Don't leave us this way: ethnography and injecting drug use in the age of AIDS

Injection drug use in an affluent beachside community in Sydney: An exploratory qualitative study

INTRODUCTION

Social research on injection drug use has focussed on marginalised groups and communities, leaving a large gap in the field's understanding of how it is experienced in other settings, including in relatively affluent communities.

METHODS

This research is based on fieldwork and 18 in-depth qualitative interviews conducted in suburban beach-side communities in Sydney collectively known as the Northern Beaches.

RESULTS

Participants did not experience stigmatisation by local health services as the norm or as a deterrent to access. Drug acquisition on the Northern Beaches occurred among closed networks of friends and acquaintances, and injecting use rarely occurred in public settings. Police contact was minimal, resulting in lower levels of criminalisation.

DISCUSSION AND CONCLUSIONS

Unlike many of the participants featured in the literature, our study participants grew up in middle and upper middle-class households, typically experiencing comfortable childhoods with little to no exposure to injection drug use. In this setting injection drug use operates covertly within the normal rhythms of middle-class life, hidden in amongst the bustle of cafés and shopping centres, and through the friendliness of neighbourhood driveway and doorstep interactions. Drug use is described as common in the area, with injecting behaviours stigmatised in ways that set it against the 'good' families and neighbourhoods of this beach-side enclave. In contrast to much of the Australian qualitative literature which frames injection drug use as a means of psychological relief or a subcultural norm, our participants described injecting as motivated by the desire to enhance pleasure and social connection.

Negotiating sex work and client interactions in the context of a fentanyl-related overdose epidemic

Despite awareness of the role of drug use in shaping sex worker/client interactions, these dynamics remain poorly understood in the context of illicit fentanyl-driven overdose epidemics. This study examined sex workers' experiences negotiating client interactions amidst a toxic drug supply in Vancouver, Canada. Findings draw from two ethnographic studies. The first, conducted between December 2016 and May 2017, examined the rapid implementation of several low-threshold supervised consumption sites. The second investigated experiences of women accessing a women-only site from May 2017 to June 2018. Data included 200 hours of fieldwork and in-depth semi-structured interviews with 34 street-based sex workers who use illicit drugs. Data were analysed thematically with attention to the risk environment. Participants described providing harm reduction services to clients as a means to reduce overdose-related risks, thus increasing sex workers' hidden labour. Participants, comments regarding criminalisation and stigma surrounding drug use and sex work indicated a reticence to report overdoses, thereby potentially increasing the risks of overdose-related harms, including death. There is an urgent need for sex worker-led overdose prevention strategies that prioritise health and safety of sex workers and their clients with specific attention to how the criminalisation of particular drugs, practices and people contributes to overdose-related risks.

"It's Helped Me a Lot, Just Like to Stay Alive": a Qualitative Analysis of Outcomes of a Novel Hydromorphone Tablet Distribution Program in Vancouver, Canada

North America is experiencing an overdose crisis driven by fentanyl, related analogues, and fentanyl-adulterated drugs. In response, there have been increased calls for "safe supply" interventions based on the premise that providing a safer alternative (i.e., pharmaceutical drugs of known quality/quantity, non-adulterated, with user agency in consumption methods) to the street drug supply will limit people's use of fentanyl-adulterated drugs and reduce overdose events. This study examined outcomes of a hydromorphone tablet distribution program intended to prevent overdose events among people who use drugs (PWUD) at high risk of fatal overdose. Semi-structured qualitative interviews were conducted with 42 people enrolled in the hydromorphone distribution program. Additionally, over 100 h of ethnographic observation were undertaken in and around the study site. Transcripts were coded using NVivo and based on categories extracted from the interview guides and those identified during initial interviews and ethnographic fieldwork. Analysis focused on narratives around experiences with the program, focusing on program-related outcomes. Our analysis identified the following positive outcomes of being enrolled in the hydromorphone tablet distribution program: (1) reduced street drug use and overdose risk, (2) improvements to health and well-being, (3) improvements in co-management of pain, and (4) economic improvements. Our findings indicate that the hydromorphone distribution program not only is effective in responding to the current overdose crisis by reducing people's use of illicit drugs but also addresses inequities stemming from the intersection of drug use and social inequality. Safe supply programs should be further implemented and evaluated in both urban and rural setting across North America as a strategy to reduce exposure to the toxic drug supply and fatal overdose.

“…I can use any syringe I find”: contextual determinants of HIV risk in public injecting settings in Nigeria

Purpose

The purpose of this study is to explore the contextual determinants of HIV risk among people who inject drugs (PWID) in public settings in Nigeria.

Design/methodology/approach

In-depth, individual interviews were conducted with 29 street-based PWID recruited through snowball sampling in Uyo, Nigeria. Interviews were tape-recorded, transcribed, coded and analysed hematically.

Findings

Homelessness and withdrawal pains encouraged consumption of drugs in public spaces (e.g. bunks, public parks). Conversely, the benefits of participation in street drug-use scenes, including reciprocity norms that guarantee free drugs during withdrawal and protection during overdose, fostered a preference for public injecting. Although participants recognized the need to inject with sterile syringes, scarcity of syringes compelled them to improvise with old syringes or share syringes, increasing risk for HIV transmission. HIV risk was exacerbated by unlawful and discriminatory policing practices, which deterred possession of syringes and encouraged risky behaviours such as rushing injection and sharing of equipment.

Practical implications

Contextual factors are key determinants of HIV risk for street-based PWID. Implementation of needle and syringe programmes as well as reforming legal frameworks and policing practices to support harm reduction are needed responses.

Originality/value

This is one of very few qualitative studies that explore risk factors for HIV transmission among PWID in West Africa. The focus on scarcity of sterile syringes and HIV risk is unique and has important policy implications.

