy, 88, 103040. https://doi.org/10.1016/j.drugpo.2020.103040 Yoon, G. H., Levengood, T. W., Davoust, M. J., Ogden, S. N., Kral, A. H., Cahill, S. R., & Bazzi, A. R. (2022). Implementation and sustainability of safe consumption sites: A qualitative systematic review and thematic synthesis. Harm Reduction Journal, 19(1), 73. https://doi.org/10.1186/s12954-022-00655-z Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Jan, 2026 Read the published version in Harm Reduction Journal → Version 1 posted Editorial decision: Revision requested 24 Jun, 2025 Reviews received at journal 23 Jun, 2025 Reviews received at journal 06 Jun, 2025 Reviewers agreed at journal 02 Jun, 2025 Reviewers agreed at journal 29 May, 2025 Reviewers invited by journal 29 May, 2025 Editor assigned by journal 29 Apr, 2025 Submission checks completed at journal 29 Apr, 2025 First submitted to journal 29 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Scher","email":"","orcid":"","institution":"University of Oxford","correspondingAuthor":false,"prefix":"","firstName":"Benjamin","middleName":"D.","lastName":"Scher","suffix":""},{"id":463799348,"identity":"5e99fbdd-0084-492a-b48a-291556e14e32","order_by":1,"name":"Nikolaos Poulopoulos","email":"","orcid":"","institution":"National and Kapodistrian University of Athens","correspondingAuthor":false,"prefix":"","firstName":"Nikolaos","middleName":"","lastName":"Poulopoulos","suffix":""},{"id":463799350,"identity":"acbe9ee6-99cd-425f-a355-87b079e2aaef","order_by":2,"name":"Christos Anastasiou","email":"","orcid":"","institution":"European Network of People Who Use Drugs, European Union","correspondingAuthor":false,"prefix":"","firstName":"Christos","middleName":"","lastName":"Anastasiou","suffix":""},{"id":463799351,"identity":"4548e0be-04e6-48f0-837c-0ade04351366","order_by":3,"name":"Benjamin W. Chrisinger","email":"","orcid":"","institution":"Tufts University","correspondingAuthor":false,"prefix":"","firstName":"Benjamin","middleName":"W.","lastName":"Chrisinger","suffix":""},{"id":463799352,"identity":"c904c2cb-96e7-49cc-90b1-516317303eff","order_by":4,"name":"David K. Humphreys","email":"","orcid":"","institution":"University of Oxford","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"K.","lastName":"Humphreys","suffix":""},{"id":463799353,"identity":"036d031b-51f0-4474-afb0-2cf730156b74","order_by":5,"name":"Gillian W. Shorter","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYHACNgjF3sDAjCJAQIsBAwPPAZK1SCQQqUXegf3Zg497/siZz3y8TbqAwU6eQSItAa8WwwM85oYznhkYy9xOK5OewZBs2CCRdgC/lgYeNmmeAwaJM6RzzKR5GJgTGCTSGwhoYX8G0lI/Q/IMSEs9YS3yDAxmIC0JEhI8IC2HgVoIOMyAmcdMcsYBY8MZPGnF1jMMjhu28TxLwG9Le/sziQ8H5OQl2A9vvF1QUS3Pz55mgN+Ww0hsMCIYkfINKFpGwSgYBaNgFGABADLPNtqqytQ0AAAAAElFTkSuQmCC","orcid":"","institution":"Queen's University Belfast","correspondingAuthor":true,"prefix":"","firstName":"Gillian","middleName":"W.","lastName":"Shorter","suffix":""}],"badges":[],"createdAt":"2025-04-29 10:53:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6555632/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6555632/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12954-025-01371-0","type":"published","date":"2026-01-26T15:58:05+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":101690833,"identity":"9e5099c1-824e-45e2-9ccc-af1a8313ae3f","added_by":"auto","created_at":"2026-02-02 16:09:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":464030,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6555632/v1/6bbca552-4d5c-4756-8500-fea2365b10e8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Benefits and Barriers: A Rapid-Ethnographic Study on the Perspectives of Potential and Actual Clients of Athens’ Drug Consumption Room","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAthens experienced severe social and economic impacts from the 2010 global financial crisis (Panori \u0026amp; Psycharis, 2018). This led to a sharp increase in numbers of people living in poverty, urban homelessness, and rates of HIV (Arapoglou \u0026amp; Gounis, 2017; Syspa et al., 2015). Despite harm reduction interventions being scaled up during the HIV outbreak of 2011 (Flountzi et al., 2022), Athens continues to face challenges, including a new surge in HIV cases linked to difficulties in delivering HIV prevention, including a lack of needle and syringe coverage during the COVID-19 pandemic and limited urban social housing (Roussos et al., 2020; Sypsa et al., 2023).\u0026nbsp;People experiencing homelessness in Athens also frequently face food and hygiene insecurity (Sypsa et al., 2020).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn April 2022, a policy window shaped by the urgency of safeguarding vulnerable populations during the COVID-19 pandemic (Rigioni \u0026amp; Tammi, 2024), led to the expansion of several progressive drug and housing interventions, including: 1) the expansion of the city’s housing first programs, 2) the liberalization and expansion of national naloxone policy and 3) the opening of a drug consumption room (DCR). Nine years after the closure of Athens’ first DCR site (Harm Reduction International, 2022), and now with support from national and local level politicians (Southwell et al., 2022), OKANA, who operate and oversee most of Greece’s drug services, opened a DCR. In addition to overdose supervision and response, the site, called Steki 46, provides a range of on-site services as well as a robust off-site referral system for auxiliary health and social care programs. Like many DCRs globally (Shorter et al., 2023), the primary aims of Steki 46 are to prevent and intervene in overdoses, provide harm reduction advice, provide sterile equipment and offer on-site primary healthcare, mental health services and social services or refer off-site (see Methods for more information on the DCR). As secondary aims, the DCR also works to reduce public drug consumption and drug-related litter in the community (Kennedy et al., 2017). In Athens, the facility also acts as the hub for OKANA’s outreach team which operates across the city.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe aim of this study was to conduct a rapid-ethnographic evaluation to provide immediate policy recommendations to OKANA on how to build on the strengths of the service and expand access. Most DCR evaluations rely on service user perspectives; here, we seek to expand understanding of the experiences and potential barriers faced by those who could benefit from the service yet do not access it (Urbanik \u0026amp; Greene, 2021). To develop a holistic understanding of Steki 46’s model of operation and service design, we captured a range of perspectives, including: 1) people who regularly attend the DCR, 2) people who use drugs locally who do not access the service and 3) DCR staff. In this paper, we analyse the perspectives of DCR users and DCR non-users. The perspectives of staff will be reported \u0026nbsp;elsewhere.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy Setting\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study took place at the Athens DCR and in the immediately surrounding neighbourhoods. This DCR is a medicalised model, with on-site GP, nurses, psychologists, counsellors and social workers \u0026nbsp;to offer wrap-around support. On the ground floor there are twelve injecting booths and an inhalation room with space for four people. The ground floor has a medical room for the on-site doctor, a kitchen, toilets, washing machines, showers and a courtyard garden for clients. On the second floor of the building there is a common room with board games, cards games, TVs, meeting rooms, a kitchen from which food is distributed to clients throughout the day, a cold-water station, a coffee machine, and offices for the on-site social workers, pro-bono legal workers, employment assistance staff. The third floor has more offices for the various professional staff and the fourth floor is the central hub and main office of the ‘streetwork’ outreach team who use the building as a base for outreach trips throughout the day, across the city. Observations and fieldwork occurred throughout the building, with client focus groups and staff interviews taking place on the second floor. Interviews with people who did not access the service but used drugs in public occurred in street-based settings. These interviews were conducted in three separate open-air drug scenes, in locations where the ‘streetwork’ team conducted their outreach activities. These tended to be alleyways and urban parks with a high density of people consuming drugs. These locations were all within 500m-2km radius of the DCR.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRapid-Ethnographic Approach\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study used a rapid-ethnographic approach. Rapid-ethnography is defined by four distinctive characteristics (Vindrola-Padros, 2018): (1) the research must be carried out over a short, compressed or intensive period of time; (2) the research captures relevant social, cultural and behavioural qualitative data and is focused on human experiences, perspectives and practices; (3) the research engages with anthropological and other social science theories promoting reflexivity and (4) data must be collected from multiple sources (various stakeholders implicated in the topic of focus), using multiple modes of data collection and is triangulated during analysis. The strengths of this approach lie in its ability to produce research with a “nuanced understanding of lived experiences while prioritizing efforts to rapidly inform interventions and decisions that address urgent health and social issues” (Collins et al., 2020, p.384).