Barriers to Safer Injection Practices Faced by People Who Use Injection Drugs, in Vancouver and Abbotsford, B.C.
Shannon Granta , BA; Tracy Tana , BMLSc; Alexis Crabtreeb , BA, MPH; Gareth Mercerb , BSc; Robert Horana , BSc; Jane A. Buxtonc , MBBS, MRCGP, MHSc, FRCPC
(a) Vancouver Fraser Medical Program 2013, UBC Faculty of Medicine, Vancouver, BC
(b) Vancouver Fraser Medical Program, MD/PhD Program, UBC Faculty of Medicine, Vancouver, BC
(c) UBC Faculty of Medicine, Vancouver, BC
Objective: Obstacles are often put in place to discourage users of injection drugs from using public facilities to inject. These include frequent security patrols, locked washroom facilities, and blue lights designed to obstruct the visualization of veins. Unfortunately, these interventions may have the unintended consequence of increasing the risks inherent to injecting drugs. We discuss these barriers and argue that they should be addressed to mitigate risk.
Methods: We interviewed 18 individuals who were previous or current users of injection drugs, with the goal of discussing the placement of blue lights in public washrooms and its impact on their ability to safely inject.
Results: Interviewees described the factors involved in selecting a location to inject. Factors that negatively influenced comfort tended to increase the likelihood of missing veins and of the need for multiple tries. These factors included: person–related factors, such as the presence of authority figures or uninvolved members of the public; environmental factors, such as the level of light and temperature; and personal issues such as the depth, size, or condition of veins.
Conclusions: While harm reduction education and the discussion of intentional barriers to the safe use of injection drugs are certainly beneficial, many physical and societal obstacles prevent users of injection drugs from using their preferred, often safer methods.
KEYWORDS: harm reduction, injection drug use, public injection
The use of injection drugs is associated with numerous harms beyond the physiologic and addictive effects of the drugs themselves. These harms can be the physical effects, such as abscess formation or bacterial introduction into blood, resulting from rushed injections or injecting under situations in which hygiene cannot be optimized.(1-5) Certain harms, such as the psychological and societal harms inherent in injecting in public spaces, are often overlooked.(6-10) The barriers that an individual encounters in his or her attempt to find a safe place to inject may significantly contribute to the likelihood of experiencing these harms.(4) These barriers may be publicly and privately employed authority figures, such as police officers and security guards, or other individuals whose presence discourages injection drug use, including any member of the public. A person who injects drugs may have difficulty accessing a vein, either due to environmental constraints or significant previous drug use, resulting in an increased risk of potential harms to the individual’s health.
Harm reduction is the principle and practice that, through the use of various approaches, aims to reduce the potential negative health, personal, and societal impacts, which may be the result of any behaviour that can be deemed risky.(11) Examples include the enactment of laws prohibiting distracted driving, or education surrounding safe sex practices. In the case of people who use injection drugs, harm reduction can include: the provision of sterile needles and other injection equipment; the availability of well– lit and clean locations for safe injection; and the improvement of accessibility to primary care for a historically underserved population.(11) One well–known harm reduction effort in the Vancouver area is the opening of Insite, a supervised injection site. Running counter to harm reduction principles, however, are efforts that members of the public or business owners may use to prevent the use of injection drugs in the vicinity of their buildings, including the installation of blue lights in public washrooms to make the visualization of veins more difficult.
The data presented in this article were collected as part of a study that aimed to assess the opinions and perceptions of people who use injection drugs on the potential harms of installing blue lights in public washrooms. During the course of qualitative data analysis, the investigators noticed a series of patterns emerging regarding criteria used by people who use injection drugs in selecting injection locations, and the barriers they encounter in attempting to inject in locations that are as safe and as comfortable as possible. It was discovered that while many people who inject drugs were aware of ways to mitigate the harms involved, these methods were not always available or easy to access. In this paper we discuss a number of reported barriers to safer injection, and we argue that many of these barriers are avoidable and should be addressed. These barriers result in unnecessary health risks and complications for members of a population who also faces significant challenges to accessing health care.
The data for this analysis were collected during a series of semistructured interviews conducted between January and March of 2011. Interview participants were recruited based on the following eligibility requirements: they had to be current or former users of injection drugs; and they had to have an awareness of the issue of blue lights in public washrooms, though participants were not required to have personally experienced injecting in a bathroom fitted with a blue light. Recruitment was done through the Vancouver Area Network of Drug Users (VANDU) and the B.C. Yukon Association of Drug War Survivors (BCYADWS, Abbotsford Chapter), both of which are community advocacy groups for people who use injection drugs in British Columbia, Canada.