"Bed Bugs and Beyond": An ethnographic analysis of North America's first women-only supervised drug consumption site

BACKGROUND

Attention to how women are differentially impacted within harm reduction environments is salient amidst North America's overdose crisis. Harm reduction interventions are typically 'gender-neutral', thus failing to address the systemic and everyday racialized and gendered discrimination, stigma, and violence extending into service settings and limiting some women's access. Such dynamics highlight the significance of North America's first low-threshold supervised consumption site exclusively for women (transgender and non-binary inclusive), SisterSpace, in Vancouver, Canada. This study explores women's lived experiences of this unique harm reduction intervention.

METHODS

Ethnographic research was conducted from May 2017 to June 2018 to explore women's experiences with SisterSpace in Vancouver's Downtown Eastside, an epicenter of Canada's overdose crisis. Data include more than 100 hours of ethnographic fieldwork, including unstructured conversations with structurally vulnerable women who use illegal drugs, and in-depth interviews with 45 women recruited from this site. Data were analyzed in NVivo by drawing on deductive and inductive approaches.

FINDINGS

The setting (non-institutional), operational policies (no men; inclusive), and environment (diversity of structurally vulnerable women who use illegal drugs), constituted a space affording participants a temporary reprieve from some forms of stigma and discrimination, gendered and social violence and drug-related harms, including overdose. SisterSpace fostered a sense of safety and subjective autonomy (though structurally constrained) among those often defined as 'deviant' and 'victims', enabling knowledge-sharing of experiences through a gendered lens.

CONCLUSION

SisterSpace demonstrates the value and effectiveness of initiatives that engage with socio-structural factors beyond the often narrow focus of overdose prevention and that account for the complex social relations that constitute such initiatives. In the context of structural inequities, criminalization, and an overdose crisis, SisterSpace represents an innovative approach to harm reduction that accounts for situations of gender inequality not being met by mixed-gender services, with relevance to other settings.

The protective effect of trusted dealers against opioid overdose in the U.S

BACKGROUND

Opioid overdose has become the leading cause of death among adults between 25 and 54 years old in the U.S. The purpose of this study is to explore the social and relational factors that shape the current opioid overdose epidemic.

METHODS

Between January 2016 and February 2017, adults in Providence, Rhode Island, who use opioids were recruited to complete structured survey and semi-structured interview about the social context of their substance use.

RESULTS

A total of 92 individuals completed a survey and an interview. Of those, 51 individuals (68.6% male, 49.0% white) discussed their relationships with drug suppliers in their interview and were included in this sub-study. Many of these participants indicated that long-term relationships with trusted dealers represent a key strategy for reducing the risk of substance use-related harm due to suppliers' alleged adoption of consumer protection strategies (e.g. refusing to sell fentanyl) and quality assurance measures (e.g. testing batches of drugs for fentanyl prior to sale).

CONCLUSION

Interpersonal relationships between individuals who use drugs and their suppliers strongly influence the risk and protective factors experienced by people who use drugs in today's opioid overdose epidemic. Evidence-based prevention strategies that are based on an awareness of-or even designed to harness-those positive and/or protective relationships that people who use drugs have already constructed for themselves are likely merited.

The Risk Environment for Adopting and Continuing Injecting Drug Use: A Qualitative Study in Uyo, Nigeria

Background: The bulk of research on adoption of injecting is from Europe and America, despite the existence of syndemics of drug injecting, HIV, and viral hepatitis globally. Objectives: This study explores adoption and continuation of injecting drug use. Methods: The study draws on in-depth interviews with 41 (n = 41) current male and female people who inject drugs recruited via snow-ball sampling in Uyo, Nigeria. A thematic and descriptive analysis was undertaken informed by the risk environment framework and focused on accounts of the factors influencing the process. Results: Accounts emphasized injecting adoption and continuation as a process influenced by individual, social, and structural factors within the risk environment, including concerns for pleasure/efficiency, prestige, exposure to/support for injecting within peer and sexual relationships, availability and purity of drugs, and dependence and increased cost of drug use. Conclusions/implications: Findings highlight the need to prevent adoption of injecting, reduce prevalence of injecting, and promote safe injecting through multi-level interventions, including peer-driven education, drug treatment services, needle and syringe distribution, oral drug substitution, and law enforcement targeting drug suppliers. The need for equivalent pleasure with minimal risk points to the strategic importance of peer interactions for inculcating new understandings of drug use and pleasure.

Women's utilization of housing-based overdose prevention sites in Vancouver, Canada: An ethnographic study

BACKGROUND

In response to a fentanyl-driven overdose crisis, low-threshold supervised consumption sites, termed overdose prevention sites (OPS), have been rapidly implemented in Vancouver, Canada. Since approximately 88% of fatal overdoses in the province occur indoors, OPS have been integrated into select non-profit-operated single room accommodations (SRA) housing. We examined the social-structural features of these housing-based OPS (HOPS) on women's overdose risk.

METHODS

Ethnographic research was conducted from May 2017 to December 2018 in Vancouver. Data included 35 in-depth interviews with women who use drugs living in SRAs and approximately 100 h of observational fieldwork in SRAs and surrounding areas. Data were analyzed using an intersectional risk environment approach, with attention to equity and violence.

FINDINGS

Findings demonstrate that the social and structural environments of HOPS created barriers for women to access these interventions, resulting in an increased overdose risk. Primary barriers included uncertainty as to who else was accessing HOPS, rules prohibiting smoking, and a lack of trust in staff's abilities to effectively respond to an overdose. Most participants considered HOPS to be unsafe environments, and expressed fear of violence from residents and/or guests. The perceived risk of violence was informed by previous experiences of assault and the witnessing of violence. Many participants thus consumed drugs alone in their rooms to better control their safety, despite heightened overdose risk. Further, most participants did not perceive themselves to be at risk of an overdose due to drug use practices and tolerance levels, and viewed using alone as a safer option than HOPS.

