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International Journal of Drug Policy 24 (2013) 220– 222

Contents lists available at SciVerse ScienceDirect

International Journal of Drug Policy

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ditorial

efining a service for people who use drugs as ‘low-threshold’: What should behe criteria?

In this issue Edland-Gryt and Skatvedt (2012) describe the var-ous barriers which drug users with mental health problems needo overcome in order to access a targeted threshold service. Whilstheir work is illuminating in terms of understanding these barri-rs, it raises the question of what a low threshold service is. Theerm ‘low-threshold’ has become an expression widely used in theeld of psychoactive drug use and harm reduction. The rationale

or introducing low-threshold facilities was to offer easy access toervices and engage marginalised clients, to motivate them to seekelp and to facilitate their navigation of the health and welfare sys-em (Lee & Zerai, 2010). Vulnerable populations such as drug usersften experience a number of real and perceived barriers to serviceccess, for example, the stigma and discrimination they experi-nce; the burden of appointments, often across several agencies;aiting periods; and feeling too tired or unwell to attend appoint-ents (Neale, Tompkins, & Sheard, 2008). Travel distance, lack of

ransport or funds for this, lack of valid documents, and costs asso-iated with treatment are other potential barriers (Drumm et al.,003). Given these barriers (or thresholds), healthcare needs mayake a lower priority than more immediate concerns such as obtain-ng food, shelter and money for drugs (Carr et al., 1996). Outgoingeferrals for simple services which could potentially be providednsite may create another ‘threshold’ for clients to navigate, andhe available evidence suggests referral uptake in such situations

ay be unsatisfactory (Kimber et al., 2008). Given the documentedmpacts of these barriers, their reduction or elimination shoulde considered a crucial feature of a low-threshold service. Someervices have sought to address these barriers through, for exam-le, provision of cost-free services from convenient locations, withppropriate opening hours, drop-in provision, outreach programsnd adjunct services from the same premises. Such low-thresholdervice provision also aims to be non-judgemental and, whereverossible, anonymous.

he introduction and evolution of the term ‘low-threshold’

The term ‘threshold’ originates from the old English termprescold’ meaning ‘doorsill’ or ‘point of entering’ (Online dictionaryf Etymology, 2012). The Merriam-Webster dictionary defines

threshold’ as a level, point, or value above which something isrue or will take place and below which it is not or will not

Merriam-Webster dictionary, 2012). ‘Low-threshold’ was firstpplied in the illicit drug field to harm reduction measures in theuropean setting (Buning, Coutinho, van Brussel, van Santen, &an Zadelhoff, 1986; Kooyman, 1984). The term’s subsequent use

955-3959/$ – see front matter © 2013 Elsevier B.V. All rights reserved.ttp://dx.doi.org/10.1016/j.drugpo.2013.03.005

varied across services and geographical settings. In some Europeancountries, it is used as an umbrella term to describe differentservices such as needle-syringe programs (NSP), opioid substitu-tion treatment (OST), shelters, counselling and health services. InSwitzerland, however, ‘low-threshold facilities’ refer to specific ser-vices that mostly provide sterile injection/inhalation equipment,basic healthcare and sometimes counselling but do not offer sub-stitution treatments (Gervasoni, Balthasar, Huissoud, Jeannin, &Dubois-Arber, 2012). In Hungary, low-threshold facilities are con-sidered primarily oriented to social services rather than healthcareoriented (Melles, Marvanykovi, & Racz, 2007). The term is alsoused in a range of other contexts, including to describe detoxifi-cation services (Hoffmann et al., 1997), drop-in centres (Michels& Stover, 2012), primary healthcare centres (Islam, Topp, Day,Dawson, & Conigrave, 2012), employment opportunities/agencies(Debeck et al., 2011), living facilities (Sempach, Scholz, & Lanz,1996) and indeed, any service contact with people who injectdrugs (PWID) (Michels & Stover, 2012). Sometimes the term is usedarm-in-arm with the term ‘harm reduction’ (e.g. low-thresholdharm reduction services) (Rachlis, Kerr, Montaner, & Wood, 2009).Even the clients themselves are described as having a threshold,so for example a high-threshold client may have to experience amajor crisis before they would take the step of accessing a ser-vice (Fernandez, McNeill, Haskew, & Orr, 2006; Kerr & Palepu,2001).

This diversity in definitions was reflected in a meeting of mem-ber nations of the European Monitoring Centre for Drugs and DrugAddiction (EMCDDA) held in 2004 that aimed to discuss data collec-tion at low-threshold services (Hedrich, 2004). Some participantssuggested that low-threshold services were those that focussedon the prevention and reduction of harm associated with drugdependence. In some countries the term was used to refer to anyharm reduction service, however, it was pointed out that not allharm reduction services are low-threshold, whereas low-thresholdservices generally have a harm reduction orientation. One viewwas that a low-threshold service should not be primarily ori-ented towards drug treatment. While some participants felt thatthe approach used to reduce access barriers defined a service aslow-threshold. One such approach was choosing an appropriateimplementation setting e.g. a location readily accessible to clients.Another was removing any bureaucratic or administrative barriers

to service access.

