Parents who use drugs: Accounting for damage and its limitation

The gendered violence of injecting-related stigma among relatively affluent, suburban women who inject drugs

INTRODUCTION

In honouring the legacy of Jude Byrne's life-long advocacy for women and mothers who use drugs, this paper presents a case study of a group of women about whom we know little about and hear even less from: women who inject drugs in relatively affluent suburbs.

METHODS

Based on a 2020 qualitative study of people who inject drugs in an affluent area of Sydney known as 'The Beaches', we use in-depth interview data to thematically explore the lived experiences of gendered stigma among women who inject drugs.

RESULTS

Even when women occupy the 'ideal' social position in terms of class (middle-class) and race (White) they remain subject to harmful forms of gendered stigma related to injecting drug use. Participants had internalised negative attitudes around injection drug use as a form of failed femininity and, despite being part of 'good' families and neighbourhoods, participants experienced forced child removal.

DISCUSSION AND CONCLUSIONS

Taking the lead from feminist intersectionality scholarship, our data illustrate how stigma and discrimination act as a form of structural violence against women who inject drugs in affluent communities. While the social relations of gender provide some degree of protection by 'performing proximity to Whiteness', gendered stigma and violence persist.

Exhausting care: On the collateral realities of caring in the early days of the Covid-19 pandemic

We explore care as a site of multiplicity and tension. Working with the qualitative interview accounts of nineteen health care workers in Colombia, we trace a narrative of 'exhausting care' in the early days of the Covid-19 pandemic. Accounts relate exhausting care to working without break in response to extraordinary demand, heightened contagion concern, the pressures of caring in the face of anticipated death, and efforts to carry on caring in the face of constraint. We bring together the work of John Law (2010, 2011) on 'collateral realities' with Lauren Berlant's (2011) thesis of 'cruel optimism' to explore care as a site of practice in which the promise of the good can also become materialised as harm, given structural conditions. Through the reflexive narrative of 'carrying on' in the face of being 'worn down' by care, a narrative which runs through health care worker accounts, we draw attention to the collateral realities of exhausting care as personal and political, at once a practice of endurance and extraction. We argue that the exhausting care that relates to the extraordinariness of the Covid-19 pandemic also resides in the ordinariness, and slower violence, of the everyday. The cruel optimism of care is a relation in which the labour of care reproduces a harmful situation.

'I was trying to get there, but I couldn't': social norms, vulnerability and lived experiences of home delivery in Mashonaland Central Province, Zimbabwe

Increasing facility-based delivery rates is pivotal to reach Sustainable Development Goals to improve skilled attendance at birth and reduce maternal and neonatal mortality in low- and middle-income countries (LMICs). The translation of global health initiatives into national policy and programmes has increased facility-based deliveries in LMICs, but little is known about the impact of such policies on social norms from the perspective of women who continue to deliver at home. This qualitative study explores the reasons for and experiences of home delivery among women living in rural Zimbabwe. We analysed qualitative data from 30 semi-structured interviews and 5 focus group discussions with women who had delivered at home in the previous 6 months in Mashonaland Central Province. We found evidence of strong community-level social norms in favour of facility-based delivery. However, despite their expressed intention to deliver at a facility, women described how multiple, interacting vulnerabilities resulted in delivery outside of a health facility. While identified as having delivered 'at home', narratives of birth experiences revealed the majority of women in our study delivered 'on the road', en route to the health facility. Strong norms for facility-based delivery created punishments and stigmatization for home delivery, which introduced additional risk to women at the time of delivery and in the postnatal period. These consequences for breaking social norms promoting facility-based delivery for all further increased the vulnerability of women who delivered at home or on the road. Our findings highlight that equitable public health policy and programme designs should include efforts to actively identify, mitigate and evaluate unintended consequences of social change created as a by-product of promoting positive health behaviours among those most vulnerable who are unable to comply.