CONCLUSION

Findings highlight how the low-barrier design and operation of HOPS can undermine women's engagement with HOPS. Overdose prevention strategies in SRAs should also include gender-specific models (e.g. women-only HOPS, women peer workers) to help mitigate barriers to these services within the context of the current overdose crisis.

The unintended consequences of emphasising blood-borne virus in research on, and services for, people who inject image and performance enhancing drugs: A commentary based on enhanced bodybuilder perspectives

Blood-borne viruses (BBVs) are an established focus of drug research and harm reduction. While a focus on BBVs has been applied to people who inject image and performance enhancing drugs (IPEDs), research has demonstrated that there are significant differences between this group and people who inject other drugs. Furthermore, the literature on BBVs and IPED use has been misrepresented by the media and harm reduction programs, with significant consequences for how some people who inject IPEDs view academic research and health services. It seems time to ask, is our current approach to the issue of BBV among people who inject IPEDs the most appropriate, and are there ways that it could be improved to ensure that there are no unintended consequences? In this commentary I suggest ways research and harm reduction efforts could tackle the issue of BBV without exacerbating existing divides between people who inject IPEDs and the health and academic communities. These suggestions are based on the views of the enhanced bodybuilders with whom I am privileged to work.

Gendered violence and overdose prevention sites: a rapid ethnographic study during an overdose epidemic in Vancouver, Canada

BACKGROUND AND AIMS

North America's overdose epidemic is increasingly driven by fentanyl and fentanyl-adulterated drugs. Supervised consumption sites, including low-threshold models (termed overdose prevention sites; OPS), are now being debated in the United States and implemented in Canada. Despite evidence that gendered and racialized violence shape access to harm reduction among women who use drugs (WWUD), this has not been examined in relation to OPS and amid the overdose epidemic. This study explores how overlapping epidemics of overdose and gendered and racialized violence in Vancouver's Downtown Eastside, one of North America's overdose epicenters, impacts how marginalized WWUD experience OPS.

DESIGN

Qualitative analysis using rapid ethnographic fieldwork. Data collection included 185 hours of naturalistic observation and in-depth interviews; data were analyzed thematically using NVivo.

SETTING

Vancouver, Canada.

PARTICIPANTS

Thirty-five WWUD recruited from three OPS.

MEASUREMENTS

Participants' experiences of OPS and the public health emergency.

FINDINGS

The rapid onset and severity of intoxication associated with the use of fentanyl-adulterated drugs in less regulated drug use settings not only amplified WWUD's vulnerability to overdose death but also violence. Participants characterized OPS as safer spaces to consume drugs in contrast to less regulated settings, and accommodation of assisted injections and injecting partnerships was critical to increasing OPS access among WWUD. Peer-administered injections disrupted gendered power relations to allow women increased control over their drug use; however, participants indicated that OPS were also gendered and racialized spaces that jeopardized some women's access.

CONCLUSION

Although women who use drugs in Vancouver, Canada appear to feel that overdose prevention sites address forms of everyday violence made worse by the overdose epidemic, these sites remain 'masculine spaces' that can jeopardize women's access.

Syringe Sharing and the Risk of Viral Transmission Among People Who Inject Drugs in Nigeria: Structural, Relational, and Subjective Influences on Behaviors

In this article, we report findings of a qualitative study on structural, relational, and subjective determinants of injecting risks. Forty-one current people who inject drugs (PWIDs) were recruited through snowball sampling in Uyo, Nigeria. They were interviewed with a loosely structured interview guide. We employed inductive and thematic analysis of interview transcripts. PWIDs recognize the risk of viral transmission through sharing of syringes. As countermeasures, they inject with sterile syringes, refuse to borrow syringes, and disinfect borrowed syringes. Risk reduction efforts are undermined by withdrawal, pleasure seeking, public injecting settings, policing, social networks, and intimate relationships. These factors create a risk environment for viral transmission. Pleasure-seeking and risk reduction practices show agency and subjectivity, counterbalancing current emphasis on structural determinants of injecting risks. Findings indicate the need for policy reforms, needle and syringe provision, oral drug substitution, safe injecting environments, and peer education. Interventions should build on PWIDs’ agency and risk management practices.

Crystal Methamphetamine use among Gay Men in Sydney

Crystal methamphetamine is used by gay men in Sydney in a variety of social and sexual contexts and by various means including injection. This paper presents detailed ethnographic data that explore some of the social and cultural characteristics of Sydney gay men's crystal use and other associated practices. The meaning of these practices is explored through a discussion of cultural boundaries and social exchange that traverses them. These boundaries help to limit drug-related harms in some ways but also generate certain risks. A nuanced understanding of the cultural meaning of various drug use practices may assist in producing culturally relevant harm-reduction education.

Syndemics: A theory in search of data or data in search of a theory?

The concept of a syndemic was proposed more than two decades ago to explain how large-scale social forces might give rise to co-occurring epidemics that synergistically interact to undermine health in vulnerable populations. This conceptual instrument has the potential to help policymakers and program implementers in their endeavors to improve population health. Accordingly, it has become an increasingly popular heuristic for advocacy, most notably in the field of HIV treatment and prevention. However, most empirical studies purporting to validate the theory of syndemics actually do no such thing. Tomori et al. (2018) provide a novel case study from India illustrating how the dominant empirical approach fails to promote deeper understanding about how hazardous alcohol use, illicit drug use, depression, childhood sexual abuse, and intimate partner violence interact to worsen HIV risk among men who have sex with men. In this commentary, I relate the theory of syndemics to other established social science and public health theories of disease distribution, identify possible sources of conceptual and empirical confusion, and provide concrete suggestions for how to validate the theory using a mixed-methods approach. The hope is that more evidence can be mobilized -- whether informed by the theory of syndemics or not -- to improve health and psychosocial wellbeing among vulnerable populations worldwide.