\u003c/p\u003e\n\u003cp\u003eOverview of Methods\u003c/p\u003e\n\u003cp\u003eThe methods of data collection were chosen specifically for their ability to rapidly observe and capture the ways in which clients as well as those who do not use the DCR, view and engage with the service. Data collection comprised seven weeks of fieldwork, including: 1) a community consultation, 2) five weeks (≈200 hours) of participant observation and fieldnotes within the DCR, 3) focus groups with regular clients, 4) informal street-based rapid-ethnographic interviews with people who do not use the service and 5) semi-structured interviews with staff and management (which will be reported elsewhere).\u003c/p\u003e\n\u003cp\u003eResearch Team and Partnerships\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was conducted as part of the doctoral work of ANONYMIZED, with fieldwork led by ANONYMIZED, a graduate student in addiction studies at the University of Athens and ANONYMIZED, project manager with the European Network of People Who Use Drugs and the Greece based Peer Network of Users of Psychoactive Substances. Both researchers are local to Athens and ANONYMIZED has a deep knowledge of the local community and environment. ANONYMIZED has lived and living experience of drug use and utilization of harm reduction and OST services in Athens and has worked as a peer researcher on several other related projects. ANONYMIZED, ANONYMIZED and ANONYMIZED supervised the project, supporting design and analysis off site, meeting regularly with the research team.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRecruitment and Sampling\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRecruitment for focus groups was done through a combination of snowball and purposeful sampling (Naderifar et al., 2017). During the initial five weeks of participant observation ANONYMIZED immersed himself within the day-to-day operations of the DCR, on the ground floor and second floor (consumption and post-consumption spaces). During this period, he built rapport with clients and discussed the scope of the project and upcoming focus group dates with eligible participants. People who signed up were encouraged to discuss the study with eligible members of their peer network. Eligibility was defined as: 1) aged 18+ years 2) used the DCR regularly, 3) provided informed consent and 4) could speak Greek. Participants in the street-based interviews were approached by ANONYMIZED who introduced the project to them. Those who wished to take part would move to a private location. ANONYMIZED would then conduct the interview. Interview eligibility matched focus groups. Additionally, participants had to have experience of consuming drugs in local public and or/semi-public environments.\u003c/p\u003e\n\u003cp\u003eCommunity Consultation, Data Collection and Compensation\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFollowing the five-week period of participant observation, ANONYMIZED led a consultation with six DCR clients. Here, the group discussed the research design and question protocols, and feedback was sought to develop the questions alongside the aims of the study, and to be trauma informed in line with best practice (Dickert \u0026amp; Sugarman, 2005). Rapid-ethnographic data collection was conducted over the final two-week period. Typically, in the morning we conducted a focus group and, in the afternoon, would accompany the ‘streetwork’ outreach team to conduct street-based interviews before returning to conduct 1-3 staff interviews. Multiple methods of qualitative data collection afforded triangulation of findings (Malina et al., 2011).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFive focus groups were conducted which lasted 40-60 mins and contained four to six people per group (total n=24). Participants were aged 30-56 years (Mean=44; SD=6.4). One participant self-identified as Black, two preferred not to say, 22 self-identified as White. There were 7 females and 18 males, 9 were housed, 4 in temporary or emergency shelter accommodation and 11 self-identified as unhoused. The question protocol was semi-structured, and participants were asked questions related to their experiences using the DCR, their views on operational policies and if they would add to or change anything about the services on offer within the facility. These included questions such as: “How often and why do you come to the DCR?”, “How would you describe your relationship with staff?”, “Which services within the facility do you tend to use?” and “Has the DCR impacted your life beyond the immediate harm reduction benefits of consuming drugs whilst supervised?”. Participants were recruited from the DCR by ANONYMIZED and ANONYMIZED, who would then accompany them upstairs to the private meeting room. Once the team had the desired number of people, ANONYMIZED explained the scope of the project, assisted people in completing the consent forms and demographic questionnaires. NP then conducted each focus group and ensured that the session was audio recorded for subsequent transcription and translation. Snacks, coffee, and soft drinks were provided during the sessions.\u003c/p\u003e\n\u003cp\u003eEthnographic street-based interviews were conducted by ANONYMIZED, who took handwritten fieldnotes and wrote down verbatim quotes of importance. These quotes were then read back to participants at the end of interviews to make sure they accurately reflected the conversation. Interviews were semi-structured and followed a question protocol relating to their experiences of street-based drug use, their perceptions of the DCR and rationale for not using it. Questions included: “How would you describe your experiences of using drugs in locations like this?”, “Have you heard of the DCR, if so, what are your views on the facility?”, “Do you ever attend the facility, if not, why?”. These interviews lasted between 5 and 15 minutes. To support anonymity, no names were taken and we\u0026nbsp;only gathered gender information. Participants in the community consultation/focus groups received €15 reimbursement; those participating in a street-based interview received €10. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthics\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was granted by the ANONYMIZED on 11/03/2023 reference ANONYMIZED as well as internal ethical approval from OKANA. The approved, anonymised ethics protocol is hosted on the Open Science Framework (DOI ANONYMIZED).\u0026nbsp;OKANA also provided logistical support through: 1) office space for focus groups, 2) snacks and drinks for clients during the sessions, 3) safeguarding support for street-based interviews. During focus groups and street-based interviews, staff were not present and could not hear what was being said. All participants gave written consent. It is also important to not that the overall ethical approach of this study was strongly informed by the authors varied prior research experience with similar populations as well as ANONYMIZED experience both as a member of and experience conducting research with this population group. Ethical questions and trade-offs were frequently considered by the research team in a way which specific to this particular study context and participant group.\u003c/p\u003e\n\u003cp\u003eData Analysis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData analysis comprised of the Braun \u0026amp; Clarke (2006) six stage reflexive thematic analysis, commencing with a process of familiarization with the data, whereby ANONYMIZED and ANONYMIZED read transcripts and fieldnotes, wrote analytic memos and collectively developed a thematic codebook to work systematically through the data, identifying relevant and meaningful information related to the research questions, as well as novel concepts inductively. These codes were then reviewed by ANONYMIZED, ANONYMIZED, ANONYMIZED and ANONYMIZED who refined and challenged the initial coding process until all the data were systematically organized into a final coding framework (Braun \u0026amp; Clarke, 2023).\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFollowing the coding of transcripts, three central themes emerged, each with several sub-themes related to the perceived and experienced benefits and barriers of the Athens DCR. Themes incorporate the views of both daily DCR service users and people who use drugs in public, street-based settings, or a combination of the two (see Table 1). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 1: Themes and sub-themes of the views of people who use drugs (who do and do not use the Athens DCR)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"678\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003eTheme\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 454px;\"\u003e\n \u003cp\u003eSub-Theme\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003e1. \u0026nbsp; Safety\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 454px;\"\u003e\n \u003cp\u003e1.1. \u0026nbsp; \u0026nbsp; \u0026nbsp;Physical safety\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 454px;\"\u003e\n \u003cp\u003e1.2. \u0026nbsp; \u0026nbsp; \u0026nbsp;Structural safety from police and criminalization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 454px;\"\u003e\n \u003cp\u003e1.3 Safety from stigma and desire for privacy\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003e2. \u0026nbsp; Connection\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 454px;\"\u003e\n \u003cp\u003e2.1. Access to basic necessities\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 454px;\"\u003e\n \u003cp\u003e2.2. Built relationships in the DCR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 225px;\"\u003e\n \u003cp\u003e3. \u0026nbsp; Barriers\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 454px;\"\u003e\n \u003cp\u003e3.1. Stigma\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 454px;\"\u003e\n \u003cp\u003e3.2. Operational barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 454px;\"\u003e\n \u003cp\u003e3.3. Physical barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e1. \u0026nbsp; Safety\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.1. \u0026nbsp; \u0026nbsp; \u0026nbsp;Physical safety\u003c/p\u003e\n\u003cp\u003eParticipants regularly contrasted the environment of the DCR to that of the \u0026lsquo;piazzas\u0026rsquo;, the local term for open-air drug scenes. This comparison often centred around the physical safety afforded by the DCR, as highlighted by one participant who described the sense of relief experienced when accessing the service: \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ldquo;The benefits, well it is a breath of fresh air away from the road, from the piazza, it\u0026rsquo;s a safe place.\u0026rdquo; (Regular DCR Client, White, Male, 40-45 yrs, Housed) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExpanding on this, another participant described how the DCR offers respite for people who use drugs and experience homelessness: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;\u003c/em\u003eIt is a place that provides security. Many younger people without shelter cannot sleep at night. They run all night right and left and come here during the day, they use early [in the day] and many times after using you see them get sleepy. They\u0026apos;re tired, they\u0026apos;re finished, and you see them come over here and look to get a little sleep...in a sheltered space they know won\u0026apos;t take away their things.\u0026rdquo; (Regular DCR Client 2, White, Male, 40-45 yrs, Unhoused)\u003cem\u003e\u0026nbsp;\u003c/em\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe ability to rest without fear of being robbed was seen as a significant benefit. This was reiterated by non-DCR users: \u003cem\u003e\u0026ldquo;Over there, there is security, while out on the street there is none and you can be easily robbed.\u0026rdquo; (Non-DCR User, Interviewee 8, Male).\u003c/em\u003e Alongside providing a safe environment, the knowledge there would be a swift medical response to keep people alive during an overdose was commonly cited as a primary benefit and reason they attended the DCR:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;You know that there are doctors here so there is no chance of you dying.\u0026rdquo; (Regular DCR Client, Black, Male, 45-50 yrs, Unhoused)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;When something happens to me they [staff] are there to help me. [Even] just watching me, I feel safe.\u0026rdquo; (Regular DCR Client, White, Male, 35-40 yrs, Unhoused) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe non-verbal reassurance provided by the presence of staff, even when no intervention was needed, was a vital aspect of participants\u0026rsquo; sense of security and trust in staff. Safety was also discussed beyond that of physical safety, with this participant associating safety with the harm reduction equipment available within the DCR: \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;With the scanner I can see the veins that are to be punctured. This is very helpful.\u0026rdquo; (Non-DCR User, Interviewee 21, Male) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite street-based interview participants not accessing the DCR, there was a general awareness and understanding of the ways in which the DCR would offer increased safety from overdose, theft, and injection-related harms. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1.2. \u0026nbsp; \u0026nbsp; \u0026nbsp;Structural safety from police and criminalization\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor many, protection from police apprehension and the risk of criminalization was a key motivator for attending the DCR: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The fact that there is a place...where we will not be bothered by the Law is \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; a good thing...it is a place where I can \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; use without the constant fear of the police.\u0026rdquo; (Regular DCR Client, White, Female, 35-40 yrs, Housed) \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSupporting this statement, this participant described how the fear and anxiety of police harassment and rushing the injection process to avoid police detection lead to physical injuries. Such injuries are rare when an individual can take their time in the DCR:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The benefit is that you\u0026apos;re not being chased by the police, the stress of use especially if it\u0026apos;s intravenous and you see the cops in front,you can easily do something wrong, as I suffered. I put a pinch of sisha [methamphetamine] together and then saw the cops in front of me [and rushed]...I have had an abscess from that which is still slowly recovering.\u0026rdquo; (Regular DCR Client, White, Male, 35-40 yrs, Unhoused)\u003c/p\u003e\n\u003cp\u003eMistrust of the police also related to whether they would respond appropriately in the event of an overdose: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026ldquo;This is where the DCR is needed because when something happens inside, staff will...help you\u0026hellip;if I\u0026rsquo;m outside, I don\u0026apos;t know if the police will call the ambulance.\u0026rdquo; (Regular DCR Client, White, Male, 35-40 yrs, Temporary Shelter Accommodation)\u003c/p\u003e\n\u003cp\u003ePolice were perceived not to prioritize the health and safety of people who use drugs. This fear extended to various other aspects of criminalization such as arrest or processing through the courts, which would also have implications such as the confiscation of drugs, and potential withdrawal:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The security you get here is that you will not be taken to court, your fix will not be taken. You don\u0026apos;t know how much I...do to get my dose, and then it just gets taken away.\u0026rdquo; (Regular DCR Client, White, Male, 50-55 yrs, Unhoused)\u003c/p\u003e\n\u003cp\u003eIn contrast, many expressed a sense of relief knowing they could use the DCR without fear of arrest or harassment, specifically contrasting interactions with police (and other community members) to those they experienced with staff:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026ldquo;There you feel safe from the residents and from the police. There I can ask about medical problems and they treat us like human beings.\u0026rdquo; (Non-DCR User, Interviewee 15, Female)\u003c/p\u003e\n\u003cp\u003e1.3. Safety from Stigma and Desire for Privacy\u003c/p\u003e\n\u003cp\u003eThere was agreement from regular clients that by ensuring privacy, the DCR provided emotional safety from stigma; there is respect and dignity not often experienced in public settings and everyday encounters with the public.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eContrasting the privacy offered within the service, this participant described feelings of shame and emotional discomfort experienced when using drugs in public settings:\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026ldquo;For me I come here [because] I don\u0026apos;t like to use on the street. I don\u0026apos;t want everyone who passes by to see me.\u0026rdquo; (Regular DCR Client, Black, Male, 45-50 yrs, Unhoused) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants described the relief of not using in public and particularly how the DCR helped reduce the visibility of drug use in public, particularly around children: \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Children now don\u0026apos;t have to see me. I\u0026hellip;come and do it [use drugs] here because otherwise I do it on the sidewalk. Imagine being with your child...and explaining to them what that is, having that bad conversation.