Recovery from alcohol problems in the absence of treatment: a qualitative narrative analysis

BACKGROUND AND AIMS

Recovery from alcohol problems in the absence of treatment or mutual-aid is very common, but under-researched. This study explores the lives of people who had resolved their alcohol problems without treatment, seeking to situate experiences of recovery in social contexts and broader life narratives.

DESIGN

The in-depth qualitative interviews were aided by a life-history methodology that invited participants to account retrospectively for their lives. A narrative analysis was undertaken.

SETTING

Two major cities (Sydney and Melbourne) in Australia.

PARTICIPANTS

People who had resolved an alcohol problem in the absence of treatment (n = 12) were recruited from the general community using convenience sampling.

MEASUREMENTS

Eligible participants had received 'minimal treatment' for an alcohol use disorder: fewer than three sessions in an outpatient treatment programme or nine sessions with mutual-aid groups (e.g. Alcoholics Anonymous), or having accessed mental health treatment for problems other than drinking at least 2 years prior or 1 year after having resolved an alcohol problem. Participants were considered to have had an alcohol use disorder if they reported two or more symptoms (DSM-V) within a 1-year period prior to the past year, using questions endorsed by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). People were considered to have resolved their alcohol use disorder by responding to the recruitment message calling for people who "used to have an alcohol problem but no longer do". The Alcohol Use Disorders Identification Test (AUDIT-C) was used to understand participant's drinking behaviours in the past 12 months.

FINDINGS

Four different narratives were identified in the analysis. In the emancipation narrative, identity development and major changes across the life-curve were associated with separating oneself from an oppressive circumstance. In discovery narratives, art culture and other consciousness-expanding experiences were sources of identity development, but sometimes a barrier to alcohol recovery. In mastery narratives, life events were understood as failures or successes, and recovery was positioned as an individual journey accomplished through increased problem awareness. Finally, in coping narratives, changes were understood as a series of continuous struggles, and recovery was made sense of through diagnostic discourses.

CONCLUSIONS

People who resolve an alcohol use disorder in the absence of treatment or mutual-aid appear to explain their recovery in terms of at least four different life narratives: emancipation, discovery, mastery or coping. Social contexts and cultures outside the treatment setting, and the various identities and narratives they provide, shape change processes.

"An Active, Productive Life": Narratives of, and Through, Participation in Public and Patient Involvement in Health Research

Public and patient involvement (PPI)-engaging the public in designing and delivering research-is increasingly expected in health research, reflecting recognition of the value of "lay" knowledge of illness and/or caring for informing research. Despite increased understanding of PPI experiences within the research process, little attention has been paid to the meaning of PPI in other areas of contributors' lives, and its value as a broader social practice. We conducted repeated narrative interviews with five experienced PPI contributors from the United Kingdom to explore how meaning is constructed through narratives of PPI in relation to their broader "life-worlds." Narratives were extremely varied, constructing identities and meanings around PPI in relation to family and social life, career and employment, financial status, and wider social agendas, as well as health. This emphasizes the importance of recognizing PPI as a social practice with diverse meaning and value beyond health research.

Diagnosing uncertainty, producing neonatal abstinence syndrome

The use of alcohol and other drugs during pregnancy is understood to be an important public health problem. One way in which this problem is expressed and responded to is via the identification and treatment of neonatal abstinence syndrome (NAS). In this article, we demonstrate how the processes of anticipating, identifying and responding to NAS are characterised by significant uncertainty among parents and health and social care practitioners. We draw on interviews with 16 parents who had recently had a baby at risk of NAS, and multidisciplinary focus groups with 27 health and social care professionals, held in Scotland, UK. NAS, and drug use in pregnancy, is a fraught and complex arena. Parents in the UK who use opioids risk losing custody of children, and must navigate a high degree of surveillance, governance and marginalisation. We suggest that considering NAS as a social diagnosis, further informed by Mol's political ontology of 'multiple' bodies/diseases, may help to produce clinical and social responses to uncertainty which avoid, rather than promote, further marginalisation of parents who use drugs. One such response is to develop a culture of relationship-based care which empowers both service providers and service users to challenge existing practice and decision-making.