Qualitative research

BACKGROUND AND AIMS

This narrative review aims to highlight key insights from qualitative research on drug use and drug users by profiling a selection of classic works.

METHODS

Consensus methods were used to identify and select four papers published in 1938, 1969, 1973 and 1984 considered to be classics.

RESULTS

These landmark qualitative studies included the first account of addiction as a social process, demonstrating that people have meaningful responses to drug use that cannot be reduced to their pharmacological effects; the portrayal of inner-city heroin users as exacting, energetic and engaged social agents; identification of the interactive social learning processes involved in becoming a drug user; the application of the 'career' concept to understanding transitions and trajectories of drug use over time; and the articulation of a framework for understanding drug use that incorporates the interaction between pharmacology, psychology and social environments.

CONCLUSIONS

These classic sociological and anthropological studies deployed qualitative research methods to show how drug use is shaped by complex sets of factors situated within social contexts, viewing drug users as agents engaged actively in social processes and worlds. Their findings have been used to challenge stereotypes about drug use and drug users, develop a deeper understanding of drug use among hidden, hard-to-research and under-studied populations, and provide the foundations for significant developments in scientific knowledge about the nature of drug use. They continue to retain their relevance, providing important correctives to biomedical and behaviourist paradigms, reminding us that drug use is a social process, and demonstrating how the inductive approach of qualitative research can strengthen the way we understand and respond to drug use and related harms.

Social-structural factors influencing periods of injection cessation among marginalized youth who inject drugs in Vancouver, Canada: an ethno-epidemiological study

BACKGROUND

Injection drug use is associated with HIV and hepatitis C transmission, overdose, and other preventable harms. These harms are heightened for structurally vulnerable injection drug-using populations, as their social conditions pose barriers to safer injecting. Previous research on injection cessation has largely focused on adult drug-using populations. Little qualitative work has examined the social, structural, and environmental factors that shape periods of injection cessation among youth and young adults. Such research is essential to understanding how we can best reduce harms among this vulnerable population as they move in and out of periods of injection cessation.

METHODS

We conducted 22 semi-structured, qualitative interviews with street-involved young people who use drugs (SY), focused on characterizing their transitions into periods of injection cessation and perceived barriers to injection cessation. Adopting an ethno-epidemiological approach, participants who had experienced at least 6 months of injection cessation were purposively recruited from an ongoing prospective cohort study of SY in Vancouver, Canada to participate in qualitative interviews. Qualitative interview findings were triangulated with the findings of a longitudinal program of ethnographic research with SY in this setting. This ethno-epidemiological approach allowed for a more robust exploration of contextual factors surrounding drug use patterns than would be possible through traditional epidemiological methods alone.

RESULTS

Findings indicate that periods of injection cessation were influenced by access to harm reduction-informed youth-focused services, transitions in route of administration (e.g., from injecting methamphetamine to the smoking of methamphetamine), and the provision of housing and social supports (e.g., from friends, family, and care providers). Conversely, participants indicated that inadequate social supports and, for some, abstinence-focused treatment methods (e.g., 12-step programs), impeded efforts to cease injecting.

CONCLUSIONS

To reduce harms, it is imperative to reorient attention toward the social, structural, and spatial contexts that surround injection drug use and shape periods of injection cessation for SY. There is an urgent need for more comprehensive youth-focused services for those engaged in injection drug use, and further study of innovative means of engaging youth.

Policing, crime and public health

This article examines the influence on policing in Sydney, Australia of the crime control strategies developed in New York City in the 1990s, which are popularly credited with having significantly reduced crime rates. The ‘New York miracle’ is considered as an ‘enthusiasm’, a positive relation of the moral panic. Claims that the NYPD reduced crime with a strategy based on ‘zero tolerance’ or ‘broken windows’ are critically examined. The second half of the article presents a case study of how international developments in policing impacted on a heroin market in Cabramatta, a suburb of Sydney which, in the 1990s, became known as Australia’s ‘heroin capital’. The study shows how transferred policies are implemented, how elements of them may conflict, and how the crucial transfer may be not so much of particular policies, but rather of less specific perceptions and attitudes, in this case a confidence in the ability of police to reduce crime. It concludes by focusing on the collateral damage (particularly to public health) caused by police crackdowns on drug markets. Research is reported which found an alarming increase in the incidence of hepatitis C among intravenous drug users as a result of policing activity in Cabramatta.

Street-Level Drug Market Activity in Sydney's Primary Heroin Markets: Organization, Adulteration Practices, Pricing, Marketing and Violence

This study is a qualitative exploration of two distinctive high-profile street drug markets in Sydney, Australia. Semi-structured interviews were conducted with 32 street-level heroin dealers about their experiences of selling drugs in these areas, market organization, drug adulteration and quality assessment practices, and the extent and impact of violence associated with these markets. Most dealers operated independently, working for themselves or in loosely defined groups of two or three with little or no hierarchy while others acted as “runners,” selling for others for a percentage of sales. A range of “folk” or nonscientific methods were employed for testing the quality of drugs, and adulteration or “cutting” of drugs was rare. Moreover, this research suggests that even during periods of heroin scarcity, increased adulteration is not an inevitable outcome. In contrast to popular perceptions, dealers in both areas cooperated with each other, and little intimidatory rivalry was reported or observed. Indeed, most participants considered violence to be fairly rare, largely avoidable, and not an inevitable consequence of their involvement in the market. Numerous popular drug market and drug dealer stereotypes about the two locations were not supported by the findings.