A clear definition is important to eliminate confusion amongclients, service providers and policy makers. For instance, repre-sentatives of a member nation of EMCDDA reported that in some

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ettings, services claiming to be low-threshold did not accept cur-ent drug users as clients. In some settings, health was a key focus ofow threshold services, whereas in Hungary, health services wereot included. In fact Melles et al. (2007) found that an absence ofealth-related services in low-threshold facilities in Hungary was aeason for their limited effectiveness. Ambiguous terminology canead to inappropriate data being used to describe and evaluate pro-rams and this can impact on policy and planning. Indeed, EMCDDAcknowledged that the contexts in which the term ‘low-threshold’as used and its interpretations were inconsistent and impreciselyefined. Their meeting in 2005 ended with a conclusion that a clearefinition of low-threshold is necessary (Hedrich, 2005).

Marlatt (1998) conceived the concept of low-threshold servicesithin the larger harm reduction umbrella and endeavoured to

dentify key aspects of such services, such as reducing barriers byngaging clients in places where they are willing to meet; achiev-ng partnership with the target group in developing new programs;nd reducing stigma by providing an integrative and normalisedpproach to high-risk substance use and sexual practices. Ryrie,ickson, Robbins, Maclean, and Climpson (1997) argue that theescriptor ‘low-threshold’ indicates both minimal requirements forntry into a service or program and a minimal requirement foretention.

In this issue, Edland-Gryt and Skatvedt (2012) apply thresholdheory to show that drug users with mental health disorders areequired to overcome at least four thresholds to have successfulccess to services. These include: the registration threshold (relatedo access to the service in general and to the staff in particular);he competence threshold (clients’ capacity to communicate theireeds or requests in a way that the staff can understand and actpon); the efficiency threshold (which may relate to both clientsnd providers); and the trust threshold. Edland-Gryt and Skatvedt2012) argue that trust may be intertwined with the other threehresholds and so may be an essential precondition for clientso cross the other thresholds in order to receive the help theyeed.

Under the most straightforward use of the term, then, low-hreshold services are those which endeavour to reduce barriers‘thresholds’) to attendance or retention, by implementing lesstringent eligibility criteria to broaden the potential client base. It is

relative term, describing lower thresholds than those of conven-ional services as there can never be a service with zero thresholds.bstinence is a key threshold or criterion which might be loweredr relaxed to increase drug users’ service access. Abstinence-basedreatment facilities present an exacting barrier to many clientsecause they may require abstention from drug use in order to gainntry, and services may be withheld or terminated in the event ofontinued drug use or relapse (Eversman, 2010; Marlatt & Tapert,993). So for example, some rehabilitation units do not have anssociated detoxification unit, and the requirement of abstinencean constitute a major obstacle to treatment entry. Sometimesin residential or outpatient settings) that requirement of absti-ence is necessary to protect other clients, who are abstinent buttill struggling with craving. Nevertheless, a requirement for absti-ence, particularly at the point of entry, precludes the service fromeing described as low-threshold.

For some commentators, low-threshold services are those thatstablish a first contact with drug users and target the ‘hard-to-each’, that is those who would not otherwise access servicesGervasoni et al., 2012). As well as removing a requirement forbstinence and other barriers, outreach and other flexible, client-riented strategies may be employed (Edland-Gryt and Skatvedt,

012). However, ‘hard-to-reach’ is a relative term, and there is aontinuum of clients from very hard to very easy to reach. Conse-uently, a criterion based on this concept may still not help to derive

clear definition of the term ‘low-threshold’. Moreover, engaging

rug Policy 24 (2013) 220– 222 221

hard-to-reach clients is a service objective rather than an opera-tional model, and services of all thresholds (low, medium and high)may have the same aim.

Defining services for drug users as ‘low-threshold’

Given such varied characterizations, the question becomes,by what criteria can a service be appropriately defined as ‘low-threshold’? Is it flexibility about a requirement for abstinence? Butwhat if a service provider tries to reduce other known barriers,but still requires clients to maintain abstinence? What if a servicedoes not demand abstinence but is unable to address other docu-mented barriers to service access, such as requirement for identitydocuments?

We suggest that there are three essential criteria that define aservice for drug users as ‘low-threshold’. Firstly, drug users shouldbe a key (but not necessarily only) target population. Secondly,abstinence from drug use should not be necessary, given thatdrug dependence is a chronic relapsing and stigmatised condition.Thirdly, other barriers to service access must be reduced as far aspossible.