Understanding and managing uncertainty in health care: revisiting and advancing sociological contributions

In this collection we revisit the enduring phenomenon of uncertainty in health care, and demonstrate how it still offers coherence and significance as an analytic concept. Through empirical studies of contemporary examples of health care related uncertainties and their management, our collection explores the different ways in which uncertainty may be articulated, enacted and experienced. The papers address a diverse range of healthcare contexts - Alzheimer's disease, neonatal surgery, cardiovascular disease prevention, cancer, addiction (use of alcohol and other drugs during pregnancy), mental health/disorders and medical education - and many tackle issues of contemporary relevance, such as an ageing population, and novel medical interventions and their sequelae. These empirical papers are complemented by a further theoretical contribution, which considers the role of 'implicit normativity' in masking and containing potential ethical uncertainty. By mapping themes across the collection, in this introduction we present a number of core analytical strands: (1) conceptualising uncertainty; (2) intersections of uncertainty with aspects of care; (3) managing uncertainty; and (4) structural constraints, economic austerity and uncertainty work. We reflect on the methodological and theoretical stances used to think sociologically about uncertainty in health care, and the strengths, silences and gaps we observe in the collection. We conclude by considering the implications of the insights gained for 'synthesising certainty' in practice and for future research in this area.

Engaging with motherhood and parenthood: A commentary on the social science drugs literature

The majority of qualitative social scientific research on the topic of parenthood and substance use focuses on mothers who use illicit drugs and their experiences of social marginalization and stigmatization. This commentary argues that new and important insights might be gained about parenting in the context of substance use by engaging more closely with everyday experiences of mothering and with contemporary theorising around motherhood and parenthood. Drawing on recent sociological studies of family life influenced by late-modern individualism and by new expert attention on the quality of parent-child relationships, the commentary proposes directions for future social research on the identities and experiences of mothers and fathers who use alcohol and other drugs.

The becoming of methadone in Kenya: How an intervention's implementation constitutes recovery potential

This analysis treats the recent introduction of methadone treatment in Kenya as a case of 'evidence-making intervention'. Using 30 qualitative interviews with people in receipt of methadone treatment in Nairobi, Kenya, methadone's becoming is treated as an effect of its narrative and material implementations. The interviews are shown to enact a narrative of methadone recovery potential towards normalcy beyond addiction. Such recovery potential is materialised in practice through social interactions wherein methadone's embodied effects are seen to be believed. Here, the recovering body affects others' recovery potential. In a context of competing claims about methadone's effects, including the circulation of doubt about experimenting with methadone treatment, embodied methadone effect helps moderate the multiverse of methadone knowledge. The material dynamics of methadone treatment delivery also affect its recovery potential, with the methadone queue enacting a rationing of recovery hope. Here, the experience of methadone's implementation loops back to a life with drugs. I conclude that there is a coexistence of potentiality and actuality, a 'methadone multiple', produced through its narrative and material implementations.

"Why Am I the Way I Am?" Narrative Work in the Context of Stigmatized Identities

There are particular complexities faced by people attempting to tell their stories in the context of social stigma, such as the hostility which often surrounds injecting drug use. In this article, we identify some of the distinct advantages of taking a narrative approach to understanding these complexities by exploring a single case study, across two life-history interviews, with "Jimmy," a young man with a history of social disadvantage, incarceration, and heroin dependence. Drawing on Miranda Fricker's notion of "hermeneutical injustice," we consider the effects of stigmatization on the sociocultural practice of storytelling. We note the way Jimmy appears both constrained and released by his story-how he conforms to but also resists the master narrative of the "drug user." Narrative analysis, we conclude, honors the complex challenges of the accounting work evident in interviews such as Jimmy's, providing a valuable counterpoint to other forms of qualitative inquiry in the addictions field.