The micro-social risk environment for injection drug use: An event specific analysis of dyadic, situational, and network predictors of injection risk behavior

BACKGROUND

This study explores the risk environment for drug use by examining injection risk behavior during specific injection episodes. By leveraging multiple observations of injection episodes of participants, the study attempts to move beyond global assessment of environmental variables to simultaneously model within (i.e., event level) as well as between (i.e., individual level) predictors of injection risk. Furthermore, gender is also explored as a potential moderator of the relationship between the association of specific partner characteristics (e.g., having an injection partner who is also a sexual partner) and injection risk behavior.

METHODS

Data is used from the Sexual Acquisition of Transmission of HIV Cooperative Agreement Study (SATHCAP). Multilevel structural equation modeling is utilized to predict within and between variations in underlying injection risk behavior as measured using four indicators of injection risk.

RESULTS

Results indicated that a number of partner level characteristics (i.e., being emotionally close with the partner, sexual partnership, being a first time partner) and one social situational (i.e., the number of non-injectors present at the injection episode) characteristic predicted event level injection risk behavior. However, the impact of partner characteristics also appears to be moderated by gender of the participants. More specifically, sharing a sexual partnership with an injection partner was more strongly associated with injection risk among females as compared to males and females indicated higher levels of risk when injecting with other females while the partner's gender showed no significant association with risk for male injectors.

CONCLUSION

These results suggest that people who inject drug do report varying levels of risk during different injection episodes and this variation can be explained by partner and situational characteristics. Improved understanding of the social processes surrounding injection episodes is required to further refine harm reduction approaches.

"Three in the Room": Embodiment, Disclosure, and Vulnerability in Qualitative Research

The researcher's body in qualitative research is often absented, an absence that can render deceptively tidy research accounts. In this article, I reflect on the interplay of embodiment and disclosure in the interview dynamic and the way in which my body became an object of inquiry in the research process. Three qualitative studies inform the article: the first exploring the experiences of 40 people living with hepatitis C in New Zealand and Australia, the second comprising life-history interviews with 38 people who inject drugs in London, and the third following 27 people through hepatitis C treatment in London. Bodily and verbal disclosures of my history, as someone with/without hepatitis C and a former heroin user, affected the energy of the interview dynamic, also embodied understandings of illness and drug use. Disclosure can enhance researcher vulnerability and I close with reflection on the ethical implications of "enhanced rapport" in the research situation.

Laws prohibiting peer distribution of injecting equipment in Australia: A critical analysis of their effects

The law is a key site for the production of meanings around the 'problem' of drugs in public discourse. In this article, we critically consider the material-discursive 'effects' of laws prohibiting peer distribution of needles and syringes in Australia. Taking the laws and regulations governing possession and distribution of injecting equipment in one jurisdiction (New South Wales, Australia) as a case study, we use Carol Bacchi's poststructuralist approach to policy analysis to critically consider the assumptions and presuppositions underpinning this legislative and regulatory framework, with a particular focus on examining the discursive, subjectification and lived effects of these laws. We argue that legislative prohibitions on the distribution of injecting equipment except by 'authorised persons' within 'approved programs' constitute people who inject drugs as irresponsible, irrational, and untrustworthy and re-inscribe a familiar stereotype of the drug 'addict'. These constructions of people who inject drugs fundamentally constrain how the provision of injecting equipment may be thought about in policy and practice. We suggest that prohibitions on the distribution of injecting equipment among peers may also have other, material, effects and may be counterproductive to various public health aims and objectives. However, the actions undertaken by some people who inject drugs to distribute equipment to their peers may disrupt and challenge these constructions, through a counter-discourse in which people who inject drugs are constituted as active agents with a vital role to play in blood-borne virus prevention in the community. Such activity continues to bring with it the risk of criminal prosecution, and so it remains a vexed issue. These insights have implications of relevance beyond Australia, particularly for other countries around the world that prohibit peer distribution, but also for other legislative practices with material-discursive effects in association with injecting drug use.

Contraception, punishment and women who use drugs

BACKGROUND

In light of the recent debate on the use of financial incentives to promote long-acting contraception and sterilisation among women who use illicit drugs we discuss attitudes to contraception, pregnancy and parenting among Australian women who inject drugs.

METHODS

Qualitative interviews were conducted with 90 women of reproductive age about contraceptive use, preferences, reproductive histories, attitudes to and experiences of parenting. All women were either currently, or had previously injected drugs. The in-depth, semi-structured interviews were compared and contrasted for themes relating to drug use, contraception, pregnancy and parenting.

RESULTS

Participants aspired to control their fertility, expressed individual contraceptive preferences and concerns for their children (both born and unborn). Most had tried a number of contraceptive methods interspersed by periods of non-use related to experiences of side-effects, being single or abstinent, believing that they were infertile and trying to conceive. Attitudes varied from woman to woman and in the same individual over their life course. Some believed that they were not likely to be capable, but most aspired to be successful mothers.

CONCLUSIONS

Women's drug use should not automatically be associated with an inability to make informed health care choices or to care for children. Evidence suggests that women who use drugs do not need to be paid to limit or end their fertility. Rather, programs that aim to reduce barriers to obtaining free, non-discriminating reproductive advice and parenting assistance would better utilise women's agency to improve their own reproductive health.