\u0026rdquo; (Regular DCR Client, White, Male, 45-50 yrs, Temporary Shelter Accommodation) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I come here in the morning hours more. Why? Because I\u0026apos;m on the street and homeless I can\u0026apos;t sit out on the step, because the police are pushing me away, the shops are kicking me of their steps...especially now with tourists. In the morning, when the whole world is out and about kicking me out...I\u0026apos;m ashamed, so I see this place as a shelter to hang out, to take some time to myself and drink some coffee. (Regular DCR Client, White, Male, 40-45 yrs, Unhoused)\u003c/p\u003e\n\u003cp\u003eThese dual perspectives, where participants reflected both on their personal relief of no longer using in public spaces and exposed to ill-treatment from the public, and the broader benefits for the community in the reduction of public drug use, demonstrates how the DCR generates important benefits for the whole community, in particular shielding others (eg., children) from visible drug use.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2. \u0026nbsp; Connection\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2.1. \u0026nbsp; \u0026nbsp; \u0026nbsp;Access to basic necessities\u003c/p\u003e\n\u003cp\u003eWhen asked what they valued at Steki 46, service users highlighted the tangible benefits to their daily lives through access to auxiliary services, food, hygiene facilities and others which provide basic necessities:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026ldquo;It is the clean space, medical care and toilets, because I am homeless [and] the main problem is [accessing] toilets. The bathroom, the washing machine\u0026hellip;the supervision of the doctor is a bonus on top of that. It all helps immensely. Also, the referrals to the hospital, to legal aid\u0026hellip;they all help.\u0026rdquo; (Regular DCR Client, White, Male, N/A yrs, Temporary Shelter Accommodation) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMany who participated in focus groups were either in situations of homelessness and/or severe financial precarity. In this context, the provision of regular snacks, sandwiches, coffee, and other donated meals was an essential resource: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;This is a very big help. Coffee for example\u0026hellip;finances are difficult, [this] is what will make the most difference to the people outside. Some days when I am broke, it really helps me to come and eat a cheese pie\u0026hellip;lunch food not just snacks.\u0026rdquo; (Regular DCR Client, White, Male, 40-45 yrs, Housed) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor individuals without a stable income, items like coffee or a sandwich made a meaningful impact. For individuals with pre-existing health conditions such as diabetes, access to food at the DCR was both a convenience and a necessity for their well-being. One participant reflected on how the staff ensured he received this support: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;[I am diabetic], when my blood sugar drops they give me something sweet. They make sure I\u0026hellip;stay safe. I really like that. The people here help immensely\u0026hellip;I am pleased to be a member here.\u0026rdquo; (Regular DCR Client, White, Male, N/A yrs, Temporary Shelter Accommodation) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese essential provisions contributed to service users\u0026rsquo; perception of care and belonging within the DCR, highlighted by this participants description of themselves as a \u0026lsquo;member\u0026rsquo;, a term encompassing a sense of belonging to the service. Whilst many began by describing the immediate, practical benefits of these auxiliary services, their accounts frequently expanded to encompass the more formal, institutionalized care they were able to access through support by DCR staff: \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;For so many years I couldn\u0026apos;t cut down, but the guys that work here helped me. They also encouraged me into a treatment program....this place has made me realise that I can really make an effort to escape this life.\u0026rdquo; (Regular DCR Client, White, Male, 40-45 yrs, Unhoused) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDCR staff supported participants\u0026rsquo; personal efforts toward change, particularly in relation to drug treatment. Previously dismissed as unattainable or unappealing by many clients, the DCR was a place where the idea of recovery, or at least reducing or making healthier choices around their drug use, became a tangible goal.\u003c/p\u003e\n\u003cp\u003e2.2. \u0026nbsp; \u0026nbsp; \u0026nbsp;Building relationships in the DCR\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMany participants described the positive social connections created in the facility. Field notes captured how only half an hour from when the DCR would open in the morning, the second-floor lounge was nearly always busy with clients watching TV, playing cards, and Tavli (Greek backgammon) with staff and clients having coffee and cigarettes on the balconies. Engaging in activities with peers and staff had positive effects, including alleviating boredom, described as a common trigger for substance use: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Here you will find other people to socialize with...do other things that fill up your time because many times you drink or use drugs out of boredom.\u0026rdquo; (Regular DCR Client, White, Male, 50-55 yrs, Housed) \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMany regular attendees also described positive relationships with staff in the context of them connecting clients to services as well as the care and respect they exemplified when working with clients: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;In the beginning, I wondered about why it exists, but there happened to be a girl, a member of staff, who showed great interest [in me] \u0026hellip;She helped me to deal with anything I needed, from benefits to whether I was interested in going into a detox program.\u0026rdquo; (Regular DCR Client, White, Male, 30-35 yrs, Unhoused) \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe ability of staff members to guide clients through complex service systems, whether related to benefits, healthcare, detox or drug treatment programs, was a frequent theme in participants\u0026apos; accounts. The positive impact of these interactions is further described by this participant: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I got my ID through the DCR with the social worker, she was very helpful. She is much more helpful than if I would have gone alone to the office\u0026hellip;that\u0026rsquo;s another good thing\u0026hellip;when there is someone in front of you who...sees that you know someone [a member of staff], everybody behaves a lot differently. Because they are very...discriminatory towards us in hospitals\u0026hellip;we are not taken seriously.\u0026rdquo; (Regular DCR Client, White, Male, 50-55 yrs, Housed) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis description of staff advocacy underscores the critical role played by staff in addressing the broader social inequalities that affect clients\u0026rsquo; ability to access wider health and social services. Participants described how staff with lived experience were particularly effective in communicating with clients and addressing their needs: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The staff are very flexible, there are also ex-users and this plays a big role. They understand us even better and are very flexible with us and polite.\u0026rdquo; (Regular DCR Client, White, Male, 40-45 yrs, Housed) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSupportive staff played an important role in clients\u0026apos; ability to access services, feel respected in potentially hostile environments, and establish a sense of trust with the facility. For many, these positive relationships were central to their continued engagement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3. \u0026nbsp; Barriers\u003c/p\u003e\n\u003cp\u003e3.1. \u0026nbsp; \u0026nbsp; \u0026nbsp;Stigma\u003c/p\u003e\n\u003cp\u003eFor some, the formality of the DCR, combined with concerns about being judged, deterred them, as noted by this participant: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;They feel more at home in the piazza. They feel like they are being mocked or feel a bit uncomfortable [in the DCR].\u0026rdquo; (Regular DCR Client, White, Male, 35-40 yrs, Unhoused)\u003c/p\u003e\n\u003cp\u003eFor individuals who feel more at ease in the less regulated space of the piazza, the transition to the DCR, which can appear more clinical or formal, may exacerbate feelings of alienation: \u003cem\u003e\u0026ldquo;I consider the space like a dentist\u0026rsquo;s office...that doesn\u0026apos;t work for me.