An open trial of equine-assisted therapy for children exposed to problematic parental substance use

Children exposed to problematic parental substance use (PPSU) often face a number of deleterious developmental outcomes, yet these children are less likely to become known to child protection and welfare services. Although there is a growing evidence base for equine-assisted therapy (EAT) as an effective treatment modality for atypically developing children and adolescents, scant research has explored the benefit of EAT for children exposed to PPSU. The current study is the first to explore the benefit of EAT for children exposed to PPSU in Victoria, Australia. Five 12-week EAT programmes were delivered from 2012 to 2015 with a total of 41 children (mean age of 10.26 years) taking part. Children's parents (n = 41) and schoolteachers (n = 31) completed the Strengths and Difficulties Questionnaire pre- and post-intervention. Parents reported that children's total difficult behaviour and emotional problems decreased following the 12-week EAT programme. In addition, parents and teachers observed a significant decrease in children's hyperactivity. The findings obtained highlight the benefit of EAT for children exposed to PPSU and thus, extends the existing evidence base for this treatment modality.

Parenthood, Child Care, and Heroin Use: Outcomes After Three Years

BACKGROUND

Internationally there is a lack of measurement on the impact of childcare on people who use drugs.

OBJECTIVES

The aim of this article was to longitudinally measure drug use, familial and social status and criminal involvement between parents and nonparents who use heroin and have children in their care.

METHODS

From 2003 to 2006, 404 participants were recruited to the Research Outcome Study in Ireland Evaluating Drug Treatment Effectiveness (ROSIE) as part of a longitudinal cohort study design. Participants completed the Maudsley Addiction Profile and 88% (n = 356) completed interviews at the 3-year period. One way between groups ANOVA with post hoc tests and backward, stepwise multiple regression were employed for analysis.

RESULTS

At follow-up, parents who had children in their care used heroin (p = .004), illicit methadone (p ≤ .001) and cocaine (p = .024) on fewer days than those who had no children, or those who had children but did not have children in their care. These differences were not observed at intake. Living with someone at intake who used drugs was found to be significantly associated with increased heroin (p ≤ .001), benzodiazepine (p = .039), and tobacco (p = .030) use at 3 years. Furthermore, a change in childcare status to caring for a child was associated with increased cannabis use (p = .025). Conclusion/Importance: While caring for children was associated with reduced heroin use at 3 years, living with a person who used at intake removed this effect, thus indicating that while individual based addiction theories reflected observed outcomes, social network connectedness was more influential.

Trust and people who inject drugs: The perspectives of clients and staff of Needle Syringe Programs

AIMS

Interest in health-care related trust is growing with the recognition that trust is essential for effective therapeutic encounters. While most trust-related research has been conducted with general patient groups, the experiences of people who inject drugs cannot be understood without acknowledging the critical role social stigma plays in shaping (mis)trust, both generally and in regards to health services specifically. This study examined the experiences of trust among clients and staff of Needle and Syringe Programs (NSPs) in one area of Sydney, Australia.

METHOD

In-depth interviews with 12 NSP staff and 31 NSP clients were conducted. Analysis was informed by a five component model of trust, with particular emphasis on the notion of "global trust" as encompassing experiences of stigma and other negative social processes related to injecting drug use. Participant experiences of trust in NSPs were compared with those within other drug-related health services. Particular attention was paid to understanding the relationship between 'identity' (as a drug user) and 'legitimacy' (as a service user) and the centrality of this relationship to the experience of global trust for PWID.

RESULTS

Notions of identity and legitimacy were inextricably bound up with the stigmatisation of drug use, shaping participants' experiences and accounts of trust in NSPs and drug treatment services. Client participants reported high levels of trust in NSPs, especially when compared with drug treatment services, describing being treated like "any other person" even when negotiating 'sensitive' issues. NSP staff participants described the establishment of trust as not only underpinning their work with clients but as something that required ongoing renewal and demonstration.