Reinforced biographies among women living with hepatitis C

In a growing body of social research it is suggested that hepatitis C virus (HCV) infection is a low priority for people who inject drugs. We expand on the evidence to explore the link between identity and health using biographical adaptation theories. We examined experiences of HCV infection and illness among women who inject drugs, women who are no longer injecting drugs, and women who have never injected drugs. We investigated the relationship between identity and illness experience and found that illness does not simply dislocate one's biographical trajectory. For women who used drugs the shared symbolism of HCV infection was understood and accepted via a self-identity linked to poverty and experience of injecting drugs. Rather than disrupting their expected life trajectory, the narratives of most women incorporated the disease experience within their life story, confirming their identity as a person who injected drugs and as someone with constant and serious life stressors.

The empirical war on drugs

In a special issue of the journal Addictions (1995) academics, researchers and health care professionals debated the status of the empirical in socially orientated drugs research. A number of researchers noted that our knowledge and understanding of drugs and drug users has changed significantly since the 1990s. Post AIDS this shift is identified as a consequence of the development of qualitative research methods. The qualitative turn in drugs research has involved a shift away form traditional epidemiological approaches and the pursuit of more socially focused methods. Whilst qualitative research has yielded important empirical data on risk behavior the pursuit of these methods has not been without controversy. In addressing the debate on methods in the drugs field this article investigates the effects of social science methods for research on injecting drug use. In so doing I examine what counts and what gets left out of research on injecting beaviour. Drawing on Actor Network Theory (ANT) I suggest Bruno Latour's methodological approach offers critical insights for addressing the empirical objects of injecting drug use.

Anthropology and addiction: an historical review

AIMS

This paper reviews the world anthropology of drugs and alcohol use literature, identifying key issues addressed by anthropologists, methods and theoretical models in use, trends in focus over time and future directions.

METHODS

Papers and books that comprise the literature were identified through computer search using the keywords: ethnography of drug use (and variants, e.g. drug ethnography, qualitative approaches in drug research), ethnography of drinking, anthropology and drug use, and anthropology and drinking. Search engines included Google Scholar, EBSCOHost, AnthroSource and PubMed. Identified sources were read and integrated into the review.

RESULTS AND CONCLUSIONS

The literature search identified a rich and growing literature on the anthropology of drinking and drug use. The research and published literature on the anthropology of drug use has grown and diversified since the 1970s, found acceptance in the wider multi-disciplinary domain of alcohol and drug studies and developed beyond the socio-cultural model to include life-style, critical medical anthropology and experiential explanatory models. Anthropological research has helped to shape the field of addiction science, e.g. ethnographic studies show that the lived worlds and self-identities of drug users have cultural order and socially constructed purpose and meaning, and experiential research shows that some addictions or aspects of addictions can be affirmative, creative and sustainable, at least at the individual level. The human immunodeficiency virus/acquired immune deficiency syndrome pandemic has significantly increased anthropological research on drug-related issues world-wide.

Staying safe from hepatitis C: engaging with multiple priorities

Hepatitis C virus (HCV) infection is a significant global public health problem. In developed countries, 90% of new infections occur among people who inject drugs (PWID), with seroprevalence increasing rapidly among new injectors. Staying Safe is an international, qualitative, social research project, the aim of which is to draw on the experiences of long-term PWID to inform a new generation of HCV prevention strategies. The Sydney project team employed life history interviews and computer-generated timelines to elicit detailed data about unexposed participants' (n =13) injecting practices, circumstances, and social networks over time. The motivations and strategies that enabled participants to avoid risk situations, and which might have helped them to "stay safe," appeared not to be directly related to harm-reduction messages or HCV avoidance. These included the ability and inclination to maintain social and structural resources, to mainly inject alone, to manage withdrawal, and to avoid injecting-related scars. These findings point to the multiple priorities that facilitate viral avoidance among PWID and the potential efficacy of nonspecific HCV harm-reduction interventions for HCV prevention.

Qualitative accounts of needle and syringe cleaning techniques among people who inject drugs in Sydney, Australia

INTRODUCTION AND AIMS

Cleaning needles/syringes is an important second-line harm reduction strategy, yet there is limited information on practices employed by people who inject drugs in Australia. This study attempts to identify and assess cleaning practices in terms of the techniques involved and the social contexts in which cleaning takes place.

DESIGN AND METHODS

As part of an exploratory qualitative study in south-west Sydney, in-depth interviews and simulated cleaning exercises were conducted with 12 people who inject drugs. Interviews were digitally recorded and transcribed verbatim. Open coding was used to inductively classify data into themes, and data were examined for patterns and variations in the relationships within and between themes.

RESULTS

Data indicate that cleaning and reuse of needles/syringes was common in this small sample. The most frequently utilised reagent was cool water. While all participants reported cleaning and reusing only their own equipment, none of the techniques demonstrated would have been sufficient to deactivate human immunodeficiency virus or hepatitis C virus.

DISCUSSION AND CONCLUSIONS

Results suggest that even where cleaning of needles and syringes is widespread, people who inject drugs may not engage in efficacious cleaning. The combination of the complexity of current cleaning messages and a lack of accurate information about efficacious techniques are likely to contribute to poor cleaning practice. Australia could benefit from the development of a nationally consistent cleaning message; however, the evidence would suggest that this would need to be accompanied by strategies designed to simplify and disseminate this information in order to increase the uptake of efficacious cleaning methods by people who inject drugs.

The growing popularity of prescription opioid injection in downtown Montréal: new challenges for harm reduction

Starting in 2007, a 2-year study based on ethnographic methodology was carried out downtown Montréal, Canada. A thematic analysis of observational and interview-based notes was conducted. Illicit prescription opioid (PO) use was widespread among street-based participants. Injection was the main mode of PO administration observed among users. Some injection practices such as "doing a wash" could pose new challenges in terms of prevention of infections. More research is needed to examine the role of illicit PO use in the development of opiate addiction and to better understand drug-using contexts that put PO users at risk of infections. The study's limitations are noted.