\u0026rdquo;\u003c/em\u003e (Non-DCR user, Interviewee 9, Male). This participant for instance who now attends the service regularly, recalled how \u0026ldquo;What was difficult...was actually showing the drugs at first\u0026rdquo;. (Regular DCR Client, White, Male, 35-40 yrs, Unhoused) The act of presenting drugs for consumption in a supervised setting can evoke vulnerability and anxiety, as people using the facility may fear judgment from staff or peers; and it diverges from street-based practices where drugs are hidden. This sentiment was corroborated by a participant who highlighted the sense of isolation, combined with feelings of apprehension about entering an unfamiliar space without peer support: \u003cem\u003e\u0026ldquo;I don\u0026apos;t know anyone there and I don\u0026apos;t feel comfortable going alone.\u0026rdquo; (Non-DCR User, Interviewee 3, Male).\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e3.2. \u0026nbsp; \u0026nbsp; \u0026nbsp;Operational barriers\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe overarching system of surveillance in the DCR, though for the purpose of reducing and responding to risk \u0026nbsp;(e.g., overdose response), was acknowledged by many through comments such as: \u0026ldquo;in the DCR there is surveillance\u0026rdquo; (Non-DCR User, Interviewee 3, Male) and created discomfort for some people. A concern voiced by several participants was the feeling of being watched, either by staff or through cameras when using drugs:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;There is the fear that there are cameras watching me there, I would like there to not be any.\u0026rdquo; (Non-DCR User, Interviewee 23, Male)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;This system of surveillance and risk reduction extended to specific moments within the intake and consumption process. For example, people who did not use the service cited the length of time from arrival at the facility to when you can consume drugs as a significant barrier. These experiences were again framed within the context of the unpleasant experiences of withdrawal:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I have been once and only once. It is a time-consuming process. When I\u0026apos;m...going through withdrawals or very high I don\u0026apos;t feel like spending it [time] there.\u0026rdquo; (Non-DCR User, Interviewee 18, Male)\u003c/p\u003e\n\u003cp\u003eThe need for immediate relief, and time for the structured intake process to occur was described as a clear barrier to service engagement. Attendees valued the medical care provision, however, for some, the time spent checking in with a doctor each time they wished to use the site was additionally a barrier: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;When you are sick, you don\u0026rsquo;t have the time to do paperwork, to see a doctor or any of those things, you don\u0026rsquo;t have time for that.\u0026rdquo; (Non-DCR User, Interviewee 6, Female) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe waiting was particularly challenging when experiencing intense withdrawal symptoms as some clients presenting to the service experienced. While medical oversight is a core feature of the DCR, these experiences highlight how it may not serve the immediate needs of their client group. There was also some identified differences in the DCR compared to the street:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Not everyone can fit into one mold, workers can\u0026apos;t understand users. I\u0026hellip;enter and they ask me what substance I have on me. I often use with my friends by doing small transactions but inside they don\u0026rsquo;t let us do any transactions or share. It is very different to how we would use on the street.\u0026rdquo; (Non-DCR User, Interviewee 12, Male)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;In the DCR there are many limits, there is surveillance, documents that you have to fill out. While on the street there are no limits, no rules\u0026rdquo; (Non-DCR User, Interviewee 3, Male)\u003c/p\u003e\n\u003cp\u003eThese participants explain how the DCR environment did not mirror socially driven consumption practices, habits, or rituals that people were able to practice in other environments, particularly in relation to sharing or exchanging drugs, a sentiment echoed by others who found that restrictions around mutual aid, such as being able to inject or assist a friend during consumption, was a reason for service avoidance: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I\u0026apos;ve went when it first opened. Often the ones who don\u0026rsquo;t want to go, it\u0026apos;s because here in the square or on the street there is more help. There [the DCR]...your friend cannot inject you, while here...people can do things like that.\u0026rdquo; (Non-DCR User, Interviewee 19, Female)\u003c/p\u003e\n\u003cp\u003eBeyond these social dynamics of drug use, certain higher-risk injection practices were not permitted, resulting in continued use within public environments where such injecting practices were not controlled or managed: \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Over there, it is forbidden to shoot in the neck or the artery. One may not want to go there because it is forbidden.\u0026rdquo; (Non-DCR User, Interviewee 10, Female)\u003c/p\u003e\n\u003cp\u003eOne final and notable operational barrier which was discussed was the service restriction for people who were in opioid substitution treatment programs (OST). This was observed during the ethnographic fieldwork and noted by this participant: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Many users do not come because...if you are in an OST program you cannot come to use.\u0026rdquo; (Regular DCR Client, White, Male, 50-55 yrs, Unhoused) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSomeone who uses drugs in public settings explained they are now disqualified from accessing the DCR despite having built important relationships with members of staff: \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The staff there are like my family looking after me. But since i\u0026apos;m in a substitution program I can\u0026apos;t go there...it\u0026apos;s forbidden.\u0026rdquo; (Non-DCR User, Interviewee 20, Male)\u003c/p\u003e\n\u003cp\u003eThe sense of disconnection experienced by this participant highlights how important the social aspect of the DCR can be for individuals who may otherwise be socially marginalised.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e3.3. \u0026nbsp; \u0026nbsp; \u0026nbsp;Physical barriers\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite the many benefits which framed beliefs around why people attend or should attend the DCR, several physical barriers were described. Distance was perceived as an important factor which may dissuade people from attending: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;I, [live] by Victoria square which is ten minutes away, but for someone who lives far away I don\u0026rsquo;t think they will come to the DCR. So it would be good if more existed.\u0026rdquo; (Regular DCR Client, White, Female, 45-50 yrs, Unhoused) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor individuals interviewed in public settings, the urgency and necessity to alleviate the withdrawal symptoms of drug dependence was often cited as the primary reason for not being able to commute long distances once they were possession of substances: \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;If I am sick [from withdrawal], I use in the first place that I can find\u0026hellip;if I am sick I will use anywhere...500m seems like 500km when you are sick\u0026rdquo; (Non-DCR User, Interviewee 6, Female) \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdditionally, regular attendees identified a lack of awareness amongst the local population of people who use drugs as a barrier to the service. Participants explained that beyond simply knowing about the service, people needed to be given a better understanding of exactly what takes place at the DCR and assurances they would be comfortable in that environment: \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;A lot don\u0026apos;t even know about it, they might have heard it as an idea, but they haven\u0026apos;t come to see for themselves. It would be great if one day staff came to pick them up to take them\u0026hellip;or [came] to show them pictures of the DCR at the piazza. They should invite them...they are suspicious and don\u0026rsquo;t dare to take the step to come over here and see.\u0026rdquo; (Regular DCR Client, White, Female, 40-45 yrs, Housed) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;When you are homeless, you generally have a lot of phobias, that\u0026apos;s why people can be suspicious. Especially to give one\u0026rsquo;s name, for it to be written down, even during intake people may wonder, why do they want to see the drugs I have?\u0026rdquo; (White, Male, 45-50 yrs, Temporary Shelter Accommodation) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese reflections underscore the notion that simply having a service available is not enough; active outreach is necessary to break down the barriers of suspicion and unfamiliarity. When we interviewed people in public settings, these sentiments were echoed: \u0026nbsp;\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Many people don\u0026apos;t know about it. Some may think that the police are cooperating and there may be a check if you go to this place.