CONCLUSION

"Global trust" assists us to better understand the complex experiences shaping PWID decisions to engage with and trust health services. The high levels of trust reported between client and NSP need to be recognised as a valuable resource for the delivery of effective health care for people who inject drugs, including encouraging behaviours to support the prevention of blood-borne viruses.

Complicating the dominant morality discourse: mothers and fathers' constructions of substance use during pregnancy and early parenthood

Introduction

Consumption of substances is a highly controversial behaviour, with those who do so commonly viewed as deviants, even criminals, or else as out of control addicts. In other work we showed that the use of substances by women who are pregnant or have recently become parents was mainly viewed by health and social care providers as morally wrong. Problematic substance use was framed through the narrow lens of gendered responsibilisation, resulting in women being seen primarily as foetal incubators and primary caregivers of infants.

Methods

In this follow-up paper we examine descriptive and qualitative data from a convenience sample of biological mothers and fathers (N = 34) recruited as part of a larger mixed methods study of the development and early implementation of an integrated primary maternity care program. We present a description of the participants’ backgrounds, family circumstances, health status, and perception of drug-related stigma. This is succeeded by a thematic analysis of their personal views on substance use during both pregnancy and the transition to parenthood.

Results

Our results show that while many mothers and fathers hold abstinence as the ideal during pregnancy and early parenting, they simultaneously recognize the autonomy of women to judge substance use risk for themselves. Participants also call attention to social structural factors that increase/decrease harms associated with such substance use, and present an embodied knowledge of substance use based on their tacit knowledge of wellness and what causes harm.

Conclusions

While these two main discourses brought forward by parents concerning the ideal of abstinence and the autonomy of women are not always reconcilable and are partially a reflection of the dissonance between dominant moral codes regarding motherhood and the lived experiences of people who use substances, service providers who are attuned to these competing discourses are likely to be more effective in their delivery of health and social services for vulnerable families. More holistic and nuanced perspectives of health, substance use, and parenting may generate ethical decision-making practice frameworks that guide providers in meeting and supporting the efforts of mothers and fathers to achieve well-being within their own definitions of problematic substance use.

"I felt for a long time like everything beautiful in me had been taken out": Women's suffering, remembering, and survival following the loss of child custody

BACKGROUND

Child Protective Services' (CPS) placements of children in out-of-home care disproportionately impact families marginalized by poverty, racism and criminalization. CPS' mandate to protect children from neglect and abuse is frequently criticized as failing to address the multiple social and structural domains shaping parents' lives, especially mothers.

METHODS

We conducted a thematic narrative analysis of in-depth interviews to explore the impact of child custody loss on 19 women who use drugs residing in Toronto, Canada. We also assessed the potential roles of intersectional forms of violence and inequities in power that can both give rise to child custody loss and mediate its consequences.

RESULTS

Trauma was identified as a key impact of separation, further exacerbated by women's cumulative trauma histories and ongoing mother-child apartness. Women described this trauma as unbearable and reported persistent symptoms of post-traumatic stress disorder and other mental health conditions. Practices of dissociation through increased use of drugs and alcohol were central in tending to the pain of separation, and were often synergistically reinforced by heightened structural vulnerability observed in increased exposure to housing instability, intimate partner violence, and initiation of injection drug use and sex work. Women's survival hinged largely on hopefulness of reuniting with children, a goal pivotal to their sense of future and day-to-day intentions toward ameliorated life circumstances.

CONCLUSION

Findings highlight needs for strategies addressing women's health and structural vulnerability following custody loss and also direct attention to altering institutional processes to support community-based alternatives to parent-child separation.

Parenthood and opioid dependence

Introduction

Many patients in maintenance treatment programs for opioid dependence are parents to underage children.