The first criterion ensures that the facility provides some ser-vices specifically for drug users. This signals from the outset thatdrug users are welcome and will not be discriminated against.Moreover, providing targeted services helps ensure that the needsof drug users are well catered for. Applying Edland-Gryt andSkatvedt’s (2012) layers of threshold, if a facility does not welcomedrug users then clients may have difficulties passing the “registra-tion” threshold, which in turn may impact the “trust” threshold.

The second criterion of not requiring abstinence is fundamen-tal to de-marginalizing clients and creating an environment whichalleviates the guilt and shame they often experience (Lee & Zerai,2010; Rich et al., 2004). This facilitates access for hard-to-reachpopulations. A need for abstinence is a key addition to Edland-Gryt and Skatvedt’s (2012) registration threshold. Correspondingly,flexibility around this requirement has a greater impact on improv-ing service access than other attempts to reduce barriers (O’Neill,2004). This flexibility, a major focus on engaging clients and the pro-vision of essential services are core principles of harm reduction.However, ‘harm reduction’ is a philosophy far broader than just amodel of service provision, and is directed at reducing negative con-sequences of any harmful behaviour/activity without necessarilyreducing that behaviour/activity per se (Edland-Gryt and Skatvedt,2012; Eversman, 2010). So there is a difference between Marlatt’s(1998) description of low-threshold services and ours. Not all harmreduction services are low-threshold, whereas most low-thresholdservices also have a harm reduction orientation.

The third criterion facilitates service entry. This may be byincluding outreach programs, an inviting atmosphere and effectiveclient engagement, anonymous and confidential service delivery,assertive referral with support for referral uptake, free-of-costand/or tailored services, peer support, integrated service modal-ities and support to help reduce personal barriers to healthcareaccess. These initiatives are likely to reduce what Edland-Gryt andSkatvedt (2012) describe as competence and efficiency barriers andto build trust in the facility and the services being offered.

So low-threshold services for drug users should be defined asthose which offer services to drug users; do not impose abstinencefrom drug use as a condition of service use; and endeavour to reduceother documented barriers to service access. Under this definition,low-threshold services include NSPs; some OST program models;

supervised injecting facilities; and many drop-in centres healthand welfare facilities and outreach services which offer servicesto drug users where abstinence from drug use is not mandatory.Together, these three criteria make low-threshold services for drug

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sers more readily identifiable and help to differentiate them fromther services.

Using this definition, a service operating under an abstinenceodel is unlikely to be considered low-threshold, even if it aims to

ttract and engage hard-to-reach clients by reducing other barrierso service access. Furthermore, any agency that imposes abstinences an ongoing condition for service provision is unlikely to success-ully sustain a low-threshold approach because the chronic naturef drug dependence means that a substantial proportion of clientsill relapse and then must be excluded. Although mutual helprograms such as Narcotics Anonymous or Alcoholics Anonymouselcome all comers, they are not services but rather programsith an expectation that participants will devote effort to recov-

ry from drugs, fundamentally conceived as abstinence. However,his does not mean that abstinence-based services are less impor-ant. Indeed a system of ‘layers’ e.g. a series of low-, medium- andigh-threshold services, which clients can navigate between, maye useful.

In conclusion, low-threshold services for drug users can beefined as those which offer services to drug users; do not imposebstinence from drug use as a condition of service access; andndeavour to reduce other documented barriers to service access.sing these criteria, the term ‘low-threshold’ can also be applied

n other contexts, such as to a facility, service or employment forWID. This working definition can help reduce confusion (Hedrich,004; Melles et al., 2007) and provide a firmer foundation for futureiscussion.

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M. Mofizul Islam ∗

Discipline of Addiction Medicine, Central ClinicalSchool, Sydney Medical School, University of Sydney,

Australia

Libby ToppResearch Strategy Unit, Cancer Council NSW, Sydney,

Australia

Katherine M. Conigrave a,b,c

a Drug Health Service, Royal Prince Alfred Hospital,Australia

b Sydney Medical School, University of Sydney,Australia

c National Drug and Alcohol Research Centre,University of New South Wales, Australia

Carolyn A. DayDiscipline of Addiction Medicine, Central Clinical

School, Sydney Medical School, University of Sydney,Australia

∗ Corresponding author at: Drug Health Services,King George V Building, RPAH, Missenden Road,

Camperdown, NSW 2050, Australia.Tel.: +61 2 9515 9726; fax: +61 2 9515 5779.

E-mail addresses: mikhokan143@yahoo.com,m.m.islam@unsw.edu.au (M. Mofizul Islam)

1 November 2012