\u0026rdquo; (Non-DCR User, Interviewee 16, Male) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe recurring theme of safety, both physical and emotional, emerges here, once again emphasizing the need for the DCR to communicate how the service will treat them with dignity, respect and ensure anonymity.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe overarching narrative from this study was that the Athens DCR is helping achieve the stated objectives of responding to overdose and connecting more people to on-site and referred auxiliary, health, social and drug treatment services. However, there remains a visible community who uses drugs in the public spaces (Hadjikou et al., 2021). People who regularly attended the DCR, many of whom experienced housing and financial insecurity and substance dependence, experienced positive outcomes echoed in the international literature (Levengood et al., 2023; Shorter et al., 2023; Yoon et al., 2022). Regular clients also spoke to potential barriers that may prevent others from accessing the service \u0026ndash; opinions supported by the experiences and perceptions of people who used drugs in public settings. These non-DCR users also spoke to additional barriers that regular service attendees had not mentioned. Despite this, non-DCR users had an awareness of the positive outcomes associated with DCR attendance. If the identified physical and operational barriers related to specific policies and design features of the Athens DCR can be adapted to meet the needs of the population currently not accessing the site, there is an evidenced desire from local non-DCR users to access the service.\u003c/p\u003e \u003cp\u003eThe results from this study align with the positive outcomes described in existing qualitative evaluations of fixed-site DCRs cited above. Firstly, the primary aim of the DCR is to supervise drug use and manage overdose risks before, during and after the consumption event \u0026ndash; in essence, keep people safe (Shorter et al, 2023). This perceived feeling of safety, particularly around \u0026lsquo;staying alive\u0026rsquo; (Stevens et al., 2024; Keemink et al., 2025) was discussed at length by participants and demonstrates an interest and motivation of clients to manage their health, echoed in the existing literature (Ali et al., 2023; Levengood et al., 2021; Marshall et al., 2011; Potier et al., 2014; Shorter et al., 2023). Clients\u0026rsquo; conception of \u0026lsquo;safety\u0026rsquo; goes far beyond the traditional public health metrics used to define safety; instead citing a broader conceptualization of the term in relation to environments and situations in which structural violence manifests: protection from police and criminalization and safety as refuge from the stigma experienced within public consumption environments. This eliminates the need to rush the injection process, hide out in unsanitary and secluded drug consumption environments, and safeguards against the threat of physical violence, and stigma all reoccurring themes within qualitative studies of urban drug scenes (Degenhardt et al., 2023; Ickowicz et al., 2017; Levitt et al., 2020; Parkin \u0026amp; Coomber, 2009; Trayner et al., 2020; Rhodes et al., 2006, 2007, 2009; Southwell et al., 2022; Vallence et al., 2018).\u003c/p\u003e \u003cp\u003eFood insecurity and a lack of access to basic hygiene facilities is a significant issue for people experiencing homelessness or vulnerable housing situations in Athens (Arapoglou et al., 2021; Arapoglou \u0026amp; Gounis, 2015; Stamouli et al., 2024). Our participants describe how the DCR bridges this gap in service provision by providing food, showers, washing machines, and toilets; and how elsewhere these needs are not met. The value placed on the provision of these services speaks to the level of need that exists regarding people's most immediate needs of safety, food, hygiene, housing \u0026ndash; all unrelated to their drug use. Thinking about the concept of intersectionality and in particular the intersectional risk environment (Collins et al., 2019), many of the clients of this facility experience intersecting forms of vulnerability (eg., food insecurity, homelessness, mental and physical health issues, etc). Athens\u0026rsquo; DCR is an example of how harm reduction services can successfully act as an engagement point for people who may not otherwise access auxiliary health and housing services, and as such is an inclusion health intervention (Scher et al., 2024). For those who do progress from the DCR into treatment whether abstinence or opioid substitution therapies and who lose access to the DCR, it is unclear where they would access this support.\u003c/p\u003e \u003cp\u003eThe second floor of the building, where clients can move onto once they have finished in the consumption space supports and facilitates increased feelings of socialization and belonging. Here, individuals relax with peers without the risks or fears that arise within the public environments. Such environments support broader behaviour change and wellbeing (Foreman-Mackey et al., 2019; Shorter, 2023; Stevens et al., 2024). Finally, participants spoke to reductions in public drug use which they saw and attributed to the presence and availability of the DCR. These perceptions of Athens\u0026rsquo; DCR contribute to an important evidence base highlighting the tangible benefits to individuals and wider communities of implementing such facilities in communities where there are substantial numbers of people who use drugs. As noted by Urbanik and Greene (2021), barriers to DCR utilization are contextually specific and therefore site-specific research is imperative in order for individual services to adapt to increase access.\u003c/p\u003e \u003cp\u003eGiven the multiple benefits of the Athens DCR, asserted by regular attendees, it is equally important to highlight the perceived barriers of people who could benefit from the service, yet who do not. In our interviews with non-DCR users, many of the stated barriers were contextual, however, others were very much a product of policies typical in medicalized DCRs. Other studies have examined such barriers through several theoretical frameworks (Urbanik \u0026amp; Greene., 2021; Ivsins et al., 2023; Xavier et al., 2021), however in this paper we group them under the categories of: 1) operational barriers, and 2) physical barriers. For each barrier, we make recommendations which could lead to greater use of the DCR.\u003c/p\u003e \u003cp\u003eA primary barrier to people accessing the DCR was the distance of the service from Athens\u0026rsquo; \u0026lsquo;piazzas\u0026rsquo;. Many explained that beyond consuming drugs with peers in these locations, crucially, people are often unable or unwilling to commute long distances to the DCR. Mobile DCR units which go out to these existing drug scenes could be effective (Shorter et al., 2022; 2023). DCR attendees suggested there may be a lack of awareness regarding the operational policies of the DCR amongst the wider population of people who use drugs. DCR non-attendees expressed that this lack of information made them feel apprehensive about attending. More direct outreach campaigns, preferably led by peers would help expanded local knowledge around the DCR, make people feel more at ease and expand access. This phenomenon has been reported in other harm reduction settings where individuals knew that a facility had been opened but had limited knowledge or understanding of the specific practices that occurred within it (Beck et al., 2024; Paquette et al., 2018; Shorter et al., 2023).\u003c/p\u003e \u003cp\u003eSeveral people, both who attended the DCR and did not, perceived self and actual stigma as a barrier. Individuals expressed apprehension around attending as they were unsure how they would be treated by staff or how they would feel being around professional, non-peer staff members. Recent research examining the perceptions of staff from drug services in Athens, has suggested that there does exist a level of stigma towards people who use drugs (Temenos et al., 2024). Whilst this may not be the case for staff in Athens\u0026rsquo; DCR, peer workers as active members of the staff team to welcome new clients is an evidence-based method of making both the intake and general service of a DCR a less intimidating or stigmatizing experience (Ivsins et al., 2023; Kennedy et al., 2019; Pijl et al., 2021).