Objective

The aim of this study was to explore how parents who are regular patients in maintenance treatment perceive their parenthood.

Methods

The study used a qualitative approach. The informants were recruited by staff at a substance abuse clinic in Sweden. Criteria for inclusion were participation in the local maintenance treatment program, having a child or children younger than 18 years, and being in contact with the child or children. Data were collected in 2012–2013 by in-depth interviews of seven fathers and five mothers and analyzed using concepts and procedures of qualitative content analysis.

Results

The central findings of the study were: 1) the parents’ concerns about possible future discrimination against their children, ie, stigma by association; and 2) the patients’ own parents’ role as the most important support in parenthood.

Conclusion

The issue of anticipated discrimination against the children of parents undergoing maintenance treatment might be an aspect to consider in the development of interventions and support. Considering the role of the patients’ own parents also seems important.

"Just make sure you can get up and parent the next day": Understanding the contexts, risks, and rewards of alcohol consumption for parents

Little is known about how parents make drinking decisions and weigh the risks and rewards of alcohol consumption in specific contexts. This qualitative study examined two questions: 1. What factors influence parental drinking decisions in different drinking contexts? 2. What do parents perceive as the risks and rewards of alcohol consumption in different drinking contexts? Purposive sampling was used to select sixty parents of children aged 10 or younger living in four mid-sized California cities. Data were collected via in-depth, semi-structured interviews. Many parents viewed drinking at family get-togethers or parties as protective of children, since the presence of multiple adults and children provide buffers when parents become intoxicated. In contrast, parents noted that drinking at home, and particularly drinking alone, transmitted potentially negative messages. Social pressures and contexts influence alcohol consumption among parents and could provide potential avenues for intervention against alcohol-related harms.

An exploration of the factors influencing parental self-efficacy for parents recovering from substance use disorders using the social ecological framework

BACKGROUND

The evidence strongly links parental self-efficacy (PSE) to parenting behaviors and child health outcomes.

PURPOSE

The purpose of this article is to apply the social ecological model to the exploration of contextual factors that influence PSE for parents recovering from substance use disorders (SUDs).

METHODS

An integrative review of the literature was conducted on PSE, parenting behaviors, and parents recovering from alcohol and other SUDs through the application of the social ecological model.

RESULTS

The results indicated that there are many individual, interpersonal, and environmental variables that influence PSE for parents with or without addiction.

CONCLUSIONS

Because PSE is a strong predictor of parenting behaviors and child health outcomes, interventions designed to improve PSE may improve the overall health outcomes of families affected by SUD. These interventions would need to address intrapersonal factors of guilt and shame associated with addiction, parenting knowledge (individual), social support (interpersonal), social networking of church, and other community support programs. The integral role of community support, multiagency collaboration (organizational), and national policies (policy) impacting funding for SUD should also be considered. Intervening on multiple ecological systems simultaneously can mitigate negative factors predictive of PSE, improve access to healthcare and service delivery, and transform and sustain positive behavioral changes for parents recovering from SUD.

Mother's little helper? Contrasting accounts of benzodiazepine and methadone use among drug-dependent parents in the UK

Aims

To explore the ways in which opioid-dependent parents accounted for their use of opioids and benzodiazepines during and after pregnancy.

Methods

Longitudinal qualitative interviews [n = 45] with 19 opioid-dependent adults recruited in Scotland, UK, were held during the antenatal and post-natal period. Interviews focused on parenting and parenting support within the context of problem drug use and were analysed using a narrative informed, thematic analysis.

Findings

The majority of participants described using benzodiazepines in addition to opioids. Almost all indicated a desire to stop or reduce opioid use, whereas cessation or reduction of benzodiazepines was rarely prioritised. In stark contrast to opioid dependence, benzodiazepine dependence was portrayed as unproblematic, therapeutic and acceptable in the context of family life. Whereas opioid dependence was framed as stigmatising, benzodiazepine use and dependence was normalised. An exception was benzodiazepine use by men which was occasionally associated with aggression and domestic abuse.