The interviews were approximately 30 minutes long and were conducted by five medical students. The interviewers referred to a previously agreed upon topic guide to structure the interviews. Topics included the respondent’s history of intravenous drug use, experiences of drug use in public locations, preferred injection practices, and perceptions of the impacts of installing blue lights in public washrooms. The participants provided written informed consent at the beginning of each interview. Following the interview, they were offered contact information for the study principal investigator and for a counsellor whom they could contact if they desired. Each of the participants was provided with an honorarium following the conclusion of the interview as an offer of appreciation of their time and for sharing their insights.
The interviews were digitally recorded and transcribed verbatim. The results were analyzed using NVivo 9, qualitative data analysis software, according to the analytic approach of interpretive description.(12) A series of concept categories were identified and organized into themes. The initial three interviews were coded by all five investigators to ensure that consensus could be reached; subsequent interviews were coded individually by the interviewer, based on the initial coding structure. Interviews were conducted until data saturation had been reached, which was the point at which no new themes emerged from the most recent round of interviews. Data saturation was agreed upon by the five interviewers following review of the coding reports. Throughout the coding process, the interviewers met to discuss the emerging themes and adjusted subsequent interviews to allow for a more in-depth exploration of these concepts. The validity of the interpretive description was checked by presenting initial findings to members of the VANDU and BCYADWS boards and incorporating their feedback into the final analyses.
Approval for this study was obtained from the Behavioural Research Ethics Board of the University of British Columbia.
RESULTS At the conclusion of the study, defined above as data saturation, 18 interviews had been conducted. All participants had used injection drugs; eight were current injectors. All participants were aware of the use of blue lights, although not all had an accurate understanding of their purpose. Eight of the individuals were interviewed in Abbotsford, and ten in Vancouver. Six women and 12 men were interviewed, and both men and women were represented at both sites.
In each interview, we explored how the participant selected a location to inject. A majority of participants stated that privacy was a main priority in their selection. Preferred physical locations included the individual’s home and other indoor locations, such as public washrooms. The indoors were considered ideal places in that they provide warmth compared to the outdoors, where colder temperatures often made for more difficulty accessing veins. Indoor areas also provided privacy and protection from authority figures such as police or security guards, whose presence could mean drug confiscation or possible incarceration. Being indoors could also ensure that other people, including uninvolved members of the public, were not present; many participants expressed concern with respect to being seen or judged by others. Many of the participants stated that being outdoors also resulted in rushed injections if other people were nearby or approached the individual, which increases the likelihood of mistakes. Being outdoors was also often accompanied by a lack of clean water for injecting. One participant expressed his concerns about injecting outside:
Well, yeah, the outdoors isn’t as good anymore. There’s chances for getting arrested more. And it’s too rushed because you’re thinking that the cops are going to come and get you now and because it’s not like it used to be. It used to be they wouldn’t bother you too much. But now they might, so you want to get it done. You can make mistakes and miss or whatever.
The other topics discussed with each of the participants included: confidence in their injecting ability and the individual’s drug of choice. The interviewees discussed numerous obstacles to safer injecting, most of which were mentioned by multiple individuals.
The presence of authority figures, in particular the police, was mentioned repeatedly during the interviews. Many participants preferred not to inject in public areas such as alleys, streets, and public washrooms due to the fear of police being nearby. Security guards and bouncers were also cited as authority figures who may become involved by confiscating drugs or using aggressive force, such as spraying injectors with water. Manywere also concerned about the possibility of jail time when the police became involved. One individual stated that intervention by the police had increased in recent years and that it was an increasing cause of preferring to inject elsewhere. In addition to avoidance of public injection, participants indicated that the presence of authority figures resulted in rushed injections, which increased the likelihood of making mistakes such as missing veins and losing drugs.