\u003c/p\u003e \u003cp\u003eInterviewees cited the fear or being recorded or watched over during the consumption process as a barrier. This finding has been noted elsewhere and has led to DCRs being theorized as sites of governmentality (Fischer, 2004; Scher, 2019, 2020), where under the biomedical guise of harm reduction, behaviour is monitored and guided towards specific consumption practices. Indeed, the DCR\u0026rsquo;s emphasis on safety may deter individuals who equate privacy with freedom. Whilst supervision and surveillance is the central component to keeping people safe within supervised consumption facilities, making small adaptations to DCR policies, such as having a peer worker do the frontline supervision, with clinical staff in the background to intervene should an overdose occur, could make individuals feel more relaxed (Kennedy et al., 2019; McNeil et al., 2014). Also, better advertising that people\u0026rsquo;s personal information and details of service attendance (frequency, substance consumed, etc) will not be passed on to other health and social care agencies may also have a positive impact on service uptake.\u003c/p\u003e \u003cp\u003eAs noted by Urbanik \u0026amp; Greene (2021), the emphasis on risk reduction within DCRs, may be at odds with the needs for people who could benefit from the service. Issues arise when the environment and permitted practices within DCRs do not reflect the positive elements of socialization, pleasure or consumption ritual obtained or performed outside facilities (Clua-Garcia, 2020; Duncan et al., 2017, 2021). Non-DCR users specifically cited the extended time to arrive at the site, fill in paperwork, meet with the doctor and then access the consumption space as a deterrent, again specifically within the context of experiencing withdrawals. Where possible, policies could be reviewed related to the mandatory check to acknowledge withdrawal whilst maintaining operational licences. Where efficiencies are possible, this will avoid unwanted situations in the DCR where individuals leave and consume drugs in public or isolated locations with risks to the individual and the public.\u003c/p\u003e \u003cp\u003eSeveral other restrictions around the consumption process existed, for example: no sharing of drugs, no assisted injecting, no sharing of booths. Whilst these restrictions are typical of more medicalized DCRs and have been reported widely in other global contexts (Cassie et al., 2022; Ivsins et al., 2023; Urbanik \u0026amp; Greene, 2021; Xavier et al., 2021), participants in Athens cited such policies as factors dissuading access. For example, during the intake process which took place upon each use of the service, the doctor would ask what and how much an individual was about the consume. A \u0026lsquo;harm reduction conversation\u0026rsquo; would ensue. Here the doctor would sometimes recommend the person take less than planned or split their dose into smaller batches. Although this was not mentioned during interviews with people who use drugs, it was described during staff interviews. These conversations and the power dynamics in these conversations are unlike those which could occur on the street and could dissuade people already apprehensive around the DCR experience.\u003c/p\u003e \u003cp\u003eFinally, several individuals reported as they were enrolled in OST programs, a key evidence-based harm reduction tool, they could not access the facility. Whilst the purpose of OAT is to support individuals in achieving their treatment goals (Nosyk et al., 2011; O\u0026rsquo;Connor et al., 2021) and reduce overdose risk by halting their consumption of drugs from the illicit market, this restriction also meant that an important support system of socialization and auxiliary services was cut off from this client group. Additionally, the subsequent inability of these clients to access the DCR when enrolled may lead some individuals to use in riskier, unsupervised settings, undermining harm reduction objectives of the service. Amending this policy could be considered to expand access to the DCR and auxiliary health and welfare services.\u003c/p\u003e \u003cp\u003ePolicy implications\u003c/p\u003e \u003cp\u003eA significant proportion of non-DCR users understood the ways in which the DCR could benefit them - by reducing overdose risk, safeguarding them from physical and structural violence common on the street, increasing their access to auxiliary services and offering privacy during the consumption process. With this awareness in mind, we believe that implementing the recommended changes to DCR policies could effectively reduce the current barriers described in this paper. Not only will this allow more people to benefit from the DCR, but it will also decrease the prevalence of public drug use currently present within Athens\u0026rsquo; city centre (Hadjikou et al., 2021).\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eWe explore participant perspectives at a specific point in time (May/June 2023). It is important to note that views may change, especially given the service has adapted certain policies, such as expanding their operating hours, increasing the number of DCR staff with lived experience, increased numbers of mobile DCRs in Athens and on-site drug checking services, all which may have increased access to the site and altered client perspectives. Transcripts were translated from Greek to English. Although this was to a professional standard, there may be some nuance and context which was lost in how people communicated. Our findings may also subject to selection bias, with participants potentially holding different perspectives to individuals who declined to be interviewed or could not be reached (Collier et al., 2004). This limitation is important to consider, as it may affect the diversity of viewpoints captured in our study. Finally, the views of people who access services are context specific and highly localized, our findings may not represent the realities of other communities in which DCRs are implemented and future research should look to assess benefits and barriers in other contexts as a way of adapting local DCR policies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights both the current successes and limitations of Athens\u0026rsquo; DCR. Whilst the facility is undoubtedly preventing and responding to overdoses, providing essential health and social care services and reducing the impacts of structural violence for those who experience homelessness or who would otherwise consume substances in public settings, there remains a substantial number of people who do not access the site who use drugs in public settings. These participants identified physical and operational barriers, such as restrictive consumption practices and the timeliness of the intake and consumption process as factors which discouraged them from accessing the DCR. Addressing these barriers through more flexible policies, expanded outreach and communication of the DCR and integrating peer workers could increase service access. More broadly, adapting these policies to be more reactive to the needs of local people who use drugs could reduce the presence and visibility of street-based drug use and improve public health outcomes for people who use drugs in Athens.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eBDS conceptualised the study and wrote the ethics application. NP, CA and BDS conducted the fieldwork, data collection and data analysis. BDS wrote the first draft and all co-authors assisted with comments and editing. BWC, DHK and GWS oversaw the study as doctoral supervisors.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to acknowledge the Society for the Study of Addiction for funding this research through their doctoral studentship program.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe approved and anonymised ethics protocol is hosted on the Open Science Framework (https://osf.io/vs4at). Data is available from authors upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAli, F., Russell, C., Kaura, A., Leslie, P., Bayoumi, A. M., Hopkins, S., \u0026amp; Wells, S. (2023). Client experiences using a new supervised consumption service in Sudbury, Ontario: A qualitative study. 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Harm Reduction International. https://hri.global/wp-content/uploads/2022/11/GSHR-2022_Western-Europe.pdf\u003c/li\u003e\n\u003cli\u003eHadjikou, A., Pavlopoulou, I. D., Pantavou, K., Georgiou, A., Williams, L. D., Christaki, E., Voskarides, K., Lavranos, G., Lamnisos, D., Pouget, E. R., Friedman, S. R., \u0026amp; Nikolopoulos, G. K. (2021). Drug Injection-Related Norms and High-Risk Behaviors of People Who Inject Drugs in Athens, Greece. AIDS Research and Human Retroviruses, 37(2), 130\u0026ndash;138. https://doi.org/10.1089/aid.2020.0050\u003c/li\u003e\n\u003cli\u003eIckowicz, S., Wood, E., Dong, H., Nguyen, P., Small, W., Kerr, T., Montaner, J. S. G., \u0026amp; Milloy, M.-J. (2017). Association between public injecting and drug-related harm among HIV-positive people who use injection drugs in a Canadian setting: A longitudinal analysis. 