Using ethnographic fieldwork to inform hepatitis C vaccine preparedness studies with people who inject drugs

BACKGROUND

Feasibility studies are an important component of preparations for field trials of biomedical prevention interventions, including vaccines.

METHODS

We conducted ethnographic fieldwork to assess feasibility, including eligibility and willingness to participate, prior to recruitment of a prospective observational study of hepatitis C negative people who inject drugs (PWID) in Sydney, Australia. Five staff conducted ethnographic fieldwork in 16 locations during 2008. Observations and interactions with PWID were recorded as field notes and data were used iteratively to guide targeting of locations and the follow-up of networks and individuals.

RESULTS

Findings informed the development of the study protocol, resulting in changes in the amount and type of participant reimbursement and the quantity of blood collected at screening, as well as highlighting the need for increased emphasis on communicating eligibility and exclusion criteria and study remuneration procedures.

CONCLUSION

Results illustrate the value of ethnographic research in facilitating consultation and discussion with potential participants in natural settings, identifying motivations and concerns prior to study commencement and providing affected community input into the development of research protocols.

The elusive search for definitive evidence on routine screening for intimate partner violence

Routine screening for intimate partner violence (IPV) has been introduced in many health settings to improve identification and responsiveness to IPV. The debate about the level of evidence required to warrant routine screening continues. Three assumptions have impeded progress in measuring the impact of screening. The first is that routine screening is a test only which does not of itself have an impact on patients. The second is that it can be assessed by evaluating interventions provided to women after abuse is identified through screening. The third is that there can be an agreed appropriate intervention for IPV. Each of these assumptions is problematic. In addition, there are significant impediments to evaluating screening as an intervention through a randomized control trial. These include identification of the study group, isolating the control group from the intervention, ethics, lack of baseline data, and recall bias. A range of study designs is required and a rethink of assumptions is needed in researching this area.

Reconceptualizing early and late onset: a life course analysis of older heroin users

PURPOSE

Researchers' knowledge regarding older users of illicit drugs is limited despite the increasing numbers of users. In this article, we apply a life course perspective to gain a further understanding of older adult drug use, specifically contrasting early- and late-onset heroin users.

DESIGN AND METHODS

We collected qualitative data from 29 older heroin users. Life course analysis focused on the users' experiences across the life span.

RESULTS

The findings suggest that those aging into heroin use (late onset) are disadvantaged compared to those who are maturing in (early onset) except in areas of health.

IMPLICATIONS

We propose that conceptualizing the use of heroin and other illicit drugs among older adults based on the user's life course trajectory will provide insights for social and health services, including drug treatment.

Có vay có tra (What goes around comes around): culture, risk and vulnerability to blood-borne viruses among ethnic Vietnamese injecting drug users

INTRODUCTION AND AIMS

Ethnic and cultural differences in vulnerability to drug-related harms have received little attention in Australia. The current study aimed to explore the influence of cultural beliefs and practices on vulnerability to blood-borne viral infections (BBVIs) among ethnic Vietnamese IDUs and to identify barriers to this group accessing health and preventive programmes.

DESIGN AND METHODS

Observational fieldwork and in-depth interviews (n = 58) were conducted in South Western Sydney. Participants were recruited using a mix of snowball and theoretical sampling strategies. Open coding was used to inductively classify data into themes and data examined for regularities and variations in relationships between and within themes.

RESULTS

Participants embraced pluralistic approaches to prevention, diagnosis and treatment, relying on co-existing layers of beliefs and utilising both traditional and western remedies. Four main cultural characteristics influenced vulnerability to BBVIs: trust and obligation, stoicism, the importance of 'face' and beliefs in fate. Other factors influencing injecting risk included low levels of knowledge, being in a state of withdrawal, availability of sterile injecting equipment and environmental constraints. Barriers to accessing services included stigma and discrimination, concerns in relation to confidentiality, long waiting times, resistance to pharmacotherapy treatment and language and financial barriers.

DISCUSSION AND CONCLUSIONS

Results indicate a need for interventions based on culturally specific meanings and contexts of health, illness and risk. By understanding how culture impacts risk and protective behaviours among ethnic Vietnamese IDUs, clinicians and other service providers will be better equipped to meet the needs of this vulnerable group.

Quantifying hepatitis C transmission risk using a new weighted scoring system for the Blood-Borne Virus Transmission Risk Assessment Questionnaire (BBV-TRAQ): applications for community-based HCV surveillance, education and prevention

Background

The hepatitis C virus (HCV) is a major cause of drug-related morbidity and mortality, with incidence data implicating a wide range of HCV transmission risk practices. The Blood-Borne Virus Transmission Risk Assessment Questionnaire (BBV-TRAQ) is a content valid instrument that comprehensively assesses HCV risk practices. This study examines the properties of a new weighted BBV-TRAQ designed to quantify HCV transmission risk among injecting drug users (IDU).

Methods

Analyses of cross-sectional surveys of Australian IDU (N = 450) were used to generate normative data and explore the properties of a weighted BBV-TRAQ. Items weights were assigned according to expert key informant ratings of HCV risk practices performed during the development stages of the BBV-TRAQ. A range of item weights was tested and psychometric properties explored. A weighting scheme was recommended based on the plausibility of normative subscale data in relation to research evidence and the ability of BBV-TRAQ scores to discriminate between HCV positive and negative participants.

Results

While retaining the psychometric properties of the unweighted scale and demonstrating good internal reliability. By taking into account the relative transmission risk of a broad range of putative HCV practices, the weighted BBV-TRAQ produced promising predictive validity results among IDU based on self-report HCV status, particularly among young and less experienced injectors.