Conclusions

Drug-dependent parents attach different meanings to opioid and benzodiazepine use and dependence in the context of parenthood. Divergent meanings, and stigma, may impact on stated commitment to stability or recovery from dependent drug-use. Attention should be paid to the way in which policy and practice regarding OST and benzodiazepines reflects this divergence.

The nature and extent of child protection involvement among heroin-using mothers in treatment: high rates of reports, removals at birth and children in care

INTRODUCTION AND AIMS

A substantial proportion of women in treatment for substance use problems are mothers of dependent children, but only a small number of studies have explored the nature and extent of their child protection involvement with substance-using mothers themselves.

DESIGN AND METHODS

A large sample of mothers on the opioid treatment program (OTP) in Sydney, Australia, were interviewed. This paper describes their characteristics, the extent and nature of their involvement with the child protection system, the parenting-related interventions provided and their views of their own parenting.

RESULTS

The 171 mothers were disadvantaged and marginalised and had 302 children under the age of 16 years, 99 of whom were in out-of-home care. Nearly half the children in care (n = 42) had been removed at the time of their birth, and half (n = 49) had been removed from a mother who was on an OTP at the time. Among the younger children (age 1-2 years), higher proportions had been removed at birth than among the older children. None of the 32 mothers who had a child removed at birth and then gave birth subsequently retained care of their new baby. Women often chose to enter treatment (63.6%) for child-related reasons (35%) and attempted to shield their children from their substance use. Few health services were provided to them outside the availability of OTP.

DISCUSSION AND CONCLUSIONS

Entering treatment presents an opportunity for improving outcomes for these women and their children and to reduce future involvement with the child protection system.

It's not just the alcohol: gender, alcohol use, and intimate partner violence in Mae La refugee camp, Thailand, 2009

Alcohol use is common in many conflict-displaced populations; population perspectives of alcohol use have not been well studied. Interviews were conducted with a convenience sample of 97 people (September-December 2009) in Mae La, a long-standing refugee camp on the Thai-Burma border, and analyzed thematically. Intimate partner violence (IPV) emerged as a prominent theme, with four subthemes: alcohol use is subject to strongly gendered social controls; alcohol use is changing under the pressures of displacement; IPV is an emergent alcohol-related harm; the relationship between IPV and alcohol is complex. The study's limitations are noted, and future practice and research directions are discussed.

Narrating the social relations of initiating injecting drug use: transitions in self and society

Few studies have explored drug injectors' accounts of their initiation of others into injecting. There also lacks research on the social relations of initiating injecting drug use in transitional society. We draw upon analyses of 42 audio-recorded semi-structured interviews with current and recent injecting drug users, conducted in 2009 in the Republic of Moldova, a transitional society of south-eastern Europe. A thematic analysis informed by narrative theory was undertaken, focusing on accounts of self-initiation and the initiation of others. We also reflect upon the potential of peer efforts to dissuade would-be injectors from initiating. Findings emphasise initiation into injecting as a symbolic identity transition, enabled through everyday social relations. In turn, our analysis locates the drug transitions of the self inside an account of societal transition. We find that personal narratives of self transition are made sense of, and presented, in relation to broader narratives of social transition and change. Furthermore, we explore how narratives of self-initiation, and especially the initiation of others, serve to negotiate initiation as a moral boundary crossing. Self-initiation is located inside an account of transitioning social values. In looking back, initiation is depicted as a feature of a historically situated aberration in normative values experienced by the 'transition generation'. Accounts of the initiation of others (which a third of our sample describe) seek to qualify the act as acceptable given the circumstances. These accounts also connect the contingency of agency with broader narratives of social condition. Lastly, the power of peers to dissuade others from initiating injection was doubted, in part because most self-initiations were accomplished as a product of agency enabled by environment as well as in the face of peer attempts to dissuade.