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(2014). \u0026lsquo;Safer environment interventions\u0026rsquo;: A qualitative synthesis of the experiences and perceptions of people who inject drugs. Social Science \u0026amp; Medicine, 106, 151\u0026ndash;158. https://doi.org/10.1016/j.socscimed.2014.01.051\u003c/li\u003e\n\u003cli\u003eNaderifar, M., Goli, H., \u0026amp; Ghaljaie, F. (2017). Snowball Sampling: A Purposeful Method of Sampling in Qualitative Research. Strides in Development of Medical Education, 14(3). https://doi.org/10.5812/sdme.67670\u003c/li\u003e\n\u003cli\u003eNosyk, B., Guh, D. P., Sun, H., Oviedo-Joekes, E., Brissette, S., Marsh, D. C., Schechter, M. T., \u0026amp; Anis, A. H. (2011). Health related quality of life trajectories of patients in opioid substitution treatment. Drug and Alcohol Dependence, 118(2\u0026ndash;3), 259\u0026ndash;264. https://doi.org/10.1016/j.drugalcdep.2011.04.003\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Connor, A. M., Cousins, G., Durand, L., Barry, J., \u0026amp; Boland, F. (2020). Retention of patients in opioid substitution treatment: A systematic review. PLOS ONE, 15(5), e0232086. https://doi.org/10.1371/journal.pone.0232086\u003c/li\u003e\n\u003cli\u003ePanori, A., \u0026amp; Psycharis, Y. (2018). The impact of the economic crisis on poverty and welfare in Athens. \u003cem\u003eRegion et Developpement\u003c/em\u003e, \u003cem\u003e48\u003c/em\u003e, 23-40. \u003c/li\u003e\n\u003cli\u003ePaquette, C. E., Syvertsen, J. L., \u0026amp; Pollini, R. A. (2018). Stigma at every turn: Health services experiences among people who inject drugs. International Journal of Drug Policy, 57, 104\u0026ndash;110. https://doi.org/10.1016/j.drugpo.2018.04.004\u003c/li\u003e\n\u003cli\u003eParkin, S., \u0026amp; Coomber, R. (2009). Public injecting and symbolic violence. Addiction Research \u0026amp; Theory, 17(4), 390\u0026ndash;405. https://doi.org/10.1080/16066350802518247\u003c/li\u003e\n\u003cli\u003ePijl, E., Oosterbroek, T., Motz, T., Mason, E., \u0026amp; Hamilton, K. (2021). Peer-assisted injection as a harm reduction measure in a supervised consumption service: A qualitative study of client experiences. Harm Reduction Journal, 18(1), 5. https://doi.org/10.1186/s12954-020-00455-3\u003c/li\u003e\n\u003cli\u003eRhodes, T. (2009). Risk environments and drug harms: A social science for harm reduction approach. International Journal of Drug Policy, 20(3), 193\u0026ndash;201. https://doi.org/10.1016/j.drugpo.2008.10.003\u003c/li\u003e\n\u003cli\u003eRhodes, T., Kimber, J., Small, W., Fitzgerald, J., Kerr, T., Hickman, M., \u0026amp; Holloway, G. (2006). Public injecting and the need for \u0026lsquo;safer environment interventions\u0026rsquo; in the reduction of drug‐related harm. 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K., Panopoulos, A., Kantzanou, M., Katsoulidou, A., Psichogiou, M., Fotiou, A., Pharris, A., Van De Laar, M., Wiessing, L., Jarlais, D. D., Friedman, S. R., \u0026amp; Hatzakis, A. (2015). Homelessness and Other Risk Factors for HIV Infection in the Current Outbreak Among Injection Drug Users in Athens, Greece. American Journal of Public Health, 105(1), 196\u0026ndash;204. https://doi.org/10.2105/AJPH.2013.301656\u003c/li\u003e\n\u003cli\u003eSypsa, V., Roussos, S., Tsirogianni, E., Tsiara, C., Paraskeva, D., Chrysanthidis, T., Chatzidimitriou, D., Papadimitriou, E., Paraskevis, D., Goulis, I., Kalamitsis, G., \u0026amp; Hatzakis, A. (2023). A new outbreak of HIV infection among people who inject drugs during the COVID-19 pandemic in Greece. International Journal of Drug Policy, 117, 104073. https://doi.org/10.1016/j.drugpo.2023.104073\u003c/li\u003e\n\u003cli\u003eTemenos, C., Koutlou, A., Kyriakidou, S., \u0026amp; Galanaki, S. (2024). Assessing stigma: Health and social worker regard towards working with people using illicit drugs in Athens, Greece. Harm Reduction Journal, 21(1), 175. https://doi.org/10.1186/s12954-024-01091-x\u003c/li\u003e\n\u003cli\u003eTrayner, K. M. A., McAuley, A., Palmateer, N. E., Goldberg, D. J., Shepherd, S. J., Gunson, R. N., Tweed, E. J., Priyadarshi, S., Milosevic, C., \u0026amp; Hutchinson, S. J. (2020). Increased risk of HIV and other drug-related harms associated with injecting in public places: National bio-behavioural survey of people who inject drugs. International Journal of Drug Policy, 77, 102663. https://doi.org/10.1016/j.drugpo.2020.102663\u003c/li\u003e\n\u003cli\u003eUrbanik, M.-M., \u0026amp; Greene, C. (2021). Operational and contextual barriers to accessing supervised consumption services in two Canadian cities. International Journal of Drug Policy, 88, 102991. https://doi.org/10.1016/j.drugpo.2020.102991\u003c/li\u003e\n\u003cli\u003eVallance, K., Pauly, B., Wallace, B., Chow, C., Perkin, K., Martin, G., Zhao, J., \u0026amp; Stockwell, T. (2018). Factors associated with public injection and nonfatal overdose among people who inject drugs in street-based settings. Drugs: Education, Prevention and Policy, 25(1), 38\u0026ndash;46. https://doi.org/10.1080/09687637.2017.1351524\u003c/li\u003e\n\u003cli\u003eVindrola-Padros, C. (2021). Rapid ethnographies: A practical guide. Cambridge University press.\u003c/li\u003e\n\u003cli\u003eXavier, J., Rudzinski, K., Guta, A., Carusone, S. C., \u0026amp; Strike, C. (2021). Rules and Eligibility Criteria for Supervised Consumption Services Feasibility Studies \u0026ndash; A Scoping Review. International Journal of Drug Policy, 88, 103040. https://doi.org/10.1016/j.drugpo.2020.103040\u003c/li\u003e\n\u003cli\u003eYoon, G. H., Levengood, T. W., Davoust, M. J., Ogden, S. N., Kral, A. H., Cahill, S. R., \u0026amp; Bazzi, A. R. (2022). Implementation and sustainability of safe consumption sites: A qualitative systematic review and thematic synthesis. Harm Reduction Journal, 19(1), 73. https://doi.org/10.1186/s12954-022-00655-z \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6555632/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6555632/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003eIn April 2022, a new Drug Consumption Room (DCR) opened in Athens’ city centre. To date, no qualitative research has evaluated the operational strengths and weaknesses of the site from the viewpoint of DCR clients and people who use drugs locally in public settings and do not access the DCR.\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003eRapid-ethnographic fieldwork was conducted over a seven-week period. This comprised an initial five-week period of non-participant observation (≈200 hours) followed by a community consultation regarding the research design and question protocols. Qualitative data were then collected through five focus groups with 24 regular DCR clients and 25 street-based interviews with non-DCR clients who consume drugs in public settings.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eRegular DCR clients reported increased physical, structural, and emotional safety and increased connection with auxiliary health and social services and staff and peers. Those who did not use the facility could see potential benefits but noted several operational and contextual barriers. These results are presented through three themes (1) Safety, (2) Connection and (3) Barriers, each with several sub-themes.\u003c/p\u003e\n\u003cp\u003eConclusion\u003c/p\u003e\n\u003cp\u003eAddressing DCR barriers could increase service access, reduce the presence and visibility of public drug use and improve public health outcomes for people who use drugs in Athens. Indeed, some of these barriers have been addressed since the research was conducted (eg., by expanding operating hours, increasing the number of staff with lived experience, offering on-site drug checking), illustrating the value of evaluating the efficacy of a DCR from the perspective of actual and potential clients.\u003c/p\u003e","manuscriptTitle":"Benefits and Barriers: A Rapid-Ethnographic Study on the Perspectives of Potential and Actual Clients of Athens’ Drug Consumption Room","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-02 04:49:22","doi":"10.21203/rs.3.rs-6555632/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-24T08:02:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-23T15:00:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-06T10:54:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"149110332440797496821813714565590315304","date":"2025-06-02T13:29:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"125958076751075815572921444762836820766","date":"2025-05-29T17:34:12+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-29T11:53:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-29T13:05:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-29T13:04:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"Harm Reduction Journal","date":"2025-04-29T10:40:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5d1435bb-9a3a-46c2-9986-6fc9dc330f8d","owner":[],"postedDate":"June 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-02T16:06:16+00:00","versionOfRecord":{"articleIdentity":"rs-6555632","link":"https://doi.org/10.1186/s12954-025-01371-0","journal":{"identity":"harm-reduction-journal","isVorOnly":false,"title":"Harm Reduction Journal"},"publishedOn":"2026-01-26 15:58:05","publishedOnDateReadable":"January 26th, 2026"},"versionCreatedAt":"2025-06-02 04:49:22","video":"","vorDoi":"10.1186/s12954-025-01371-0","vorDoiUrl":"https://doi.org/10.1186/s12954-025-01371-0","workflowStages":[]},"version":"v1","identity":"rs-6555632","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6555632","identity":"rs-6555632","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}