Low threshold programmes
Jéróme Reynaud
Sociologist (1) j.reynaud@
Stéphane Akoka Sociologist (2)
stephane akoka@

The "low threshold" concept was developed in the 1990s as a means of getting prevention messages across to drug users out of touch with traditional health care structures. Rave missions are now being carried out to approach young people from more socially integrated circles who are casual users of the latest synthetic drugs.

Low threshold interventions have made it possible to contact substance users who were drifting farther and farther away from institutional prevention and care programmes.

One of the revolutions that took place in the 1990s in the realm of social assistance and public health care was the "low threshold" concept*. Given the likelihood that whole populations might escape all control because they either would not or could not fulfil the conditions of entry to the special schemes available (giving up drugs beforehand, undergoing interviews, complying with certain rules), the conditions of access to these programmes were reviewed. Deviance began to be viewed in the 1980s in terms of social exclusion rather than psychological susceptibility, and this paved the way for a new approach to drug addiction from the social assistance and health care point of view. This approach involves working on the streets, reaching out to people in difficult situations, peer prevention* and teaching self-reliance rather than attempting to tackle the users' problems from the outside. Low threshold programmes have made it possible to contact users of psychoactive substances* who were drifting farther and farther away from institutional prevention and care programmes. Rave missions have made it possible, for example, to address young non'   injecting, casual or novice consumers of psychoactive substances (the mean age of this group is 23). The great majority of these young people claim that their drug use is perfectly under their control. Unfortunately, this does not prevent them from taking frequent risks as to which substances they take and how they go about it. It is as essential to provide the new users of the latest designer drugs with relevant information and the practical means of taking health precautions as it was with the injectable drug users ten years ago.

The first experiments on these lines (syringe exchange programmes (SEPs)* based on buses, working on the streets) were launched by associations. Over the years, the low threshold approach developed with the opening of the first boutiques, syringe exchange points and sleepins, and rave missions were eventually set up. These outreach programmes can be said to involve three different stages.

The first stage, which is the first step towards complete negotiated immersion in the locality, consists of setting up boutiques, sleep-ins and support centres (SEPs and/or day-time and night-time centres). These places are open to the outside world but are nevertheless highly institutionalised because of their permanent urban location. Although the low threshold approach is supposed to do away with all constraints, the users naturally have to comply with the minimum internal regulations when attending these facilities.

The second stage of involvement, which is that of total negotiated immersion in the locality, results in syringe exchange points, low threshold methadone buses* and rave missions. The mobility of these structures enables them to actually enter the social gathering points where drugs are being used, whether they are in the town centres or whether they are places of leisure. The presence of mobile units and booths does, however, remind people of the institutional aspects of the operation. Triggering interactions therefore involves a process of negotiation, but less obviously so than in the previous stage. If the users feel they are being manipulated, they are free to leave whenever they like.

Suspending judgement is a tool which makes it possible to imagine how risks and harm are perceived in the context of drug use. There exists only one way so far of achieving the third and last stage of involvement, which is that of total, nonnegotiated immersion: by implementing outreach programmes (working on the streets, in apartment buildings, in the places occupied by squatters and those where illicit psychoactive substances are being sold, purchased and consumed). This approach is the one that comes most closely in touch with the whole social context bound up with drug use. With no institutional support to hand, the prevention workers have to adapt to the logic of the places they are exploring. The success of the venture will depend on the workers' ability to detect, note and make use of whatever seems to be meaningful in a hitherto unknown environment.

What the prevention workers reaching out in this way to the most socially disadvantaged groups are being asked to do is something radically new. It is not just a question of their physical ability to undertake work of this kind. Reaching out to people on the fringes means that the workers have to invest social precincts with which they have never been traditionally familiar before.

It is vital that the logic underlying the social context in these places should be properly understood by all these pioneers; otherwise, they might miss the point, resulting in the failure of any action taken. To be effective, low threshold workers therefore need to have detailed knowledge about the neighbourhoods where they are working. They must understand the codes and customs and know how to manage interactions with people under the influence of illicit substances. Although this competence might look like a kind of know-how, there is no need, in our opinion, for workers to have actually taken drugs themselves to be able to acquire this know-how. A non-judgmental attitude is the main tool here, and this enables workers to see exactly how risk, harm, passing time and even pleasure are represented and perceived by users of various kinds.

Those who have acquired the necessary empirical knowledge, showing empathy for the users themselves, have gradually been able to define procedures for building strong, long-lasting relationships based on mutual trust with the people targeted and identifying needs that had not been noticed before, which is most important. Rave missions are interventions which do not focus on a specific group of users but on the specific social arenas in which substance use takes place: these are places of leisure. Although techno circles, with their highly tolerant outlook, were the first to agree to letting prevention institutions into their midst, rave parties are far from being the only places where interventions of this kind are required: large-scale consumption of psychoactive substances has been reported to occur in many other places such as concerts, festivals, clubs and discotheques.

1 From the Rave mission run by Mutualité Francaise Alpes-Maritimes/Médecins du Monde, PES Médecins du Monde, Nice, France.

2 From the Rave mission run by Mutualité Francaise Alpes-Maritimes/Médecins du Monde, Groupe de recherche sur la Vulnérabilité Sociale (GRVS). For further information, please contact: mdmrd06 a

RAVE MISSION WORKERS FROM MÉDECINS DU MONDE

what their work consists of

• Running emergency aid posts: these are manned by a team including a qualified doctor and nurses equipped with a basic emergency aid unit.

• Monitoring recent trends in the use of psychoactive substances;

• Public health watch activities: working with the Observatoire Francais des Drogues et des Toxicomanies, and affiliated with the rapid warning system set up by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA);

• Providing risk and harm reduction services focusing on the use of psychoactive substances: qualified workers provide information and counselling, are available to talk to, test drugs, distribute prevention items (brochures, condoms, water, cereal bars, straws, etc.);

• Working to prevent addictive behaviour: social and health professionals give consultations, diagnosis, orientation, arrange for referral to other structures and subsequent follow-up; • Running drop-in centres for users previously contacted by the Rave Mission programmes: these centres are permanently staffed during the daytime.