The barriers mentioned in this paper primarily result from the fact that finding a vein can be difficult in many circumstances and that many factors can decrease the chance of doing so successfully. Finding a vein can be difficult when the individual is cold, which is one factor in preferentially selecting an indoor location such as home. It can also be difficult when an individual is dehydrated or, in the opinion of one participant, when injection is attempted early in the morning. For some, small veins or veins which are located deep in the arm are a significant problem, an issue which is compounded by long–term drug use due to “scarred” or “collapsed” veins, as described by a number of the study participants. Small veins appear to be a more significant problem in women, which many noted made female drug users more vulnerable to the barriers mentioned here and to the risks associated with a difficult injection. Each of these factors could result in multiple attempts being required before an individual could find a useable vein.
Some participants noted that they had the option of employing others’ assistance with injecting, which was associated with its own potential harms. The need for help can arise from poor lighting, difficult–to–access veins, or fear of needles. One participant stated that it was more often women who required assistance because of the increased difficulty in accessing their veins and stated that there will often be a fee associated with getting assistance, such as a portion of the drug. One participant explained the ease with which he can often find peers to help with his injections:
I just live a couple blocks from here, and, you know, most of the time I’m around my place. If I can’t get it myself there’s usually somebody I can find to help me to do it, you know, that can get it into this arm for me or something.
Some interviewees described the difficulty of trying to inject while they were still high, complicated by hallucinations or tremors. One participant described his experience:
Well, I’ve been too high, and I couldn’t find the vein, and I missed. Like, I went through it or beside it or something, right. Mostly you go through it if you got the small vein. And you go too straight down instead of angled inside, like, you know, push it inside the vein or go through it, right. I used to miss the odd time, though, but not really. Usually I just pushed it in once and it would flag itself.
Each of these issues posed a problem for those who wished to inject at safe injection sites such as Insite because assisted injection is prohibited by Health Canada guidelines, which prevents Insite staff from assisting clients with injecting. As a result, users were often forced to find an alternative location to inject.
This study was designed to investigate the impact of the installation of blue lights in public washrooms; however, in analyzing the responses of the participants, we discovered that numerous other factors played a significant part in preventing injection drug users from being able to safely inject. These barriers to safety had many potential results, such as infection, bleeding, and not insignificantly, psychosocial stress, feelings of shame, and social marginalization.(7) It was clear that these barriers were not the result of an oversight in knowledge. Each of the participants was aware of aspects of harm reduction and addressed these directly in their interviews. Many mentioned Insite, and stated that they had previously gone there to inject. Most individuals mentioned the importance of good lighting and the dangers of using contaminated water or of injecting multiple times. In discussing the above barriers with the interviewers, the participants as a whole identified that these barriers were limitations to safety and that the conditions under which they used injection drugs were often less than ideal due to these factors. In this way, it was clear that public information and individual counseling, while certainly beneficial in raising awareness, are not sufficient to significantly mitigate the majority of harms that users of injection drugs face.
In order to enable consistent adoption of harm reduction practices, proponents and practitioners need to consider the numerous barriers to safer injection encountered by people who use injection drugs. As presented in this article, attempts to dismantle these barriers cannot end with teaching individual users of injection drugs about harm reduction practices. Previous studies have noted that the relationship between public injecting and the injecting environment is tightly bound, but that an insufficient amount of research has been done regarding the nature of that connection.(4,6) We suggest that this study lends further credence to the assertion that harm reduction should move to include societal interventions and policy changes along with the already beneficial practices of individual education. Advocating for more enabling policing practices would reduce potential harms, as it has also been previously noted that high levels of enforcement have been shown to have negative health impacts due to reduced access to sterile syringes and increased risky injection practices.(4,11) Another effective strategy could be advocating for increasing the availability and accessibility of locations to practice safer injecting, as well as assisted injecting through peer interventions such as the VANDU Injection Support Team.(6) Increasing the number of options in place would benefit a larger group of injection drug users, as one harm reduction method used by one individual may not be suitable for another. Advocating for more enabling policing, increasing numbers and types of safe injecting locations, continuing individual education, and increasing public awareness will continue to open up options for people who use injection drugs and begin to break down the barriers to increased safety and mitigation of harm.
The authors gratefully acknowledge the assistance of the Vancouver Area Network of Drug Users and the Abbotsford Chapter of the BC-Yukon Association of Drug War Survivors. This study received funding from the Social Accountability and Community Engagement Initiative of the University of British Columbia Faculty of Medicine. Alexis Crabtree is supported by a BCCDC-CIHR-UBC MD/PhD Studentship. Gareth Mercer is supported by a CFRI-CIHR-UBC MD/PhD studentship.
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