Conclusion

Brief, easy to administer and score, and inexpensive to apply, the utility of the BBV-TRAQ for community based education and prevention is enhanced by the application of item weights, potentially offering a valid surrogate measure for HCV infection among IDU.

Is the rural idyll bad for your health? Stigma and exclusion in the English countryside

The aim of this paper is to challenge assumptions that life in the English countryside is a healthy existence. This paper proposes that public health practitioners should consider the problems of stigma and social exclusion sometimes faced by individuals in rural areas. Using ethnographic research from a village in South East England the experiences of several individuals are examined to illustrate how stigma impacts on the health and well-being of those supposedly living in the rural idyll. It also argues for more ethnographic research to be conducted in health studies, particularly in rural areas, to gain deeper insight into health experiences.

Incidence and risk factors for hepatitis C seroconversion in injecting drug users in Australia

AIMS

To determine the incidence of hepatitis C virus (HCV) infection and identify risk factors for seroconversion.

DESIGN

Prospective cohort study. Participants were recruited through direct approaches, street-based outreach, methadone and sexual health clinics and needle and syringe programmes.

SETTING

Urban, regional and rural settings in New South Wales, Australia.

PARTICIPANTS

Injecting drug users (IDUs) (n = 584) were screened and tested for exposure to HCV. Between 1999 and 2002 antibody HCV negative IDUs (n = 368) were enrolled and followed-up every 3-6 months until seroconversion or study completion.

MEASUREMENTS

Interviewer-administered baseline and follow-up questionnaires consisted of 131 items and included demographics, drug use and risk behaviour. Approximately 10 cc of whole blood was drawn at each visit. Specimens were stored at -70C and serology performed using one or two third-generation enzyme-linked immunosorbent assays and polymerase chain reaction testing.

FINDINGS

Sixty-eight seroconversions were observed and incidence was 30.8 per 100 person-years, with incidence in IDUs injecting < 1 year, 133 per 100 person-years. Independent predictors of seroconversion were female gender, duration of injecting, injecting cocaine, shared use of filters and recruitment strategy.

CONCLUSIONS

Women, new initiates and IDUs recruited via outreach appear to be at increased risk of infection. Results confirm the significance of cocaine injection as a risk factor and provide the first evidence outside North America of the link between shared use of drug preparation equipment and incident HCV infection. Prevention efforts should attempt to raise awareness of the risks associated with drug sharing and, in particular, the role of potentially contaminated syringes in HCV infection.

Sex workers in agricultural areas: Their drugs, their children

Most research on female sex workers is urban-based, emphasizing economic necessity and risk-taking. Few authors discuss sex workers and their children. The objective of the present study was to ethnographically explore the influence of street life on childrearing by women involved in sex work in agricultural areas of the southeastern USA. Interviews took place with 38 women. Findings suggest that the sampled women followed the usual paths into substance use. Most began using substances before they began sex work, at which time use escalated to crack-cocaine. Children of 32 of the 34 women who were mothers were living separately from their mothers. None the less, mothers took an interest in children's wellbeing, and many visited them whenever possible. Their principal concern was assuring that children were raised in the best way available. One daughter followed her mother into sex work, and a few older children drank moderately. Several children had experienced abuse from persons other than parents, but the long-term effects of this abuse are unknown.

Age differentials in the impacts of reduced heroin: effects of a "heroin shortage" in NSW, Australia

BACKGROUND

This paper uses a unique event, the Australian heroin shortage, to see whether an abrupt, substantial and sustained change in heroin supply had different effects on harms related to heroin use among younger and older heroin users.

METHOD

Indicator data were examined by age group on the number of persons entering treatment for heroin and amphetamine dependence, arrests for heroin use/possession and number of drug related deaths in NSW, Australia. Data were analysed using times series analysis.

RESULTS

There was a 41% reduction in the number of new registrations for opioid pharmacotherapy per month among 25-34 year olds, and a 26% reduction among 15-24 year olds, but no apparent changes among older age groups. Similarly, reductions in the number of non-pharmacological heroin treatment episodes were most pronounced among younger age groups. There was a 49% reduction in the number of heroin possession/use offences among those aged 15-24 years, compared to declines of 31-40% among older age groups. Declines in heroin related deaths were greatest among 15-24 year olds (65% reduction). There was no change in other drug related deaths in any age group.

CONCLUSIONS

A reduction in heroin supply was followed by greater reductions in heroin related harms among younger than older people, across a number of outcome domains.

The impact of changes to heroin supply on blood-borne virus notifications and injecting related harms in New South Wales, Australia

Background

In early 2001 Australia experienced a sudden and unexpected disruption to heroin availability, know as the 'heroin shortage'. This 'shortage has been linked to a decrease in needle and syringe output and therefore possibly a reduction in injecting drug use. We aimed to examine changes, if any, in blood-borne viral infections and presentations for injecting related problems related to injecting drug use following the reduction heroin availability in Australia, in the context of widespread harm reduction measures.

Methods

Time series analysis of State level databases on HIV, hepatitis B, hepatitis C notifications and hospital and emergency department data. Examination of changes in HIV, hepatitis B, hepatitis C notifications and hospital and emergency department admissions for injection-related problems following the onset of the heroin shortage; non-parametric curve-fitting of number of hepatitis C notifications among those aged 15–19 years.

Results

There were no changes observed in hospital visits for injection-related problems. There was no change related to the onset heroin shortage in the number of hepatitis C notifications among persons aged 15–19 years, but HCV notifications have subsequently decreased in this group. No change occurred in HIV and hepatitis B notifications.

Conclusion

A marked reduction in heroin supply resulted in no increase in injection-related harm at the community level. However, a delayed decrease in HCV notifications among young people may be related. These changes occurred in a setting with widespread, publicly funded harm reduction initiatives.